Selection of initial therapy for renal cell carcinoma

DCC protein expression in clear cell renal cell carcinoma

OBJECTIVES

To investigate whether the expression of protein from the "deleted in colorectal cancer" (DCC) gene, which predicts a poor outcome for patients with colorectal carcinoma, can also serve as a prognostic factor in renal cell carcinoma (RCC).

PATIENTS AND METHODS

The expression of DCC was evaluated immunohistochemically in 94 paraffin-embedded tumour samples from patients with stage T1, T2, and T3 clear cell RCC. The mean follow-up was 52.3 months. The endpoints of the study were recurrence of disease and death from disease.

RESULTS

The under-expression of DCC protein was detected in 63% of patients who died from the disease and in 36% with no evidence of disease. DCC protein under-expression was detected in all patients with T1 tumours who died from the disease, in half the T2 tumours and in two-thirds of T3 tumours.

CONCLUSION

DCC protein under-expression correlated with more aggressive tumour behaviour and a greater risk of death from RCC. However, a larger cohort of patients should be assessed before drawing definitive conclusions.

Staging Renal Cell Carcinoma With Helical CT: The Revised 1997 AJCC and UICC TNM Criteria

The TNM staging system for renal cell carcinoma, revised in 1997 by the UICC and AJCC, has important implications for tumor prognosis and surgical planning. Multislice helical CT of the kidneys plays a vital role in the detection, characterization, and staging of renal cell carcinoma, and for surgical planning. Radiologists should be familiar with state-of-the-art helical CT techniques, the revised TNM staging criteria, and the varied appearances of renal tumors, tumor cell types, and the wide variety of metastatic disease that occurs in advanced cases.

Significance of angiogenesis and microvascular invasion in renal cell carcinoma

The aim of this study is to evaluate the relationship between tumor angiogenesis and microvascular invasion, and the subsequent development of metastatic disease in patients undergoing surgery for renal cell carcinoma (RCC). The study group consisted of 102 patients who underwent surgery for RCC between the years 1990 and 1997 in our institute with a mean follow up period of 81.3 months. Paraffin blocks were stained for Factor VIII - related antigen and CD34 which decorate endothelial cells in order to assess angiogenesis and microvascular invasion and their relevance for developing metastatic disease. When Factor VIII- related antigen staining was used we found that the microvessel count correlated with the development of metastatic disease with a mean count of 49.7 for patients with no evidence of disease and a mean count of 95.5 for patients who developed metastatic disease (p<0.05). We also found that microvascular invasion correlated with the development of metastatic disease. It was demonstrated in 55.5% of patients who developed metastatic disease versus 23.8% of patients with no evidence of disease with Factor VIII staining (p<0.05), and in 33.3% and 7.1%, respectively (p<0.05) with CD34 staining. This study suggest that demonstration of intense angiogenesis and micro-vascular invasion may be a predictor of a more aggressive tumor mandating closer follow up and consideration of adjuvant therapy.

Comparison of preoperative embolization followed by radical nephrectomy with radical nephrectomy alone for renal cell carcinoma

A series of 474 patients with renal cell carcinoma (RCC), who had radical nephrectomy during a period of 15 years, was studied to assess the prognostic significance of various pathologic parameters (tumor stage [pT], lymph node status, metastasis, tumor grade, venous involvement) and value of preoperative embolization of renal artery. There were: 20 (4%) pT1, 204 (43%) pT2, 245 (52%) pT3, and 5 (1%) pT4 patients. All 474 patients underwent nephrectomy including a group of 118 (25%) patients (24 pT2, 90 pT3, and 4 pT4) who underwent preoperative embolization of the renal artery. To compare treatment outcomes in embolized patients with RCC, a group of 116 (24%) nonembolized patients with RCC was selected. This group was matched for sex, age, stage, tumor size, and tumor grade, with the embolized patients (p<0.01). All important prognostic factors were studied as to their influence on survival by the treatment group. The overall 5- and 10-year survival was 62% and 47%, respectively. The 5- and 10-year survival rates were significantly better (p<0.01) for patients with pT2 than for those with pT3 tumors (79% vs. 50% and 59% vs. 35%, respectively). Involvement of regional lymph nodes (N+) was an important prognostic factor for survival in patients with pT3 tumors. The 5-year survival for pT3 N+ was 39%, compared with 66% in those with pT3N0 (p<0.01). Preoperative embolization was also an important factor influencing survival. The overall 5- and 10-year survival for 118 patients embolized before nephrectomy was 62% and 47%, respectively, and it was 35% and 23%, respectively, for the matched group of 116 patients treated with surgery alone (p = 0.01). The most important finding of this study was an apparent importance of preoperative embolization in improving patients' survival. This finding needs to be interpreted with caution and confirmed in a prospective randomized trial.

Four new human renal cell carcinoma cell lines expressing globo-series gangliosides

Clinicopathological studies revealed that monosialosyl galactosyl globoside (MSGG) and disialosyl galactosyl globoside (DSGG) expressed by renal cell carcinoma (RCC) are one of the biochemical indicator related to the metastatic potential. The present study examines the characteristics of four new human RCC cell lines and compares the expression of MSGG and DSGG among them using TLC immunostaining and flow cytometry. TOS-1 and TOS-2 were derived from metastatic subcutaneous tissues. TOS-3 and TOS-3LN were derived from the primary lesion and from metastatic lymph nodes respectively. Monolayer culture, light microscopy and electron microscopy of these cells showed that these cell lines were derived from RCC. TLC immunostaining and flow cytometric analysis revealed increased levels of MSGG in TOS-2 and TOS-3LN, and increased DSGG in TOS-1 and TOS-3LN. These cell lines would be useful for functional studies of globo-series ganglioside expressed by RCC.

Renal neoplasms amenable to partial nephrectomy: MR imaging

PURPOSE

To determine the magnetic resonance (MR) imaging characteristics of renal lesions in patients who undergo technically successful partial nephrectomy.

MATERIALS AND METHODS

Between February 1991 and September 1997, 38 patients (41 lesions) who underwent partial nephrectomy at a single institution were preoperatively evaluated with contrast material-enhanced, multiplanar, surface-coil MR imaging. Imaging findings that could affect the decision to perform partial nephrectomy were retrospectively evaluated: tumor size; tumor location; presence of pseudocapsule; suspected tumor invasion of renal sinus fat, renal collecting system, renal vein, or perinephric fat; and morphologic and physiologic status of the contralateral kidney. Correlation was made with surgical and pathologic findings.

RESULTS

Thirty-three of 41 lesions (80%) were renal cell carcinomas, five were oncocytic neoplasms (12%), two were hemorrhagic cysts (5%), and one was an angiomyolipoma (2%). Twenty-four of 41 (59%) lesions had pseudocapsules. In most cases, the perinephric fat (n = 38 [93%]), the renal sinus fat (n = 31 [76%]), and the renal collecting system (n = 39 [95%]) were correctly interpreted as being uninvolved by tumor.

CONCLUSION

Renal neoplasms amenable to partial nephrectomy can be identified and characterized with contrast-enhanced, multiplanar, surface-coil MR imaging.

Renal parenchyma-sparing surgery in carcinoma

BACKGROUND

There is controversy regarding the role of renal-sparing surgery in patients with kidney cancer who have a functioning contralateral kidney.

METHODS

The present study aimed to review the recent experience of renal-sparing surgery at Royal Prince Alfred Hospital (RPAH), Sydney. Eighteen consecutive patients undergoing conservative surgery for kidney tumours at RPAH between February 1987 and January 1995, were reviewed. Eleven patients had imperative indications for conservative surgery and the remaining seven patients had elective indications. Ten patients had modified enucleation with a margin of normal parenchyma. Six patients underwent partial nephrectomy and two had wedge resections. Patients were followed up at 1, 6 and 12 months, and thence every 6-12 months. Follow-up ranged from 9 to 104 months (mean: 46.2 months, median: 48 months).

RESULTS

Sixteen of the 18 patients were still alive at the end of the follow-up (October 1995), with no clinical evidence of local or distant metastasis. The two deaths were not related to the fact that these patients had conservative surgery. The average tumour dimensions were 43 mm x 49 mm, with an average volume of 194 mm3. All resections were complete, with margins ranging between 1.0 and 20.0 mm (mean: 8.7 mm). The survival rate in the present study is comparable to those found by other researchers.

CONCLUSIONS

Conservative surgery is indicated in renal tumours where radical surgery would render the patient anephric. Conservative surgery, however, is controversial in a patient with a normal contralateral kidney. The present study has shown that renal parenchyma-preserving surgery for localized tumours provides a feasible treatment option.

Imaging approach to staging of renal cell carcinoma

Current imaging techniques, especially CT and MR imaging, make accurate preoperative staging of renal cell carcinoma possible. Because surgery provides the only effective therapy and because survival depends on local and distant extent, precise staging is critical for preoperative planning and prognosis. This article reviews the advantages, limitations, accuracy, and pitfalls of each of the imaging approaches to staging renal cell carcinoma, concentrating on CT and MR imaging. This information then is summarized in a suggested overall approach to staging renal cell carcinoma.

Resection of hypernephromas with vena caval or right atrial tumor extension using extracorporeal circulation and deep hypothermic circulatory arrest: a multidisciplinary approach

OBJECTIVE

Among retroperitoneal tumors, renal cell carcinoma most often invades the retrohepatic inferior vena cava or the right atrium. Even in these cases, radical nephrectomy may be performed with curative intention. The aim of this retrospective study was to elucidate the impact of cardiopulmonary bypass and hypothermic circulatory arrest on surgical complications, primary mortality, and long-term survival.

PATIENTS AND METHODS

From Jan. 1981 till Aug. 1996, 44 patients were operated upon for renal cell carcinoma with advanced vena caval extension. The patients were divided into two groups. In 19 cases (Cardiopulmonary Bypass Group), extracorporeal circulation and deep hypothermic circulatory arrest was used. The Conventional Technique Group comprised 25 patients who had radical nephrectomy, paraaortic lymphadenectomy and extirpation of the intracaval tumor thrombus applying common principles in vascular surgery. The median age was 59 years with a range from 42 to 78 years in the Cardiopulmonary Bypass Group, and 60 years, ranging from 22 to 72 years, in the Conventional Technique Group. In addition, both groups did not differ in gender, UICC TNMG staging classification, and perioperative risk factors. A review of the patient charts was done and surveys were sent to survivors or nearest of kin. Wilcoxon test and log-rank test were used as appropriate.

RESULTS

A lower intraoperative complication rate was found in patients who had surgery using cardiopulmonary bypass. This was especially true with embolization of the tumor thrombus into the pulmonary arteries: 0.0% in Cardiopulmonary Bypass Group and 16.0% in Conventional Technique Group (P < 0.05). Severe hemorrhage occurred in 10.5% (Cardiopulmonary Bypass Group) and 16.0% (Conventional Technique Group). This translated into a significantly lower perioperative mortality in the Cardiopulmonary Bypass Group when compared to the Conventional Technique Group (5.6 and 16.0%, respectively). In spite of these results, differences in long-term survival did not reach statistical significance. But, a trend to superior long-term survival was apparent. The mean survival was 1289 +/- 278 days in the Cardiopulmonary Bypass Group and 746 +/- 166 days in the Conventional Technique Group.

CONCLUSIONS

Due to acceptable long-term results, the resection of hypernephromas showing extensive vena caval invasion seems to be justified. The use of cardiopulmonary bypass and hypothermic circulatory arrest is able to decrease primary morbidity and mortality. However, the influence on long-term survival remains to be proven.

Report of 337 patients with renal cell carcinoma emphasizing 110 with stage IV disease and review of the literature

BACKGROUND

In the literature, the interdependence of variables, including stage, sex, age, tumor size, therapy, and survival, is complex. The size variable has heretofore received relatively little emphasis.

METHOD

This was a retrospective evaluation of 337 patients with kidney cancer treated at the University of Illinois Affiliated Hospitals. Data were collected on stage, sex, age, tumor size, TNM stage, therapy, and survival. Statistical analyses included Kaplan-Meier 5-year survivals, as well as multivariate analysis utilizing the Cox regression model. A subset of 110 patients with TNM Stage IV disease is further evaluated employing a multivariate analysis. The principal form of therapy was nephrectomy.

RESULT

Five-year survivals by stage varied from 100% for Stage I, 96% for Stage II, 59% for Stage III, to 16% for Stage IV. In the subset of 110 patients with TNM Stage IV disease, those with a single metastasis had better survivals than those with two or more. Those having nephrectomy had better survivals (P < 0.05). Therapy (in addition to nephrectomy) was curative (defined as cytotoxic chemotherapy or immunotherapy) in 40 patients and palliative (defined as radiation to bone metastases, hormone therapy, or supportive) in 70 patients. Multivariate analysis of TNM Stage IV variable differences indicated that only tumor size differences and nephrectomy significantly affected survival.

CONCLUSIONS

Of importance is the observation that among these patients. Survival is directly correlated with tumor size.

Renal parenchyma-sparing surgery as conservative treatment of renal cell carcinoma

OBJECTIVE

To evaluate the role of parenchyma-sparing surgery in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Between 1965 and 1990, 34 patients with RCC underwent renal parenchyma-sparing surgery. There were 22 men and 12 women with a mean age of 62 years (range 40-89). Ten patients underwent enucleation (Group A), 15 partial nephrectomy (Group B), and nine a combination of procedures (Group C). Conservative surgery was performed in the presence of a normal contralateral unit in four patients (12%).

RESULTS

Five patients developed local recurrence. Metastases appeared in six patients (18%) from 12 to 58 months post-operatively. Adequate renal function was obtained in 32 of the 34 patients. The mean follow-up for all patients was 64.6 months overall, 75.6 months for group A, 64.1 months for group B and 53.4 months for group C. The 3 and 5 year probabilities of survival for all patients were 77.8% and 69.5% respectively. The probabilities of 3 and 5 year survival were 80% for group A, 80% for group B and 71.4% and 57.1% for group C.

CONCLUSION

Enucleation and partial nephrectomy are both viable options in the management of solitary or bilateral RCC, as there is no decline in effective tumour control and prognosis. Larger groups and longer follow-ups are needed to assess the role of renal parenchyma-sparing surgery more definitively.

Transverse "S" laparotomy for radical nephrectomy and upper retroperitoneal access

A modified transverse laparotomy is described that allows for safe removal of bulky kidney or adrenal tumors and suprarenal hilar lesions in cases of metastatic testicular cancer. The full exposure of the upper retroperitoneal area provided by this access obviates the need for a thoracoabdominal incision with its attendant drawbacks. Our experience with the transverse S laparotomy in more than 80 patients with large renal or retroperitoneal tumors confirmed the wide local exposure obtained, short hospital stay and absence of pulmonary complications that can occur after the thoracoabdominal approach.

A phase I/II study of alternating constant rate infusion floxuridine with constant rate infusion vinblastine for the treatment of metastatic renal cell carcinoma

BACKGROUND

Metastatic renal cell carcinoma (RCC) is largely chemoresistant. The efficacy of cell cycle specific chemotherapeutic agents, particularly those with short half-lives, may be enhanced by the use of constant rate infusion schedules. Infusional floxuridine has been demonstrated to have a response rate of approximately 20%. Infusional vinblastine has not been tested extensively in patients with metastatic RCC. The sequential use of these agents was designed to increase efficacy and limit toxicity.

METHODS

Fifteen patients with metastatic RCC were treated with constant rate infusion floxuridine, 0.075 mg/kg/day for 14 days, followed by a constant rate infusion of vinblastine, 0.7 mg/m2/day for 14 days. The cycle repeated every 28 days and floxuridine and vinblastine doses were incrementally increased until the maximum tolerated dose (MTD) for each patient was reached.

RESULTS

Four patients had partial responses (27%), which were maintained for 3, 9, 16 and 19+ months, whereas five patients had stable disease for 3-15 months. Median survival from initiation of therapy was 379 days. Three of four responses occurred in nonpulmonary locations, and all responses occurred in patients who had a prior nephrectomy. MTD for floxuridine was 0.1 mg/kg/day and for vinblastine, 0.7 mg/m2/day. Toxic reaction to floxuridine was limited to diarrhea, whereas the principle dose-limiting toxic reaction for vinblastine was neutropenia. Catheter-related complications were also observed.

CONCLUSIONS

Alternating constant rate infusion floxuridine and constant rate infusion vinblastine is active in the treatment of metastatic RCC. Whether this regimen is superior to infusional floxuridine is undetermined. Although the toxicity associated with this regimen is manageable, it appears to be more severe than that reported with infusional floxuridine alone.

Ultrasound characteristics of renal cryosurgery

The ability to visualize renal cryosurgery using ultrasound was tested in an animal model. Five dogs underwent open laparotomy and ultrasound-monitored cryosurgery of both kidneys. On each kidney two cryolesions were made. The borders of the frozen region were identified on ultrasound as a hyperechoic rim created by the interface between frozen and unfrozen tissue. The thawed cryolesion appeared hyperechoic compared with the unfrozen kidney. Excellent correlation between the ultrasound and autopsy measurements of the cryolesions was obtained. Knowing this, renal cryosurgery under ultrasound monitoring may be possible.

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.

The value of postoperative irradiation in renal cell cancer

This is a retrospective analysis of 147 evaluable patients, with histologically proven renal cell carcinoma, who were referred to our center between 1977 through 1988. All patients with disease limited to the kidney underwent nephrectomy. Post-operative megavoltage irradiation, with a median dose of 46 Gy, was given to 56 patients, using parallel opposing portals, or multiple field technique. Five and 10 year actuarial survivals in irradiated patients (Rt+) were 50 and 44%, respectively, and in non-irradiated patients (Rt-) 40 and 32%, respectively. The disease recurred locally in a total of 19 patients; 16 had tumor bed recurrence and three had scar recurrence. Local recurrence by stage was as follows: T2 N0M0: RT+ 0/17, RT- 2/28; T3 N0M0: RT+ 4/37 (10%), RT- 11/30 (37%) (p less than 0.05); T4 N0M0: RT+ 1/2, RT- 1/5. Two of the local recurrences in irradiated patients developed in a surgical scar which was not included in the treatment volume. Significant toxicity developed in three patients (5%). It is concluded that post-operative irradiation can reduce local recurrence rate in T3 N0M0 renal cell carcinoma. It is recommended that the surgical scar should always be included in the treatment volume and irradiated to a full dose.

Value of serum alkaline phosphatase and radionuclide bone scans in patients with renal cell carcinoma

Ninety-one patients who underwent radical nephrectomy for renal cell carcinoma (RCC) were reviewed to determine the prognostic value of serum alkaline phosphatase (SAP) levels and radionuclide bone scan. A preoperative SAP greater than 127 IU/L was a strong indicator of eventual disease progression or death, and an elevated SAP was a better predictor of eventual outcome than bone scan.

Differential sensitivity of renal cell carcinoma xenografts towards therapy with interferon-alpha, interferon-gamma, tumor necrosis factor and their combinations

Whereas cytokine therapy has proven efficacy in the treatment of metastatic renal cell carcinoma (RCC), many questions regarding the use of these drugs remain unanswered. In the present study we evaluated the antiproliferative effects of human recombinant alpha-interferon (IFN), gamma-interferon and tumor necrosis factor-alpha (TNF) on eight human RCC xenografts. In particular, the importance of the administration route, dosage and tumor load was investigated. Response to the cytokines differed widely amongst the different tumors. Of three tested routes of administration (i.v., i.p. and s.c. peritumoral), only the s.c. peritumoral route was effective against tumor growth. After 6 weeks of therapy consisting of 150 or 1,500 units IFN/g given s.c. peritumorally three times a week or 30,000 units TNF/g given five times a week, alpha-IFN treatment resulted in 2%-100% growth inhibition; gamma-IFN, in 7%-80%; and TNF, in 35%-75% as compared with the untreated control. Growth of five of eight tumor lines could be inhibited completely by combinations of IFN and TNF, whereby the tumor dimensions at the beginning of therapy were decisive for the results. In some cases IFNs had optimal doses; however, the antitumor effects of TNF were always dose-dependent. Our studies indicate that the doses at which the optimal direct effects of cytokines are measured are critically dependent on the tumor treated. Although direct effects are only one part of the mode of action of cytokines, our results indicate that dosage of cytokines may need individualisation.