BACKGROUNDThe metastatic renal cell carcinoma (mRCC) patients treated with upfront cytoreductive nephrectomy combined with α-interferon yields additional overall survival (OS) benefits. It is unclear whether mRCC patients treated with vascular endothelial growth factor receptor-tyrosine kinase inhibitor (VEGFR-TKI) will benefit from such cytoreductive nephrectomy either. The aim of the study was to identify variables for selection of patients who would benefit from upfront cytoreductive nephrectomy for mRCC treated with VEGFR-TKI.

METHODSClinical data on 74 patients enrolled in 5 clinical trials conducted in Cancer Hospital (Institute), Chinese Academy of Medical Sciences from January 2006 to January 2014 were reviewed retrospectively. The survival analysis was performed by the Kaplan-Meier method. Comparisons between patient groups were performed by Chi-square test. A Cox regression model was adopted for analysis of multiple factors affecting survival, with a significance level of α = 0.05.

RESULTSFifty-one patients underwent cytoreductive nephrectomy followed by targeted therapy (cytoreductive nephrectomy group) and 23 patients were treated with targeted therapy alone (noncytoreductive nephrectomy group). The median OS was 32.2 months and 23.0 months in cytoreductive nephrectomy and noncytoreductive nephrectomy groups, respectively (P = 0.041). Age ≤45 years (P = 0.002), a low or high body mass index (BMI <19 or >30 kg/m2) (P = 0.008), a serum lactate dehydrogenase (LDH) concentration >1.5 × upper limit of normal (P = 0.025), a serum calcium concentration >10 mg/ml (P = 0.034), and 3 or more metastatic sites (P = 0.023) were independent preoperative risk factors for survival. The patients only with 0-2 risk factors benefited from upfront cytoreductive nephrectomy in terms of OS when compared with the patients treated with targeted therapy alone (40.0 months vs. 23.2 months, P = 0.042), while those with more than 2 risk factors did not.

CONCLUSIONSFive risk factors (age, BMI, LDH, serum calcium, and number of metastatic sites) seemed to be helpful for selecting patients who would benefit from undergoing upfront cytoreductive nephrectomy.

Adult ; Aged ; Aged, 80 and over ; Carcinoma, Renal Cell ; mortality ; surgery ; Cytoreduction Surgical Procedures ; Female ; Humans ; Kidney Neoplasms ; mortality ; surgery ; Male ; Middle Aged ; Nephrectomy ; Proportional Hazards Models

The prognostic impact of body mass index (BMI) in patients with upper tract urothelial carcinoma (UTUC) is an ongoing debate. Our study aimed to investigate the prognostic role of BMI in patients treated with radical nephroureterectomy (RNU) for UTUC from a multi-institutional Korean collaboration. We retrospectively reviewed data from 440 patients who underwent RNU for UTUC at four institutions in Korea. To avoid biasing the survival estimates, patients who had previous or concomitant muscle-invasive bladder tumors were excluded. BMI was categorized into approximate quartiles with the lowest quartile assigned to the reference group. Kaplan-Meier and multivariate Cox regression analyses were performed to assess the influence of BMI on survival. The lower quartile BMI group showed significantly increased overall mortality (OM) and cancer specific mortality (CSM) compared to the 25%-50% quartiles and upper quartile BMI groups. Kaplan-Meier estimates showed similar results. Based on multivariate Cox regression analysis, preoperative BMI as a continuous variable was an independent predictor for OM and CSM. In conclusion, preoperative underweight patients with UTUC in Korea survive less after RNU. Preoperative BMI may provide additional prognostic information to establish risk factors.
Aged ; Asian Continental Ancestry Group ; Body Mass Index ; Carcinoma, Transitional Cell/*mortality ; Cystectomy/*mortality ; Female ; Humans ; Kidney Pelvis/surgery ; Male ; Nephrectomy/*mortality ; Republic of Korea ; Retrospective Studies ; Thinness/*mortality ; Ureter/surgery ; Urinary Bladder/surgery ; Urologic Neoplasms/*mortality/pathology/*surgery ; Urothelium/pathology/*surgery

PURPOSE: To evaluate the impact of adjuvant chemotherapy (AC) in patients with upper tract urothelial carcinoma and lymphovascular invasion (LVI) after radical nephroureterectomy (RNU). MATERIALS AND METHODS: We retrospectively analyzed the clinical records and clinicopatholgic outcomes of patients (n=552) treated with RNU between 1986 and 2013. Patients treated with neoadjuvant chemotherapy and those for whom LVI status was not recorded were excluded. Patients were divided into two groups according to LVI (n=86) or no LVI (n=256). RESULTS: The study included 344 patients (240 men and 104 women) with a median of 53.9 months of follow-up (range, 1-297 months) after RNU. Tumors were organ confined (T2/N0) in 211 (61.3%) and tumor grade high in 291 (84.6%). AC was administered in 64 patients (18.6%). A total of 280 patients (81.4%) were treated with surgery alone. Patients with LVI tended to be older (p=0.049), have a higher pT stage (pT3/T4, p<0.001), be pN+ (p<0.001), have a high tumor grade (p<0.001), and experience recurrence (p<0.001). In the multivariate analysis, LVI was an independent prognostic factor for cancer-specific survival and overall survival (p=0.002 and p<0.001, respectively). The multivariate analysis demonstrated that in the subgroup of patients with LVI, AC was a significant prognostic factor for cancer-specific survival and overall survival (hazard ratio, 0.51; p=0.027 and hazard ratio, 0.50; p=0.025, respectively). CONCLUSIONS: AC does not seem to reduce mortality in patients with advanced upper tract urothelial carcinoma after RNU. In the subgroup of patients with LVI, AC had a positive impact on cancer-specific survival and overall survival. LVI would be helpful for selecting patients who are appropriate for AC.
Aged ; Carcinoma, Transitional Cell/drug therapy/*mortality/surgery ; *Chemotherapy, Adjuvant ; Female ; Follow-Up Studies ; Humans ; Kidney Neoplasms/drug therapy/*mortality/surgery ; Lymphatic Metastasis ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Grading ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Nephrectomy ; Prognosis ; Retrospective Studies ; Survival Rate ; Ureter/pathology ; Ureteral Neoplasms/drug therapy/*mortality/surgery ; Urinary Tract/pathology

The aim of this study was to evaluate the diagnostic and prognostic value of clinical-positive nodes at preoperative imaging (cN1) in patients with non-metastatic renal cell carcinoma (RCC) treated with lymph node dissection (LND). We retrospectively reviewed data for a cohort of 440 consecutive patients (cN0, 76.8%; cN1, 23.2%) with cTanyNanyM0 RCC who underwent nephrectomy and LND from 1994 to 2013. Metastasis-free survival (MFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Multivariate Cox regression analysis was performed to determine significant predictors of MFS and CSS. The mean number of lymph nodes (LNs) examined for all patients was 8.3, and pN1 disease was identified in 31 (7.0%). LN staging by preoperative imaging had a sensitivity of 65%, a specificity of 80%, and an accuracy of 77%. During a median follow-up of 69 months, 5-yr MFS and CSS were 83.6% and 91.3% in patients with cN0 and 49.2% and 70.1% in patients with cN1, demonstrating a trend toward worse prognosis with radiologic lymphadenopathy (all P < 0.001). Furthermore, differences in MFS and CSS between the cN0pN0 and cN1pN0 groups were significant (all P < 0.001). Clinical nodal involvement is an important determinant of adverse prognosis in patients with non-metastatic RCC who undergo LND.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Carcinoma, Renal Cell/*mortality/*secondary/surgery ; Female ; Humans ; Kidney Neoplasms/*mortality/radiography/*surgery ; Lymph Node Excision/*mortality ; Lymphatic Metastasis ; Male ; Middle Aged ; Nephrectomy/*mortality ; Prevalence ; Prognosis ; Reproducibility of Results ; Republic of Korea/epidemiology ; Retrospective Studies ; Risk Assessment ; Sensitivity and Specificity ; Survival Rate ; Young Adult

The association of body mass index, smoking, and blood pressure, which are related to the three well-established risk factors of renal cell carcinoma, and survival in patients with renal cell carcinoma is not much studied. Our objective was to evaluate this association. A cohort of 1,036 patients with low stage (pT1 and pT2) renal cell carcinoma who underwent radical or partial nephrectomy were enrolled. We retrospectively reviewed medical records and collected survival data. The body mass index, smoking status, and blood pressure at the time of surgery were recorded. Patients were grouped according to their obesity grade, smoking status, and hypertension stage. Survival analysis showed a significant decrease in overall (P = 0.001) and cancer-specific survival (P < 0.001) with being underweight, with no differences of smoking status or perioperative blood pressure. On multivariate analysis, perioperative blood pressure > or = 160/100 mmHg (HR, 2.642; 95% CI, 1.221-5.720) and being underweight (HR, 4.320; 95% CI, 1.557-11.984) were independent predictors of overall and cancer-specific mortality, respectively. Therefore, it is concluded that being underweight and perioperative blood pressure > or = 160/100 mmHg negatively affect cancer-specific and overall survival, respectively, while smoking status does not influence survivals in patients with renal cell carcinoma.
Adult ; Aged ; Aged, 80 and over ; Blood Pressure ; Body Mass Index ; Carcinoma, Renal Cell/diagnosis/*mortality/surgery ; Cohort Studies ; Female ; Follow-Up Studies ; Humans ; Kidney Neoplasms/diagnosis/*mortality/surgery ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Staging ; Nephrectomy ; Retrospective Studies ; Risk Factors ; Smoking ; Survival Rate

OBJECTIVETo determine the effect of laparoscopic radiofrequency ablation of T1aN0M0 renal cell carcinoma (RCC) with regular follow-up.

METHODSAll patients underwent surgery from March 2006 to March 2009. Eight cases were solitary kidney. Twenty-two cases of left RCC and 18 cases of right RCC were diagnozed by ultrasonography and CT scanning.All of the cases were T1aN0M0 stage. No metastasis was found by iconography test. By ultrasound positioning, laparoscopic radiofrequency were performed on the renal tumor. All patients were followed up with eGFR and enhanced-CT.

RESULTSAll patients underwent laparoscopic radiofrequency ablation surgery successfully. The mean operation time was (101 ± 19) minutes and the mean blood loss was (90 ± 14) ml (no blood transfusion pre- and post-operation). During postoperative follow-up, enhanced CT revealed complete ablation in 39 cases (the success rate was 97.5%), and 1 residue tumor was confirmed by enhanced CT 7 days post operation. This patient was under close surveillance because of solitary kidney. No progression of the residue tumor was found during the follow-up. One case of recurrence was confirmed by enhanced CT in 6 month after operation. The 3-year recurrence rate was 2.5%. No further intervation was performed on this patient and no change was found in the recurrence area during the follow-up. Both 3-year total survival rate and 3-year cancer specific survival rate were 100%. The mean eGFR was (72 ± 9) ml/(min·1.73 m(2)) in 3 years after surgery. There was no significant difference between pre-and post-operation (P > 0.05).

CONCLUSIONMid-term follow-up results show the effectiveness and safety of laparoscopic radiofrequency ablation in the treatment for T1aN0M0 RCC and have no negative influence on the renal function.

Carcinoma, Renal Cell ; mortality ; surgery ; Catheter Ablation ; methods ; Female ; Follow-Up Studies ; Humans ; Kidney Neoplasms ; mortality ; surgery ; Laparoscopy ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; epidemiology ; Treatment Outcome

PURPOSE: Minimally invasive management of small renal tumors has become more common. We compared the results of partial nephrectomy by video-assisted minilaparotomy surgery (VAMS), open, and laparoscopic techniques. MATERIALS AND METHODS: We retrospectively compared clinicopathological, oncological, and functional outcomes in 271 patients who underwent partial nephrectomy for renal tumors at one institution from 1993 to 2007; including 138 by VAMS, 102 by open, and 31 by laparoscopic technique. RESULTS: Mean follow-up was 47.7+/-29.1 months. No statistically significant differences in the three groups were found in tumor size, tumor location, estimated blood loss, complication rate, preoperative glomerular filtration rate (GFR), and GFR at last follow-up. Ischemic time was shorter in the open (26.9 min) and VAMS (29.3 min) groups than in the laparoscopic group (31.0 min, p=0.021). Time to normal diet and hospital stay were shorter in the VAMS (1.8 days and 5.4 days) and laparoscopic (1.8 days and 4.7 days) groups than in the open group (2.4 days and 7.3 days, p=0.036 and p<0.001, respectively). Of 180 patients with cancer, positive surgical margins occurred in 2 of 82 patients (2.4%) in the VAMS group, none of 75 patients in the open group, and 3 of 23 patients (13.0%) in the laparoscopic group (p=0.084). In the VAMS, open, and laparoscopic groups, 5-year disease-free survival was 94.8%, 95.8%, and 90.3% (p=0.485), and 5-year cancer-specific survival was 96.3%, 98.6%, and 100%, respectively (p=0.452). CONCLUSION: Partial nephrectomy using VAMS technique provides surgical, oncologic, and functional outcomes similar to open and laparoscopic techniques.
Adult ; Aged ; Carcinoma, Renal Cell/mortality/*surgery ; Female ; Humans ; Kidney Neoplasms/mortality/*surgery ; Laparoscopy/instrumentation/*methods ; Laparotomy/instrumentation/*methods ; Male ; Middle Aged ; Nephrectomy/instrumentation/*methods ; Retrospective Studies ; Treatment Outcome ; Video-Assisted Surgery/instrumentation/*methods

BACKGROUNDWith a trend that renal tumors are being detected at an earlier stage, classical radical nephrectomy is being reconsidered. More conservative techniques are being proposed. To clarify the indication for synchronous adrenalectomy in radical nephrectomy for renal cell carcinoma which has been questioned since the 1980s, this study evaluates the role of adrenalectomy and recommends a new indication for adrenalectomy in renal cell carcinoma.

METHODSA systemic search was performed, using PubMed and Google Scholar, of all English language studies published up to March 2012 that compared adrenalectomy with adrenal-sparing surgery, in surgery for renal cell carcinoma. We assessed preoperative imaging for adrenal involvement and the relationship of tumor location with adrenal metastases. Twenty-one studies (20 retrospective and 1 prospective) involving 11 736 patients were included.

RESULTSThe mean incidence of ipsilateral adrenal involvement from renal cell carcinoma was 4.5%. Synchronous adrenalectomy did not alter survival (hazard ratio (HR) = 0.89, 95% confidence interval (CI) 0.67 - 1.19, P = 0.43; odds ratio (OR) = 1.10, 95%CI 0.84 - 1.44, P = 0.49). Upper pole tumors were not associated with a higher incidence of ipsilateral adrenal metastases. Pooled preoperative imaging: sensitivity, specificity, positive predictive value and negative predictive value were 92% (95%CI 0.84 - 0.97), 95% (95%CI 0.93 - 0.96), 71.6% and 98.5% respectively.

CONCLUSIONSAdrenal involvement from renal cell carcinoma is rare, even in advanced tumours. Synchronous adrenalectomy does not offer any benefit, even for "high risk" patients. We suggest that only patients with a positive preoperative adrenal finding on preoperative imaging for a solitary adrenal metastasis should undergo adrenalectomy as part of the radical nephrectomy.

Adrenal Gland Neoplasms ; secondary ; surgery ; Adrenalectomy ; methods ; Carcinoma, Renal Cell ; mortality ; surgery ; Humans ; Kidney Neoplasms ; mortality ; surgery ; Nephrectomy ; methods ; Survival Rate

INTRODUCTIONRenal cell carcinoma (RCC) in young patients is uncommon but thought to represent a distinctive clinical entity from older patients with different clinico-pathologic features and outcomes. We evaluated the association of age at the time of diagnosis with pathological staging, histological parameters, disease recurrence and overall survival (OS) following radical or partial nephrectomy for non-metastatic RCC in native kidneys.

MATERIALS AND METHODSA retrospective review of 316 patients with RCC after nephrectomy at a single institution between January 2001 and June 2008 was performed. Eligible patients included all histologically proven primary non-metastatic RCC treated by radical or partial nephrectomy. They were categorised into group A (≤ 40 years at diagnosis) and B (> 40 years). Differences in clinical parameters were analysed using the Mann Whitney U test. The prognostic potential of age at diagnosis was evaluated using Cox proportional hazards regression. Survival was estimated using the Kaplan Meier method.

RESULTSThere were 33 patients in group A and 283 patients in group B. There were more non-clear cell tumours in the younger group (30% vs 14%, P <0.05). No statistical differences were found in the stage and grade of both groups. At a median follow-up time of 41 months, the younger group had a higher metastatic rate (18% vs 10.5%, P <0.05), lower 5-year cancer-specific survival (82% vs 98%, P <0.05) and lower 5-year OS (82 % vs 95%, P <0.05).

CONCLUSIONYounger patients were more likely to have non-clear cell RCC with higher disease recurrence and lower OS. They should not be assumed to have similar features and outcomes as screen-detected early RCC in older patients.

Adult ; Age Factors ; Aged ; Aged, 80 and over ; Carcinoma, Renal Cell ; diagnosis ; mortality ; pathology ; surgery ; Female ; Humans ; Kaplan-Meier Estimate ; Kidney Neoplasms ; diagnosis ; mortality ; pathology ; surgery ; Male ; Middle Aged ; Nephrectomy ; Prognosis ; Proportional Hazards Models ; Recurrence ; Retrospective Studies ; Statistics, Nonparametric ; Survival Analysis

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. Cephalic extension of the thrombus is closely related to perioperative morbidity. We purposed to design a safe and successful surgical strategy through a review of our surgical experience and treatment results in 35 patients (male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with radical nephrectomy between January 1997 and December 2006. The limit of tumor extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular exclusion was performed in 12 patients and cardiopulmonary bypass in 7. Thirty-two primary closures, 2 patch closures, and 1 graft interposition were performed. One patient underwent simultaneous pulmonary embolectomy because of an operative pulmonary embolism. There was no operative mortality, and the overall survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation under long venotomy on fully exposed involved IVC is recommended for successful result in a bloodless operative field. The applicability of liver mobilization, hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the level of thrombus.
Adult ; Aged ; Carcinoma, Renal Cell/mortality/secondary/*surgery ; Female ; Humans ; Kidney Neoplasms/complications/mortality/*surgery ; Male ; Middle Aged ; Neoplasm Staging ; Nephrectomy ; Pulmonary Embolism/complications/surgery ; Severity of Illness Index ; Survival Rate ; Tomography, X-Ray Computed ; Vena Cava, Inferior/*surgery ; Venous Thrombosis/etiology/*surgery