Negative impact of rurality on lung cancer survival in a population-based study.

INTRODUCTION: Several studies have suggested that rurality is a risk factor for worse prognosis in cancer. METHODS: The study population included the 2268 lung cancer cases collected between 1981 and 1996 in the Doubs Cancer Registry (France). RESULTS: The numbers of patients were 849 (31.8%) in rural areas and 89 (3.3%) in very rural areas. The relative 5-year survival was 15.2% in rural areas and 13.4% in urban areas (p = 0.5), and 2.7% in very rural areas and 14.4% in extended urban areas (p = 0.02). Multivariate analyses of observed and relative survival showed that patients living in very rural areas (p < 0.0001), 65 years of age and older and having small cell carcinoma had a significantly shorter survival. CONCLUSIONS: This study showed that the multidimensional definition of rurality identified a population with unfavorable prognoses.

Multicenter determination of optimal interobserver agreement using the Fuhrman grading system for renal cell carcinoma: Assessment of 241 patients with > 15-year follow-up.

BACKGROUND: The Fuhrman system is the most widely used nuclear grading system for renal cell carcinoma (RCC). Although Fuhrman nuclear grade is widely accepted as a significant prognostic factor, its reproducibility, as reported in the limited number of series available in the literature, appears to be low. METHODS: Between 1980 and 1990, 255 cases of RCC (pT1-3bN0M0) were treated with radical nephrectomy at the Department of Urology, University Hospital, Strasbourg, France. In a retrospective multicenter study, 3 pathologists independently classified 241 of these 255 cases according to the Fuhrman grading system. The authors searched for optimal interobserver agreement by collapsing the grading system to a three-tiered scheme and then to a two-tiered scheme. In addition, overall survival curves were generated according to the classic four-tiered scheme and also according to the best collapsed scheme. The kappa index was used to assess the level of agreement between each pair of observers, and the Cox model was used for multivariate survival analyses. RESULTS: The mean interobserver kappa value was 0.22 (range, 0.09-0.36). The best concordance was obtained by collapsing to a system in which low-grade (Grade 1-2) disease was compared with high-grade (Grade 3-4) disease. Doing so improved the mean interobserver kappa value to 0.44 (range, 0.32-0.55). Fuhrman grade was an independent prognostic factor for all 3 pathologists (P = 0.01, P < 0.0001, and P = 0.004, respectively), and nuclear grade continued to have independent prognostic value after the optimal collapsing algorithm was performed (P = 0.004, P = 0.0003, and P = 0.005). CONCLUSIONS: Collapsing of the Fuhrman grading system to a two-tiered scheme led to an improvement in interobserver agreement while preserving the independent prognostic value of nuclear grade.

Prognostic value of microscopic venous invasion in renal cell carcinoma: long-term follow-up.

OBJECTIVE: To assess the prognostic value of microscopic venous invasion (MVI) in a long-term follow-up series. PATIENTS AND METHOD: 255 patients had a radical nephrectomy between 1980 and 1990 for pT1 to pT3b N0 M0 renal cell carcinoma. We reviewed the disease free, specific and overall survival after 183 months of median follow-up. Survival analyses using Kaplan-Meier and Log-rank models for univariate comparisons and Cox proportional hazards model for multivariate analyses were performed. The studied variables were: age, size, side, extracapsular invasion, renal vein invasion, local stage, Fuhrman's grade and MVI. RESULTS: MVI was found in 74 cases (29%). The MVI was strongly correlated to metastases appearance and survival (p < 0.0001). Multivariate analysis of disease free survival showed the following independent variables: size (p < 0.0001) and Fuhrman's grade (p < 0.0001). For cancer specific survival, the analysis found size (p < 0.0001), age (p = 0.0005), Fuhrman's grade (p = 0.0035) and MVI (p = 0.016) with a relative risk of cancer related death of 2.16. Independent prognostic factors of overall survival were age (p < 0.0001), size (p < 0.0001), MVI (p = 0.015) and Fuhrman's grade (p = 0.045). The relative risk of cancer related death for MVI is 1.82. CONCLUSION: It seems that MVI is an independent prognostic factor of survival for patients with pT1 to pT3b N0 M0 renal cell carcinoma.

Prognostic value of multifocality on progression and survival in localized renal cell carcinoma.

OBJECTIVE: Incidence of multifocality in Renal Cell Carcinoma (RCC) is estimated at between 5 and 25%. Multifocality has been largely studied because of the growing interest in conservative surgery which is a risk of local recurrence. The aim of this study is to evaluate the relationship between multifocality and other prognostic parameters and whether it is an independent prognostic factor. MATERIAL AND METHODS: From 1980 to 1990, 255 patients (median age: 60.9 years) were treated by radical nephrectomy for pT1 to pT3b N0M0 RCC. The median follow-up time was 183 months. Multifocality was defined as the existence of at least one other tumoral localization, macroscopically and microscopically diagnosed as renal cell carcinoma, in the same kidney. Studied parameters were: age, sex, side, size, stage, Fuhrman's grade, capsular invasion, renal vein involvement and microvascular invasion. Survival was assessed with Kaplan-Meier and Cox models. RESULTS: 37 cases of multifocal RCC were diagnosed (14.5%). There was only a significant correlation with stage (p=0.002) and with capsular invasion (p=0.002). No other factor was correlated with multifocality. It had no influence on the risk of metastatic progression, overall or specific survival. CONCLUSION: There is a significant correlation between capsular invasion and multifocality that has to be considered before proposing conservative surgery for a localized RCC. Multifocality has no influence on survival or metastatic progression in case of radical nephrectomy.

[Extended total nephrectomy with laparoscopy in localized renal carcinoma. Report of 25 cases compared with 32 conventional surgical cases]. / Néphrectomies totales élargies par laparoscopie pour carcinome rénal localisé. A propos de 25 cas comparés à 32 chirurgies conventionnelles.

STUDY OBJECTIVE: To evaluate the benefits obtained during the learning phase of laparoscopic nephrectomy (LN) for clinical stage cT1 and cT2 renal cancers. PATIENTS AND METHODS: We retrospectively compared our first 25 cases of LN (13 right, 12 left) with 32 nephrectomies performed by Conventional Surgery (CS) (17 right, 15 left) between May 2000 and December 2001. The LN group comprised 18 men and 7 women with a mean age of 63.8 years. The CS group comprised 18 men and 14 women with a mean age of 67.7 years. Preoperative, intraoperative, postoperative and histological parameters were compared by analysis of the variance or nonparametric Mann-Whitney U test for quantitative variables and Chi-square test for qualitative data. RESULTS: Preoperative and histological parameters, blood loss, quantity and duration of analgesics and the complication rate were similar in the two groups. Resection was complete in every case. The mean duration of radical nephrectomy was significantly shorter by CS (p < 0.001). Return of bowel sounds was more rapid (p = 0.002) and patients were discharged from hospital earlier (p = 0.004) after LN. CONCLUSION: Laparoscopic nephrectomy for cancer must be performed by an operator experienced in laparoscopy. During the learning phase, this procedure provided benefits in terms of return of bowel sounds and length of hospital stay, which should encourage teams performing laparoscopy to perform radical nephrectomy by laparoscopy.

[Prognostic value of tumor location of urothelial tumors of the bladder, after total cystectomy]. / Intérêt pronostique de la localisation tumorale des cancers urothéliaux de vessie, après cystectomie totale.

OBJECTIVE: Comparison of the various treatment protocols for bladder cancer requires identification of survival prognostic factors. Some clinical parameters, such as tumour sub-site, have still not been studied. The authors therefore analysed the prognostic value of this factor, in combination with known prognostic factors, after radical cystectomy for urothelial bladder tumour. MATERIALS AND METHOD: 120 patients were treated for pure urothelial bladder tumour with pelvic lymphadenectomy, between January 1980 and January 1999, in a single centre. The prognostic value of the various sub-sites was studied by univariate and multivariate survival analysis. RESULTS: The 5-year survival decreased from 62% to 19% in the case of a lesion involving the bladder dome (p = 0.0001). Multivariate analysis demonstrated the following independent prognostic factors: local invasion pT < or = 3 (p = 0.003), lymph node involvement (p = 0.05) and involvement of the dome (p = 0.002). Other tumour sub-sites had an effect on survival on univariate analysis that was not confirmed on multivariate analysis. CONCLUSION: Although stages pT and pN are prognostic factors recognized by all studies, invasion of the bladder dome appears to have a major independent influence on survival. This result must be confirmed by other studies, in view of its potential influence for determination of homogeneous patient groups in controlled trials.