Renal cell carcinoma. Natural history and results of treatment

Renal cell carcinoma: long-term survival and late recurrence

In a series of 506 patients with renal cell carcinoma survival was analyzed in terms of pathologic stage, histologic grade, and a combination of stage and grade. Data reveal that stage, grade and the combination are important prognostic indicators. Invasion of the renal pelvis is not an important factor in staging the disease. Women had a better survival rate than men. The prognosis for patients with dark cell tumors was no worse than that for patients with clear cell tumors when correlated with the more important factors of tumor stage and grade. Renal vein involvement alone, excluding concomitant capsular or nodal involvement, had an adverse effect on survival. Of the patients who survived 10 years from the date of nephrectomy 11 per cent had late recurrence.

Surgical treatment of metastatic disease in the thyroid gland

Metastatic disease in the thyroid gland is uncommon in clinical practice. Preoperative investigation with thyroid scan and fine-needle aspiration biopsy verified or strongly suggested metastatic disease in seven out of nine patients. All patients were treated by thyroid surgery. Three patients died within 4 months in disseminated disease. The remaining seven patients had a survival rate of between 1 and 5 years. Three patients are still alive 12, 29, and 48 months after thyroid surgery. Surgical treatment for metastatic disease in the thyroid, especially due to metastatic renal carcinoma and melanoma, is recommended.

[Prognosis of metastatic renal cell carcinoma related to the pattern of metastasis (author's transl)]

Hundred nine unselected patients with metastatic renal cell carcinoma have been stratified into 3 groups according to their type of metastasis: 17 patients with sceletal involvement only, 67 patients with visceral metastases, and 21 patients with a mixed type of metastasis. Four patients with a locoregional pattern of recurrence were not included in the analysis. The survival data (evaluated by life table analysis and a modified Wilcoxon-Rang-test) revealed a better prognosis for patients presenting exclusively with osseous metastases compared to the group with visceral metastases. The patients with osseous metastases showed a median survival time from diagnosis of 29.9 months compared to 11.6 months in patients with visceral involvement. Considering only patients whose metastases have been detected after a period of latency post nephrectomy, there is a further increase in the survival in favour of the patients with sceletal metastases and the difference to the group with visceral metastases becomes statistically highly significant.

How accurate is angiographic staging of renal carcinoma?

Angiographic interpretations were compared with the pathologic findings of 75 patients undergoing nephrectomy for renal carcinoma. Angiography correctly predicted the clinical stage in only 36 per cent of the cases. This failure rate was attributed to the lack of consistent radiologic criteria for determining invasion of the perinephric fat, renal vein, and extension to regional lymph nodes.

The natural history of metastatic renal cell carcinoma: a computer analysis

Survival factors of 86 patients with metastatic renal cell carcinoma were studied by computer analysis. Cumulative survival was 53 per cent at 6 months, 43 per cent at 1 year, 26 per cent at 2 years and 13 per cent at 5 years. Survival was influenced favorably by confinement of metastases to the lungs, by the absence of local recurrence or persistence of tumor and by a longer interval free of disease after removal of the primary tumor. Medical therapy improved survival during the first year after diagnosis of metastases but no objective regression of tumor was observed. Excision of metastatic foci significantly improved survival for up to 5 years (p less than 0.05 and p less than 0.02) after which most patients died of recurrence. Palliative or adjunctive nephrectomy in patients with metastases was associated with a 6 per cent mortality rate but it increases survival over other patients with metastases at the time of diagnosis of renal carcinoma who did not undergo nephrectomy. This difference was owing to patient selection and survival of those who had adjunctive nephrectomy was no greater than that of the study population as a whole. However, based on the factors that were associated with improved survival palliative nephrectomy may be beneficial when a limited number of metastases treatable by excision or radiation therapy are present, when effective systemic therapy exists or when the primary tumor produces severe symptoms.

Pulmonary resection for metastatic renal adenocarcinoma: pathologic findings and therapeutic value

Forty-four cases of metastatic renal adenocarcinoma to the lung were studied to assess the efficacy of surgical management and to review the histological criteria for diagnosis. Our data support the role of surgical resection in patients with unilateral pulmonary metastasis. Adverse prognostic features include radiographically multiple lesions and involvement of tracheobronchial lymph nodes. A better survival was associated with extensive tumor necrosis. In patients presenting initially with pulmonary metastases, nephrectomy is indicated only when the metastases are unilateral. The various histological patterns of the neoplasm, and features helpful in differential diagnosis are discussed. An intravenous pyelogram (IVP) is indicated for all patients presenting with clear cell tumors of the lung. In certain cases a renal arteriogram may be necessary to exclude the possibility of a renal primary.

Immune RNA therapy for renal cell carcinoma: survival and immunologic monitoring

Twenty patients with metastatic renal cell carcinoma and nine patients with minimal residual disease (MRD) but at high risk for recurrence following nephrectomy received weekly four milligram intradermal injections of purified RNA extracted from lymphoid organs of sheep immunized with human renal cell carcinoma. Eighty-six consecutive UCLA patients with metastatic renal cell carcinoma served as retrospective controls. Survival between subpopulations in each group matched by computer according to extent and location of metastases, age, sex, and interval between nephrectomy and occurrence of metastases were compared by Life Table Analysis. Survival was significantly greater in RNA-treated patients (P < .05) who had multiple metastases limited to the lungs when compared with matched controls. RNA therapy did not influence survival of patients with metastases to other sites (bone, brain, liver, lymph nodes, or skin) or multiple organ involvement. All nine MRD patients treated with RNA remained free of recurrence for a mean observation period of 18 months, range ten to 34 months. No significant toxicity was observed. Changes in skin test responses were related primarily to tumor burden. Increased lymphocyte mediated cytotoxicity in RNA recipients was associated with a somewhat improved survival period. Changes in absolute lymphocyte counts had no correlation with clinical course, and complement fixing antibody generally decreased after excision of tumor, was absent in patients with progression, and was present in low levels in patients with a favorable clinical response. RNA therapy may be of value in selected patients with metastatic renal cell carcinoma, and as an adjunct to definitive surgery.

The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.

Clinical comparison between vascular and avascular renal cell carcinoma

Of 72 patients with renal cell carcinoma 19 were found to have an angiographic avascular neoplasm. These avascular tumors have a lower incidence of vein and capsule invasion than vascular tumors. Among these avascular cancers papillary adenocarcinoma was the predominant histologic pattern. Patients with papillary tumors seem to have a lower clinical stage and increased survival rate than patients with non-papillary tumors.

Regression of pulmonary metastases from renal carcinoma

This article describes a patient who had a nephrectomy and hormone therapy for renal carcinoma. There was roentgenographic evidence of pulmonary metastases at the time of surgery. He was alive and showed no clinical or roentgenographic evidence of pulmonary metastases six and one-half years after treatment.

Metastatic hypernephroma to the head and neck

Hypernephroma is one of the most common visceral adenocarcinomas which metastasize to the head and neck. The metastasis may precede discovery of the primary or follow it. The most common sites of metastatic hypernephroma to the head and neck are the sinonasal tract, skin, cervical lymphatics, and mandible. Three cases of metastatic hypernephroma are presented and one of these is the first documented report of a metastasis to the parotid gland. The other two were found in the sinonasal tract.

Hypernephroma in children

Two cases of childhood hypernephroma are presented, bringing to 88 the number of cases of this unusual tumor authenticated in the literature. Both children were black males, four and eight years old. Both had Stage II right renal lesions which were treated with radical nephrectomy and postoperative irradiation. One has been followed up for over seven years and is free of disease. A brief summary of the incidence, treatment, and prognosis of this unusual childhood malignancy is presented.

Renal cell carcinoma: natural history and chemotherapeutic experience

Eght-four patients with renal cell carcinoma were analyzed retrospectively in order to 1) determine the effectiveness of systemic chemotherapy-hormonal and non-hormmonal, 2) identify the clinical features of renal cell carcinoma that may be important in prognosis and 3) characterize the paraneoplastic features of renal cell carcinoma. Metastatic disease was present at diagnosis in 57 per cent of the cases and developed within 1 year in an additional 19 per cent of the cases were paradoxically associated with a longer survival (20 months median) compared to single-organ metastasis (5 to 11 months median). Paraneoplastic syndromes occurred in up to 40 per cent of patients with variable survival. Metastatic disease was unresponsive objectively to either primary nephrectomy or to a variety of chemotherapy trials.

Combined intra-arterial actinomycin D and radiation therapy for surgically unresectable hypernephroma

One primary goal of preoperative radiotherapy for hypernephroma is to reduce the volume of tumor and, therefore, improve the possibility of resection. It is important that this goal be accomplished promptly so that 4 to 6 weeks after radiation therapy nephrectomy can be attempted. A longer waiting period may allow fibrosis of the normal surrounding tissues and make surgery more difficult. In addition, longer waiting periods could theoretically increase the probability of metastasis. Therefore, we plan to continue clinical investigation on the use of combined intra-arterial actinomycin D and radiotherapy as a possible useful means of improving the possibility of prompt surgical resection, since theoretically this regimen may be a method of increasing the effective radiation dose to the hypernephroma without increasing the effective radiation dose to surrounding normal tissue, such as bowel. The method may also have merit as an improved means of palliating selected patients with metastases who are symptomatic from a bulky primary hypernephroma.

Is nephrectomy justified in patients with metastatic renal carcinoma?

The survival data of 93 patients with metastatic renal carcinoma are discussed with respect to the site of metastasis and whether nephrectomy was performed as part of the initial treatment. Analysis of the cumulative survival rates revealed that nephrectomy significantly increased survival only for those patients pesenting exclusively with osseous metastases. Nephrectomy did not alter survival for patients with pulmonary and/or soft tissue metastases.