Using percentage of sarcomatoid differentiation as a prognostic factor in renal cell carcinoma

Is there a minimum percentage of sarcomatoid component required to affect outcomes of localised renal cell carcinoma?

OBJECTIVE

To evaluate and compare the outcomes of patients with localised renal cell carcinoma (RCC) with and without sarcomatoid features and the impact of this on cancer recurrence and survival.

MATERIAL AND METHODS

The Canadian Kidney Cancer information system database was used to identify patients diagnosed with localised RCC between January 2011 and December 2022. Patients with pT1-T3, n Nx-N0N1, M0 stage and documented sarcomatoid status were included. Patients with sarcomatoid RCC were categorised according to the sarcomatoid component percentage (%Sarc). Inverse probability of treatment weighting scores were used to balance the groups. Cox proportional hazards models were used to assess the impact of sarcomatoid status and %Sarc on recurrence-free and overall survival.

RESULTS

A total of 6660 patients (201 with and 6459 without sarcomatoid features) with non-metastatic RCC were included. %Sarc data were available in 155 patients, and the median value was 10%. The weighted analysis revealed that the presence of sarcomatoid features was associated with an increased risk of developing metastasis and increased risk of mortality compared to absence of sarcomatoid features. A %Sarc value >10 was associated with an increased risk of developing metastasis and of mortality compared to a %Sarc value ≤10.

CONCLUSIONS

Patients with a %Sarc >10 have an increased risk of recurrence and mortality. These patients may benefit from a more stringent follow-up and %Sarc could represent an important criterion in the risk assessment for adjuvant therapy.

Clinical features and response to immune combinations in patients with renal cell carcinoma and sarcomatoid de-differentiation (ARON-1 study)

Metastatic renal cell carcinoma (mRCC) carrying sarcomatoid features (sRCC) has aggressive biology and poor prognosis. First-line immunotherapy (IO)-based combinations have improved the outcome of clear cell RCC patients, including that of sRCC. Real-world data confirming the adequate first-line management of sRCC is largely lacking. We investigated the clinical features and the outcome of sRCC patients treated with IO-based combinations within the ARON-1 study population (NCT05287464). The primary objective was to define the incidence and baseline clinical characteristics of sRCC compared with non-sRCC patients. The secondary objective was to describe the outcome of sRCC patients based on type of first-line treatment (IO + IO vs. IO + tyrosin kinase inhibitor [TKI]). We identified 1362 mRCC patients with IMDC intermediate or poor risk, 226 sRCC and 1136 non-sRCC. These two subgroups did not differ in terms of baseline characteristics. The median overall survival (OS) was 26.8 months (95%CI 21.6-44.2) in sRCC and 35.3 months (95%CI 30.2-40.4) in non-sRCC patients (p = .013). The median progression-free survival (PFS) was longer in non-sRCC patients compared to sRCC (14.5 vs. 12.3 months, p = .064). In patients treated with first-line IO + TKI the median OS was 34.4 months compared to 26.4 months of those who received IO + IO (p = .729). The median PFS was 12.4 months with IO + TKI and 12.3 months with IO + IO (p = .606). In conclusion, we confirm that sRCC are aggressive tumors with poor prognosis. IO-based combinations improve survival outcomes of sRCC patients, regardless from the type of strategy (IO + IO versus IO + TKI) adopted.

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Immunotherapy treatment for sarcomatoid renal cell carcinoma: case report and literature review

Introduction

Sarcomatoid renal cell carcinoma (SRCC) is clinically rare, accounting for ~1.0-1.5% of renal parenchymal tumors. Although the concept of SRCC was proposed in 1968, the molecular mechanisms and immunological characteristics of sarcomatoid changes remain unclear. In the era of targeted therapy, the overall survival (OS) of patients with SRCC is typically less than 12 months.

Case presentation

This article reports a case of SRCC in an 81-year-old male. Progression-free survival (PFS) was as long as 25 months and OS was 30 months after immunotherapy and the effect was significant. This is the first report of successful use toripalimab in the treatment of SRCC.

Clinical discussion

SRCC is a rare type of renal cancer with no obvious specific clinical manifestations or imaging findings, and the diagnosis of the disease is based on pathological examinations. SRCC has a high degree of malignancy, progresses rapidly, and has a poor prognosis. The effect of traditional treatment is limited, and immune checkpoint inhibitors may have therapeutic potential.

Conclusions

Toripalimab may be effective and further exploration is anticipated to advance a new period of SRCC.

Sarcomatoid Dedifferentiation as a Predictor of Cancer-Specific Mortality in Surgically Treated Localized Renal Cell Carcinoma

BACKGROUND

In contemporary surgically treated patients with localized high-grade (G3 or G4) clear-cell renal cell carcinoma (ccRCC), it is not known whether presence of sarcomatoid dedifferentiation is an independent predictor and/or an effect modifier, when cancer-specific mortality (CSM) represents an endpoint.

METHODS

Within the Surveillance, Epidemiology, and End Results database, all surgically treated localized high-grade ccRCC patients treated between 2010 and 2020 were identified. Univariable and multivariable Cox-regression models were used.

RESULTS

In 18,853 surgically treated localized high-grade (G3 or G4) ccRCC patients, 5-year CSM-free survival was 87% (62% vs. 88% with vs. without sarcomatoid dedifferentiation, p < 0.001). Presence of sarcomatoid dedifferentiation was an independent predictor of higher CSM (hazard ratio [HR] 1.8, p < 0.001). In univariable survival analyses predicting CSM, presence versus absence of sarcomatoid dedifferentiation in G3 versus G4 yielded the following hazard ratios: HR 1.0 in absent sarcomatoid dedifferentiation in G3; HR 2.7 (p < 0.001) in absent sarcomatoid dedifferentiation in G4; HR 3.9 (p < 0.001) in present sarcomatoid dedifferentiation in G3; HR 5.1 (p < 0.001) in present sarcomatoid dedifferentiation in G4. Finally, in multivariable Cox-regression analyses, the interaction terms defining present versus absent sarcomatoid dedifferentiation in G3 versus G4 represented independent predictors of higher CSM.

CONCLUSIONS

In contemporary surgically treated patients with localized high-grade ccRCC, sarcomatoid dedifferentiation is not only an independent multivariable predictor of higher CSM, but also interacts with tumor grade and results in even better ability to predict CSM.

Sarcomatoid and Rhabdoid Renal Cell Carcinoma: Clinical, Pathologic, and Molecular Genetic Features

Renal cell carcinoma (RCC) with sarcomatoid and rhabdoid morphologies has an aggressive biological behavior and a typically poor prognosis. The current 2022 WHO classification of renal tumors does not include them as distinct histologic entities but rather as transformational changes that may arise in a background of various distinct histologic types of RCC. The sarcomatoid component shows malignant spindle cells that may grow as intersecting fascicles, which is reminiscent of pleomorphic undifferentiated sarcoma. The rhabdoid cells are epithelioid cells with eccentrically located vesicular nuclei with prominent nucleoli and large intracytoplasmic eosinophilic inclusions. Studies have shown that RCCs with sarcomatoid and rhabdoid differentiation have distinctive molecular features. Sarcomatoid RCC harbors shared genomic alterations in carcinomatous and rhabdoid components, but also enrichment of specific genomic alterations in the sarcomatoid element, suggesting molecular pathways for development of sarcomatoid growth from a common clonal ancestor. Rhabdoid differentiation also arises through clonal evolution although less is known of specific genomic alterations in rhabdoid cells. Historically, treatment has lacked efficacy, although recently immunotherapy with PD-1/PD-L1/CTLA-4 inhibitors has produced significant clinical responses. Reporting of sarcomatoid and rhabdoid features in renal cell carcinoma is required by the College of American Pathologists and the International Collaboration on Cancer Reporting. This manuscript reviews the clinical, pathologic, and molecular features of sarcomatoid RCC and rhabdoid RCC with emphasis on the morphologic features of these tumors, significance of diagnostic recognition, the molecular mechanisms of tumorigenesis and differentiation along sarcomatoid and rhabdoid lines, and advances in treatment, particularly immunotherapy.

Special populations in metastatic renal cell carcinoma

PURPOSE OF REVIEW

This review focuses on special populations poorly represented in current evidence-based practice for metastatic renal cell carcinoma (mRCC). This includes the elderly and frail, patients on immunosuppression or with autoimmune diseases, patients with brain, liver, and/or bone metastases, and RCC with sarcomatoid features.

RECENT FINDINGS

Certain populations are poorly represented in current trials for mRCC. Patients with central nervous system (CNS) metastases are often excluded from first-line therapy trials. Modern doublet systemic therapy appears to benefit patients with bone or liver metastases, but data supporting this conclusion is not robust. Post-hoc analyses on patients with sarcomatoid differentiation have shown improved response to modern doublet therapy over historical treatments. The elderly are underrepresented in current clinical trials, and most trials exclude all but high-performing (nonfrail) patients, though true frailty is likely poorly captured using the current widely adopted indices. It is difficult to make conclusions about the efficacy of modern therapy in these populations from subgroup analyses. Data from trials on other malignancies in patients with autoimmune diseases or solid organ transplant recipients on immunosuppression suggest that immune checkpoint inhibitors (ICIs) may still have benefit, though at the risk of disease flare or organ rejection. The efficacy of ICIs has not been demonstrated specifically for RCC in this group of patients.

SUMMARY

The elderly, frail, and immunosuppressed, those with tumors having aggressive histologic features, and patients with brain, bone, and/or liver metastases represent the populations least understood in the modern era of RCC treatment.

Demographic Patterns and Clinicopathological Analysis of Sarcomatoid Renal Cell Carcinoma in US Population

BACKGROUND

Sarcomatoid renal cell carcinoma (RCC) is defined by the presence of any amount of sarcomatoid components admixed with other RCC histologic subtypes. Our investigation utilizes a large, diverse set of sarcomatoid RCC patients to summarize clinical, demographic, and pathological factors along with demographic disparities that may affect the prognosis and survival of sarcomatoid RCC patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was employed to compile data from 2000 to 2018 from 2695 patients diagnosed with sarcomatoid RCC.

RESULTS

The mean age for sarcomatoid RCC diagnosis is 62.8 years. Males (68.2%) and White patients (82.6%) were more likely to be diagnosed with sarcomatoid RCC. Among the 64.4% of tumors with known size, 35.4% were less than 7 cm, 27.6% were 7.1 to 10 cm, and 36.4% were larger than 10 cm. Among the 95.8% of patients with known stage, 15.3% were localized, 28.9% were regionalized, and 55.8% were found in distant sites. Among the 44.2% of cases with known metastases site, lung was found to be the most common metastatic site.. Surgery was the most common treatment (70.9%). While the overall 5-year survival was 18.1%, it was 27.1% among patients who underwent surgery. Independent risk factors for mortality include age > 60 years, distant stage, and tumor size > 10 cm, per our multivariate analysis.

CONCLUSION

Sarcomatoid RCC most commonly affects White males in their seventh decade. Increased age, distant stage, and size > 10 cm tumor size have associations with unfavorable prognosis. Surgery is associated with better survival outcomes in localized disease and multimodal therapy (surgery with adjuvant chemoradiation was associated with better survival.).

The association between PD-1 / PD-L1 expression and clinicopathological features in sarcomatoid renal cell carcinoma

BACKGROUND

Sarcomatoid renal cell carcinoma (sRCC) accounts for about 4%-5% of all kidney cancers. Previous studies showed that PD-1 and PD-L1 expression was higher in sRCC compared to non-sRCC. In the present study, we aimed to investigate PD-1/PD-L1 expression and its association with clinicopathological features in sRCC.

METHODS

The study included 59 patients diagnosed with sRCC between January 2012 and January 2022. The expression of PD-1 and PD-L1 in sRCC was detected by immunohistochemical staining, and its correlation with clinicopathological parameters was analyzed by χ2 test and Fisher exact test. Kaplan-Meier curves and log-rank tests were used to describe the overall survival (OS). The prognostic significance of clinicopathological parameters on OS was assessed by Cox proportional hazards regression analysis.

RESULTS

Among the 59 cases, the positive expression of PD-1 and PD-L1 was 34 cases (57.6%) and 37 cases (62.7%), respectively. PD-1 expression was not significantly correlated with any parameters. However, PD-L1 expression was significantly correlated with tumor size and pathologic T stage. OS was shorter in the subgroup of patients with PD-L1-positive sRCC compared with the PD-L1-negative subgroup. There was no statistically significant difference in OS between PD-1-positive and negative subgroups. According to our study, the univariate and multivariate analysis indicated that pathological T3 and T4 was an independent risk factor in PD-1-positive sRCC.

CONCLUSION

We studied the relationship between PD-1/PD-L1 expression and clinicopathological characteristics in sRCC. The findings may provide valuable implications for clinical prediction.

Sarcomatoid renal cell carcinoma: MRI features and their association with survival

OBJECTIVE

To evaluate MRI features of sarcomatoid renal cell carcinoma (RCC) and their association with survival.

METHODS

This retrospective single-center study included 59 patients with sarcomatoid RCC who underwent MRI before nephrectomy during July 2003-December 2019. Three radiologists reviewed MRI findings of tumor size, non-enhancing areas, lymphadenopathy, and volume (and percentage) of T2 low signal intensity areas (T2LIA). Clinicopathological factors of age, gender, ethnicity, baseline metastatic status, pathological details (subtype and extent of sarcomatoid differentiation), treatment type, and follow-up were extracted. Survival was estimated using Kaplan-Meier method and Cox proportional-hazards regression model was used to identify factors associated with survival.

RESULTS

Forty-one males and eighteen females (median age 62 years; interquartile range 51-68) were included. T2LIAs were present in 43 (72.9%) patients. At univariate analysis, clinicopathological factors associated with shorter survival were: greater tumor size (> 10 cm; HR [hazard ratio] = 2.44, 95% CI 1.15-5.21; p = 0.02), metastatic lymph nodes (present; HR = 2.10, 95% CI 1.01-4.37; p = 0.04), extent of sarcomatoid differentiation (non-focal; HR = 3.30, 95% CI 1.55-7.01; p < 0.01), subtypes other than clear cell, papillary, or chromophobe (HR = 3.25, 95% CI 1.28-8.20; p = 0.01), and metastasis at baseline (HR = 5.04, 95% CI 2.40-10.59; p < 0.01). MRI features associated with shorter survival were: lymphadenopathy (HR = 2.24, 95% CI 1.16-4.71; p = 0.01) and volume of T2LIA (> 3.2 mL, HR = 4.22, 95% CI 1.92-9.29); p < 0.01). At multivariate analysis, metastatic disease (HR = 6.89, 95% CI 2.79-16.97; p < 0.01), other subtypes (HR = 9.50, 95% CI 2.81-32.13; p < 0.01), and greater volume of T2LIA (HR = 2.51, 95% CI 1.04-6.05; p = 0.04) remained independently associated with worse survival.

CONCLUSION

T2LIAs were present in approximately two thirds of sarcomatoid RCCs. Volume of T2LIA along with clinicopathological factors were associated with survival.

Hot topics in renal cancer pathology: implications for clinical management

INTRODUCTION

The updated European Association of Urology (EAU) Guidelines issued a weak recommendation for adjuvant pembrolizumab for patients with high-risk operable clear cell Renal Cell Carcinoma (ccRCC). High risk of recurrence was defined, as per protocol-criteria, as T2 with nuclear grade 4 or sarcomatoid differentiation, T3 or higher, regional lymph node metastasis, or stage M1 with no evidence of disease. Considering the heterogeneous population included in the recommendation, it has been questioned if adjuvant pembrolizumab may lead to overtreatment of some patients as well as undertreatment of patients with worse prognosis.

AREAS COVERED

In this review, we discuss the issues related to the assessment of pathological features required to identify those patients harboring a high-risk tumor, highlighting the issue related to interobserver variability and discuss the currently available prognostic scoring systems in ccRCC.

EXPERT OPINION

PPathologist assessment of prognostic features suffers from interobserver variability which may depend on gross sampling and the pathologist's expertise. The presence of clear cell feature is not sufficient criteria by itself to define ccRCC since clear cell can be also found in other histotypes. Application of molecular biomarkers may be useful tools in the near future to help clinicians identify patients harboring tumors with worse prognosis.

Primary squamous cell carcinoma with sarcomatoid differentiation of the kidney associated with ureteral stone obstruction: A case report

BACKGROUND

Primary squamous cell carcinoma (SCC) with sarcomatoid differentiation of the kidney was rarely reported. This disease is usually related to renal stones, and due to a lack of symptoms and radiological features, patients usually attend the hospital with late stage disease.

CASE SUMMARY

A 54-years-old female presented with left flank pain and an abdominal mass for 6 mo. Imaging studies revealed that the left kidney was enlarged and massive hydronephrosis was present. A stone was seen in the ureteropelvic junction. The patient subsequently underwent left radical nephrectomy, and histopathological examination of the mass revealed a poorly differentiated renal SCC with sarcomatoid differentiation. After primary surgery, the patient received four cycles of tirelizumab. Four months later, the patient developed adrenal, lymph, and uterine appendage metastases.

CONCLUSION

SCC of the kidney has a poor prognosis, and should be considered in patients with a renal mass, long-standing urinary calculi and massive hydronephrosis.

The significance of sarcomatoid and rhabdoid dedifferentiation in renal cell carcinoma

Dedifferentiation in renal cell carcinoma (RCC), either sarcomatoid or rhabdoid, is an infrequent event that may occur heterogeneously in the setting of any RCC histology and is associated with poor outcomes. Sarcomatoid dedifferentiation is associated with inferior survival with angiogenesis targeted therapy and infrequent responses to cytotoxic chemotherapy. However, immune checkpoint therapy has significantly improved outcomes for patients with sarcomatoid dedifferentiation. Biologically, sarcomatoid dedifferentiation has increased programmed death-ligand 1 (PD-L1) expression and an inflamed tumor microenvironment, in addition to other distinct molecular alterations. Less is known about rhabdoid dedifferentiation from either a clinical, biological, or therapeutic perspective. In this focused review, we will discuss the prognostic implications, outcomes with systemic therapy, and underlying biology in RCC with either sarcomatoid or rhabdoid dedifferentiation present.

The Role of Cytoreductive Nephrectomy in Renal Cell Carcinoma with Sarcomatoid Histology: A Case Series and Review of the Literature

Background: Renal cell carcinoma with sarcomatoid dedifferentiation represents a rare histological entity characterized by aggressive behavior, limited efficacy of tyrosine kinase inhibitors or mTOR inhibitors, and poor outcome. The immune checkpoint inhibitor therapy regimen combining ipilimumab with nivolumab represents a new standard of care for this patient population due to a hitherto unprecedented response rate and overall survival. On the other hand, the role of cytoreductive nephrectomy in metastatic renal cell carcinoma, in particular, with sarcomatoid histology, remains controversial. Patient and Methods: In the present case series, we report six patients with locally advanced or synchronous metastatic sarcomatoid renal cell carcinoma and intermediate or poor International Metastatic RCC Database Consortium (IMDC) risk score, five of whom were successfully subjected to cytoreductive nephrectomy. Results: All six patients received the combination regimen of ipilimumab with nivolumab. Five of these patients underwent upfront cytoreductive nephrectomy followed by systemic treatment without any significant delay, with a durable treatment outcome. Notably, two patients with poor prognostic features achieved a long-term major partial response to therapy. We also performed a review of the literature on optimal treatment strategies for patients with sarcomatoid renal cell carcinoma. Conclusion: Herein, we highlight the feasibility of performing cytoreductive nephrectomy in patients with intermediate/poor prognosis metastatic renal cell carcinoma with sarcomatoid dedifferentiation followed by immunotherapy with ipilimumab and nivolumab. To enhance the chances of immunotherapy success, cytoreductive nephrectomy should also be considered for patients presenting with a disease with adverse prognostic parameters.

Prognostic value of the ratio of maximum to minimum diameter of primary tumor in metastatic clear cell renal cell carcinoma

Background

Several models and markers were developed and found to predict outcome of advanced renal cell carcinoma. This study aimed to evaluate the prognostic value of the ratio of maximum to minimum tumor diameter (ROD) in metastatic clear cell renal cell carcinoma (mccRCC).

Methods

Patients with mccRCC (n = 213) treated with sunitinib from January 2008 to December 2018 were identified. Cutoff value for ROD was determined using receiver operating characteristic. Patients with different ROD scores were grouped and evaluated. Survival outcomes were estimated by Kaplan–Meier method.

Results

The optimal ROD cutoff value of 1.34 was determined for progression free survival (PFS) and overall survival (OS). Patients in ROD ≥ 1.34 group had shorter PFS (9.6 versus 17.7 months, p < 0.001) and OS (25.5 versus 32.6 months, p < 0.001) than patients in ROD < 1.34 group. After adjustment for other factors, multivariate analysis showed ROD ≥ 1.34 was an independent prognostic factor for PFS (p < 0.001) and OS (p = 0.006). Patients in ROD ≥ 1.34 group presented higher proportions of pT3/4 stage (89.2% versus 10.8%, p = 0.021), WHO/ISUP grade III/IV (72.0% versus 28.0%, p = 0.010), tumor necrosis (71.0% versus 29.0%, p = 0.039), sarcomatoid differentiation (79.1% versus 20.9%, p = 0.007), poor MSKCC risk score (78.4% versus 21.6%, p < 0.001) and poor IMDC risk score (74.4% versus 25.6%, p < 0.001) than ROD < 1.34 group.

Conclusion

Primary tumor with higher ROD was an independently prognostic factor for both PFS and OS in patients with mccRCC who received targeted therapy. Higher ROD was also associated with high pT stage, high WHO/ISUP grade, sarcomatoid features, tumor necrosis, poor MSKCC and IMDC risk score.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-01047-y.

A Rare Case of Sarcomatoid Renal Cell Carcinoma in a Young Adult Patient

Background

Sarcomatoid differentiation is a rare condition that could present in different subtypes of renal cell carcinomas (RCCs) and is associated with a significantly poor prognosis. Sarcomatoid renal cell carcinoma (SRCC) patients are typically aged between 54 and 63, with a male-to-female ratio ranging from 1.3:1 to 2:1. Here, we report a case of SRCC in a 29-year-old female patient.

Case Presentation

A 29-year-old female presented with left flank pain. A large lump was palpated on left flank and there was costovertebral angle tenderness. The lump was enlarged, and the patient also suffered from anemia. Abdominopelvic CT demonstrated solid mass with an internal gliosis in the left part of the renal cortex and the solid component was enhanced with contrast admission. Then, the patient underwent left radical nephrectomy with wide perirenal excision and paraaortic lymph nodes resection. Histopathological examination revealed SRCC with no lymphovascular invasion.

Conclusion

The scarcity of data on SRCCs emphasizes the need for ongoing research into the biology, diagnostics, and effective treatment options for patients with this disease, as responses to conventional therapies have been disappointing, leaving patients with few options. Cytoreductive nephrectomy for SRCC patients with metastatic disease is debatable, although some research suggests resection at any stage in patients with good performance status. In this case, radical nephrectomy was performed and there was no evidence of metastasis.

Complete response to combination therapy using nivolumab and ipilimumab for metastatic, sarcomatoid collecting duct carcinoma presenting with high expression of programmed death-ligand 1: a case report

BACKGROUND

Collecting duct carcinoma and sarcomatoid renal cell carcinoma are tumors with poor prognosis. Immune checkpoint inhibitors have been established as the standard treatment for advanced renal cell carcinoma. Some cases of remission of collecting duct carcinoma and sarcomatoid renal cell carcinoma have been reported using immune checkpoint inhibitor interventions. Specifically, sarcomatoid renal cell carcinoma expresses high levels of programmed death-ligand 1, an immune checkpoint protein, and immune checkpoint inhibitors have been reported to be highly effective for treating sarcomatoid renal cell carcinoma.

CASE PRESENTATION

We describe the case of a 70-year-old Japanese male who underwent radical right nephrectomy for a right renal mass identified on computed tomography. The pathological examination demonstrated that the renal mass was urothelial carcinoma and collecting duct carcinoma with sarcomatoid changes, and programmed death-ligand 1 was highly expressed with a tumor proportion score of more than 10%. There was no evident submucosal connective tissue invasion in the urothelial carcinoma component, and collecting duct carcinoma was diagnosed as primary cancer. The tumor-node-metastasis classification was pT3aN0, venous invasion 1, lymphovascular invasion 0, and Fuhrman nuclear grade 4. Two months after the nephrectomy, multiple metastases were observed in both lungs, the right hilar lymph node, and the S6 segment of the right liver lobe. We initiated first-line combination therapy with nivolumab (240 mg, fixed dose) and ipilimumab (1 mg/kg). One day after administration, the patient developed drug-induced interstitial pneumonia, thus we applied steroid injections. After one administration of immunotherapy, the metastatic lesion showed complete response within 6 months, which was maintained after 3 years.

CONCLUSION

We report the first case of complete response to a single dose of combination therapy with nivolumab and ipilimumab for metastatic collecting duct carcinoma with sarcomatoid changes and high expression of programmed death-ligand 1. This case suggests high expectations for immune checkpoint inhibitors as treatment for sarcomatoid-transformed renal carcinoma tumors that express high levels of programmed death-ligand 1.

Sarcomatoid Renal Cell Carcinoma: The Present and Future of Treatment Paradigms

Sarcomatoid renal cell carcinoma (sRCC) is an aggressive form of kidney cancer that is associated with poor prognosis. It can arise from any histologic type of renal cell carcinoma. The majority of cases will present with advanced or metastatic disease requiring systemic therapy. Nephrectomy is the treatment of choice in locally resectable disease. The therapeutic options for sRCC have evolved in the past decade. Cytotoxic chemotherapy and monotherapy with targeted therapy (VEGF and mTOR) have historically shown poor response rates and survival in the treatment of metastatic sRCC. The use of checkpoint inhibitors and their combination with targeted therapy against VEGF has changed the landscape and outcomes for renal cell carcinoma. Given the rarity of sRCC most of the data on treatment is from small cohorts or extrapolation from larger clinical trials. The benefit from the combination of checkpoint inhibitors and targeted therapy to VEGF has shown promise in the sRCC population in post hoc analysis of large clinical trials. Future research focusing on further characterizing the unique biologic and clinical features of sRCC is critical in advancing the knowledge and developing effective therapy to improve clinical outcomes and survival.

Sarcomatoid renal cell carcinoma: biology, natural history and management

Sarcomatoid dedifferentiation is an uncommon feature that can occur in most histological subtypes of renal cell carcinomas (RCCs) and carries a decidedly poor prognosis. Historically, conventional treatments for sarcomatoid RCCs (sRCCs) have shown little efficacy, and median survival is commonly 6–13 months. Despite being first described in 1968, the mechanisms driving sarcomatoid dedifferentiation remain poorly understood, and information and treatment options available to physicians and patients are limited. When diagnosed at an early stage, surgical intervention remains the treatment of choice. However, preoperative identification through routine imaging or biopsy is unreliable and most patients present with advanced disease and systemic symptoms. For these patients, the role of cytoreductive nephrectomy is disputed. The expansion of immunotherapies approved for RCCs has generated a search for biomarkers that might be indicative of treatment response in sRCCs, although a proven effective systemic agent remains elusive. PDL1 expression is increased in sarcomatoid dedifferentiated renal tumours, which suggests that patients with sRCCs could benefit from PD1 and/or PDL1 immune checkpoint blockade therapy. Treatment outcomes for sarcomatoid tumours have remained relatively consistent compared with other RCCs, but further investigation of the tumour–immune cell microenvironment might yield insights into further therapeutic possibilities.

In this Review, Blum et al. summarize the current knowledge on sarcomatoid renal cell carcinoma, a diagnosis characterized by the presence of sarcomatoid dedifferentiation and a poor prognosis. They discuss the origin, presentation, molecular biology and treatment of this disease.

Sarcomatoid dedifferentiation is not considered to be a unique histological subtype of renal cell carcinomas (RCCs); rather, it can be present within any subtype of RCCs.

Sarcomatoid dedifferentiation appears in ~4% of all RCCs, but is present in ~20% of all metastatic RCCs. According to WHO guidelines, any RCC with sarcomatoid dedifferentiation is a WHO–International Society of Urological Pathology grade 4 lesion.

Sarcomatoid dedifferentiation is often heterogeneously present within RCCs, making routine imaging and biopsy unreliable for preoperative detection. Surgical resection for localized disease is the standard of care, with subsequent close monitoring of patients following surgery.

In patients with metastatic disease, conventional therapies such as surgery and systemic agents have been ineffective and overall 5-year survival remains at 23.5–33%.

Previous genomic analyses have failed to identify definitive mutational drivers of disease. However, sarcomatoid RCCs (sRCCs) have been shown to have higher PD1 and PDL1 expression than other subtypes of RCCs. Newer combinations of immune checkpoint inhibitor immunotherapies could yield improved responses and outcomes.

Studies investigating sRCCs are limited by patient numbers owing to the low incidence of sRCCs and their advanced stage at presentation. Multi-institutional efforts to establish a consensus on treatment recommendations based on highly powered data are essential.

Patients with sarcomatoid renal cell carcinoma - re-defining the first-line of treatment: A meta-analysis of randomised clinical trials with immune checkpoint inhibitors

BACKGROUND

Sarcomatoid renal cell carcinoma (sRCC) represents a rare form of renal cell carcinoma marked by an aggressive biology, poor prognosis and little benefit from anti-angiogenic targeted therapy. More promising results come from the recent therapeutic strategy based on immune checkpoint inhibitor (ICI) combinations.

MATERIALS AND METHODS

For this meta-analysis, we searched MEDLINE/PubMed, the Cochrane Library and American Society of Medical Oncology (ASCO) Meeting abstracts for phase II or III randomised clinical trials. Data extraction was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The hazard ratios (HRs) for progression-free survival (PFS) and overall survival (OS) with the relative 95% confidence intervals were extracted from studies. Summary HRs were calculated using random- or fixed-effects models, depending on the heterogeneity of the included studies.

RESULTS

Four studies were selected for final analysis, including 467 patients (226 treated in with ICI combinations and 241 received sunitinib in the control arms). ICI-based combinations were associated with an improved PFS and OS compared with sunitinib, with a reduction of more than 40% of progression (HR = 0.56; p < 0.0001) and mortality (HR = 0.56; p = 0.001) risk. Moreover, ICI-based combinations are associated with a objective response rate (ORR) of more than 50% (versus 20% with sunitinib), corresponding to a doubled risk of achieving an ORR compared with controls (relative risk [RR] = 2.15; p < 0.00001). Finally, immunotherapy significantly increased the possibility to obtain complete responses (RR = 8.15, p = 0.0002) with an incidence of 11%.

CONCLUSION

Our data support the efficacy of ICI-based combinations for sRCC therapy, redefining the first-line treatment.

Epidemiology, Risk Assessment, and Biomarkers for Patients with Advanced Renal Cell Carcinoma

In the preceding two decades, several milestones have been reached in the management of patients with metastatic renal cell carcinoma (mRCC), including the development of novel targeted agents paralleling an increased understanding of the molecular biology of this disease process. Recently, a renewed enthusiasm for immunotherapy in the form of immune checkpoint blockade has resulted in significant strides in the treatment of mRCC. Despite these advances, treatment remains challenging for clinicians, and only modest survival benefits are observed with current treatment paradigms. The risk-stratification tools and investigated predictive and prognostic biomarkers in patients with mRCC are detailed in this review.

Clinicopathologic features and prognostic factors in patients with renal cell carcinoma with sarcomatoid differentiation

Renal cell carcinoma with sarcomatoid differentiation (RCCs) is rare, accounting for 1-8% of all RCC histological subtypes. In this study, we examined 139 patients with RCCs and aimed to explore their clinicopathologic features and prognostic factors. From January 2007 to January 2019, patients who were pathologically diagnosed with RCCs were included in this retrospective study. Data on clinicopathologic features and overall survival were collected. The expression of CK, vimentin, CK7, and CD10 in the sarcomatoid regions of RCCs was detected. The Kaplan-Meier curves and log-rank tests were used to describe the effect of clinicopathologic characteristics on overall survival. A Cox regression model was used to evaluate risk factors for prognosis. A total of 139 patients with RCCs were identified. The median age at diagnosis was 60 years. The median survival time of all patients was 39 months. The three- and five-year survival rates were 50.2% and 44.0%, respectively. A high pathologic T stage (pT3 and pT4), microvascular invasion, and lymph node metastasis were significant predictors of prognosis. Pathologic T4 stage and lymph node metastasis were independent prognostic factors for overall survival in patients with RCCs. Furthermore, the expression of CD10 was a prognostic factor for overall survival. In this study, a relatively large cohort of patients with RCCs was analyzed. We summarized the clinicopathologic features of RCCs and explored the risk factors for prognosis. Our findings may provide valuable prediction for clinical strategy.

Outcomes and prognosticators of stage 4 renal cell carcinoma with pathological T4 primary lesion using a large, Canadian, multi-institutional database

INTRODUCTION

The primary objective of this study was to evaluate outcomes and prognosticators in patients who underwent radical nephrectomy (RN) or cytoreductive nephrectomy (CN), depending on the clinical stage of disease preoperatively, with a pathological T4 (pT4) renal cell carcinoma (RCC) outcome. There is little data on the outcome of this specific subset of patients.

METHODS

From 2009-2016, we identified patients in the Canadian Kidney Cancer information system (CKCis) who underwent RN or CN and were found to have pT4 RCC. Clinical, operative, and pathological variables were analyzed with univariable and multivariable Cox proportional hazard models to identify factors associated with overall survival (OS). Survival curves were created using Kaplan-Meier methods and compared using the log-rank test.

RESULTS

A total of 82 patients were included in the study cohort. Median patient age was 62 years (interquartile range [IQR] 55, 70). Fifty (61%) patients had clear-cell histology and 14 (17%) had sarcomatoid characteristics. Median followup was 12 months (IQR 3, 24). At last followup, eight (10%) patients are alive with no evidence of disease, 27 (33%) are alive with disease, four (5%) were lost to followup, 36 (44%) died of disease, and seven (8%) died of other causes. Tumor histological subtype (clear-cell vs. non-clear-cell) (p=0.0032), larger tumor size (cm) (p=0.012), and Fuhrman grade (G4 vs. G2-G3) (p=0.045) were significantly associated with mortality in a multivariable Cox regression model.

CONCLUSIONS

For patients with pT4 RCC after RN or CN, survival is poor. Sarcomatoid features, non-clear-cell histology, and presence of systemic symptoms were associated with worse OS.

Analysis of the factors influencing the survival time of patients with sarcomatoid renal cell carcinoma

The aim of the present study was to identify the factors influencing the survival time of patients with sarcomatoid renal cell carcinoma (SRCC). Between January 2000 and September 2017, a total of 21 patients were enrolled, all of whom were diagnosed with SRCC. In total, eight prognostic factors were analyzed using the Kaplan-Meier estimator, a log-rank test and Cox's proportional hazards model. The log-rank test results revealed that there was a significant association between the proportion of sarcoma elements and survival time of patients with SRCC (P<0.05). In addition, there was a significant association between post-operative drug treatment and SRCC survival time (P<0.05). The results of the Kaplan-Meier estimate demonstrated that the survival curve of post-operative drug treatment was significantly greater compared with the survival curve of patients who did not undergo drug treatment (P<0.05). The survival curve of patients with a proportion of sarcoma elements <50% was significantly greater compared with the survival curve of patients with a proportion of sarcoma elements ≥50% (P<0.05). Furthermore, the Cox's proportional hazards model revealed that the mortality risk in post-operative patients without drug treatment was 5.822 times greater compared with that of patients with drug treatment (P<0.05). Mortality risk in patients with a proportion of sarcoma elements ≥50% was 4.682 times higher compared with that of patients with sarcoma elements <50% (P<0.05). Finally, post-operative drug therapy was revealed to be a protective factor which significantly affected the survival time of patients with SRCC [risk ratio (RR)=0.172], in addition to the proportion of sarcoma elements ≥50% (RR=4.682). In conclusion, drug therapy should be promoted upon patient diagnosis with SRCC and attention should be given to the proportion of sarcomatoid components.

Sarcomatoid Renal Cell Carcinoma: Population-Based Study of 879 Patients

BACKGROUND

Sarcomatoid renal cell carcinoma (sRCC) constitutes a rare and aggressive subtype of renal cell carcinoma. We aimed to investigate its clinicopathologic characteristics and outcomes at a national level.

PATIENTS AND METHODS

We accessed the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010-2015) and extracted data on patients with sRCC. We estimated median, 1-, 3-, and 5-year disease-specific survival (DSS) probabilities after generation of Kaplan-Meier curves and used multivariable regression to evaluate variables associated with nephrectomy and DSS.

RESULTS

A total of 879 patients with sRCC were identified; 60.9% patients had stage IV disease at diagnosis, and the median tumor size was 8.3 cm (interquartile range, 5.5-12 cm). The 5-year DSS were 77.7%, 67.8%, 35.4%, and 3.5% for patients with stage I, II, III, and IV disease at diagnosis, respectively; median DSS was 9 months (interquartile range, 4-42 months) for the entire cohort. Older age (hazard ratio [HR] = 1.01; 95% confidence interval [CI], 1.00-1.02), higher tumor stage (stage III vs. I: HR = 3.81; 95% CI, 2.18-6.67; stage IV vs. I: HR = 9.89; 95% CI, 5.80-16.98), and performance of nephrectomy (HR = 0.53; 95% CI, 0.43-0.66) were found to independently affect DSS.

CONCLUSION

In the largest sRCC cohort to date, we found that most patients present with metastatic disease, and the prognosis for this disease remains extremely poor. Nephrectomy should be considered in all patients with acceptable surgical risk, including cytoreductive nephrectomy in carefully selected patients with metastatic disease.

Ki-67 index and percentage of sarcomatoid differentiation were two independent prognostic predictors in sarcomatoid renal cell carcinoma

Purpose

To identify whether and which of pathological features of sarcomatoid differentiation (SD) in renal cell carcinoma (RCC) can be used as independent predictors associated with overall survival (OS).

Materials and methods

After institutional review board approval, patients with a diagnosis of sarcomatoid RCC (sRCC), spindled RCC, or RCC with the presence of spindle cells between 2003 and 2017 were further selected and re-examined. The primary pathological features including histological subtypes, tumor necrosis, Ki-67 index of SD, and the percent of SD (%SD) were included into analysis. Histological subtypes were categorized into clear-cell RCC and nonclear-cell RCC. Ki-67 index of SD was confirmed by immunohistochemical staining. %SD was estimated through reviewing all of the tumor sections microscopically and then giving an approximate %SD within the entire tumor. The clinical relevant prognostic predictor's association with OS was analyzed within Cox proportional hazards regression models. Survival curves were generated using the Kaplan-Meier method, and OS differences were compared using the log-rank test.

Results

A total of 2,089 consecutive patients of RCC were referred to our department, of whom 62 (3.0%) patients were identified with histological element of SD after re-examining the available slides of suspicious cases. Finally, 53 patients were included into survival analysis after excluding 9 patients without adequate information. Thirty-eight (71.7%) patients died at last follow-up. The median OS for all patients was 11.0 months from the date of surgery. In patients with clinical distant metastasis (cM₁), the median OS was only 3 compared with 21 months for patients with no clinical distant metastasis (cM₀). Tumor stage, status of clinical distant metastasis, Ki-67 index, and %SD were independent predictors of multivariate analysis in overall 53 patients. However, in the cohort of cM₀ patients, we found that only %SD and Ki-67 index were two independent predictors of OS in multivariate analysis.

Conclusion

Patients with sRCC are associated with very poor prognosis. Ki-67 index of SD and %SD were identified as the two most important independent predictors particularly for nonmetastatic patients. The limitations of our study were also observed, and further studies are needed.

The prognostic value and clinicopathological features of sarcomatoid differentiation in patients with renal cell carcinoma: a systematic review and meta-analysis

Background and purpose

Numerous studies have demonstrated that sarcomatoid differentiation is linked to the risk of renal cell carcinoma (RCC). However, its actual clinicopathological impact remains inconclusive. Therefore, we undertook a meta-analysis to evaluate the pathologic and prognostic impacts of sarcomatoid differentiation in patients with RCC by assessing cancer-specific survival, overall survival, recurrence-free survival, progression-free survival, and cancer-specific mortality.

Materials and methods

In accordance with the preferred reporting items for systematic reviews and meta-analysis statement, relevant studies were collected systematically from PubMed, Embase, and Web of Science to identify relevant studies published prior to January 2018. The pooled effects (hazard ratios, odds ratios, and standard mean differences) and 95% confidence intervals were calculated to investigate the association of sarcomatoid differentiation with cancer prognosis and clinicopathological features.

Results

Thirty-five studies (N=11,261 patients [n=59-1,437 per study]) on RCC were included in this meta-analysis. Overall, the pooled analysis suggested that sarcomatoid differentiation was significantly associated with unfavorable cancer-specific survival (HR=1.46, 95% CI: 1.26-1.70, p<0.001), overall survival (HR=1.59, 95% CI: 1.42-1.78, p<0.001), progression-free survival (HR=1.61, 95% CI: 1.35-1.91, p<0.001), recurrence-free survival (HR=1.60, 95% CI: 1.29-1.99, p<0.001), and cancer-specific mortality (HR=2.36, 95% CI: 1.64-3.41, p<0.001) in patients with RCC. Moreover, sarcomatoid differentiation was closely correlated with TNM stage (III/IV vs I/II: OR=1.84, 95% CI: 1.12-3.03, p=0.017), Fuhrman grade (III/IV vs I/II: OR=8.37, 95% CI: 2.92-24.00, p<0.001), lymph node involvement (N1 vs N0: OR=1.88, 95% CI: 1.08-3.28, p=0.026), and pathological types (clear cell RCC-only vs mixed type: OR=0.48, 95% CI: 0.29-0.80, p=0.005), but was not related to gender (male vs female, OR=0.86, 95% CI: 0.58-1.28, p=0.464) and average age (SMD=-0.02, 95% CI: -0.20-0.17, p=0.868).

Conclusion

This study suggests that sarcomatoid differentiation in histopathology is associated with poor clinical outcome and advanced clinicopathological features in RCC and could serve as a poor prognostic factor for RCC patients.

Addressing the best treatment for non-clear cell renal cell carcinoma: A meta-analysis of randomised clinical trials comparing VEGFR-TKis versus mTORi-targeted therapies

AIM

Non-clear cell renal cell carcinoma (nccRCC) tumours include a heterogeneous group of malignancies that profoundly differ in terms of morphology, genetic profile, clinical behaviour and prognosis. The optimal treatment algorithm for nccRCC is still unknown and derived mainly from evidence available for ccRCC, being therefore represented by targeted agents against vascular endothelial growth factor and mammalian target of rapamycin (mTOR) pathways. We aimed to compare the efficacy of vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR-TKis) and mTOR inhibitors (mTORi) for the treatment of nccRCC patients.

METHODS

Searching the MEDLINE/PubMed, Cochrane Library and American Society of Clinical Oncology Meeting abstracts prospective studies were identified. Data extraction was conduced according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The measured outcomes were progression-free survival (PFS), overall survival (OS) and the overall response rate (ORR).

RESULTS

Four randomised controlled trials were selected for final analysis, with a total of 332 patients evaluable for PFS. Treatment with TKi significantly reduced the risk of progression compared with mTORi (hazard ratio [HR] = 0.71; 95% confidence interval [CI] 0.60-0.84; p < 0.0001). This difference remained significant when sunitinib was compared with everolimus in first-line setting (HR = 0.67; 95% CI, 0.56-0.80; p < 0.00001). In the 332 patients evaluable for OS, no significant difference was found between TKi and mTORi (HR = 0.86; 95% CI, 0.67-1.12; p = 0.27). In the 176 evaluable patients, TKis therapy did not improve the ORR when compared with mTORi (relative risk [RR] = 2.21; 95% CI, 0.87-5.60; p = 0.09), even if treatment with sunitinib doubled the probability of achieving a tumour response.

CONCLUSIONS

Treatment with TKis significantly improves PFS, but not OS, when compared with mTORi. Moreover, sunitinib as first-line therapy reduces the risk of progression compared with everolimus; therefore, supporting the standard treatment paradigm broadly used for ccRCC patients. The relatively modest efficacy of available targeted therapies reinforces the need of future histology based, molecular driven therapeutic paradigm.

Skeletal Muscle Metastases and Inferior Vena Cava Involvement in a Patient with Clear Cell Renal Cell Carcinoma and Sarcomatoid Differentiation

Introduction: Renal cell carcinoma has a propensity to propagate into the renal vein and inferior vena cava. A small percentage has distant metastasis at presentation. Pulmonary, hepatic, cerebral and bone metastases are common, but skeletal muscle involvement is rare.

Case presentation: We present the case of a 51-year-old patient complaining of right flank pain, gross hematuria and a painful left laterothoracic mass. Preoperative examination revealed a tumor in the inferior pole of the right kidney, thrombosis of the right renal vein that extended into the inferior vena cava and a left laterothoracic tumor. We decided on a preoperative digital subtraction angiography and selected embolization of the laterothoracic mass. We performed right radical nephrectomy with vena cava thrombus excision and excision of the left laterothoracic tumor. The pathological examination revealed a clear cell renal carcinoma with sarcomatoid differentiation of the right kidney. Metastases with the above features were noticed in the right adrenal gland and in the skeletal muscle of the chest wall.

Conclusions: The surgical resection of large renal tumors with associated thrombus within the inferior vena cava is challenging to any surgeon. The preoperative embolization of the metastatic tumor is helpful in the reduction of pain and intraoperative blood loss.

Percentage of sarcomatoid component as a prognostic indicator for survival in renal cell carcinoma with sarcomatoid dedifferentiation

OBJECTIVE

Renal cell carcinoma with sarcomatoid dedifferentiation (sRCC) is associated with higher stage of presentation and worse survival. The objective of this study was to examine the clinicopathologic characteristics associated with overall survival (OS), specifically examining the percentage of sarcomatoid component (PSC).

METHODS

We reviewed clinicopathologic data for all nephrectomized patients with confirmed sRCC. Histologic slides were rereviewed by dedicated genitourinary pathologists to ascertain PSC. Patient characteristics were tabulated overall and by disease stage. Cutpoints in the PSC providing a meaningful difference in OS were identified by recursive partitioning analysis (RPA). Factors selected included age group, gender, race, clinical stage, tumor histology, presurgical systemic therapy, lymphovascular invasion, and tumor size. The Kaplan-Meier method and log-rank test were used to assess differences in OS.

RESULTS

Among 186 patients with sRCC, 64 (34%) had localized, and 122 (66%) had metastatic disease at presentation. Patients had primarily clear cell histology (73%). Median follow-up was 12.1 months (range: 0.1-242.2mo). Median OS was 12.6 months (95% CI: 10.7-14.9mo). Univariate RPA identified a PSC cutpoint of 10% as prognostically significant. Patients with PSC>10% were at higher risk of death when compared with patients with PSC≤10% (45% vs. 61% 1-y OS; P = 0.04). Multivariate RPA revealed that tumor size, presence of metastatic disease, and PSC were significantly associated with OS. Among 4 identified groups, patients with localized disease and tumor size≤10cm were most likely to be alive at 1 year (89%), and patients with metastatic disease and PSC>40% were least likely to be alive at 1 year (28%; P<0.001).

CONCLUSION

PSC appears to be a prognostic factor in patients with sRCC, with larger percentage of involvement portending a worse survival, especially in patients with metastatic disease.