Impact of tumor size on the clinical outcomes of patients with Robson State I renal cell carcinoma

Surgical treatment of renal cell carcinoma with tumor thrombosis of the inferior vena cava and the right heart: How we do it

OBJECTIVE

Renal cell carcinoma with inferior vena cava thrombosis is a rare disease with a poor prognosis without surgical treatment. We report our 11-year experience in the surgical treatment of renal cell carcinoma with extension of the inferior vena cava.

METHODS

We conducted a retrospective analysis of patients undergoing surgical treatment for renal cell carcinoma with invasion of the inferior vena cava in two hospitals from May 2010 to March 2021. To assess the spread of the tumor process invasion, we used the Neves and Zincke classification.

RESULTS

A total of 25 people underwent surgical treatment. Sixteen patients were men, nine were women. Thirteen patients underwent cardiopulmonary bypass (CBP) surgery. The following postoperative complications were recorded: two cases of disseminate intravascular coagulation (DIC), two cases of acute myocardial infarction (MI) and one case of coma of unknown reason, Takotsubo syndrome and postoperative wound dehiscence. Three patients deceased (16.7%) of DIC syndrome and AMI. After discharge, one of the patients had a recurrence of tumor thrombosis 9 months after surgery, and another patient had the same 16 months later, presumably due to the neoplastic tissue in the adrenal gland on the contralateral side.

CONCLUSION

We believe that this problem should be dealt with by an experienced surgeon with a multidisciplinary team in the clinic. The use of CPB provides benefits and reduces blood loss.

Staging of renal cell carcinoma: current progress and potential advances

Formal staging classifications for renal cell carcinoma (RCC) were first proposed in 1978 and were incorporated into the Tumour, Nodes, Metastases (TNM) system initially published by the Union Internationale Contre le Cancer (UICC) in 1978. There has been a gradual evolution of grading criteria through six separate editions of the UICC TNM Classification, with the latest edition being published in 2016. Somewhat surprisingly there were no changes to the T category criteria from the 2009 to the 2016 editions of the classification, although an erratum has subsequently been published that incorporated the minor changes included in the eighth edition of the TNM Classification published by the American Joint Committee on Cancer. Localised tumours are staged according to the size of the primary tumour, with the TNM classification recognising that these tumours may exceed 10 cm in diameter. This is unfortunate as there is good evidence to demonstrate that, for clear cell RCC, virtually all tumours >7 cm in diameter and a substantial proportion of tumours <7 cm in diameter, show extra-renal spread. Infiltration of tumour beyond the renal capsule into the peri-renal fat is also categorised as T3a, however the clinical importance of this remains unclear. The classification of microvascular invasion within the renal sinus requires clarification, as does the prognostic significance of tumour in small vessels within the kidney.

Renal cell carcinoma staging: pitfalls, challenges, and updates

Renal cell carcinoma (RCC) is unusual among cancers in that it often grows as a spherical, well-circumscribed mass. Increasing tumour size influences the pathological pT stage category within pT1 and pT2, with cutoffs of 40, 70 and 100 mm; however, with increasing size also comes a sharp increase in the likelihood of renal sinus or renal vein tributary invasion, such that clear cell RCC rarely reaches 70 mm without invading one of these. To clarify some previous challenges in assigning tumour stage, the American Joint Committee on Cancer 2016 tumor-node-metastasis classification has removed the requirements than vein invasion be recognised grossly and that vein walls contain muscle for the diagnosis of vein invasion. Renal pelvis invasion has also been added as an additional route to pT3a. Multinodularity or finger-like extensions from a renal mass should be viewed with great suspicion for the possibility of vein or renal sinus invasion, and, as tumour size increases to over 40-50 mm, thorough sampling of the renal sinus interface should always be undertaken. With increasing interest in adjuvant therapy in renal cancer, the pathologist's role in RCC staging will continue to be an important prognostic parameter and a tool for selection of patients for enrolment in clinical trials.

Updates in Pathologic Staging and Histologic Grading of Renal Cell Carcinoma

The most important prognostic parameter in renal cell carcinoma is tumor stage. Although pathologic primary tumor (pT) categories are influenced by tumor size (pT1-pT2), critical elements (≥pT3) are dictated by invasion of structures, including renal sinus, perinephric fat, and the renal vein or segmental branches. Because this invasion can be subtle, awareness of the unique characteristics of renal cell carcinoma is critical for the pathologist to aid in clinical decision making. This review addresses challenges in pathologic stage and grade reporting and updates to the World Health Organization and American Joint Commission on Cancer classification schemes.

Epidemiology of Renal Cell Carcinoma

The increasing incidence of RCC in most populations may in part be due to increasing numbers of incidentally detected cancers with new imaging methods. Further, the increase is not only limited to small local tumours but also includes more advanced tumours, which may to some part explain the still high mortality rates. The variation in incidence between populations may have several other explanations. Traditionally the starting point has included thoughts of environmental exposures, which so far have only in part explained the causes of RCC, by means of cigarette smoking and obesity, which may account for approximately 40% of cases in high-risk countries (Table 2). Further, the genetic variations may be of importance as a cause of the difference between populations. Continued research in RCC is needed with the knowledge that nearly 50% of patients die within 5 years after diagnosis. The further search for environmental exposures should take in account the knowledge that RCC consists of different types with specific genetic molecular characteristics. These genetic alterations have in some cases been suggested to be associated with specific exposures. Furthermore, there might exist a modulating effect of genetic polymorphisms among metabolic activation and detoxification enzymes. Hence, a further understanding of the genetic and molecular processes involved in RCC will hopefully give us a better knowledge how to analyse and interpret exposure associations that have importance for both initiation and progression of RCC.

Clinical prognostic factors and survival outcome in renal cell carcinoma patients--a malaysian single centre perspective

BACKGROUND

This study concerns clinical characteristics and survival of renal cell carcinoma (RCC) patients in University Malaya Medical Centre (UMMC), as well as the prognostic significance of presenting symptoms.

MATERIALS AND METHODS

The clinical characteristics, presenting symptoms and survival of RCC patients (n=151) treated at UMMC from 2003-2012 were analysed. Symptoms evaluated were macrohaematuria, flank pain, palpable abdominal mass, fever, lethargy, loss of weight, anaemia, elevated ALP, hypoalbuminemia and thrombocytosis. Univariate and multivariate Cox regression analyses were performed to determine the prognostic significance of these presenting symptoms. Kaplan Meier and log rank tests were employed for survival analysis.

RESULTS

The 2002 TNM staging was a prognostic factor (p<0.001) but Fuhrman grading was not significantly correlated with survival (p=0.088). At presentation, 76.8% of the patients were symptomatic. Generally, symptomatic tumours had a worse survival prognosis compared to asymptomatic cases (p=0.009; HR 4.74). All symptoms significantly affect disease specific survival except frank haematuria and loin pain on univariate Cox regression analysis. On multivariate analysis adjusted for stage, only clinically palpable abdominal mass remained statistically significant (p=0.027). The mean tumour size of palpable abdominal masses, 9.5±4.3cm, was larger than non palpable masses, 5.3±2.7cm (p<0.001).

CONCLUSIONS

This is the first report which includes survival information of RCC patients from Malaysia. Here the TNM stage and a palpable abdominal mass were independent predictors for survival. Further investigations using a multicentre cohort to analyse mortality and survival rates may aid in improving management of these patients.

There is no place for targeted therapy neoadjuvant treatment in Polish Health System - An analysis of radical nephrectomies in patients with large kidney tumors

Introduction

Despite the introduction of better diagnostic tools, very large kidney tumors are still not so rare in our country. The paper presents our experience in the treatment of 12 patients with kidney tumors larger than 14 cm in size.

Material and methods

Between spring 2009 and autumn 2011, radical nephrectomies were performed in 12 patients due to a large kidney tumor (larger than 14 cm in size). Symptoms (hematuria, weight loss, anemia, etc.) were not present in all the patients, but the kidney tumor was confirmed by imaging studies (ultrasound, CT, MRI) in all of them.

Results

Full recovery was observed with no severe complications in all of the patients treated with radical nephrectomy. Pathological staging was correctly established by imaging studies in all of them. After a few months, five of patients (41.6%) required systemic therapy due to lymph node involvement.

Conclusions

Patients with large kidney tumors should be treated in selected medical centers that have experience in the treatment of such cases. Radical nephrectomy has to be the method of choice in the treatment of patients with this kind of tumor and its diameter should not disqualify from surgical treatment, which is still the only chance for the patients to be cured, as no adjuvant chemotherapy treatment has proved to be significantly effective.

Collecting system invasion and Fuhrman grade but not tumor size facilitate prognostic stratification of patients with pT2 renal cell carcinoma

PURPOSE

The 7th edition of TNM for renal cell carcinoma introduced a subdivision of pT2 tumors at a 10 cm cutoff. In the present multicenter study the influence of tumor size as well as further clinical and histopathological parameters on cancer specific survival in patients with pT2 tumors was evaluated.

MATERIALS AND METHODS

A total of 670 consecutive patients with pT2 tumors (10.4%) of 6,442 surgically treated patients with all tumor stages were pooled (mean followup 71.4 months). Tumors were reclassified according to the current TNM classification, and subdivided in stages pT2a and pT2b. Cancer specific survival was analyzed using the Kaplan-Meier method, and univariable and multivariable analyses were used to assess the influence of several parameters on survival.

RESULTS

Tumor size continuously applied and subdivided at 10 cm or alternative cutoffs did not significantly influence cancer specific survival. In addition to N/M stage, Fuhrman grade and collecting system invasion also had an independent influence on survival. Integration of a dichotomous variable subsuming Fuhrman grade and collecting system invasion (grade 3/4 and/or collecting system invasion present vs grade 1/2 and collecting system invasion absent) into multivariate models including established prognostic parameters resulted in improvement of predictive abilities by 11% (HR 2.3, p <0.001) for all pT2 cases and 151% (HR 3.1, p <0.001) for stage pT2N0M0 cases.

CONCLUSIONS

Tumor size did not have a significant influence on cancer specific survival in pT2 tumors, neither continuously applied nor based on various cutoff values. To enhance prognostic discrimination, multifactorial staging systems including pathological features should be implemented. The prognostic relevance of the variable subsuming Fuhrman grade and collecting system invasion should be considered for future evaluation.

Unravelling the complexity of metastasis - molecular understanding and targeted therapies

Despite recognizing the devastating consequences of metastasis, we are not yet able to effectively treat cancer that has spread to vital organs. The inherent complexity of genomic alterations in late-stage cancers, coupled with numerous heterotypic interactions that occur between tumour and stromal cells, represent fundamental challenges in our quest to understand and control metastatic disease. The incorporation of genomic and other systems level approaches, as well as technological breakthroughs in imaging and animal modelling, have galvanized the effort to overcome gaps in our understanding of metastasis. Future research carries with it the potential to translate the wealth of new knowledge and conceptual advances into effective targeted therapies.

Lymphangitic metastasis of recurrent renal cell carcinoma to the contralateral lung causing lymphangitic carcinomatosis and respiratory symptoms

Renal cell carcinoma comprises 80%-85% of kidney malignancies. For early presentations, nephrectomy provides a high cure rate, but patients usually present at advanced stages, leading to poor outcomes. Even for patients without metastatic spread who undergo nephrectomy, metastatic recurrence is frequent. We report the case of a patient who underwent nephrectomy for stage iii renal cell carcinoma and who presented 20 months later with respiratory symptoms consistent with pneumonia, influenza, or (less likely) congestive heart failure or a cardiac event. Persistent right pleural effusion on serial chest radiographs despite treatment prompted computed tomography evaluation, which revealed lymphangitic carcinomatosis, a very rare form of renal cell carcinoma metastasis to the lung. This preliminary finding was confirmed by right middle lobe tissue biopsy through bronchoscopy and cytopathology examination.

Validation of the 2009 TNM version in a large multi-institutional cohort of patients treated for renal cell carcinoma: are further improvements needed?

BACKGROUND

A new edition of the TNM was recently released that includes modifications for the staging system of kidney cancers. Specifically, T2 cancers were subclassified into T2a and T2b (< or =10 cm vs >10 cm), tumors with renal vein involvement or perinephric fat involvement were classified as T3a cancers, and those with adrenal involvement were classified as T4 cancers.

OBJECTIVE

Our aim was to validate the recently released edition of the TNM staging system for primary tumor classification in kidney cancer.

DESIGN, SETTING, AND PARTICIPANTS

Our multicenter retrospective study consisted of 5339 patients treated in 16 academic Italian centers.

INTERVENTION

Patients underwent either radical or partial nephrectomy.

MEASUREMENTS

Univariable and multivariable Cox regression models addressed cancer-specific survival (CSS) after surgery.

RESULTS AND LIMITATIONS

In the study, 1897 patients (35.5%) were classified as pT1a, 1453 (27%) as pT1b, 437 (8%) as pT2a, 153 (3%) as pT2b, 1059 (20%) as pT3a, 117 (2%) as pT3b, 26 (0.5%) as pT3c, and 197 (4%) as pT4. At a median follow-up of 42 mo, 786 (15%) had died of disease. In univariable analysis, patients with pT2b and pT3a tumors had similar CSS, as did patients with pT3c and pT4 tumors. Moreover, both pT3a and pT3b stages included patients with heterogeneous outcomes. In multivariable analysis, the novel classification of the primary tumor was a powerful independent predictor of CSS (p for trend <0.0001). However, the substratification of pT1 tumors did not retain an independent predictive role. The major limitations of the study are retrospective design, lack of central pathologic review, and the small number of patients included in some substages.

CONCLUSIONS

The recently released seventh edition of the primary tumor staging system for kidney tumors is a powerful predictor of CSS. However, some of the substages identified by the classification have overlapping prognoses, and other substages include patients with heterogeneous outcomes. The few modifications included in this edition may have not resolved the most critical issues in the previous version.

Reassessing the current UICC/AJCC TNM staging for renal cell carcinoma

CONTEXT

The outcome prediction for renal cell cancer (RCC) remains controversial, and although many parameters have been tested for prognostic significance, only a few have achieved widespread acceptance in clinical practice. The TNM staging system defines local extension of the primary tumour (T), involvement of regional lymph nodes (N), and presence of distant metastases (M).

OBJECTIVE

This review focuses on reassessing the current TNM staging system for RCC.

EVIDENCE ACQUISITION

A literature search in English was performed using the National Library of Medicine database and the following keywords: renal cell cancer, kidney neoplasm, and staging. We scrutinized 1952 references, and 62 were selected for review based on their pertinence, study size, and overall contribution to the field.

EVIDENCE SYNTHESIS

The prognostic significance of tumour size for localized RCC has been investigated in a large number of studies. As a consequence, many modifications of the TNM staging system were primarily made to the size cut points between stage I and II tumours. The latest three revisions of the TNM system are systematically reviewed. For the heterogeneous group of locally advanced RCCs, involving different anatomic structures surrounding the kidney, the situation is still the subject of controversial scientific dispute. In detail, perirenal fat invasion, direct infiltration of the ipsilateral adrenal gland, invasion of the urinary collecting system, infiltration of renal sinus fat, and vena cava and renal vein thrombosis are disputed. Finally, staging of lymph node metastases and distant metastatic disease is discussed.

CONCLUSIONS

Special emphasis should be put on renal sinus invasion for stage evaluation. Retrospective studies relying on material collected at a time when no emphasis was placed on adequate sampling of the renal sinus should be treated with caution. In view of new treatment opportunities, the current TNM staging system of RCC and any other staging system must be dynamic.

Advances and controversies in grading and staging of renal cell carcinoma

Despite the considerable progress made in our understanding of the pathogenesis, genetics, and pathology of renal cell carcinoma (RCC), difficulties remain relating to the prediction of clinical outcome for individual cases. Although there is evidence to show that high-grade tumors have a poorer prognosis when compared to those of low grade, debate remains regarding the predictive value of grading, especially for those tumors classified into the intermediate grades. Numerous composite morphologic and nuclear grading systems have been proposed for RCC and although that of the Fuhrman classification have achieved widespread usage, the validity of the grading criteria of this classification has been questioned. In addition, there are few studies that have attempted to validate the Fuhrman system for RCCs beyond that of the clear cell subtype. Recent studies have indicated that grading of papillary RCC should be based on nucleolar prominence alone and that the components of the Fuhrman grading classification do not provide prognostic information for chromophobe RCC. Independent of tumor grade, the prognostic importance of tumor stage for RCC is well recognized. The Union Internationale Contre le Cancer/American Joint Committee for Cancer Staging and End Results Reporting TNM staging system is now in its sixth edition (2002) and recent refinements have focused on defining size cut points that will identify apparently localized tumors that will develop recurrence and/or metastases despite attempted curative surgery. In parallel with these studies it has been shown that infiltration of the renal sinus is an important prognostic factor, being observed in almost all tumors >7 cm in diameter. Questions remain as to the appropriate stratification of regional extension of RCC, as defined in the T3 tumor-staging category. Recent modifications to this category have been suggested combining the level of infiltration of the venous outflow tract with the presence or absence of infiltration of the adrenal gland and/or perirenal fat. Similarly, the utility of classifying lymph node involvement by tumor is debated, although it is well recognized that lymph node infiltration is associated with a poor prognosis. Although the current TNM classification does provide useful prognostic information it would appear that further modifications are justified to enhance the predictive value of staging for RCC.

The contemporary role of surgery in kidney cancer

The diagnosis and treatment of renal cell carcinoma (RCC) has been the subject of major changes since the late 1980s. Initially, surgery was the only treatment available, but more recently, systemic therapies have been developed, and their introduction has modified some of the surgical indications for rcc. In addition, refinements in surgical technique and the introduction of minimally invasive approaches have revolutionized patient care and bear the promise of even more improvements to come. This paper provides an up-to-date overview of recent developments in the surgical treatment of RCC.

Renal cell carcinoma: risk assessment and prognostic factors for newly diagnosed patients

Surgical management of renal cell carcinoma is the most effective treatment for patients with localized disease. In patients with advanced renal cell carcinoma, immune modulation-based therapies are typically used to improve cancer-specific survival. Similar to most cancers, tumor grade and stage are linked to the tumor's biologic potential. Integrating these factors with patients' performance status can help predict their long-term disease-free survival, the likelihood of tumor recurrence, and the median time to failure following surgery and immunotherapy. A novel integrated staging system and a postoperative renal cell carcinoma specific nomogram, along with standardized quality of life assessments have been shown to be useful clinical tools to aid in patient counseling, determining optimal follow-up imaging protocols, and identifying patients who might benefit from early enrollment in adjuvant therapy protocols. This article offers clinicians a review and summary of the most recent evidence-based research related to risk assessment among patients with newly diagnosed renal cell carcinoma.

Surgical management of large renal tumors

In addition to an increased occurrence of small, localized, incidentally discovered renal cell carcinomas (RCCs), there has been an upward trend in the incidence of advanced renal tumors per unit of population and in disease mortality worldwide. As radical nephrectomy remains the standard of care in treating localized RCC, this manuscript focuses on surgical approaches. We defined 'large renal tumors' as those greater than 7 cm or those with venous involvement. We discuss operative strategies in both open and laparoscopic surgery as well as approaches to special circumstances, including patients with tumor thrombus and the indications for nephron-sparing surgery in patients with greater than T2 RCC. The literature pertaining to controversial areas such as preoperative renal artery embolization and the clinical utility of metastectomy and cytoreductive therapy are also reviewed. The theoretical basis and potential applications of neoadjuvant therapy for larger renal tumors is examined as well.

Does Tumor Size or Microvascular Invasion Affect Prognosis in Patients with Renal Cell Carcinoma?

BACKGROUND

We retrospectively evaluated the effects of tumor size and microvascular tumor invasion on the clinical outcomes of patients who had undergone radical nephrectomy for renal cell carcinoma (RCC).

METHODS

One-hundred and sixty-two patients who received radical nephrectomy for localized or locally invasive RCC from 1989 to 2002 were included. We evaluated a new cut-off value for tumor size by dividing patients into groups by tumor diameter from 3.0 to 7.0 cm in 1.0 cm increments and compared the prognosis with that predicted by the 2002 TNM classification. We also re-classified localized microvascular tumor invasion as invasive disease.

RESULTS

Univariate analyses showed a 5.0 cm cut-off provided the greatest difference in recurrence (p = 0.004) and survival (p = 0.001). Microvascular invasion made no significant difference in tumor recurrence and tumor-specific survival. However, in the new categories used in this study, survival in the locally invasive group was poor compared with the localized group.

CONCLUSION

Our study showed that a tumor diameter of 5.0 cm might be the critical size to determine the prognosis of patients with localized RCC. Microvascular invasion seemed to have the necessity of re-evaluation in the TNM classification for patients with RCC.

Update on the epidemiology and biology of renal cortical neoplasms

A new era is developing in the understanding of the diagnosis, classification, and management of renal-cell carcinoma (RCC). Historically, RCC has been divided into subtypes on the basis of the histopathologic findings alone. Now, genetic alterations, nuclear characteristics, and clinical criteria are routinely incorporated into the classification. The greater use of axial imaging that began in the 1980s dramatically increased the incidence of RCC, but there has not been a decrease in the percentage of cases that are metastatic. Nevertheless, many incidental lesions prove to be benign, so there is renewed enthusiasm for biopsy before treatment is selected. Genetic conditions associated with RCC, such as Von Hippel Lindau and Birt-Hogg-Dube syndromes, along with genetic analyses of tumors, have provided considerable insight into the pathogenesis of these lesions. Renal-cell carcinoma is resistant to chemotherapy, and high-dose interleukin-2 is the only regimen currently approved by the Food and Drug Administration for the treatment of advanced RCC. Stem cell transplantation is an evolving therapy. The vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and transforming growth factor-alpha pathways are promising targets for medical therapy of RCC. Bevacizumab, a monoclonal antibody that acts as a competitive blocker of the VEGF receptor; sorafenib, an oral well-tolerated tyrosine kinase inhibitor that blocks the intracellular second-messenger system associated with the VEGF receptor; sunitinib, a multitarget inhibitor of kinases associated with the VEGF and PDGF receptors; temsirolimus (CCI-779), a kinase blocker that inhibits the mammalian target of rapamycin pathway; and erlotinib, an inhibitor of the tyrosine kinases associated with the EGF receptor, have shown promise. Combinations of the above therapies and cytokines also are being investigated, as there may be synergistic effects.

Evolving principles of surgical management and prognostic factors for outcome in renal cell carcinoma

The generally accepted principles for the surgical management of renal cell carcinoma (RCC) were first described more than 30 years ago. Since then, much has changed in the understanding of the basic biology and genetics of kidney cancer. Improvements in cross-sectional imaging has allowed for more accurate preoperative clinical staging of renal tumors, and the necessity of completing all the components of the radical nephrectomy have been questioned. Surgical techniques have also evolved, and technology has advanced to make possible new methods of managing renal tumors. The TNM staging system is currently the most extensively used system to provide prognostic information for RCC. However, data published in the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate and predictive prognostic factors. Furthermore, the recent discovery of molecular tumor markers are expected to revolutionize the staging of RCC and lead to the development of new therapies based on molecular targeting. This review will examine the evolving principles in the surgical management of RCC as well as provide an update on current staging modalities and prognostic factors.

[Survival analysis for localized renal cell carcinoma. Prognostic value of 1997 TNM classification]

BACKGROUND

The 5th edition of TNM classification for renal cell carcinoma changed the cut-off point of the tumor size for localized tumors, achieving a better distribution of patients with similar survival. Nevertheless, because of the variable evolution of renal cell carcinoma, the prognostic significance of tumor size is questioned as a staging criterion in organ-confined renal cell carcinoma. We analyse renal cell carcinoma specific survival and the prognostic significance of tumor size in I and II stage.

METHODS

We made a retrospective study with 158 renal cell carcinoma surgically treated in our hospital along 12 years. It was created a data base with clinical variables from patient and tumor and analyzed pathological staging, nuclear grade and specific survival, overall stage I and II.

RESULTS

27 renal cell carcinoma were pT1 (17.08%), 52 pT2 (32.91%), 45 pT, (28.45%), 10 pT3B (6.32%), y 24 pT4 (15.18%). The specific survival at 5 years for pT1-pT2, I-II stage, was 100% and 94% respectively, and no statistic significant differences were found between stage I and II (log-rank test 0.53, p>0.05). The specific survival at 5 years for pT3a, pT3B, y pT4 was 76.5%, 66.6% y 38.4%. There was a significant difference in survival in accordance with the tumor location, intrarenal (T1 y T2) versus extrarenal (T3A, T3B, T4) (log-rank test 9.06, p< 0.05). According to nuclear grade we don't find significant differences for pT1 y pT2 (Fisher test, p=1). Regarding the relation between pT stage and nuclear grade of the tumor we obtained a chi-square inear tendency of 38.19, p<0.001.

CONCLUSION

The differences in the evolution of the organ-confined renal cell carcinoma with respect to the tumor size may be due to other molecular and biological variables, probably associated with stage, not controlled in essays. The TNM classification for organ-confined renal cell carcinoma based in tumor size seems artificial. New revisions of the classification system are necessary to identify which organ-confined carcinoma will have unfavourable evolution and to include them in a different category.

Early renal cell cancer

Renal cell cancer (RCC) mostly arises from the proximal renal tubules and is classified as an adenocarcinoma. The most reliable treatment for RCC is surgical excision; chemotherapy or radiotherapy does not have a practical effect on RCC. In selected patients, immunotherapy, including cytokine administration, has survival benefits. There is no established definition of early RCC. Surgical removal of organ-confined disease (T1 and T2) is likely to achieve tumor-free status leading to good prognosis. Possible definitions, diagnosis and treatment options for T1 and T2 disease are discussed.

Proposal for revision of the TNM classification system for renal cell carcinoma

BACKGROUND

The current study defined an optimal tumor size breakpoint to stratify localized renal cell carcinoma (RCC) into groups with significantly different cancer-related outcomes and proposed a revision of the TNM classification system.

METHODS

The authors analyzed the data from 1138 patients who had undergone partial or radical nephrectomy for localized RCC at 7 European urologic centers. The optimal pathologic size breakpoint was calculated using the martingale residuals from a Cox proportional hazards regression model.

RESULTS

The mean follow-up time was 87 months. The scatterplot of tumor size versus expected risk of death per patient suggested that an interval of 5-6 cm was appropriate. A total of 720 (63.3%) and 418 (36.7%) patients had tumors measuring < or = 5.5-cm and tumors measuring > 5.5-cm, respectively. Significant cancer-specific survival differences between the two groups of patients were reported in the series by all the centers participating in the study. On univariate analysis, the other variables found to be associated with cancer-specific survival were the patient's age, symptomatic tumor presentation, and the Fuhrman nuclear grade. On multivariate analysis, the pathologic stage of the primary tumor defined according to the 5.5-cm breakpoint was found to be an independent predictor of cancer-specific survival, as well as age, mode of presentation, and nuclear grade. According to the multivariate analysis, the authors clustered patients into 3 groups with statistically significant outcome differences: 1) patients with < or = 5.5-cm incidentally detected RCC; 2) patients with < or = 5.5-cm symptomatic RCC; and 3) patients with > 5.5-cm RCC. This cancer-related outcome stratification was valid regardless of the patient's age.

CONCLUSIONS

The 5.5-cm breakpoint was found to be the optimal tumor size breakpoint with which to stratify patients with organ-confined RCC. The study supported the upgrade of the TNM classification system according to this breakpoint.

pT1 SUBSTAGING IN RENAL CELL CARCINOMA: VALIDATION OF THE 2002 TNM STAGING MODIFICATION OF MALIGNANT RENAL EPITHELIAL TUMORS

PURPOSE

Tumor size has been used as one of the criteria to stratify renal cell carcinoma (RCC) into different pathological stages (pT). The recent 2002 UICC/TNM classification of malignant epithelial renal tumors is modified to substratify pT1 RCC into pT1a (less than 4.0 cm) and pT1b (greater than 4.0 but less than 7.0 cm). In this study we ascertained if this stage modification has prognostic relevance.

MATERIALS AND METHODS

A total of 259 consecutive radical nephrectomy specimens of organ confined RCC from 1970 to 1997 at 1 institution, including 153 of conventional RCC (CRCC), 71 of papillary RCC, 28 of chromophobe RCC, 1 of collecting duct carcinoma and 6 of RCC not otherwise specified, with a mean clinical followup of 7.5 years (median 6.4) were included in the study.

RESULTS

There were 115 pT1a (44.4%), 95 pT1b (36.7%) and 49 pT2 tumors (18.9%). Disease recurrences (DR) and disease specific death occurred in 2 (1.7%) and 0 cases (0%) of pT1a, 7 (7.3%) and 5 (5.3%) of pT1b, and 16 (32.6%) and 12 (24.5%) of pT2. DR for pT1b was higher compared with pT1a (all histological subtypes RR 3.68), although this difference was not statistically significant (p = 0.106). If only CRCCs were analyzed, DR in the pT1b group was statistically higher compared with pT1a (RR 8.54, p = 0.047). Disease specific survival in pT1a could not be evaluated because no deaths occurred in this subgroup. DR and disease specific survival were significantly different between pT1b and pT2 tumors for all histological subtypes (RR 5.51, p = 0.001 and 5.49, p = 0.001) and for the CRCC subtype (RR 5.50, p = 0.001 and 5.18, p = 0.005, respectively). Using size as a continuous variable the logarithmic change in tumor size was a significant predictor of DR (RR 8.82, p = 0.001). All statistical analyses were adjusted for age and sex.

CONCLUSIONS

Substaging RCC into pT1a and pT1b yields prognostically important information, validating the 2002 TNM modification for malignant renal epithelial malignancies. The substratification of pT1 is particularly useful in tumors with CRCC histology.

The pT1a and pT1b category subdivision in renal cell carcinoma: is it reflected by differences in tumour biology?

OBJECTIVE

To assess systematically the possible differences in pathology between pT1a and pT1b renal cell carcinomas (RCCs), as the sixth edition of the Tumour-Nodes-Metastasis (TNM) system implemented a subdivision of category pT1 into pT1a (<4 cm) and pT1b (4-7 cm), based on clinical outcome analysis and the approach to therapy.

PATIENTS AND METHODS

Conventional histopathology and immunohistochemical expression of several biomarkers were analysed in 66 patients with pT1a and 29 with pT1b RCCs, using a tissue microarray technique.

RESULTS

After 2 years of follow-up, none of the 66 patients with pT1a and three of the 29 with pT1b tumours developed progressive disease. The tumour was grade 3 in four (6%) pT1a and 11 (38%) pT1b RCCs. Immunohistochemically, pT1a RCCs were characterized by strong expression of p27 (79%), bcl-2 (67%), MUC1 (87%), insulin-like growth factor (IGF)-I (71%) and CD10 (88%), as well as moderate expression of IGF-I receptor (43%) and low expression of epidermal growth factor receptor (EGFR, 20%). During progression to category pT1b, expression of p27 significantly decreased (54%) and EGFR expression increased (38%). Moreover, membranous staining patterns of MUC1 and CD10 changed from apical to circumferential in clear cell RCCs. p53 (pT1a 23%, pT1b 28%), E-cadherin (10% and 17%), MIB-1 (1.2% and 1.5%) and Skp2 (2% and none) expression seemed to be of minor importance.

CONCLUSION

This is the first study to show that the subdivision of category pT1 implemented in the latest issue of the TNM system is reflected by differences in conventional histopathology and expression of biomarkers.

Assessment of stage T1 (TNM 1997) for renal cell carcinoma: is recommended the subdivision in T1a and T1b?

INTRODUCTION

Classification TNM 1997 defines renal cell carcinoma smaller than 7 cm and confined to the kidney as stage T1. Our goal is to discuss if tumors smaller than 4 cm have the same behavior characteristics then tumors between 4 and 7 cm, to compose the same stage of the disease.

MATERIALS AND METHODS

Retrospective assessment of 138 patients in stage T1 (TNM - 97), divided into 2 groups; group-1: composed of 65 patients (47%) with tumors < 4 cm, and group-2: composed of 73 patients (53%) with tumors between 4 and 7 cm. The following prognostic factors were assessed in the recurrence of the disease and survival of patients: nuclear degree, microvascular invasion, sarcomatous degeneration, and involved lymph nodes. Statistical evaluation has been accomplished through the log rank test, chi-square test, and Fisher's exact text.

RESULTS

Average tumor size was 2.5 cm for group-1, and 5.3 cm for group-2. In group-2, there was the predominance of worse prognostic factors, with high-grade tumors (p = 0.01) and presence of microvascular invasion (p = 0.001). Sarcomatous tumors and involvement of lymph nodes did only happen in group-2. Disease-free survival for group-1, analyzed in the median period of 36 months, was 100%, and for group 2, in the median period of 31 months, was 81% (p = 0.008).

CONCLUSION

The results obtained allow the conclusion that the present stage T1 for renal cell carcinoma gathers tumors of different evolution, being therefore recommendable the stratification in T1a for tumors smaller than 4 cm, and T1b for tumors between 4 and 7 cm.

Multiinstitutional European validation of the 2002 TNM staging system in conventional and papillary localized renal cell carcinoma

BACKGROUND

The current study validated the 2002 edition of the TNM staging system in a multicenter, multinational European series of localized renal cell carcinoma (RCC).

METHODS

The authors analyzed the clinical data of 2217 patients who had undergone radical or partial nephrectomy for localized RCC in 7 urologic centers.

RESULTS

In the current study, 1065 patients (48%) were classified as having pT1a disease, 771 (34.8%) were classified as having pT1b disease, and 381 (17.2%) were classified as having pT2 disease. Tumor histotype was conventional RCC in 1886 patients (85%), papillary in 182 (8.2%) patients, chromophobe in 64 (2.9%) patients, and unclassified in 85 (3.8%) patients. The mean follow-up time was 65.36 +/- 52.09 months. The 5 and 10-year disease-specific survival probabilities were 95.3% and 91.4% in patients with pT1a disease, 91.4% and 83.4% in patients with pT1b disease, and 81.6% and 75.2% in patients with pT2 disease (log-rank test P value = 0.0000). The disease-specific survival rates of patients with pT1a RCC were significantly higher than those recorded in patients with pT1b and pT2 RCC. Similarly, the disease-specific survival probabilities of patients with pT1b RCC were significantly better than those of patients with pT2 RCC. Analyzing the seven series individually, the 2002 TNM staging system provided appropriate stratification for only one series. The 2002 TNM staging system allowed significant stratification of the cancer-related outcomes in the subgroup of patients with conventional RCC but not in those with papillary carcinomas.

CONCLUSIONS

The application of the 2002 TNM staging system in the current multicenter series enabled the authors to demonstrate optimal stratification of patients with localized RCC. Stratifying by tumor histotype, the data coming from the whole group analysis were reconfirmed for clear cell RCC only.

SYMPTOMS AS WELL AS TUMOR SIZE PROVIDE PROGNOSTIC INFORMATION ON PATIENTS WITH LOCALIZED RENAL TUMORS

PURPOSE

T stage stratification of organ confined renal tumors is based only on tumor size. Currently T1a and T1b are defined as tumors less or greater than 4 cm. However, to our knowledge the validity of this stratification has not been determined. We determined whether symptoms could add additional prognostic information when integrated with tumor size into the TNM classification.

MATERIALS AND METHODS

Patients with T1-T2N0M0 renal tumors at 6 academic centers in Europe and the United States were included in this study. T stage was defined according to the 2002 TNM classification. Age, gender, T stage, tumor size, symptoms at presentation, Fuhrman grade and cancer specific survival were determined in all cases. Survival estimates were compared using the Kaplan-Meier method and multivariate analysis of the data were performed with the Cox model.

RESULTS

A total of 1,771 patients with pT1-T2N0M0 renal tumors were included in this study. There were 1,148 males and 623 females. Mean age was 59.6 years. Median tumor size was 5 cm. Of the tumors 781 (44.1%), 616 (34.8%) and 374 (21.1%) were stages T1a, T1b and T2, respectively. In 825 patients (46.6%) symptoms were related to renal cancer. T stage and symptoms strongly correlated, in that 67%, 51% and 29% of patients with T1a, T1b and T2 tumors, respectively, were asymptomatic. Symptoms increased the risk of cause specific death for each T stage level. On multivariate analysis Fuhrman grade (HR 1.46), T stage (HR 1.81) and symptoms (HR 2.98) were independent predictors of survival. Based on these results 4 groups resulting from combinations of 2002 TNM stage and symptoms with significantly different risks of death were defined, namely 1) T1a-4 cm or less without symptoms, 2) T1b-4 cm or less with symptoms and greater than 4 cm without symptoms, 3) T2a-greater than 4 cm and 7 cm or less with symptoms, and 4) T2b-greater than 7 cm with symptoms

CONCLUSIONS

In this study we noted that a system combining tumor size and symptoms can accurately stratify patients for predicting survival in those with organ confined renal tumors. Our data support the idea that symptoms should be integrated in further modifications of the TNM system.

Neoplasm Staging and Organ-Confined Renal Cell Carcinoma: A Systematic Review

OBJECTIVES

Several TNM staging system editions were published over the years for renal cell carcinoma (RCC). Using a search strategy similar to the one used by the TNM process Subcommittee for "literature watch", we searched MEDLINE with the intent to critically analyze literature concerning the different TNM editions and the data regarding the optimal breakpoints to substratify localized RCC.

MATERIAL AND METHODS

The electronic search was conducted as follows: "Neoplasm staging" [MeSH] AND "Carcinoma, Renal Cell" [MeSH]. At the end of a process of abstract analysis performed separately by three of the authors, 34 papers were included in the systematic review.

RESULTS

All the 34 selected papers were retrospective studies. According to the 1987 version of TNM classification, no paper showed statistically significant cancer-specific survival probability differences between stage I and stage II RCC. According to the 1997 TNM version, the results were controversial. While a few papers found significantly different cancer-specific survival rates between stage I and stage II RCC, several others failed to do so. With the aim to stratify patients with localized RCC, most of the papers proposed an ideal breakpoint ranging from 4.5 to 5.5 cm.

CONCLUSION

This literature review highlighted that a correct definition of the staging of organ-confined RCC was far from being achieved and provided an appropriate synopsis of the available data for further update of the TNM staging system.

Application of TNM, 2002 version, in localized renal cell carcinoma: is it able to predict different cancer-specific survival probability?

OBJECTIVES

To verify whether the latest version of the TNM staging system (2002) could predict different cancer-specific survival in patients with localized renal cell carcinoma (RCC; Stage T1-T2N0M0).

METHODS

According to the 2002 TNM staging system, we reassigned the pathologic stage of 702 patients who had undergone surgical treatment for RCC from 1976 to 2000. We selected 491 patients with localized RCC (pT1-T2N0M0). In 334 patients (68.0%), we had performed radical nephrectomy; in 121 (24.6%), elective nephron-sparing surgery; and in 36 (7.3%), imperative nephron-sparing surgery. Cancer-specific survival was estimated according to the Kaplan-Meier method. The log-rank test and Cox's proportional hazard model was used for univariate and multivariate analysis, respectively.

RESULTS

Of the 491 tumors, 249 (50.7%) were classified as pT1a, 155 (31.6%) as pT1b, and 87 (17.7%) as pT2. The median follow-up was 75 months. The 5-year and 10-year cancer-specific survival probabilities were, respectively, 97.4% and 95.6% in the pT1a patients, 92.5% and 89.8% in the pT1b patients, and 89.3% and 78.5% in the pT2 patients. The survival curve comparison was statistically significant both between pT1a and pT1b (log-rank test, P = 0.01) and between pT1a and pT2 (log-rank test, P = 0.0007). No statistically significant difference was observed between the pT1b and pT2-specific survival probabilities (log-rank test, P = 0.42).

CONCLUSIONS

The 2002 TNM staging system does not seem able to predict different cancer-specific survival between pT1b and pT2 RCC. These data highlight the need to define an optimal breakpoint to stratify patients with localized RCC.

Low clinical stage renal cell carcinoma: relevance of microvascular tumor invasion as a prognostic parameter

PURPOSE

Renal cell carcinoma is a tumor with unpredictable behavior and defining reliable prognostic factors would be extremely valuable in the clinical setting. Tumor stage, nuclear grade and tumor cell type are the main prognostic clinical parameters available. In this study we evaluated the role of microvascular involvement in the primary lesion for predicting tumor behavior in patients with low stage clinical disease.

MATERIALS AND METHODS

A total of 95 patients with clinically localized renal cell carcinoma (stages T1-T2 Nx M0) underwent radical nephrectomy and/or nephron sparing surgery, and were followed for a median of 45 months. The impact of microvascular tumor invasion on disease progression and its correlation with known pathological outcomes (tumor size, nuclear grade and cell type) were studied.

RESULTS

Microvascular tumor invasion was observed in 24 patients (25%), of whom 50% had disease recurrence. Of the 71 patients without microvascular invasion only 4 (6%) showed tumor recurrence. When microvascular invasion was correlated with other histological parameters, a significant statistical association was noted with tumor diameter, perirenal fat invasion, macroscopic extension to the renal vein, nuclear grade, lymph node metastasis and sarcomatous elements in the tumor. Multivariate analysis showed that microvascular invasion and the involvement of regional lymph nodes were independent predictors of disease recurrence. Concerning cancer specific survival, microvascular invasion and perirenal fat infiltration were the only factors related to death.

CONCLUSIONS

Microvascular invasion is an independent and relevant clinical prognostic parameter for low clinical stage renal cell carcinoma.

Changing Concepts in the Surgical Management of Renal Cell Carcinoma

The foundations of the generally accepted principles underlying the surgical management of renal cell carcinoma (RCC) were best annunciated in 1969 by Robson in his classic description of the radical nephrectomy [J Urol 1969;101;297]. Since then, much has changed in our understanding of the basic biology and genetics of kidney cancer, advances in renal imaging and clinical staging have led to the increased detection of incidental, lower stage, organ-confined tumors more amendable to expanded surgical options, surgical techniques themselves have evolved, and surgical equipment technology has advanced to make possible new methods of managing renal tumors in situ. Thus, the management of both localized and metastatic RCC has changed dramatically in the last 20 years, predicated on these major advancements in renal imaging, surgical techniques, and the development of effective immunotherapies for advanced disease. In this review, the evolution in thinking regarding the tenets of the radical nephrectomy will be examined, including the necessity for removal of the entire kidney, the possibility of sparing the adrenal gland, when and how extensive a lymphadenectomy should be performed, the development of laparoscopic and percutaneous nephron-sparing surgery using ablative technologies, and the role of nephrectomy and metastasectomy in patients with metastatic RCC. Here, we review current concepts and outcomes on the surgical management of RCC to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

Tumor-size breakpoint for prognostic stratification of localized renal cell carcinoma

OBJECTIVES

To identify an optimal tumor-size breakpoint to distinguish between two groups with different prognoses in a large cohort of patients with localized renal cell carcinoma (RCC).

METHODS

We reviewed the clinical records of 813 patients who had undergone surgical treatment for localized RCC from 1976 to 2000. The optimal breakpoint for the pathologic size was calculated by receiver operating characteristic curve analysis.

RESULTS

The receiver operating characteristic curve analysis identified 5.5 cm as the optimal breakpoint to predict cancer-specific survival rates. The pathologic size was 5.5 cm or less in 565 neoplasms (69.5%) and more than 5.5 cm in 248 (30.5%). In the multivariate analysis, the more predictive model included the 5.5-cm-or-less pathologic size breakpoint. The pathologic size of 7 cm or less was not an independent variable in this cohort of patients.

CONCLUSIONS

In a large cohort of patients with localized RCC, 5.5 cm was the optimal breakpoint to classify patients with localized RCC into two subgroups with different prognoses; the 7-cm-or-less cutoff value was not an independent variable. The data obtained by analyzing a large cohort of consecutive patients should be validated by other large series with the prospective of redefining the TNM staging system.

Collecting system invasion in renal cell carcinoma: impact on prognosis and future staging strategies

PURPOSE

To define further the prognostic impact of urothelial invasion in renal cell carcinoma (RCC) we examined the outcome in patients presenting to our institution with kidney cancer treated with nephrectomy.

MATERIALS AND METHODS

We reviewed the medical records of 895 patients with RCC who were treated with nephrectomy between 1989 and 1999. Median followup was 31 months. Kaplan-Meier survival curves were constructed with respect to 1997 TNM stage, Fuhrman grade and University of California-Los Angeles Integrated Staging System stage, comparing patients with and without collecting system invasion. Univariate and multivariate analyses were performed. Overall survival was defined as time from nephrectomy to time of death or last followup.

RESULTS

Of the 895 patients 124 (14%) demonstrated collecting system invasion. Patients with collecting system invasion were more likely to be symptomatic and have associated metastases and/or positive nodes at diagnosis. Urothelial invasion was evident in 21 of 329 T1, 12 of 131 T2, 84 of 388 T3 and 7 of 47 T4 tumors. Three-year overall survival for patients with vs without collecting system invasion by stage was 67% vs 81% for T1, 60% vs 69% for T2, 31% vs 46% for T3 and 29% vs 12% for T4 disease. Patients with urothelial invasion incurred a significant increase in the likelihood of death and were at 1.4 times greater risk of death compared with patients without collecting system invasion.

CONCLUSIONS

Our findings suggest that collecting system invasion in RCC cases is associated with specific clinical findings as well as poor prognostic variables and it has a profound impact on prognosis in low stage tumors.

Current staging of renal cell carcinoma

Most (>80%) cancers involving the kidney are renal cell carcinoma (RCC). One third of patients diagnosed with kidney cancer have evidence of metastatic disease at the time of diagnosis, and as many as half of patients treated for localized disease eventually relapse. As is true for any other malignancy, one must determine which tumor features, patient factors, and laboratory techniques will provide diagnostic and prognostic information for patients with RCC. This article focuses on the history and rationale of the current staging systems for RCC as well as the potential for improvements by the addition of other clinical, pathologic, and molecular prognostic markers.

Prognostic factors of renal cell carcinoma

PURPOSE

Determination of prognostic factors is essential for the management of renal cell carcinoma. Stage, histological grade and type, and performance status are now well known and commonly used. During the last decade numerous predictors of patient outcome were tested. This review summarizes the most important studies, explores and compares the results, and tries to respond to the question, "Today, what do we expect of clinical, molecular and genetic factors concerning survival of patients with renal cell carcinoma?"

MATERIALS AND METHODS

Based on MEDLINE literature searches we comprehensively reviewed the literature on the prognostic factors associated with the tumor, the patient and the treatment.

RESULTS

During the last decades numerous factors have been studied but few of them maintained independent significance in terms of overall survival as assessed by multivariate analysis. Results are more often controversial from one series to another. No known molecular or cytogenetic tumor marker has been identified to help diagnose, manage or confirm renal cell carcinoma remission, progression or relapse.

CONCLUSIONS

The classical prognostic factors remain histological grade, histological type, performance status, patient age, number and location(s) of metastatic sites, time to appearance of metastases and prior nephrectomy. The only striking advancement during the last few years has been the proven contribution of radical nephrectomy for metastatic disease in patients with good performance status.