Factors of importance for prediction of survival in patients with metastatic renal cell carcinoma, treated with or without nephrectomy.

OBJECTIVE: The indications for nephrectomy in patients with metastatic renal cell carcinoma remain controversial. A number of variables were analysed to identify factors that might predict the survival time, and these factors were used to obtain guidance as to which patients might benefit from palliative nephrectomy. MATERIAL AND METHODS: We reviewed the medical records for 106 consecutive patients with primary metastatic renal cell carcinoma, including clinicopathological factors, routine laboratory data and metastatic spread. The association of the different factors to survival time was evaluated by univariate and multivariate analysis. RESULTS: A number of factors correlated to survival time in univariate analysis, including solitary versus multiple metastases, serum albumin and DNA ploidy, but after Cox multivariate analysis their significance was lost. The remaining independent prognostic factors were performance status, number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum and vein invasion with tumour thrombus formation. The factors with no association to survival time were the metastatic sites, tumour size and nuclear grade. Patients treated with nephrectomy had a significantly longer survival time than those who did not undergo nephrectomy (p < 0.001). None of the 28 patients who did not undergo nephrectomy survived for 2 years, compared with 38 of the 78 patients who were nephrectomized. CONCLUSIONS: Patients who can be expected to survive longer, and who might be recommended for nephrectomy despite metastatic disease, would have the following independent factors: a good performance status, metastases limited to one organ, low ESR, normal calcium in serum and no tumour thrombus formation.

Prognostic significance of the Heidelberg classification of renal cell carcinoma.

OBJECTIVE: The specific genetic alterations characterising renal cell carcinoma (RCC) have lead to the recognition of distinctive types of tumours. In a large material of patients, the prognostic and clinical information of these different tumour types were evaluated. METHODS: Tumours from 186 patients were evaluated retrospectively according to the guidelines given by the Heidelberg Classification Conference. All patients were primarily nephrectomised and TNM staged, and the follow-up times for alive patients varied between 44 and 174 months. RESULTS: The material consisted of 145 conventional (non-papillary), 25 papillary, 12 chromophobe and 4 unclassified RCCs. There was no difference in tumour size between the different RCC types. Among patients with conventional RCC, 37% had distant metastases at the time of diagnosis, significantly more frequently than 16% in patients with papillary and 8% in chromophobe RCC (p = 0.044 and 0.048, respectively). Conventional RCC more frequently had vein invasion compared with papillary RCC (p = 0.009). Patients with chromophobe and papillary RCC survived significantly longer than patients with conventional RCC (p = 0.017 and 0.031, respectively). CONCLUSIONS: A significant difference in clinical behaviour between the different RCC types was found. Patients with conventional RCC had a higher incidence of metastases, vein invasion and had adverse survival compared with papillary and chromophobe RCCs. Thus, the RCC types recognised by specific genetic alterations seem to represent different malignant phenotypes.

Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy.

OBJECTIVE: To define guidelines for the follow-up management of nonmetastatic renal cell carcinoma (RCC), by assessing tumour recurrences and the clinical course in patients who had undergone radical nephrectomy. PATIENTS AND METHODS: The records of 187 patients with pT1-3, N0-X, M0 RCC who underwent radical nephrectomy between 1982 and 1997 were reviewed prospectively. Clinicopathological variables were compared with the time of first recurrence, site of metastasis and reason for diagnosis. RESULTS: Metastases were diagnosed in 98 sites in 56 of the 187 patients (30%). The risk for developing metastases increased with stage; 80% of the patients had their metastases diagnosed within 3 years (median 14.5 months) after nephrectomy. The time to first diagnosis was longer for patients with pT1 tumours and for those with skeletal metastases. The cause-specific 5-year survival rate for pT1 tumours was 95%, for pT2 87% and for pT3 tumours 37%. All patients with diploid pT1-2 RCC survived, having a survival advantage over those with aneuploid pT1-2 tumours (P=0.018). Also, pT1-2 tumours of < 5 cm were associated with better survival rates. Among 74 patients with pT3 tumours, 45 got metastases; DNA ploidy in these tumours did not influence survival. Of 30 patients with lung metastases, 28 were diagnosed during follow-up, while 25 of 26 other metastatic sites were diagnosed because of symptoms. CONCLUSIONS: The risk for tumour progression depends mainly on stage; these results indicate no need for follow-up in patients with diploid pT1-2 tumours or with aneuploid pT1 tumours of < 5 cm. For patients with aneuploid pT1-2 tumours of > 5 cm and pT3 tumours, follow-up is indicated.

Radical nephrectomy is still preferable in the treatment of localized renal cell carcinoma. A long-term follow-up study.

OBJECTIVES: Due to the advances of radiological methods, an increased number of incidentally detected renal cell carcinomas is diagnosed. The reported excellent results of nephron-sparing surgery have promoted its application in patients with a normal contralateral kidney. However, the risk of local tumor recurrence and surgical complications after nephron-sparing surgery might be higher compared with radical nephrectomy. METHODS: In 89 patients with localized renal cell carcinoma treated with radical nephrectomy, long-term renal function, morbidity, and survival were evaluated. The renal function was followed up regularly with serum creatinine measurements. RESULTS: The cause-specific 5-year survival rate was 91.6%. There was neither local nor contralateral kidney tumor recurrence in any patient. Surgical complications were observed in 3% of the patients. Mean serum creatinine after the nephrectomy was 123 mumol/l without further increase during 10 years of follow-up. CONCLUSIONS: Radical nephrectomy of localized renal cell carcinoma has low morbidity, excellent local tumor control, and a high survival rate. For patients with a normally functioning contralateral kidney the long-term renal function remained adequate. Based on these data, there is no convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a normally functioning contralateral kidney.