Radical extensive surgery for renal cell carcinoma: long-term results and prognostic factors

Surgical resection of brain metastases from renal cell carcinoma in 50 patients

OBJECTIVES

Metastases are frequently diagnosed among patients with renal cell carcinoma (RCC). Of 709 patients with brain metastases (BMET) who were operated on at our institution between 1974 and 1993, 50 (7%) were of renal origin.

METHODS

Medical records were reviewed retrospectively. Survival time was calculated by the Kaplan-Meier method and Cox proportional hazards model.

RESULTS

There were 38 men and 12 women. The median age was 60 years. The primary RCC was resected in 47 patients. Forty patients had a metachronous diagnosis of RCC and BMET. Median interval between the diagnosis of RCC and BMET was 17 months. In all 50 patients overall median survival (MS) from diagnosis of primary RCC was 31.4 months and from craniotomy was 12.6 months. Postoperative mortality was 10% (5 patients). In patients with primary RCC in the left kidney (n=25) versus right kidney (n=25) median survival from craniotomy was longer; 21.3 versus 7.4 months (P<0.014). Twenty-three patients (46%) had intratumoral hemorrhage. Eight patients had cerebellar metastasis (MS, 3.0 months) and 9 had multiple metastases resected (MS, 7.6 months). Thirty-eight patients had both brain and pulmonary metastases, and 16 of them had pulmonary resection (MS, 18.6 versus 8.0 months; P<0.03). Twenty-two patients received whole-brain radiation therapy (WBRT) after craniotomy and 18 did not receive WBRT (MS, 13.3 versus 14.5 months; P<0.62). The 1-year, 2-year, 3-year, and 5-year survival was 51%, 24%, 22%, and 8.5% respectively.

CONCLUSIONS

Only the resection of lung metastasis, supratentorial location of BMET, left-sided localization of primary RCC, and lack of neurologic deficit before craniotomy were statistically significant prognostic factors in Cox regression analysis. In the absence of effective systemic treatment, we suggest that patients with BMET from RCC be considered for operative resection for treatment and palliation.

Vein invasion in renal cell carcinoma: impact on metastatic behavior and survival

PURPOSE

The development of a thrombus extending into the veins is well recognized in renal cell carcinoma. We investigated the hypothesis that vein invasion alone has no adverse impact on survival but is a highly negative factor in other tumors.

MATERIALS AND METHODS

In 200 consecutive patients invasion of the renal vein and vena cava was evaluated and compared with the clinical course.

RESULTS

A total of 26 patients had vena caval and 47 had renal vein invasion. Patients with venous invasion had a significantly shorter survival but no survival difference was demonstrated based on the level of involvement.

CONCLUSIONS

Our study indicates that vein invasion itself seems to be an important prognostic factor in renal cell carcinoma.

Reconsidering the necessity of ipsilateral adrenalectomy during radical nephrectomy for renal cell carcinoma

OBJECTIVES

Ipsilateral adrenalectomy is traditionally advocated as part of radical nephrectomy performed for renal cell carcinoma. The current study addresses the controversy of whether ipsilateral adrenalectomy should be performed routinely during radical nephrectomy.

METHODS

A total of 225 patients were treated surgically for renal cell carcinoma over an 18-year period. Of these patients, 158 underwent nephrectomy and simultaneous ipsilateral adrenalectomy and the other 67 had sparing of the ipsilateral adrenal gland. A retrospective analysis of the medical records and assessment of the clinical and the pathologic data were performed. Rates of survival and progression were evaluated in a subgroup of 109 patients, further subdivided into 54 patients who underwent concomitant adrenalectomy and 55 patients with the ipsilateral adrenal preserved during surgery.

RESULTS

Histopathologic abnormalities were detected in seven adrenal specimens (4.4%); however, only 3 patients (1.9%) had involvement of the adrenal by renal cell carcinoma. All cases of adrenal involvement were detected by the preoperative imaging modalities. Ipsilateral adrenalectomy did not improve the outcome in comparison to adrenal preservation.

CONCLUSIONS

In view of the rarity of ipsilateral adrenal metastasis, the questionable prognostic merits of concomitant adrenalectomy, and the availability of accurate imaging modalities, we conclude that ipsilateral adrenalectomy is not necessary in the majority of the patients undergoing radical nephrectomy for renal cell carcinoma.

Screening for acquired cystic kidney disease: a decision analytic perspective

Acquired cystic kidney disease (ACKD) increases the risk of renal malignancy, and many authors suggest routine screening of dialysis patients for ACKD and renal tumors. However, they have defined neither the target population, the optimal screening strategy, the magnitude of its benefit, nor its risk. We used decision analysis to evaluate strategies of performing either computed tomography (CT) or ultrasound every three years on all dialysis patients and annually on patients found to have cysts. We compared these strategies to a strategy of seeking cysts and cancer only if these are clinically suspected. The baseline analysis shows that both CT and ultrasound may decrease cancer deaths by half for patients with a life expectancy of 25 years. Screening for ACKD offers these patients as much as a 1.6 year gain in life expectancy. However, for the majority of patients beginning renal replacement therapy, age or comorbid disease substantially limits life expectancy. For such patients, the gain in life expectancy from an ACKD screening program is measured in days. Sensitivity analyses show that the benefit of screening depends on the rate of malignant transformation, which needs better definition. The gain in life expectancy does not appear to be large enough to justify an ACKD screening program for the entire ESRD population. However, for the youngest and healthiest patients, a screening program would be of benefit. The magnitude of this benefit is uncertain, because the analysis was consistently biased in favor of the screening strategies.

Renal cell carcinoma: considerations for nephron-sparing surgery

OBJECTIVES

The performance of nephron-sparing surgery in patients with a normally functioning contralateral kidney is controversial. To explore the risk factors that may contribute to the success or failure of nephron-sparing surgery, we examined the radiology and pathology reports of 278 patients who underwent radical nephrectomy for the treatment of clinically localized renal cell carcinoma.

METHODS

We collated patient data from the records of 278 patients with Stage III renal cell carcinoma entered into the Eastern Cooperative Oncology Group protocol EST 2886 and compared preoperative clinical staging with postoperative pathologic results. Patients were considered potential candidates for nephron-sparing surgery if their preoperative radiographic studies indicated that the carcinoma was a single polar lesion 5 cm or less in diameter.

RESULTS

Of 278 radical nephrectomy specimens, 36 had primary lesions 5 cm or less in diameter. Preoperative radiographic studies showed 14 of 36 would not have been considered eligible for nephron-sparing surgery. Of the remaining 22 potential candidates, pathologic studies showed multifocal lesions in 11, renal vein disease in 4, and nodal disease in 2. Only 5 of 22 patients might have had specimen-confined disease (T3a lesion).

CONCLUSIONS

Capsular-penetrating (T3a) renal cell carcinoma is not often appreciated preoperatively and is associated frequently with multifocal lesions, renal vein or nodal disease. Frozen section studies to rule out T3a disease at the time of nephron-sparing surgery may help determine which patients need radical surgery.

High incidence of asymptomatic brain lesions in metastatic renal cell carcinoma

The metastatic pattern of renal cell carcinoma has been well established. Studies have revealed a relatively high incidence of spread to lung, liver, bone and brain. A retrospective review of the records of ninety patients with metastatic renal cell carcinoma showed seven to have evidence of brain metastases. Six of the seven were asymptomatic at time of diagnosis. This study shows a significant incidence of asymptomatic brain metastases in patients with metastatic renal cell carcinoma. Subsequent to our chart review, an additional two patients have presented to our institution with asymptomatic brain lesions from metastatic renal cell carcinoma.

Solitary late recurrence of renal cell carcinoma

Late recurrence of renal carcinoma is an unusual manifestation of this tumor but can occur in as many as 11 percent of patients surviving ten years. We describe a case of a solitary lesion occurring in the nephrectomy scar ten years following surgery. The literature is reviewed. Aggressive surgical management is warranted in the treatment of these solitary lesions. The use of advanced imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can assist greatly in the management of patients.

Renal cell carcinoma in New Zealand: a national survival study

OBJECTIVE

To determine clinical and pathologic prognostic factors for renal cell carcinoma (RCC) using cases reported to a population-based cancer registry.

METHODS

All cases of RCC reported to the New Zealand Cancer Registry between 1976 and 1986 were retrieved and data analyzed to determine parameters of prognostic importance.

RESULTS

In eleven years, 1,308 cases of RCC (66.7% males and 33.3% females) were reported to the New Zealand Cancer Registry. The age-standardized incidence rate was 3.78 per 10(5) person-years and showed no significant trend over the period of the study. There was a significant difference in the age at presentation between the largest racial groups (Maori 52.2 years; non-Maori 63.2 years), which is accounted for by increased predisposing risk factors among Maori. The five-year actuarial survival rate was 42.4 percent with 63 percent of patients reported dead in follow-up to December 1990. In the series, patient gender (female > male), tumor laterality (right > left), stage (intrarenal > localized > disseminated), grade (1 > 2 > 3 > 4), and treatment modality (surgery > nonsurgery) were found to be significant prognostic factors, although only tumor stage and treatment modality were of independent significance. Tumor laterality was of prognostic significance for Stage II (localized) surgically treated tumors only.

CONCLUSIONS

The results of the study emphasize the paramount importance of tumor stage as a prognostic parameter for RCC. The prognostic significance of laterality for localized, surgically treated tumors suggests that radical nephrectomy is less likely to result in tumor clearance for left-sided RCC than for tumors on the right side.

Nephrectomy for metastatic renal cell carcinoma: a component of systemic treatment regimens

New immunotherapeutic and chemotherapeutic regimens have altered the medical approach to metastatic renal cell carcinoma (RCC). Surgery for metastatic RCC needs to be reappraised in the context of these developments. We retrospectively examined the course of 25 patients with metastatic RCC who underwent nephrectomy or resection of renal fossa recurrences as an adjunct to intended systemic therapy. Four patients (16%) had complications and there was no perioperative mortality. Of 23 patients who had surgery first, 17 received subsequent systemic therapy and 2 experienced a response. Two patients underwent nephrectomy after achieving a partial response with systemic therapy. Overall, 3 patients (12%) are alive without detectable disease, 8 (32%) are alive with disease, and 14 (56%) are dead of disease, with a median survival of 23.5 months. Nephrectomy for metastatic renal cell carcinoma may be associated with less morbidity and mortality than previously reported. When initial nephrectomy is performed, most patients go on to receive systemic therapy. Within the context of a systemic treatment regimen, nephrectomy continues to play a role in the management of selected patients with metastatic RCC.

Prognostic value of karyometric and clinical characteristics in renal cell carcinoma. Quantitative assessment of tumor heterogeneity

BACKGROUND

The variation in tumor cell differentiation within one renal cell carcinoma, also termed tumor heterogeneity, renders visual tumor grading of these carcinomas difficult. Karyometric analysis enables description of nuclear characteristics of multiple tumor areas. Hence, karyometric analysis can be used to quantify tumor heterogeneity and thus may aid in a more objective grading of renal cell carcinoma.

METHODS

In 121 patients with renal cell carcinoma (tumors in International Union Against Cancer [UICC] stages I [5 cases], II [23 cases], III [33 cases], and IV [60 cases]), clinical and karyometric features were studied to obtain routinely applicable prognostic factors. Several parts of the tumor were analyzed to obtain a measure of tumor heterogeneity. Univariate and multivariate Cox regression analyses were used to determine the predictive value of karyometric features independent of tumor stage and other clinical characteristics.

RESULTS

The Cox univariate regression analysis showed correlation of several clinical and karyometric characteristics with survival. Of the clinical characteristics, TNM stage, tumor size, weight reduction, and performance status were significantly associated with survival. The karyometric features, especially those measurements associated with tumor heterogeneity (e.g. differences in nuclear size or chromatin texture between tumor subpopulations) were of value in predicting prognosis. In the Cox multivariate regression analysis, the Robson and UICC stages proved to be the most powerful predictors of survival (P < 0.0001). Of the clinical features, weight reduction and performance score were the only characteristics offering additional information regarding tumor stage (P < 0.0001). From the karyometric analysis quantification of anisokaryosis in the tumor at time of diagnosis offered additional prognostic information. Moreover, the differences of karyometric features within the tumor presumably associated with tumor heterogeneity correlated with survival. Using the features from the multivariate analysis, prognostic groups could be defined.

CONCLUSION

We conclude that karyometric analysis offers a useful means for quantifying tumor heterogeneity. Multivariate Cox analysis revealed additional value of a grading system based on karyometric analysis to tumor stage. Karyometric analysis can be a useful tool for stratification of patient populations.

Extended Lymphadenectomy during Radical Nephrectomy for Renal Cell Carcinoma. A Prospective Study

The role and extension of lymphadenectomy during radical nephrectomy for renal cell cancer still remain a matter of debate. From June 1989 to March 1992, 137 consecutive extended lymphadenectomies were performed in patients undergoing radical nephrectomy for renal cell cancer at the Department of Urology of Padua. Ten patients (7.3%) had a pathologically proved nodal involvement. Only 2 patients had a distant nodal involvement in the absence of metastases to hilar nodes. Both patients with microscopic metastases had massive involvement of hilar nodes. Due to short median follow-up no clinical consideration on survival can be drawn.

Microscopic venous infiltration as predictor of relapse in renal cell carcinoma

In a retrospective analysis at a single institution we evaluated the significance of various pathological phenomena on the disease-free survival of patients with radically resected renal cell carcinoma. Parameters considered were tumor extension (pT stage) according to the International Union Against Cancer, tumor invasion into the renal vein or vena cava (V stage), standard histological grading (G stage), nuclear grading (F stage) and microscopic venous infiltration. The pT stage had a significant impact on disease-free survival (p = 0.0004) of patients with radically resected tumors, as did G stage (p = 0.0001) and F stage (p = 0.002). In contrast to some previously reported results tumor extension to the renal vein and vena cava showed no influence on disease-free survival (p = 0.077). On the other hand, microscopic venous infiltration, defined as local tumor infiltration through all vessel structures including the endothelial layer leading to a free tumor extension into the vessel, had a significant impact on disease-free survival (p less than 0.0001). When stratifying either tumor size or nuclear differentiation against microscopic venous infiltration, the latter retained a superior influence on disease-free survival (p = 0.01 and p = 0.0079, respectively). We conclude that microscopic venous infiltration is the most important predictor of relapse in renal cell carcinoma.

What are the benefits of extended dissection of the regional renal lymph nodes in the therapy of renal cell carcinoma

In a prospective study of 511 patients we compared the data of 320 who underwent systematically extended dissection of the regional lymph nodes with data of 191 who underwent only facultative dissection of the lymph nodes, which means that no lymph nodes had been removed or only a few were taken for staging purposes. Only patients without distant metastases and who were less than 72 years old were included. All patients were treated with a transabdominal approach. The incidence of positive nodes in the patients with systematically extended lymphadenectomy was 17.5% and for patients with facultative lymphadenectomy it was 10%. Survival rates of patients with facultative lymphadenectomy were 58% after 5 years and 40.9% after 10 years, compared to 66% and 56.1%, respectively, for patients with systematically extended lymphadenectomy (p less than 0.01). Patients with stage pT1-2 (Robson stage I) and pT3aN0M0 (Robson stage II) tumor obviously had the highest benefits with extended lymphadenectomy. Operative mortality was less than 1% after systematically extended lymphadenectomy and 3.8% after facultative lymphadenectomy. We conclude from our data that the systematic and extended lymphadenectomy improves the prognosis of patients with renal cell carcinoma without any additional operative risks.

Magnetic resonance imaging in the staging of renal cell carcinoma

A prospective study has been carried out to examine the role of magnetic resonance imaging (MRI) in the investigation of renal cell carcinoma in 24 patients. In all cases the inferior vena cava (IVC) was well demonstrated with MRI. In 14 out of 15 patients where surgical correlation was available, the MRI and operative staging were in agreement. Magnetic resonance imaging and computed tomographic (CT) staging were in agreement in 16 out of the 17 patients where both were performed. In one case, CT suggested hepatic invasion but this was found not to be present on MRI and at operation. Magnetic resonance imaging also provided substantial additional information in three patients, including two cases where MRI demonstrated a patent IVC that appeared occluded on CT (one of which also had vertebral metastases seen on MRI but missed on CT) and one case where CT failed to demonstrate minimal involvement of the IVC. Magnetic resonance imaging is an accurate means of staging renal cell carcinoma with clear advantages over CT. In no case in this series was inferior vena cavography found to be necessary.

Interleukin-2 immunotherapy followed by resection of residual renal cell carcinoma

We administered 10 (E5) units per kg. interleukin-2, 3 times daily, with or without lymphokine-activated killer cells, to 10 patients with metastatic renal cell carcinoma. All patients had metastases to the lung, and 3 of 5 patients who had previously undergone nephrectomy had metastases to the renal fossa. Of the 9 patients who completed at least 1 course of therapy 3 had complete regression of disease outside the abdomen, including 2 who were rendered disease-free after subsequent cytoreductive surgery (nephrectomy in 1 and resection of the renal fossa recurrence in 1). Viable tumor comprised less than 1% of each surgical specimen. Our results support the view that initial treatment with interleukin-2 immunotherapy, followed by abdominal cytoreductive surgery if the peripheral metastases have regressed, may be preferable to the practice of performing abdominal cytoreductive surgery before administering interleukin-2 immunotherapy for patients with widely metastatic renal cell carcinoma.

Partial nephrectomy for renal cell carcinoma: indications, results and implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.