Increased incidental detection and reduced mortality in renal cancer--recent retrospective analysis at eight institutions

Incidental detection beyond pathological factors as prognostic predictor of renal cell carcinoma

PURPOSE

To evaluate the prognostic significance of different detection modalities of renal cell carcinoma (RCC) in a large cohort of patients who had been previously submitted to surgery in two teaching hospitals in Italy.

MATERIALS AND METHODS

We reviewed the clinical records of 1446 patients who had been submitted to surgical treatment for RCC at the Departments of Urology of Padua (n=747) and Verona (n=699) from 1976 to 2000. Patients were classified into two groups according to the detection mode: symptomatic and incidental. The cancer-specific survival probability was estimated according to the Kaplan-Meier method. In order to compare the survival curves the log rank test was used. The predictive independent value of the variables was examined using the Cox proportional hazards model.

RESULTS

Six hundred and thirty patients (43.6%) were treated for incidental RCC and 816 (56.4%) for symptomatic RCC. In the incidental group, the size (p<0.001), the pathological stage (p<0.001) and the nuclear grading (p<0.001) of tumors were lower than those causing symptoms. The 5-year and 10-year cancer-specific survival probability were 84% and 75% in the incidental group, and 66% and 54.5% in the symptomatic group (p<0.0001), respectively. At a multivariate analysis, the mode of detection was an independent predictive variable (H.R. 1.559), as well as pathological stage (H.R. 1.809), nuclear grading (H.R. 1.411), size <or=4 cm (H.R. 1.667), and venous involvement (H.R. 1.526).

CONCLUSION

In patients with RCC, the detection modality can predict the cancer-specific survival rate independently of tumor pathological stage and grading.

Renal cell carcinoma: gender difference in incidental detection and cancer-specific survival

OBJECTIVE

To look for an increase in the incidental detection of renal cell carcinoma (RCC) over the last two decades and to see if different patterns of healthcare use for men and women have implications for tumour detection and survival.

MATERIAL AND METHODS

We present an historical series of 368 consecutive patients treated with nephrectomy for RCC during the period 1978-2000. The patients were classified according to detection mode (incidental or symptomatic disease), TNM stage and cancer-related death.

RESULTS

The frequency of incidentally detected RCC (IRCC) increased from 21.1% to 34.7% between the first and second decades of the study. The IRCC group had significantly more low-stage (I-II) tumours (p = 0.002), a smaller tumour size (p < 0.0001) at operation and significantly better cancer-specific survival (p = 0.0048) than the symptomatic renal cell carcinoma (SRCC) group. The frequency of women was significantly higher in the IRCC group than in the SRCC group (p = 0.02). Females had significantly more low-stage (I-II) tumours (p = 0.02) and better cancer-specific survival (p = 0.05) than males.

CONCLUSIONS

The number of incidentally discovered renal tumours is increasing. IRCC have lower TNM-stage and are smaller than SRCC. IRCC have better long term cancer specific survival than SRCC. The better survival rate found in females may be due to more extensive use of the healthcare system by females than males.

Prognostic value of nuclear grading in patients with intracapsular (pT1-pT2) renal cell carcinoma. Long-term analysis in 213 patients

BACKGROUND

The TNM classification system considers tumor size and, in particular tumor, greatest dimension as the only prognostic indicator for intracapsular renal cell carcinoma (RCC). The objective of the current study was to evaluate the role of nuclear grading and its importance as a prognostic indicator in patients with intracapsular (T1-T2) RCC.

METHODS

A retrospective study was performed on 213 patients with RCC limited to the kidney who were free from distant metastases at the time of diagnosis and who underwent radical nephrectomy from January 1990 to November 1999. All patients were staged according to the 1997 TNM classification system. Nuclear grading was determined according to the criteria proposed by Fuhrman et al. The patients' status was evaluated last in November 2000. The mean follow-up was 52 months (range, 12-130 months). The probability of survival was estimated by using the Kaplan-Meier method, with the long-rank test used to estimate differences among levels of the analyzed variables. A multivariate Cox proportional hazards model was performed to estimate the relative importance of the variables in predicting survival.

RESULTS

The 5-year disease specific survival rates for patients with pT1 and pT2 tumors were 93.5% and 61.1%, respectively. The 5-year disease specific survival rates for patients with Grade 1, Grade 2, and Grade 3-4 tumors were 95.9%, 86.8%, and 60.1%, respectively. A comparison of the survival curves both by stage and grade showed a statistically significant difference. For patients with pT1 lesions, the 5-year disease specific survival rate was 94.2% for patients with Grade 1-2 disease and 89.8% for patients with Grade 3-4 disease. For patients with pT2 lesions, the 5-year disease specific survival rate was 72.2% for patients with Grade 1-2 disease and 20% for patients with Grade 3-4 disease.

CONCLUSIONS

Within intracapsular tumors that measure > 7.0 cm in greatest dimension, nuclear grade is an important morphologic variable for predicting long-term survival. Identification of patients with nuclear Grade 3-4 tumors is important prognostically to determine the metastatic potential of pT2 tumors, because this subgroup of patients may benefit from adjuvant immunotherapy.

Radio frequency ablation of renal cell carcinoma: preliminary clinical experience

PURPOSE

We assess the feasibility, safety and efficacy of radio frequency ablation of small peripheral renal cell carcinomas.

MATERIALS AND METHODS

Five patients with a histologically proven renal cell carcinoma 30 to 40 mm. in diameter were treated with radio frequency ablation. A triple needle electrode was percutaneously advanced into each tumor under sonographic (4 cases) or computerized tomography (CT) (1) guidance. The radio frequency generator was activated for 15 minutes in each location where the electrode had been placed. Patients were then followed with CT and blood tests every 2 months for 6 months and every 3 months thereafter.

RESULTS

Four tumors required 1 radio frequency delivery and 1 required 2 applications during the same session. No complications were encountered except for a subcapsular hematoma in 1 patient, which resolved spontaneously. Two patients experienced transient hematuria. Of the patients 4 were discharged from the hospital after 2 days and 1 after 1 day. After 6 to 18 months (median 9) all patients were tumor-free on CT without suppress additional treatment.

CONCLUSIONS

In this small preliminary study radio frequency ablation of small peripheral renal cell carcinomas appears to be a feasible, safe and promising technique.

The changing natural history of renal cell carcinoma

PURPOSE

Our understanding of the natural history of renal cell carcinoma, the role of nephrectomy, the benefits of immunotherapy and the possibilities of new technologies are evolving and being integrated with advances in classification and staging. We reviewed the relevant literature to clarify these pertinent questions and provide a current review of the changes in the epidemiology, treatment and prognosis of patients with renal cell carcinoma.

MATERIALS AND METHODS

We comprehensively reviewed the peer reviewed literature on the current management of and results of treatment for renal cell carcinoma.

RESULTS

The incidence of and mortality from renal cell carcinoma have continuously increased during the last 50 years. Despite this increase in the number of new patients and consequently the number of deaths yearly the percent of those surviving for 5 years has notably improved. Factors related to improved survival include advances in renal imaging, earlier diagnosis, improved staging, better understanding of prognostic indicators, refinement in surgical technique and the introduction of immunotherapy approaches for advanced disease.

CONCLUSIONS

Currently patients with localized and metastatic renal cell carcinoma have had improvements in outlook and the therapeutic options available have expanded.

The changing natural history of renal cell carcinoma

PURPOSE

Our understanding of the natural history of renal cell carcinoma, the role of nephrectomy, the benefits of immunotherapy and the possibilities of new technologies are evolving and being integrated with advances in classification and staging. We reviewed the relevant literature to clarify these pertinent questions and provide a current review of the changes in the epidemiology, treatment and prognosis of patients with renal cell carcinoma.

MATERIALS AND METHODS

We comprehensively reviewed the peer reviewed literature on the current management of and results of treatment for renal cell carcinoma.

RESULTS

The incidence of and mortality from renal cell carcinoma have continuously increased during the last 50 years. Despite this increase in the number of new patients and consequently the number of deaths yearly the percent of those surviving for 5 years has notably improved. Factors related to improved survival include advances in renal imaging, earlier diagnosis, improved staging, better understanding of prognostic indicators, refinement in surgical technique and the introduction of immunotherapy approaches for advanced disease.

CONCLUSIONS

Currently patients with localized and metastatic renal cell carcinoma have had improvements in outlook and the therapeutic options available have expanded.

Regional lymph node dissection in the treatment of renal cell carcinoma: is it useful in patients with no suspected adenopathy before or during surgery?

OBJECTIVES

To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery.

PATIENTS AND METHODS

A series of 167 patients with RCC, free from distant metastases at diagnosis, and who underwent radical nephrectomy at our hospital between January 1990 and October 1997, was reviewed. The mean (median, range) follow-up was 51 (45, 19-112) months. Of the 167 patients, 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional LND limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery. Of these 59 patients, 49 had no evidence of nodal metastases before or during surgery. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables.

RESULTS

The overall 5-year survival was 79%; the 5-year survival rate for the 108 patients who underwent radical nephrectomy alone was 79% and for the 49 who underwent LND was 78%. Of the 49 patients with no suspicion of lymph node metastases, one (2%) was found to have histologically confirmed positive nodes.

CONCLUSION

These results suggest that there is no clinical benefit in terms of overall outcome in undertaking regional LND in the absence of enlarged nodes detected before or during surgery.

The prevalence of renal cell carcinoma: a nation-wide survey in Japan in 1997

BACKGROUND

The present study was conducted to investigate the incidence of renal cell carcinoma by sex, age group and different regions in Japan.

METHODS

The survey was conducted from the beginning of January 1997 to the end of December 1997. A total of 1306 Institutions in all 47 prefectures throughout Japan were requested to register cases.

RESULTS

There were 6358 persons with renal cell carcinoma, consisting of 4372 men and 1986 women. The age-specific incidence rates showed a peak in the age group of 65-70 years in both men and women. The crude incidence rates per 100 000 population for men and women were 7.1 and 3.1, respectively, and age-standardized incidence rates per 100 000 population for men and women were 4.9 and 1.8, respectively. The incidence rates in the Hokkaido region were significantly higher than in other regions (P < 0.05), among which there was no significant difference in incidence rates.

CONCLUSIONS

The present study showed that the incidence rates of renal cell carcinoma in Japan were approximately the same as among Japanese in Los Angeles. The rates were, however, lower than North American and European countries, but higher than China, Central or South American countries and African countries. The reasons for the high incidence of renal cancer in the Hokkaido region are not entirely clear. Further epidemiologic research is required.

Management of small renal tumors: an overview

The incidental finding of a small renal mass poses a therapeutic dilemma. The traditional treatment of clinically important masses has been radical nephrectomy. Recently, nephron-sparing surgery has emerged as a viable alternative; and experimental minimally invasive percutaneous tissue ablation techniques, including cryotherapy and radiofrequency ablation, are being evaluated. In this review, we discuss the dilemma posed by frequent renal imaging and the increased proportion of incidental tumors being detected, the limitations of needle biopsies for histologic diagnosis, nephron-conserving and minimally invasive surgery, and the possible merits of radiofrequency ablation and cryotherapy. We envision a defined role for minimally invasive percutaneous or extracorporeal ablation of small renal tumors.

Renal cell carcinoma

Several renal cell carcinoma (RCC) prognostic factors show promise, including K1-67, p53/mdm-2, and vascular endothelial growth factor. The combination of increased incidence of RCC and diagnosis during earlier stages has generated interest in local therapeutic options. Nephron-sparing surgery and laparoscopic nephrectomy continue to gain support and may become the standard of care in select patients. Standard therapy for metastatic disease continues to be cytokine-based therapy with little benefit gained from adding granulocyte-macrophage-colony-stimulating factor, retinoic acid, or adoptive immunotherapy. The addition of chemotherapy, such as capecitabine, floxuridine, and vinblastine, may increase the effectiveness of immunotherapy; nonmyeloablative stem cell transplantation has shown early promise in metastatic disease.

Incidental renal cell carcinoma-age and stage characterization and clinical implications: study of 1092 patients (1982-1997)

OBJECTIVES

To compare the epidemiologic, clinical, and pathologic characteristics of incidental and symptomatic renal cell carcinoma in a large series of patients, with emphasis on age distribution and its potential impact in defining groups of patients that may benefit from early detection programs.

METHODS

Records of 1092 patients with renal tumors from 1982 to 1997 were reviewed. Age, clinical presentation, and pathologic stage and grade were analyzed. Special attention was given to the age distribution and its relationship to the incidental or symptomatic diagnosis.

RESULTS

The overall mean age and proportion of patients older than 65 gradually increased (from 57 to 62.6 years and from 24.7% to 48.7%, respectively) from 1982 to 1997. The mean age in the incidental group rose steadily higher than in the symptomatic group. A progressive increase of incidental tumors from 13.0% in 1982 to 1983 to 59.2% in 1996 to 1997 was observed. A lower stage (74.3% versus 49.1%), grade (75.5% versus 56.9%), and percentage of metastases at presentation (10.4% versus 19.6%) were registered in the incidentally found neoplasms than in the symptomatic neoplasms. Eighty-two (80.4%) of 102 patients who underwent conservative surgery had incidental renal cell carcinoma.

CONCLUSIONS

Our data confirm a rapid and dramatic change in the epidemiologic and clinical characteristics of renal cancer, with an increasing number of incidentally found tumors presenting with lower stage, grade, and percentage of metastases. An unexpected but significantly higher rate of renal neoplasms was observed in older patients. The stage, grade, and patient age observed in our series of incidentally found tumors raises the question of whether to leave the current diagnostic approach unaltered, thus benefiting a subgroup of patients with clinically unrecognized and possibly indolent renal cell carcinoma, or to extend early detection programs to younger patients with potentially more aggressive tumors.

Incidental extracolonic findings at CT colonography

PURPOSE

To determine the frequency of extracolonic findings at computed tomographic (CT) colonography and the effect of these findings on subsequent patient treatment and cost.

MATERIALS AND METHODS

Conventional transverse CT colonographic scans in 264 consecutive patients were evaluated independently by two radiologists. Extracolonic findings were classified as having high, moderate, or low clinical importance. The effect of CT findings on patient treatment was assessed with chart review. The cost of additional examinations was calculated by using 1999 Medicare reimbursements.

RESULTS

Thirty (11%) patients had highly important extracolonic findings, which resulted in further examinations in 18 (7%) patients, including ultrasonography in 10, CT in 13, and intravenous pyelography in one. Six patients underwent surgery because of incidentally discovered CT colonographic findings. Two patients with findings of moderate or low importance underwent additional imaging. A total of $7,324 was required for work-up for extracolonic findings (mean of an additional $28 per examination). Three extracolonic malignancies were overlooked at CT colonography.

CONCLUSION

Additional work-up of extracolonic CT colonographic findings was relatively infrequent but was often worthwhile when performed for lesions classified as highly important. The evaluation of extracolonic structures at CT colonography has definite limitations with regard to solid organs but can help detect serious disease without substantially increasing the cost per patient.

Prognostic indicators for renal cell carcinoma: a multivariate analysis of 643 patients using the revised 1997 TNM staging criteria

PURPOSE

We determine independent prognostic indicators for renal cell carcinoma using the revised 1997 TNM staging criteria.

MATERIALS AND METHODS

The records of 643 consecutive patients undergoing partial or radical nephrectomy at our institution between 1987 and 1998 were reviewed. Preoperative evaluation of functional status using the Eastern Cooperative Oncology Group (ECOG) criteria was performed in all cases. Renal cell carcinoma grade and stage were evaluated using the 1997 American Joint Committee on Cancer grading and TNM staging criteria, respectively. Patients were followed for a mean plus or minus standard deviation of 47+/-40 months (median 87). Kaplan-Meier survival curves were used to determine 5-year cancer specific survival for all patient groups. Univariate analysis using log rank sum tests was performed to evaluate the prognostic significance of overall TNM stage, tumor stage, disease grade and ECOG status. Multivariate analysis was performed to determine which factors had an independent impact on survival of patients with renal cell carcinoma.

RESULTS

The 5-year cancer specific survival rate was 91%, 74%, 67% and 32% for TNM stages I, II, III and IV lesions, respectively (p<0.001). Analysis demonstrated a survival rate of 83% for stage T1, 57% for stage T2, 42% for stage T3 and 28% for stage T4 disease (p<0.001), and 89% for grade 1, 65% for grade 2, and 46% for grades 3 and 4 (p<0.001). Multivariate analysis revealed that overall TNM stage and grade of disease were the most important prognostic indicators for renal cell carcinoma (p<0.001). ECOG classification was a less significant predictor (p = 0.031) and tumor stage was not shown to have any independent impact on patient survival (p = 0.138).

CONCLUSIONS

Better survival rates of patients with localized and advanced renal cell carcinoma can be demonstrated with recent advances in diagnosis and treatment. The revised 1997 TNM criteria manifest an appropriate adjustment in staging renal cell carcinoma based on these improvements, with overall stage correlating with cancer specific survival. In contrast, while effectively predicting survival, tumor stage did not demonstrate an independent impact on renal cell carcinoma prognosis under multivariate analysis. Instead, other factors, such as ECOG status and more importantly grade of disease, appeared to affect survival significantly as independent elements. Based on our recent experience with patients treated for renal cell carcinoma in the era of enhanced technology and improved survival, tumor grade and molecular markers may serve as useful adjuncts to TNM staging in guiding treatment and predicting survival outcomes.

Renal cell carcinoma: prognostic significance of incidentally detected tumors

PURPOSE

We determined the prognostic significance of incidentally discovered renal cell carcinoma in the era of increased incidental detection.

MATERIALS AND METHODS

We reviewed the records of 633 consecutive patients who underwent radical or partial nephrectomy for renal cell carcinoma at our institution between 1987 and 1998. Patients were divided into those who were asymptomatic and tumor was diagnosed incidentally and those diagnosed after presenting with any of the classic symptoms of renal cell carcinoma or subsequent metastasis. All renal cell carcinoma lesions were assigned a stage and grade according to 1997 TNM criteria. All patients were followed postoperatively to assess survival rates, and monitor recurrence and metastasis.

RESULTS

Of the 633 patients 95 (15%) were treated for incidentally discovered renal cell carcinoma and 538 (85%) presented with symptoms secondary to renal cell carcinoma at diagnosis. Patient age and sex distribution were similar in the 2 groups. Stage I lesions were observed in 62.1% of patients with incidental renal cell carcinoma and in 23% with symptomatic renal cell carcinoma. In contrast, stage IV lesions were present in 27.4% of patients with incidental versus 54% with symptomatic renal cell carcinoma. Thus, incidental lesions were of significantly lower stage than those causing symptoms (p <0.001). Similarly 15.8% of incidental but 42.4% of symptomatic lesions were grade 3 or 4 (p = 0.006). Patients were followed postoperatively for a mean of 47 months plus or minus 40 months. The 5-year cancer specific survival rate was significantly higher for incidental than for symptomatic tumors (85.3% versus 62.5%). Likewise, the local and distal recurrence rates were higher for symptomatic lesions. When adjusted for stage, no difference in survival was noted in the 2 groups for stages I to III disease and a minimally significant difference was noted for stage IV cancer. Multivariate analysis of stage and grade attributed the survival difference in stage IV disease to the significantly higher grade of symptomatic lesions.

CONCLUSIONS

At presentation incidental tumors are of significantly lower stage and grade than tumors producing symptoms. Subsequently these clinically and histologically less aggressive lesions lead to better patient survival and decreased recurrence. Thus, the detection of renal cell carcinoma before symptom onset enables treatment of less aggressive tumors and provides a better prognosis for patients. Given these data efforts should be directed toward the development of a screening protocol to detect these lesions early, so that they may be prevented from progressing to the point when symptoms are apparent and prognosis becomes worse. In addition, the significant correlation of tumor grade with survival in our study further demonstrates the prognostic value of tumor grade and molecular markers for the future evaluation and treatment of renal cell carcinoma.

Kidney cancer in Canada: the rapidly increasing incidence of adenocarcinoma in adults and seniors

PURPOSE

To examine kidney cancer incidence and mortality patterns since 1969 in Canada.

METHOD

Linear regression of the log rates was used to estimate secular trends by age group and sex, and age-period-cohort models were fitted to examine changes in kidney cancer and renal adenocarcinoma incidence rates.

RESULTS

A substantial increase in incidence rates was observed among those 35 years and older, with average increases of 2.5% or more annually for both sexes. Age-period-cohort modelling suggested that much of this increase resulted from a period effect. Changes in mortality were much more modest, especially among those aged 0-34, for whom mortality rates actually declined by an average of 4.2% and 5.4% annually for males and females respectively.

CONCLUSIONS

Kidney cancer incidence rates have increased significantly, especially renal adenocarcinoma among adults and seniors. Diagnostic improvements and increasing levels of obesity in the Canadian population may have contributed to these trends.