The surgical management of renal cell carcinoma

Minimally invasive radical nephrectomy: a contemporary review

Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.

Resection and reconstruction of the inferior vena cava for neoplasms

AIM: To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC).

METHODS: The approach to caval resection depends on the extent and location of tumor involvement. The supra- and infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins.

RESULTS: The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography.

CONCLUSION: There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.

Reassessment of renal cell carcinoma lymph node staging: analysis of patterns of progression

OBJECTIVES

To evaluate the prognostic value of lymph node (LN) metastasis and the therapeutic role of LN dissection (LND) in patients with renal cell carcinoma.

METHODS

We reviewed the medical records of 1503 patients who had undergone nephrectomy from 1990 to 2007. The patients were stratified according to the number, location, and size of LN metastases. The disease-free survival, cancer-specific survival, and survival relative to the preoperative suspicion of LN metastasis were analyzed.

RESULTS

Of the 1503 patients, 726 (48.3%) had Stage pN0, 37 (2.5%) had Stage pN+, including 16 with pN1 and 21 with pN2, and 740 (49.2%) had Stage pNx. The average number of LNs removed was 5 (range 1-33), and the average size of the metastasized LNs was 2.4 cm (range 0.8-6). Of the patients without preoperative clinical evidence of LN metastasis, 203 underwent LND; all had Stage pN0. The LN stage was a significant predictor of distant metastasis-free survival (P = .002) and cancer-specific survival (P = .001) between the pNx/pN0 and pN+ groups but not between the pN1 and pN2 groups. Metastasized LN size (<3 vs ≥3 cm) also significantly predicted for distant metastasis-free survival (P = .003) and cancer-specific survival (P = .001). In LN-positive patients, LND improved local recurrence-free survival but not distant metastasis-free survival or cancer-specific survival.

CONCLUSIONS

The current LN staging system, which is dependent on the number of metastatic LNs, did not significantly correlate with the prognosis in patients with renal cell carcinoma. In contrast, LN size (<3 vs ≥3 cm) better reflected the effect of this disease on survival. The therapeutic role of LND might be limited.

A p120 catenin isoform switch affects Rho activity, induces tumor cell invasion, and predicts metastatic disease

p120 catenin is a cadherin-associated protein that regulates Rho GTPases and promotes the invasiveness of E-cadherin-deficient cancer cells. Multiple p120 isoforms are expressed in cells via alternative splicing, and all of them are essential for HGF signaling to Rac1. However, only full-length p120 (isoform 1) promotes invasiveness. This selective ability of p120 isoform 1 is mediated by reduced RhoA activity, both under basal conditions and following HGF treatment. All p120 isoforms can bind RhoA in vitro, via a central RhoA binding site. However, only the cooperative binding of RhoA to the central p120 domain and to the alternatively spliced p120 N terminus stabilizes RhoA binding and inhibits RhoA activity. Consistent with this, increased expression of p120 isoform 1, when compared with other p120 isoforms, is predictive of renal tumor micrometastasis and systemic progression, following nephrectomy. Furthermore, ectopic expression of the RhoA-binding, N-terminal domain of p120 is sufficient to block the ability of p120 isoform 1 to inhibit RhoA and to promote invasiveness. The data indicate that the increased expression of p120 isoform 1 during tumor progression contributes to the invasive phenotype of cadherin-deficient carcinomas and that the N-terminal domain of p120 is a valid therapeutic target.

Renal cell carcinoma clinically involving adjacent organs

BACKGROUND

Historically, patients with nonmetastatic renal cell carcinoma (RCC) involving adjacent organs have been considered inoperable and incurable. The oncologic efficacy of an aggressive surgical approach was evaluated in a selected subpopulation of RCC patients. Further, an attempt was made to define the clinical and pathologic characteristics predictive of surgical failure.

METHODS

With Institutional Review Board approval, the institutional nephrectomy database of 3470 patients treated at MD Anderson Cancer Center from 1990 to 2006 was searched for RCC patients treated with radical nephrectomy and resection of at least 1 adjacent organ thought to be directly involved by RCC. Patients with nonmetastatic RCC and a minimum follow-up of 6 months were included in the analysis.

RESULTS

In all, 30 patients with clinical T4NxM0 RCC and median follow-up of 32.3 months (range, 8.5-140.1) met the study inclusion criteria and comprise the dataset for the analysis. On pathologic evaluation 60% of patients were clinically overstaged, as only 12 (40%) of 30 patients demonstrated direct invasion into adjacent organs resected. None of the clinical tumor characteristics predicted a finding of pathologic T4 RCC. Nodal involvement and pathologic T stage were significant independent predictors of disease recurrence (hazard ratio [HR] 3.726, P = .043, and HR 2.414, P = .045, respectively) and cancer-specific survival (HR 17.145, P = .002, and HR 3.791, P = .024, respectively). Disease recurred in 11 of 18 (61.1%) of <pT4 patients and in 10 of 12 (83.3%) of pT4 patients at a median 13.3 and 2.3 months, respectively; 13 (73.3%) <pT4 patients and 5 (41.7%) pT4 patients were alive at the time of analysis.

CONCLUSIONS

True pathologic involvement of adjacent organs by RCC cannot be predicted from pre- or intraoperative parameters. A significant proportion of patients clinically suspected of having T4 RCC are downstaged, and benefit from aggressive surgical resection with en bloc removal of involved organs.

Renal tumors: technical success and early clinical experience with radiofrequency ablation of 18 tumors

PURPOSE

To evaluate the feasibility, safety, and technical efficacy of image-guided radiofrequency ablation (RFA) for the treatment of small peripheral renal tumors and to report our early results with this treatment modality.

METHODS

Twenty-two RFA sessions for 18 tumors were performed in 11 patients with renal tumors. Indications included coexistent morbidity, high surgical or anesthetic risk, solitary kidney, and hereditary predisposition to renal cell carcinoma. Ten patients had CT-guided percutaneous RFA performed on an outpatient basis. One patient had open intraoperative ultrasound-guided RFA. Technical success was defined as elimination of areas that enhanced at imaging within the entire tumor. With the exception of one patient with renal insufficiency who required gadolinium-enhanced MRI, the remaining patients underwent contrast-enhanced CT for post-treatment follow-up assessment. Follow-up was performed after 2-4 weeks and then at 3, 6, 12 months, and every 12 months thereafter.

RESULTS

Fourteen (78%) of 18 tumors were successfully ablated with one session. Three of the remaining four tumors required two sessions for successful ablation. One tumor will require a third session for areas of persistent enhancement. Mean patient age was 72.82 +/- 10.43 years. Mean tumor size was 1.95 +/- 0.79 cm. Mean follow-up time was 10.91 months. All procedures were performed without any major complications.

CONCLUSIONS

Our early experience with percutaneous image-guided radiofrequency ablation demonstrates it to be a feasible, safe, noninvasive, and effective treatment of small peripheral renal tumors.

Reassessing the Current TNM Lymph Node Staging for Renal Cell Carcinoma

OBJECTIVE

The most commonly used staging system for renal cell carcinoma (RCC) is the tumor-node-metastasis (TNM) system. In the most recent TNM edition, lymph node (LN) involvement is defined as pN0, pN1, or pN2, depending on the number of metastatic LNs (none, 1, or >1). This study evaluated the prognostic value of this classification and tried to improve its clinical impact by considering an additional parameter, that is, LN density (ratio between number of positive LNs and total number of LNs retrieved).

METHODS

All pathologic reports of radical nephrectomies performed for RCC in two urologic centers between November 1983 and December 1999 were reviewed. For each patient, complete clinical and pathologic data, number of LNs removed, location and number of positive LNs, and LN density were recorded. The Kaplan-Meyer method and the log-rank test were used to calculate cause-specific survival rates and to compare survival curves, respectively.

RESULTS

A total of 735 patients underwent radical nephrectomy. Lymphadenectomy was performed in 618 cases, and the rate of positive LNs was 14.2%. The 5-yr cause-specific survival rate of pN+ patients was 18%, with no statistically significant difference between pN1 and pN2. The average number of LNs removed was 13 (range, 1-35). The median number of LNs involved was 3 (range, 1-18). LN density ranged between 3.7% and 100% (median, 22.9%). The number of LNs removed had no impact on survival in pN+ patients. The only significant unfavorable prognostic factors were >4 LNs involved (p = 0.02) and LN density >60% (p = 0.01).

CONCLUSION

The results show that in RCC the current TNM stratification of positive LNs is not significantly correlated with prognosis. From our data it appears that classification as < or =4 or >4 LNs involved, supported by LN density, better reflects the impact of the disease on survival.

A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma

PURPOSE

We determined the primary pathological features of clear cell renal cell carcinoma that are predictive of positive regional lymph nodes at radical nephrectomy (RN) and developed a protocol for the selective use of extended lymph node dissection.

MATERIALS AND METHODS

We studied 1,652 patients who underwent RN for unilateral pM0 sporadic clear cell renal cell carcinoma between 1970 and 2000. A multivariate logistic regression model was used to determine the pathological features of the primary tumor that were associated with positive regional lymph nodes at RN.

RESULTS

There were 887 (54%) patients with no positive nodes (pN0), 57 (3%) with 1 positive node (pN1), 11 (1%) with 2 or more positive nodes (pN2) and 697 (42%) who did not have any lymph nodes dissected (pNx). Nuclear grade 3 or 4 (p <0.001), presence of a sarcomatoid component (p <0.001), tumor size 10 cm or greater (p = 0.005), tumor stage pT3 or pT4 (p = 0.017) and histological tumor necrosis (p = 0.051) were significantly associated with positive regional lymph nodes in a multivariate setting. These features can be used to identify candidates for extended lymph node dissection at the time of RN. For example, only 6 (0.6%) of the 1,031 patients with 0 or 1 of these features had positive lymph nodes at RN compared with 62 (10%) of the 621 patients with at least 2 of these features.

CONCLUSIONS

The primary tumor pathological features of nuclear grade, sarcomatoid component, tumor size, stage and presence of tumor necrosis can be used to predict patients at the greatest risk for regional lymph node involvement at RN.

The role of lymphadenectomy in renal cell carcinoma

The standard of care for localized and metastatic renal cell carcinoma includes a nephrectomy. The potential benefits for lymphadenectomy include more accurate staging, decreased risk of local recurrence, and improved survival. However, the benefits of lymph node dissection have not been proven.

Hepatic resection for metastatic renal tumors: is it worthwhile?

BACKGROUND

Liver metastases of malignant renal tumors are regarded as having an ominous prognosis because they are infrequently amenable to radical surgery and respond poorly to chemotherapy. Little is known of the outcome of isolated metastases to the liver for which resection is potentially curative.

METHODS

Data on 14 patients with liver metastases from renal tumors who underwent a liver resection in a single center between 1982 and 2001 were analyzed retrospectively.

RESULTS

There was no operative or postoperative mortality. The median survival was 26 months, with a survival rate of 69% at 1 year and 26% at 3 years. The curative pattern of hepatectomy (2-year survival, 69% vs. 0%; P =.001), an interval between the nephrectomy and the diagnosis of liver metastases in excess of 24 months (2-year survival, 71% vs. 25%; P =.05), tumor size <50 mm (2-year survival, 83% vs. 17%; P =.006), and the possibility of achieving a repeat hepatectomy in the case of recurrence (2-year survival, 100% vs. 21%; P =.02) were associated with a better outcome after the liver resection. Four patients were alive without evidence of disease at 6, 12, 26, and 96 months after the first hepatic resection, and one was alive with hepatic recurrence 18 months after resection.

CONCLUSIONS

In patients with liver metastases of malignant renal tumors, an aggressive policy for achieving tumor eradication seems to offer a chance for long-term survival, especially after a long disease-free interval from the nephrectomy. However, despite an aggressive policy for achieving tumor eradication, recurrence frequently occurs after liver resection.

The number of lymph nodes examined and staging accuracy in renal cell carcinoma

OBJECTIVE

To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC).

PATIENTS AND METHODS

We reviewed the operative and pathology reports of 725 patients with RCC submitted for RN. All tumours were classified using the fifth edition of the Tumour-Nodes-Metastasis classification. For each patient the number of lymph nodes removed was recorded. The patients were divided into five different groups according to the number of nodes removed, i.e. group 1, 1-4; group 2, 5-8; group 3, 9-12; group 4, 13-16; and group 5, >or= 17. We evaluated the factors that affected the number of lymph nodes removed with nodal dissection and the variables that influenced the incidence of nodal involvement.

RESULTS

Lymphadenectomy was performed in 608 patients (83.8%); in these patients the rate of lymph node metastases was 13.6%. The median (range) number of nodes removed was 9 (1-43); there was a statistically significant correlation between the number of nodes removed and the percentage of nodal involvement (r = 0.6; P < 0.01). The rate of pN+ was significantly higher in the patients with >or= 13 than in those with < 13 nodes examined (20.8% vs 10.2%; P < 0.001). For organ-confined and locally advanced tumours there was a statistically significant difference in the pN+ rate between patients with < 13 or >or= 13 nodes examined (3.4% vs 10.5%, and 19.7% vs. 32.2%, respectively).

CONCLUSIONS

The proportion of tumours classified as pN+ increased with the number of lymph nodes examined. In RCC,> 12 lymph nodes need to be assessed for optimal staging.

Magnetic resonance imaging-guided laser thermal ablation of renal tumours

OBJECTIVE

To test the hypothesis that magnetic resonance imaging (MRI)-guided laser thermal ablation (LTA) of inoperable renal tumours is a safe, tolerable and potentially effective treatment.

PATIENTS AND METHODS

Nine patients (aged 56-81 years) with malignant renal tumours underwent percutaneous LTA under MRI guidance in a 0.5 T open magnet. Real-time colour thermal mapping was used to monitor tumour ablation, and the follow-up was with gadolinium-enhanced MRI at 6 weeks and (where appropriate) 3-4 months after the procedure. Tumour volume and percentage tumour enhancement before and after ablation were compared. The percentage of tumour ablated on real-time T1-weighted thermal maps was compared with that on gadolinium-enhanced follow-up MRI.

RESULTS

The mean (range) follow-up was 16.9 (3-32) months after the first ablation. The mean tumour size did not change significantly, but the mean percentage of viable tumour decreased significantly from 73.7% before to 29.5% after ablation (P = 0.012, Wilcoxon signed-ranks test). Thermal maps correlated moderately well with follow-up MRI in predicting the extent of tumour ablation (Pearson correlation coefficient 0.55). There were two minor and one major complication.

CONCLUSION

In this pilot study of patients unsuitable for surgery, MRI-guided LTA of renal tumours was safe, feasible (being well tolerated by the patient) and significantly reduced enhancing tumour volume by a mean of 45%.

[Renal surgery]

Predominantly during the past century. This review paper addresses the most relevant issues in the historic evolution of renal surgery and establishes the criteria that guide the current situation in the most prevalent and relevant renal conditions (neoplasia, lithiasis, infections and transplantation). Eventually, the attitudes which in the author's opinion will guide the future of renal surgery are established.

Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma

PURPOSE

We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma.

MATERIALS AND METHODS

Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status.

RESULTS

In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate.

CONCLUSIONS

Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.

The role of resection for patients with renal carcinoma

Metastatic renal cancer is responsive in some cases to immunotherapeutic agents. Indications for nephrectomy in the face of metastatic disease have traditionally included palliation of symptoms caused by the primary tumor, and nephrectomy combined with metastatectomy in patients with resectable metastases. Recent findings from a Southwest Oncology Group trial strongly suggest that cytoreductive nephrectomy, combined with immunotherapy, may also result in improved survival in patients with unresectable metastases.

Should laparoscopy be the standard approach used for radical nephrectomy?

Since its inception in June 1990, laparoscopic radical/total nephrectomy for renal tumor has been successfully applied worldwide to hundreds of patients. Recent 5-year follow-up data have shown this procedure to produce cancer control identical to that of open radical/total nephrectomy. Although in most centers the cost of the procedure remains higher than open surgery, the patient benefits of decreased pain, reduced hospitalization, less blood loss, and more rapid convalescence appear to be universal. At this time, we believe that laparoscopic radical/total nephrectomy for the treatment of renal tumors should become the new standard of care.

Independent value of tumor size and DNA ploidy for the prediction of disease progression in patients with organ-confined renal cell carcinoma

BACKGROUND

Greater than 20% of patients with apparently localized renal cell carcinoma (RCC) present with disease progression after surgery. The objective of the current study was to improve the ability of clinicians to predict prognosis in patients with localized RCC.

METHODS

The authors studied 154 patients with organ-confined RCC classified as pT1 to pT2-pN0-M0 who underwent radical nephrectomy. Follow-up ranged from 24-128 months (median, 72 months). Several morphologic parameters of the tumor were considered. DNA content was analyzed by flow cytometry and tumor size was determined from the surgical specimen. A Cox proportional hazards regression model was used to identify significant independent prognostic factors for disease progression.

RESULTS

At 5 and 10 years of follow-up, disease free survival was found to be 87% and 86%, respectively. Univariate analysis revealed that DNA content, Furhman grade, and tumor size had a statistically significant predictive value for disease progression, whereas, with regard to grade, the difference was significant only between patients with Grade 3 tumors and all other patients with Grade 1-2 tumors (P < 0. 0001). Although DNA content was found to correlate with tumor size (P < 0.0001), multivariate analysis showed that these were the only significant independent predictors of disease progression. The sum of DNA content and tumor size therefore was considered to distinguish separate risk groups. For a patient with diploid RCC, the risk of progression increased from 4% if the tumor size was 3 cm to 43% if the tumor size was 10 cm. For a patient with nondiploid RCC, this risk was 32% if the tumor size was 3 cm, increasing to 99% for tumors measuring 10 cm.

CONCLUSIONS

Stratification of organ-confined RCC according to tumor size and DNA content could possibly provide more information that could be useful in the selection of individuals with significantly different risks of disease progression.

Right Heart Bypass for Inferior Vena Cava Tumor Thrombus Extending into Heart

Radical nephrectomy with en bloc inferior vena caval tumor thrombectomy improves survival in patients with renal cell carcinoma with a tumor thrombus extending into the inferior vena cava. Cardiopulmonary bypass with or without deep-hypothermic circulatory arrest is advocated when the tumor thrombus extends into the right heart chambers. Right heart bypass was used to remove such a tumor thrombus successfully for the first time in a patient with renal cell carcinoma.

MR-guided laser thermoablation of inoperable renal tumors in an open-configuration interventional MR scanner: preliminary clinical experience in three cases

A minimally invasive technique for performing magnetic resonance (MR)-guided laser interstitial thermoablation (LITT) for inoperable renal tumors is described. Three patients were treated using a percutaneous technique with real-time MR guidance in an open access interventional MR scanner. Laser therapy was delivered using a neodymium-YAG source via a water-cooled applicator system. Thermal lesions were monitored in real time using a color thermometry sequence. All patients were discharged the following day with no complications. Follow-up with gadolinium-enhanced MRI in a conventional high-field system confirmed necrosis in targeted tissue, and further treatment is planned for one patient. We concluded that LITT can be useful in treating inoperable renal malignancy and merits further evaluation. J. Magn. Reson. Imaging 1999;10:545-549.

Prognostic index of renal carcinomas

Authors analysed the survival of 126 patients operated for kidney carcinomas. The data on anamnesis, laboratory results and TNM histological classification were compared with the results on "relative survival" and correlation analysis was performed. Based on these, the 12 most important criteria (with the highest correlation coefficient) were emphasized and regression equation was formed based on the TSP (Time Series Processing) Version 4 (Hall). Using this method, a numerical prognostic index can be established for the judgement of prognosis regarding certain patients.

Expression of globo-series gangliosides in human renal cell carcinoma

Gangliosides have been shown to be involved in development, differentiation, oncogenesis, and cancer progression. We investigated immunohistochemical expression of globo-series gangliosides in human renal cell carcinoma (RCC) and whether their expression is related to the clinical course. The expression of globo-series gangliosides was evaluated in fresh-frozen sections of 55 primary renal tumors and 8 metastatic deposits using monoclonal antibodies RM1 and RM2, which define monosialosyl and disialosyl galactosylgloboside, respectively. The immunoreactivity of primary tumors to RM1 and/or RM2 was correlated with the clinicopathological data. Cumulative incidence of metastasis detected at initial diagnosis and during the follow-up period was significantly higher in the cases whose primary tumors were RM1/RM2-positive (RM1 and/or RM2-positive) than in the RM1/ RM2-negative (neither RM1 nor RM2-positive) cases (P < 0.05). During the follow-up period, metastasis developed in none of the RM1/RM2-negative cases which had not shown metastasis at initial diagnosis. High nuclear grade was observed only in the RM1/RM2-positive cases. The RM1/RM2-positive rate of the metastatic deposits was higher than that of the primary tumors. Furthermore, a metastatic deposit obtained from one of the cases whose primary tumors were equivocal for RM1/ RM2 was extensively stained by RM1 and RM2. These results indicate that globo-series gangliosides may be one of the biochemical indicators related to the metastatic potential of human RCC.

Renal neoplasm: The prognostic significance of nodal involvement

– Histologically-proven positive nodal involvement has a markedly negative affect on the prognosis of patients subjected to surgery for renal neoplasm. The incidence of nodal metastases reported in literature is wide-ranging and depends on various factors. A critical retrospective evaluation of literature in terms of survival curves and prognostic factor analysis highlights a particularly heterogeneous picture, due to much methodological bias and frequent violation of assumptions of the statistical analyses used. All these factors prevent a precise, independent prognostic value from being assigned to nodal involvement. The results of the single randomised prospective study (protocom EORTC 30881) on the therapeutic effectiveness of lymphadenectomy have been weakened by the low reported incidence of nodal involvement (about 5%). One of the most plausible explanations for this is the change in the natural history of renal tumours, which are currently diagnosed at low volume and stage, with a consequently low rate of nodal and/or distant metastases. This change in the natural history of the disease has increased the frequency of non-elective nephron-sparing surgery with optional nodal dissection over the last few years. This new approach has weakened the traditionally recognised role of lymphadenectomy in staging the disease.

Flow cytometry in renal cell carcinoma

– The most important prognostic factors in renal carcinoma are the stage and grade. World literature is full of information on new markers, the analysis of DNA with the cytofluorimetric method being foremost, as it allows the cell lines in the neoplasm to be assessed and at the same time the ploidy and cell cycle stages to be studied. We have found an excellent correlation between the ploidy and cell grade. After a preliminary study we can conclude that the method is easy to perform and to reproduce. The procedure is also interesting for retrospective studies which allow the pathologist to select the blocks to be examined, thereby avoiding those widely contaminated by hemorrhages or necrosis.

Suprarenal inferior vena cava filter placement prior to transcatheter arterial embolization (TAE) of a renal cell carcinoma with large renal vein tumor thrombus: prevention of pulmonary tumor emboli after TAE

To prevent embolization of necrotic renal vein tumor after transcatheter embolization of a left renal cell carcinoma, we placed a suprarenal Bird's nest inferior vena cava filter. The patient tolerated the procedure well and had extensive tumor infarction including the tumor thrombus on 6-month follow-up computed tomography.

Imaging in the staging of renal cell carcinoma

Imaging is extremely important in determining the type of surgery undertaken in patients with proven renal cell carcinoma. In this review, the strength and limitations of each of the relevant techniques are outlined, highlighting particularly the correlation between the imaging findings and the pathological staging. Over the past decade, CT has become the most widely used technique for staging renal cell carcinoma, partly due to the very high overall accuracy of up to 90% that has been achieved. MRI appears to have a similar overall accuracy to CT, whereas ultrasound is less accurate than CT or MRI in the overall staging of tumours. However, ultrasound is extremely accurate in identifying and localising the clinically important tumour extension into the intra-hepatic vena cava and right atrium and if local surgical practice requires only a knowledge of venous invasion, a technically adequate ultrasound examination may suffice. All techniques are unreliable in detecting early perinephric spread.

Flow-cytometric DNA analysis of paraffin-embedded renal cell carcinoma tissue from patients treated by parenchymal-sparing surgery

OBJECTIVE

To determine the utility of deoxyribonucleic acid (DNA) ploidy pattern, detected by flow cytometry, in predicting the outcome of renal cell carcinoma (RCC).

PATIENTS AND METHODS

DNA content was retrospectively assessed by flow cytometry in 28 primary paraffin-embedded RCCs from 24 patients (16 men and eight women, mean age 61.9 years, range 40-89) who had undergone renal parenchymal-sparing surgery.

RESULTS

Tumour recurred locally in three patients, two with diploid tumours and one with aneuploid tumour. Two patients with diploid tumours had metastatic disease 11-58 months after surgery. Only one patient with aneuploid tumour developed metastatic disease. There was no difference in local recurrence or metastases with the type of renal parenchymal-sparing surgery used (enucleation or partial nephrectomy) nor any significant difference in overall survival (P = 0.11).

CONCLUSION

While DNA content might be of considerable predictive value for patients with RCC, these results showed that there was no difference in mortality rate, recurrence rate, or type of renal parenchymal-sparing surgery used between aneuploid and diploid tumours.

The role of nuclear morphometry for predicting disease outcome in patients with localized renal cell carcinoma

BACKGROUND

More than one-third of patients with localized renal cell carcinoma (RCC) will have disease progression after nephrectomy. Present histopathologic variables cannot accurately predict the outcome of individual patients.

METHODS

Nuclear morphometry was performed by an image analyzer on histologic sections from 39 specimens of pathologic T1 and T2 classification RCC. All patients underwent radical nephrectomy and were followed for a mean of 7.6 years. A univariate analysis and then a multivariate stepwise regression method were used to correlate results with patients' outcome.

RESULTS

The best predictors of disease free interval were mean nuclear elongation factor (MNEF) (P = 0.023), mean nuclear regularity factor (MNRF) (P = 0.034), and mean nuclear area (MNA) (N = 0.038). Univariate analysis identified a significant correlation between patient survival and MNEF (P = 0.009), MNRF (P = 0.020) and MNA (P = 0.023). Combination of MNEF and MNA was even more strongly associated with survival (P = 0.0013). Multivariate analysis revealed that MNA (P = 0.044) and MNEF (P = 0.045) correlated independently with survival.

CONCLUSION

These results suggest that nuclear morphometry provides objective independent prognostic information for patients with localized RCC.

Pulmonary tumour and inferior vena cava tumour thrombus: rare presentation of renal transitional cell carcinoma. Case report

A transitional cell carcinoma from the pyelocaliceal system, initially presenting as a pulmonary tumour, extended into the inferior vena cava, the tenth reported case of this type. The literature is reviewed with special reference to vena cava involvement by such tumours and immunohistochemical staining pattern.

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.

A solitary and synchronous metastasis of renal cell carcinoma to the bladder

We report a case of renal cell carcinoma with solitary metastasis to the bladder which occurred and was treated synchronously. The mode of spread and possible treatment modalities are discussed with relevant information from the literature.

Metastatic renal cell carcinoma to the contralateral ureter

Renal cell carcinoma uncommonly metastasizes to the ureter, with only rare reports of metastatic lesions developing in the contralateral side. Recently at our institution, two patients presented with contralateral ureteral metastases from a primary renal adenocarcinoma; one was synchronous and the second metachronous. Following extensive metastatic evaluations, both lesions were believed to be solitary metastases. The involved ureters were managed with total ureterectomy and construction of an ileal ureter. We report these two cases and review the literature.

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: an institutional review

BACKGROUND

Solitary metastases from a primary renal cell carcinoma (RCC) occur in < 10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented.

MATERIALS AND METHODS

Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970-1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded.

RESULTS

Metastases were intrathoracic (n = 20), intracranial (n = 7), and intraabdominal or in the extrapleural chest wall soft tissue (n = 10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival.

CONCLUSION

A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances.