Development of renal cell carcinoma (RCC) diagnostics and impact on prognosis.

OBJECTIVE: To evaluate imaging methods and prognoses between small renal cell carcinomas (RCCs) and larger tumours according to the era of diagnostics. PATIENTS AND METHODS: In all, 784 consecutive patients diagnosed with RCC between 1964 and 1997 at the Pirkanmaa Hospital District in Finland were included. Patients were divided into two groups: tumours of ≤3.0 and >3.0 cm in diameter. Prognosis was analysed according to the era of diagnostics: (i) pre-computed tomography (CT) and pre-ultrasound (US), (ii) US era and (iii) CT era. RESULTS: Small tumours became more common: in the pre-CT and pre-US era, only 4.4% of tumours were small; however, in the CT era 16% were small tumours. More diagnostic methods were used in studying small tumours. CT proved to be the most reliable method, although it was actually better at diagnosing large tumours. Relapses occurred less frequently among patients with small tumours; more than half of the tumours that developed distant metastases (16.0%) already evinced them at the time of diagnosis. There were no relapses after 14 years of follow-up among small tumours, whereas large tumours relapsed within that time. RCC was the cause of death in 14.9% of patients with small tumours vs 50.7% with large tumours. The best prognosis was among patients with small tumours diagnosed with CT. CONCLUSION: Among patients with small tumours, prognosis has improved along with better diagnostics, although some showed relapse during a surveillance period of up to 14 years.

Changes in symptoms of renal cell carcinoma over four decades.

OBJECTIVE: To determine whether there has been a change in typical symptoms of renal cell carcinoma (RCC), by evaluating the symptoms of patients diagnosed during four decades, as although the increasing incidence of a diagnosis of incidental RCC has been widely reported, the change in other symptoms has not. PATIENTS AND METHODS: The study included RCC cases diagnosed in the Pirkanmaa Hospital District between 1964 and 1997. The original medical records of 970 patients with 982 RCC tumours were analysed. Primary symptoms were recorded and changes were analysed in three groups, i.e. diagnoses made before 1980, in the 1980s and in the 1990s. Symptoms were also analysed according to stage, tumour class, gender and age. RESULTS: The incidence of haematuria (P < 0.01) and an increased erythrocyte sedimentation rate (P < 0.001) decreased, but there was no change in other symptoms. Incidental diagnoses increased from 12% to 19% (P < 0.01). Less chronic or systemic symptoms were noted more recently. Stage and tumour class were highly correlated with symptoms: systemic symptoms increased (24% in stage I to 72% in stage IV, a highly statistically significant increase) and asymptomatic tumours became rarer (27% in stage I to 8% in stage IV, again a highly significant increase) with increasing stage. Haematuria was more common in male patients, anaemia and flank pain in women. Elderly patients were more often asymptomatic than younger patients, with 70-79-year-olds being the least symptomatic. CONCLUSIONS: Incidental cases of RCC have recently become more common. Haematuria, hypersedimentation, chronic and systemic symptoms have decreased. Stage, tumour class, gender and age are correlated with symptoms.

Prognostic factors and long-term survival in renal cell cancer patients.

OBJECTIVE: The long-term survival of renal cell cancer (RCC) patients is not reported in the recent literature. This study evaluated the significance of known clinical prognostic factors and long-term survival in a large centrally treated Finnish RCC population. MATERIAL AND METHODS: In 948 patients diagnosed between 1964 and 1997 the relative overall survival (OS) was calculated up to 25 years by Bayesian analysis and the life-table method. The effect of gender, age, cancer stage, TNM (tumour, node, metastasis) class, Fuhrman's grade, symptoms and year of diagnosis was studied. RESULTS: Women and patients aged 40-49 years had better survival. Stage, TNM class and grade proved relevant for prognosis. The relative 5-year overall survival was 88%, 63%, 65% and 15% in stages I-IV, respectively. Asymptomatic patients had better survival, their median survival being 8.1 years as against 9.1 years in patients with local symptoms and only 1.7 years in patients with systemic symptoms. The year of diagnosis was not significant in prognosis. CONCLUSIONS: The most important explanatory factors were stage, age and clinical presentation of the tumour. RCC patients showed diminishing overall survival in the follow-up, with no plateau; almost 57% of patients developed local recurrence or distant metastases even after a very long disease-free interval.

Validation of a preoperative risk index as a predictor of perioperative morbidity and hospital costs in coronary artery bypass graft surgery.

OBJECTIVE: To validate a previously developed model (CABDEAL) for predicting postoperative morbidity for coronary artery bypass graft (CABG) surgery patients using the New York State Statewide Planning and Research Cooperative System (SPARCS) database and to examine the effects of preoperative risk factors, postoperative complications, and death on costs of care for CABG surgery. DESIGN: Retrospective database review. SETTING: Governmental agency database of cardiac surgery. PARTICIPANTS: CABG surgery patients (n = 15,388). INTERVENTIONS: A previously developed preoperative risk model (CABDEAL) was applied to all patients. Predicted length of hospital stay and costs were compared with actual length of stay and costs, using a charge-to-cost conversion formula. MEASUREMENTS AND MAIN RESULTS: The CABDEAL model was moderately predictive of outcomes. The specificity was 64%, the sensitivity was 73.8%, and the receiver operating characteristic curve area was 0.728. Morbidity in the form of postoperative complications was recorded in 24.5% (3,770 patients), and the mortality rate was 3.4% (527 patients). The mean (+/- SD) total hospital cost was 28,408 US dollars +/-28,982, and the median cost was 21,644 US dollars. Based on the linear regression model, an equation was developed for predicting total costs: Cost (in US dollars) = 22,952 + (3,277. [CABDEAL score]). CONCLUSION: The previously developed CABDEAL model was predictive of increased morbidity in the SPARCS database. Total hospital costs increased nearly linearly with increasing CABDEAL score. These results encourage the development of models for preoperative estimation of costs related to perioperative morbidity.

Performance of three preoperative risk indices; CABDEAL, EuroSCORE and Cleveland models in a prospective coronary bypass database.

OBJECTIVES: The aim of the present study was to evaluate the performance of three different preoperative risk models in the prediction of postoperative morbidity and mortality in coronary artery bypass (CAB) surgery. METHODS: Data on 1132 consecutive CAB patients were prospectively collected, including preoperative risk factors and postoperative morbidity and in-hospital mortality. The preoperative risk models CABDEAL, EuroSCORE and Cleveland model were used to predict morbidity and mortality. A C statistic (receiver operating characteristic (ROC) curve) was used to test the discrimination of these models. RESULTS: The area under the ROC curve for morbidity was 0.772 for the CABDEAL, 0.694 for the EuroSCORE and 0.686 for the Cleveland model. Major morbidity due to postoperative complications occurred in 268 patients (23.6%). The mortality rate was 3.4% (n=38 patients). The ROC curve areas for prediction of mortality were 0.711 for the CABDEAL, 0.826 for the EuroSCORE and 0.858 for the Cleveland model. CONCLUSIONS: The CABDEAL model was initially developed for the prediction of major morbidity. Thus, it is not surprising that this model evinced the highest predictive value for increased morbidity in this database. Both the Cleveland and the EuroSCORE models were better predictive of mortality. These results have implications for the selection of risk indices for different purposes. The simple additive CABDEAL model can be used as a hand-held model for preoperative estimation of patients' risk of postoperative morbidity, while the EuroSCORE and Cleveland models are to be preferred for the prediction of mortality in a large patient sample.