Survival after complete surgical resection of multiple metastases from renal cell carcinoma.

BACKGROUND: Although a role for resection of solitary metastases from renal cell carcinoma (RCC) has been described, the utility of surgery in patients with multiple sites of disease has been less well defined. The authors report the survival of patients who underwent complete metastasectomy for multiple RCC metastases. METHODS: The authors identified 887 patients who underwent nephrectomy for RCC between 1976 and 2006 who developed multiple metastatic lesions. The impact of complete metastasectomy on survival was evaluated controlling for the timing, location, and number of metastases and for patient performance status. RESULTS: Of 887 patients, 125 (14%) underwent complete surgical resection of all metastases. Complete metastasectomy was associated with a significant prolongation of median cancer-specific survival (CSS) (4.8 years vs 1.3 years; P < .001). Patients who had lung-only metastases had a 5-year CSS rate of 73.6% with complete resection versus 19% without complete resection (P < .001). A survival advantage from complete metastasectomy also was observed among patients with multiple, nonlung-only metastases, who had a 5-year CSS rate of 32.5% with complete resection versus 12.4% without complete resection (P < .001). Complete resection remained predictive of improved CSS for patients who had ≥ 3 metastatic lesions (P < .001) and for patients who had synchronous (P < .001) and asynchronous (P = .002) multiple metastases. Moreover, on multivariate analysis, the absence of complete metastasectomy was associated significantly with an increased risk of death from RCC (hazard ratio, 2.91; 95% confidence interval, 2.17-3.90; P < .001). CONCLUSIONS: The current results indicated that complete resection of multiple RCC metastases may be associated with long-term survival and should be considered when technically feasible in appropriate surgical candidates.

Independent validation of the 2010 American Joint Committee on Cancer TNM classification for renal cell carcinoma: results from a large, single institution cohort.

PURPOSE: In 2010 the American Joint Committee on Cancer updated the renal cell carcinoma TNM classification. Without independent validation of the new classification its predictive ability for cancer specific survival and generalizability remains unknown. In this setting we determined the predictive ability of the 2010 TNM classification compared to that of the 2002 classification. MATERIALS AND METHODS: Using the nephrectomy registry at our institution we retrospectively reviewed the records of 3,996 patients with unilateral or bilateral synchronous renal cell carcinoma treated with radical nephrectomy or nephron sparing surgery between 1970 and 2006. Cancer specific survival was estimated using the Kaplan-Meier method and predictive ability was evaluated using the concordance index. RESULTS: There were 1,165 deaths (29.1%) from renal cell carcinoma a median of 1.9 years after surgery compared to a median followup of 7.4 years for survivors. The estimated 10-year cancer specific survival rate was 96%, 80%, 66%, 55%, 36%, 26%, 25% and 12% for patients with 2010 primary tumor classifications of pT1a, pT1b, pT2a, pT2b, pT3a, pT3b, pT3c and pT4, respectively (p <0.001). The multivariate concordance index for the 2002 and 2010 TNM classifications was 0.848 and 0.850, respectively. CONCLUSIONS: The new 2010 classification remains a robust predictor of cancer specific survival compared to the 2002 classification by dividing pT2 lesions into pT2a and pT2b, reclassifying ipsilateral adrenal involvement as pT4, reclassifying renal vein involvement as pT3a and simplifying nodal involvement as pN0 vs pN1. However, the 2010 TNM classification showed only modest improvement in predictive ability compared to the 2002 classification.

Increasing prevalence and associated risk factors for methicillin resistant Staphylococcus aureus bacteriuria.

PURPOSE: Infections due to methicillin resistant Staphylococcus aureus are becoming increasingly prevalent in hospitals and in the community. We reviewed our institutional experience to determine whether methicillin resistant S. aureus is becoming a more common cause of bacteriuria and to determine if there are specific risk factors that may predict the development of methicillin resistant S. aureus bacteriuria. MATERIALS AND METHODS: We reviewed all urine cultures with a pure growth of a single organism obtained at our institution from 1997 and 2007. Patients with urine cultures positive for methicillin resistant S. aureus were compared to a cohort with cultures positive for methicillin sensitive S. aureus, and to a third cohort with cultures positive for Escherichia coli to determine patient characteristics and associated risk factors. RESULTS: We identified 7,100 and 9,985 positive urine cultures performed in 1997 and 2007, respectively. The most common urinary organism was E. coli. The number of patients with methicillin resistant S. aureus bacteriuria increased from 18 (0.3%) to 74 (0.8%) (p <0.001). On multivariate analysis older age (p = 0.004), catheter use (p = 0.004), hospital exposure (p <0.001) and patient comorbidity (p <0.001) were associated with methicillin resistant S. aureus bacteriuria compared with E. coli bacteriuria. CONCLUSIONS: Methicillin resistant S. aureus remains rare as a cause of bacteriuria but its incidence has increased during the last decade. Risk factors for methicillin resistant S. aureus bacteriuria include increased age, patient comorbidity, hospital exposure and catheter use. For patients with these risk factors and new onset urinary symptoms, methicillin resistant S. aureus should be considered a possible cause of urinary tract infection.

Superficial genitourinary abscesses in children: emergence of methicillin resistant Staphylococcus aureus.

PURPOSE: The prevalence of methicillin resistant Staphylococcus aureus is increasing. However, little is known about methicillin resistant S. aureus in the genitourinary tract, particularly in children. We assessed the incidence of pediatric genitourinary methicillin resistant S. aureus superficial abscess requiring surgical intervention. MATERIALS AND METHODS: We reviewed the records of all children undergoing surgical debridement of superficial abscess at a single institution between 1995 and 2007. We assessed surgical site, organism identity, patient comorbidity, methicillin resistant S. aureus risk factors, number of procedures and patient outcome. RESULTS: Surgical debridement of a superficial genitourinary abscess was performed in 60 children. Patient age ranged from 29 days to 17 years (median 3 years). A single debridement was generally curative, with only 5 patients (8.3%) requiring more than 1 procedure. One patient (1.7%) died of sepsis postoperatively due to Pseudomonas infection. One patient had myelomeningocele, 1 had undergone renal transplant and 2 were undergoing chemotherapy at the time of debridement. None of these 3 patients had a methicillin resistant S. aureus infection. Methicillin resistant S. aureus was more common in the groin/genitalia and less common in the perineum (p = 0.007). The incidence of methicillin resistant S. aureus increased during the study period, accounting for none of 40 infections between 1995 and 2003, and 8 of 20 (40%) from 2004 to 2007 (p <0.001). CONCLUSIONS: Methicillin resistant S. aureus has become the predominant organism causing pediatric superficial genitourinary abscesses at our institution, accounting for three-quarters of all surgically managed infections in the last 2 years. Methicillin resistant S. aureus was more common at the groin and genitalia. One debridement was generally curative, and patient morbidity was low with aggressive treatment.