Comparison of presentation and outcome for patients 18 to 40 and 60 to 70 years old with solid renal masses.

PURPOSE: We compared histological subtype, pathological features and outcome of patients with solid renal masses who were 18 to 40 years old vs patients who were 60 to 70 years old. MATERIALS AND METHODS: We conducted a retrospective review of the Mayo Clinic Nephrectomy Registry from 1970 to 2000, and identified 124 patients 18 to 40 years old and 1,067 patients 60 to 70 years old available for analysis. RESULTS: There was no significant difference in the incidence of benign solid renal masses between patients 18 to 40 years old and those 60 to 70 years old (13.7% vs 10.2%). Among patients with renal cell carcinoma (RCC), younger patients were more likely to have chromophobe RCC (13.1% vs 3.6%) and less likely to have clear cell RCC (70.1% vs 81.5%) than older patients. Among patients with clear cell RCC, younger patients were more likely to have stage pT2b or lower tumors (82.7% vs 69.9%) and a higher incidence of cystic clear cell RCC (10.7% vs 2.2%) than older patients. Younger patients had an improved cancer specific survival compared with older patients but this difference was not statistically significant (risk ratio 0.71, p =0.127). CONCLUSIONS: We found that patients 18 to 40 years old were more likely to have chromophobe and less likely to have clear cell RCC compared with patients 60 to 70 years old. We did not identify a higher incidence of papillary RCC in younger patients. Patients with clear cell RCC 18 to 40 years old had a higher incidence of low stage and cystic tumors compared with patients 60 to 70 years old, features which have been shown to have a favorable prognosis. These factors likely contributed to improved cancer specific survival for younger patients.

Prognostic features of pathologic stage T1 renal cell carcinoma after radical nephrectomy.

OBJECTIVES: To assess the effect of renal cell carcinoma (RCC) subtype, tumor size, and Fuhrman grade on clinical outcome in patients with pathologic T1 (pT1) RCC treated with radical nephrectomy. METHODS: Between 1970 and 1998, 840 patients underwent radical nephrectomy for pT1 RCC. Tumors were subtyped and graded. Univariate and multivariate Cox proportional hazards models were fitted to assess the features associated with metastasis-free survival (MFS) and cancer-specific survival (CSS). We identified a range of tumor sizes of clear cell RCC in which a transition occurred from low to high risk. Cox proportional hazards models were then fitted by using size cutoffs. RESULTS: The mean follow-up (+/- SD) was 9.4 +/- 6.6 years among the patients alive at latest follow-up. At 10 years, the CSS and MFS for clear cell RCC (n = 682) were 89.1% and 88.6%, respectively; for papillary RCC (n = 122), they were 95.5% and 93.8%; and for chromophobe RCC (n = 33), they were both 100%. The differences in CSS (P = 0.013) and MFS (P = 0.023) between clear cell RCC and the other subtypes were statistically significant. For clear cell RCC, tumor size and Fuhrman grade were independently associated with CSS and MFS (P <0.001). A transition in risk occurred for tumor sizes between 4.5 and 5.0 cm, and the tumor size cutoff of 5.0 cm had the highest concordance index for predicting CSS and MFS. CONCLUSIONS: RCC subtype is a strong independent prognostic variable for patients with pT1 RCC treated with radical nephrectomy. For clear cell RCC, Fuhrman grade and tumor size are independently associated with CSS and MFS.

Immunohistochemistry as a predictor of clinical outcome in patients given postoperative radiation for subtotally resected pituitary adenomas.

There is general agreement that postoperative radiation therapy is beneficial for patients with subtotally resected pituitary adenomas. We have identified 41 such patients treated during a 20-year period who received postoperative irradiation for a pituitary adenoma. The usual dose was 5040 cGy in 28 fractions. The mean follow-up time was 10.3 years. On routine hematoxylin and eosin (H&E) staining, there were thirty-three chromophobe, seven eosinophilic, and one basophilic adenoma. Tissue blocks were stained for growth hormone (GH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), prolactin (PRL), and/or adrenocorticotropin (ACTH) using the peroxidase-antiperoxidase immunohistochemistry (IHC) method. Routine H&E staining was a poor predictor of the IHC stain. While most patients with a known clinical endocrine syndrome stained positive on IHC for the suspected offending hormone, many patients without a clinical syndrome also stained positive indicating the presence of hormonally occult adenomas in this locally invasive group. The IHC stain results were compared to clinical outcome. The presence of positive GH IHC staining decreased the 15-year progression-free survival (PFS) from 100% to 64% compared to GH negative adenomas (p = 0.06). There was a trend toward decreased 15-year PFS in patients who did not stain for LH. Positive staining for prolactin, ACTH, or TSH had no influence on the progression-free survival. We conclude that additional prognostic information can be obtained in this subset of patients (by performing IHC analysis) that is not known by the clinical presentation or appearance on H&E stain.

Treatment of chromophobe adenmas with megavoltage tirradiation.

From 1956-1972, 62 previously untreated patients with chromophobe adenomas received high-dose (average equivalent dose: 5700rads in 6 weeks) megavoltage (4-4.8 MeV) irradiation at Stanford, 33 postoperatively and 29 as the only intended treatment. Initialtreatment failure rates were 18% and 41%, respectively; however, overall control was 85% and 90%, despite 2 uncontrolled "invasive" adenomas in each group. Nine of the 12 failures in the group treated by irradiation alone had cystic tumors, and 9 of the 12 "failed" in less than 3 months. Despite a considerably greater degree of abnormal vision initially in the postoperative irradiation group, improvement of vision with treatment in that group was 83% (19% returned to normal) compared to 46% (only 8% to normal) in the irradiation alone group. Based upon an evaluation of the extent of findings at diagnosis and our results, we recommend surgical decompression followed by 5000 rads in 5 weeks for patients with any one or more of the following findings: 1)more than minimal depression of peripheral visual fields; 2) corrected visual actuity of less than 20/30 in either eye; or 3)more than 1-cm suprasellar extension of tumor. We recommend irradiation alone, as specified, for smaller adenomas accompanied by less extensive or no visual abnormalities.