Distant Metastasis of Renal Cell Carcinoma With a Diameter of 3 cm or Less—Which is Aggressive Cancer?

Small renal cell carcinoma accompanied by extensive inferior vena cava tumor thrombus diagnosed by percutaneous transvenous biopsy

Introduction

Up to 10% of patients with renal cell carcinoma present with tumor thrombus in the inferior vena cava. We report that a case of small renal cell carcinoma with tumor thrombus extending above the diaphragm for which transvenous biopsy was performed for diagnosis.

Case presentation

A 79-year-old man performed computed tomography to evaluate hepatic dysfunction, which revealed intravenous tumor extending above the diaphragm and a 15-mm-sized exophytic tumor in right kidney. Imaging suggested that the renal tumor was renal cell carcinoma. As this tumor was small and exophytic, confirmation of the intravenous tumor being tumor thrombus associated with renal cell carcinoma was difficult. We simultaneously performed transvenous biopsy on the intravenous tumor and percutaneous biopsy on the renal tumor for obtaining histologic diagnoses. The final diagnosis was small renal cell carcinoma accompanied by tumor thrombus above the diaphragm.

Conclusion

Transvenous biopsy may be useful for the definitive diagnosis of inferior vena cava-tumor thrombus in cases of small renal cell carcinoma.

Risk factors of recurrence after robot-assisted laparoscopic partial nephrectomy for solitary localized renal cell carcinoma

To evaluate the recurrence rate and risk factors of recurrence after robot-assisted laparoscopic partial nephrectomy for solitary renal cell carcinoma (RCC). A total of 1265 cases of initial solitary localized RCC were analyzed. The baseline characteristics, complexity (REANL nephrometry score), intra- and peri-operative outcomes, and recurrence were evaluated. Logistic regression was performed to evaluate the factors affecting recurrence after RAPN for solitary localized RCC. Recurrence after robot-assisted partial nephrectomy (RAPN) occurred in 29 patients (2.29%). The median follow-up was 36.0 months. The N domain (nearness to collecting system/sinus) (odd ratio (OR) 3.517, 95% confidence interval (CI) 1.557-7.945, p = 0.002), operation time (OR 1.005, 95% CI 1.001-1.010, p = 0.013), and perioperative transfusion (OR 5.450, 95% CI 1.197-24.816, p = 0.028) affected recurrence. Distant metastasis among patients with recurrence was significantly associated with nearness to the collecting system/sinus (OR 2.982, 95% CI 1.162-7.656, p = 0.023) and distance between the mass and collecting system/sinus (OR 0.758, 95% CI 0.594-0.967, p = 0.026). Nearness to the collecting system/sinus, operation time, and perioperative transfusion affect recurrence after RAPN for solitary localized RCC. Moreover, the proximity to the collecting system/sinus and distance between the mass and collecting system/sinus were significantly related to distant metastasis after RAPN.

Development and validation of A CT-based radiomics nomogram for prediction of synchronous distant metastasis in clear cell renal cell carcinoma

Background

Early identification of synchronous distant metastasis (SDM) in patients with clear cell Renal cell carcinoma (ccRCC) can certify the reasonable diagnostic examinations.

Methods

This retrospective study recruited 463 ccRCC patients who were divided into two cohorts (training and internal validation) at a 7:3 ratio. Besides, 115 patients from other hospital were assigned external validation cohort. A radiomics signature was developed based on features by means of the least absolute shrinkage and selection operator method. Demographics, laboratory variables and CT findings were combined to develop clinical factors model. Integrating radiomics signature and clinical factors model, a radiomics nomogram was developed.

Results

Ten features were used to build radiomics signature, which yielded an area under the curve (AUC) 0.882 in the external validation cohort. By incorporating the clinical independent predictors, the clinical model was developed with AUC of 0.920 in the external validation cohort. Radiomics nomogram (external validation, 0.925) had better performance than clinical factors model or radiomics signature. Decision curve analysis demonstrated the superiority of the radiomics nomogram in terms of clinical usefulness.

Conclusions

The CT-based nomogram could help in predicting SDM status in patients with ccRCC, which might provide assistance for clinicians in making diagnostic examinations.

Predictive Factors Affecting Metastasis of Small Renal Mass and Its Prognostic Analysis

BACKGROUND

The incidence of small renal mass (SRM) increases, and the prognosis of SRM is poor once metastasized. Therefore, we conducted this study to assess the clinical and pathological characteristics of SRM to determine the risk factors that influence the metastasis and prognosis of SRM.

METHODS

A small renal mass is defined as a solid tumor mass with the largest diameter of 4 cm or less on the pathological diagnosis. The metastasis is confirmed by imaging or pathological examination. We retrospectively included 40 patients with metastatic SRM (mSRM) treated in the department of urology of Peking University Third Hospital from October 2002 to October 2020. Meanwhile, 358 patients with nonmetastatic SRM treated in our hospital from January 2015 to December 2017 were selected as controls. Clinicopathologic features were compiled.

RESULTS

Multivariate logistic regression analysis showed that age (P = .027, odds ratio [OR] = 1.037, 95% confidence interval [CI] 1.004-1.070), clinical symptoms (P < .001, OR = 4.311, 95% CI 1.922-9.672), World Health Organization/International Society of Urological Pathology (WHO/ISUP) nuclear grade 3/4 (P = .004, OR = 7.637, 95% CI 1.943-30.012; P = .004, OR = 20.523, 95% CI 2.628-160.287), and lymphatic invasion (P = .030, OR = 15.844, 95% CI 1.314-191.033) were risk factors for distant metastasis of SRM. Once metastasis occurs, the prognosis of SRM is poor. Multivariate Cox regression analysis of the prognosis of mSRM showed that age (P = .016, hazard ratio [HR] = 1.125, 95% CI 1.022-1.239), preoperative serum creatinine (P = .041, HR = 1.003, 95% CI 1.000-1.005), vascular invasion (P = .041, HR = 1.003, 95% CI 1.000-1.005), and metastasis (P < .001, HR = 24.069, 95% CI 4.549-127.356) were risk factors for overall survival (OS), and only metastasis (P < .001, HR = 9.52, 95% CI 5.43-16.7) was a risk factor for progression-free survival (PFS) of SRM.

CONCLUSIONS

SRM with advanced age, clinical symptoms, high pathological nuclear grade, and lymphatic invasion are more likely to have distant metastasis. And SRM with older age, poor preoperative basic renal function, pathological vascular invasion, and metastasis have worse OS.

Risk factors for recurrence after operation in patients with pT1a renal cell carcinoma: sub-analysis of the multi-institutional national database of the Japanese Urological Association

BACKGROUND

More patients with renal cell carcinoma are now diagnosed with the disease in its early stages. Although patients with pT1a renal cell carcinoma have a good prognosis and low recurrence rate, a few patients still experience recurrence. Herein, we evaluated the clinicopathological risk factors for postoperative recurrence of pT1aN0M0 renal cell carcinoma.

METHODS

An renal cell carcinoma survey was conducted by the Japanese Urological Association to register newly diagnosed cases of renal cell carcinoma. A total of 1418 patients diagnosed with pT1aN0M0 renal cell carcinoma who underwent surgery as the primary surgical treatment were included. We analyzed the recurrence-free survival using the Kaplan-Meier method and clinicopathological factors for recurrence using Cox proportional hazards models.

RESULTS

Among 1418 patients, 58 (4.1%) had recurrences after a median follow-up of 62.8 months. The median time to recurrence was 31.0 months. Metastases to the lungs and the bone were observed in 20 and 10 cases, respectively. Significant differences in sex, tumor size, Eastern Cooperative Oncology Group performance status, and dialysis history, preoperative hemoglobin levels, C-reactive protein levels and creatinine levels were observed between the recurrence and non-recurrence groups. Multivariate analysis identified male sex, high C-reactive protein level and tumor size ≥3 cm as independent risk factors. The 5-year recurrence-free survival of patients with 0, 1, 2 and 3 risk factors was 99.0, 97.2, 93.1 and 80.7%, respectively.

CONCLUSIONS

Male sex, tumor diameter and a high C-reactive protein level were independent recurrence risk factors for pT1a renal cell carcinoma; special attention should be paid to patients with these risk factors during postoperative follow-up.

CT Radiomics for the Prediction of Synchronous Distant Metastasis in Clear Cell Renal Cell Carcinoma

PURPOSE

The aim of this study was to construct and verify a computed tomography (CT) radiomics model for preoperative prediction of synchronous distant metastasis (SDM) in clear cell renal cell carcinoma (ccRCC) patients.

METHODS

Overall, 172 patients with ccRCC were enrolled in the present research. Contrast-enhanced CT images were manually sketched, and 2994 quantitative radiomic features were extracted. The radiomic features were then normalized and subjected to hypothesis testing. Least absolute shrinkage and selection operator (LASSO) was applied to dimension reduction, feature selection, and model construction. The performance of the predictive model was validated through analysis of the receiver operating characteristic curve. Multivariate and subgroup analyses were performed to verify the radiomic score as an independent predictor of SDM.

RESULTS

The patients randomized into a training (n = 104) and a validation (n = 68) cohort in a 6:4 ratio. Through dimension reduction using LASSO regression, 9 radiomic features were used for the construction of the SDM prediction model. The model yielded moderate performance in both the training (area under the curve, 0.89; 95% confidence interval, 0.81-0.97) and the validation cohort (area under the curve, 0.83; 95% confidence interval, 0.69-0.95). Multivariate analysis showed that the CT radiomic signature was an independent risk factor for clinical parameters of ccRCC. Subgroup analysis revealed a significant connection between the SDM and radiomic signature, except for the lower pole of the kidney subgroup.

CONCLUSIONS

The CT-based radiomics model could be used as a noninvasive, personalized approach for SDM prediction in patients with ccRCC.

[SMALL RENAL CELL CARCINOMA PRESENTING WITH HUGE SACRALMETASTASIS: A CASE REPORT]

A 66-year-old man with buttock pain and intermittent claudication visited a nearby doctor. Magnetic resonance imaging revealed a tumor of 8 cm in diameter in his sacrum. He was referred to our hospital. Abdominal contrast enhanced computed tomography revealed a small mass of 2.5 cm in diameter on his left kidney and he was diagnosed with metastatic bone disease after needle tumor biopsy. However, needle biopsy of the renal tumor demonstrated no evidence of malignancy. As he rejected further examination, we started treatment using the tyrosine kinase inhibitor sunitinib. However, it had little effect on his sacral metastasis and he developed massive bowel bleeding twice. Extensive invasion from the sacral metastasis to the back side of the rectum was found on colonoscopy. The patient died 2 months after the introduction of sunitinib. The final diagnosis based on pathological autopsy was renal cell carcinoma with sacral metastasis.

Inferior Vena Cava Occlusion and Ilio-Iliac Arteriovenous Fistula Caused by Tumor Invasion: A Case Report

An 80-year-old woman presented with general fatigue and leg edema for several months. Ultrasonography and contrast-enhanced computed tomographic angiography revealed inferior vena cava thrombosis, ilio-iliac arteriovenous fistula (AVF), and iliac artery pseudoaneurysm. Furthermore, malignant cells were observed in the aspirated thrombus. Although thrombus aspiration and anticoagulant therapy were unsuccessful in reducing the thrombotic mass and alleviating her symptoms, endovascular therapy for AVF and pseudoaneurysm improved her leg edema without recurrence or any endoleak. These findings highlight that endovascular therapy can be effective in older adults with cancer because of its low invasiveness.

Risk of metastasis for T1a renal cell carcinoma

INTRODUCTION

While active surveillance for small renal mass is gaining acceptance, controversy still continues on true metastatic potential of small renal cell carcinoma (RCC). Thus, we investigated the risks of synchronous/metachronous metastases and their potential predictors among T1a RCC patients who underwent surgical treatment.

METHODS

We reviewed data from 2114 patients who received radical or partial nephrectomy for small renal tumor (≤ 4 cm) from 1990 to 2013. For our study, patients were stratified into four different groups according to tumor size (group 1: 0-1.0 cm, group 2: 1.1-2.0 cm, group 3: 2.1-3.0 cm, group 4: 3.1-4.0 cm). Univariate and multivariate analyses were performed to analyze metastatic potentials according to tumor size and identify useful predictors of metastases.

RESULTS

Among 1913 T1a RCC patients, there were low but nonnegligible rates of metastases (group 2: 1.1 %, group 3: 3.3 %, group 4: 6.0 %, respectively). Kaplan-Meier analysis showed significant differences in metastasis-free survivals between groups (p < 0.001). A linear positive association was observed between tumor size and metastatic rate (p < 0.001). Diabetic T1a RCC patients showed significantly inferior metastasis-free survival than nondiabetic counterparts (p = 0.003). Multivariate analysis revealed that tumor size and history of diabetes mellitus were independently associated with metastasis in T1a RCC.

CONCLUSIONS

As T1a RCCs present low but nonnegligible risk of metastasis, patients with small renal mass should be counseled on such risk when offered active surveillance. Larger tumor size and history of diabetes mellitus may be associated with higher risk of metastasis in T1a RCC.

Tumor necrosis is a strong predictor for recurrence in patients with pathological T1a renal cell carcinoma

Patients with pT1aN0M0 renal cell carcinoma (RCC) generally have good prognosis, and recurrence is rare. However, metastasis develops postoperatively in a small number of patients with pT1aN0M0 RCC. The present study was undertaken to identify predictors for recurrence in patients with pT1aN0M0 RCC. We reviewed the clinicopathological factors of 133 patients with pT1aN0M0 RCC who underwent radical or partial nephrectomy at the Department of Urology, National Defense Medical College (Saitama, Japan). Clinicopathological factors, including age, gender, tumor size, histological subtype, tumor grade, microvascular invasion, histological tumor necrosis, C-reactive protein levels and performance status were reviewed. These factors were compared between patients with and without postoperative recurrence. Recurrence-free survival (RFS) and cause-specific survival (CSS) rates were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to determine independent factors predicting recurrence in patients with pT1aN0M0 RCC. The 5-year RFS and CSS rates were 97.2 and 99.1%, respectively. When clinicopathological factors were compared between patients with and without recurrence, tumor size (P=0.0390) and percentage of tumor necrosis (P<0.0001) were significantly different between groups. All patients with recurrence had primary lesions ≥3 cm. By univariate analysis, tumor size (P=0.0379) and the presence of tumor necrosis (P=0.0319) were significant predictors for recurrence; tumor necrosis was also an independent predictor for recurrence (P=0.0143). In patients with pT1b tumors ≤5 cm (recurrence rate, 16.8%; n=48), the percentage of tumor necrosis was significantly higher in patients with recurrence compared with those without (P=0.0261). This suggests that tumor necrosis may be an important predictor for recurrence in small RCCs. Although recurrence is rare in pT1a RCC, the presence of tumor necrosis may be an important predictor for recurrence. Particularly, patients presenting with pT1a RCC with histological tumor necrosis should undergo careful follow-up.

The impact of tumour size on the probability of synchronous metastasis and survival in renal cell carcinoma patients: a population-based study

BACKGROUND

The observed low metastatic potential and favorable survival of small incidentally detected renal cell carcinomas (RCCs) have been a part of the rationale for recommending partial nephrectomy as a first treatment option and active surveillance in selected patients. We examined the relationship between tumor size and the odds of synchronous metastases (SMs) (primary outcome) and disease specific survival (secondary outcome) in a nationwide RCC registry.

METHODS

Retrospective study of the 794 RCC patients diagnosed in Iceland between 1971 and 2005. Histological material and TNM staging were reviewed centrally. The presence of SM and survival were recorded. Cubic spline analysis was used to assess relationship between tumor size and probability of SM. Univariate and multivariate statistics were used to estimate prognostic factors for SM and survival.

RESULTS

The probability of SM increased in a non-linear fashion with increasing tumor size (11, 25, 35, and 50%) for patients with tumors of ≤4, 4.1-7.0, 7.1-10.0, and >10 cm, respectively. On multivariate analysis, tumor size was an independent prognostic factor for disease-specific survival (HR = 1.05, 95% CI 1.02-1.09, p < 0.001), but not for SM.

CONCLUSION

Tumor size affected the probability of disease-specific mortality but not SM, after correcting for TNM staging in multivariate analysis. This confirms the prognostic ability of the 2010 TNM staging system for renal cell cancer in the Icelandic population.

Predictors of locally advanced and metastatic disease in patients with small renal masses

Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? There is a small cohort of patients who have small renal masses with metastatic potential, yet risk factors for having this more aggressive disease are largely unknown. In a large sampling of the US population, older patients and men were more likely to have small renal masses at an advanced stage.

OBJECTIVES

To assess the prevalence metastatic and locally advanced renal cell carcinoma (RCC) in the US population with small renal masses (SRMs). To determine what patient and tumour characteristics predict having more advanced SRMs.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology and End Results (SEER) registry, we identified 14, 962 patients who were diagnosed between 1988 and 2007 with RCC ≤ 3 cm in size. Patients were separated by stage into those with metastatic, locally advanced and localized disease. Differences in baseline characteristics between patients in these three groups were assessed. After controlling for age, sex, grade, tumour size and year of surgery, a logistic regression analysis was performed to determine the likelihood of having non-localized disease.

RESULTS

In the SEER cohort, 13, 574 (90.7%) patients with RCC ≤ 3 cm in size were diagnosed with localized disease, 938 (6.3%) patients had invasion beyond the kidney into regional lymph nodes or nearby organs, and 450 (3.0%) patients had distant metastasis. Patients with metastasis were older (65.9 years) compared to those with localized disease (59.5 years) (P < 0.001). Independent preoperative predictors of having more aggressive disease at diagnosis (locally advanced/metastatic) included older age, particularly age >70 years (odds ratio, OR, 2.42; 95% confidence interval, CI, 2.03-2.88), male sex (OR, 1.50; 95% CI, 1.33-1.70) and tumour size >2.5 (OR, 1.41; 95% CI, 1.25-1.58).

CONCLUSIONS

A small subset (3%) of patients in the USA with RCC ≤ 3 cm in size have distant metastasis. Older patients, men and those with tumours 2.5-3.0 cm in size have a greater probability of presenting with non-localized disease . Clinicians should be aware that there is a risk of metastases in patients with SRMs and also familiarize themselves with the characteristics associated with advanced disease.

Characteristics of aggressive variants in T1a renal cell carcinoma

PURPOSE

To explore factors associated with metastasis and prognosis in T1a renal cell carcinoma (RCC).

METHODS

We retrospectively reviewed 451 cases of sporadic T1aRCC among 1,060 patients admitted to the Department of Urology at Hamamatsu University Hospital and affiliated hospitals between 1978 and 2007. Clinicopathological factors were analyzed for metastatic and prognostic risks.

RESULTS

We identified 32 RCC patients with metastatic disease, 22 with synchronous and 10 with metachronous metastatic RCC. Patients with metastatic disease had a significantly higher incidence of symptomatic cancer, as well as greater tumor size, C-reactive protein (CRP) level, sarcomatoid component ratio, histological grade 3 and microvascular invasion than those without metastasis. Among the 32 patients with metastasis, there is no significant difference in clinicopathological factors. The most common site of metastasis was bone. Among patients with metastatic T1aRCC, findings at diagnosis of a symptomatic cancer, CRP level of 0.4 mg/dL or more, tumor size of 3.0 cm or greater, histological grade 3, a sarcomatoid component and microvascular invasion appeared to be significant and independent risk factors. Significant independent risk factors with metachronous metastatic RCC were a symptomatic cancer and a sarcomatoid component at diagnosis. A CRP level of 0.4 mg/dL or more was also an independent prognostic factor for overall survival.

CONCLUSION

RCC patients with findings at diagnosis of a symptomatic cancer, a sarcomatoid component and CRP level of 0.4 mg/dL or more require intensive follow-up.