Renal cell carcinoma: natural history and chemotherapeutic experience

Metastatic renal cell carcinoma of the posterior nasal septum as the first presentation 10 years after nephrectomy

Metastasis of renal cell carcinoma (RCC) to the head and neck region is infrequent, and metastatic RCC in the nasal cavity and paranasal sinuses is rare. Although there are reported cases of RCC to the paranasal sinuses, isolated metastasis of RCC to the nasal septum is extremely rare. This report describes a case of metastatic RCC of the posterior nasal septum that presented as severe epistaxis in a patient who underwent nephrectomy for RCC 10 years previously.

Surgical treatment of sacral metastases: indications and results

OBJECT

Hematogenous metastases to the sacrum can produce significant pain and lead to spinal instability. The object of this study was to evaluate the palliative benefit of surgery in patients with these metastases.

METHODS

The authors retrospectively reviewed all cases involving patients undergoing surgery for metastatic disease to the sacrum at a single tertiary cancer center between 1993 and 2005.

RESULTS

Twenty-five patients (21 men, 4 women) were identified as having undergone sacral surgery for hematogenous metastatic disease during the study period. Their median age was 57 years (range 25-71 years). The indications for surgery included palliation of pain (in 24 cases), need for diagnosis (in 1 case), and spinal instability (in 3 cases). The most common primary disease was renal cell carcinoma. Complications occurred in 10 patients (40%). The median overall survival was 11 months (95% CI 5.4-16.6 months). The median time from the initial diagnosis to the diagnosis of metastatic disease in the sacrum was 14 months (95% CI 0.0-29.3 months). The numerical pain scores (scale 0-10) were improved from a median of 8 preoperatively to a median of 3 postoperatively at 90 days, 6 months, and 1 year (p < 0.01). Postoperative modified Frankel grades improved in 8 cases, worsened in 3 (due to disease progression), and remained unchanged in 14 (p = 0.19). Among patients with renal cell carcinoma, the median overall survival was better in those in whom the sacrum was the sole site of metastatic disease than in those with multiple sites of metastatic disease (16 vs 9 months, respectively; p = 0.053).

CONCLUSIONS

Surgery is effective to palliate pain with acceptable morbidity in patients with metastatic disease to the sacrum. In the subgroup of patients with renal cell carcinoma, those with the sacrum as their solitary site of metastatic disease demonstrated improved survival.

Paraneoplastic symptoms: cachexia, polycythemia, and hypercalcemia are, respectively, related to vascular endothelial growth factor (VEGF) expression in renal clear cell carcinoma

OBJECTIVES

To evaluate whether there is a relation between expression of vascular endothelial growth factor (VEGF) and any of the paraneoplastic syndromes (PNS) in clear cell renal cell carcinoma (ccRCC) patients.

MATERIALS AND METHODS

A total of 667 patients with ccRCC and at least one PNS were included. Thorough history taking, physical examinations, and laboratory tests were used to diagnose PNS. Immunohistochemistry was performed for VEGF evaluation.

RESULTS

There were 10 different PNS identified in the population. Sixty patients had a single paraneoplastic presentation. In all patients, presence of cachexia (n = 267, P < 0.0001), polycythemia (n = 40, P = 0.0014), and hypercalcemia (n = 48, P = 0.0006) was correlated to VEGF expression. Correlation was neither acquired in Stauffer's syndrome, pyrexia, elevated erythrocyte sedimentation rate (ESR), anemia, thrombocytosis, hypertension, neuromyopathy nor obtained within patients with single PNS.

CONCLUSIONS

Relations between PNS and VEGF expression in renal cell carcinoma (RCC) has not been studied yet. The results we gained hereby can help us further understand the mechanistic of PNS in RCC.

Malignant hypercalcemia--a hospital survey

A hypercalcemia frequency of 1.5% was found in patients with malignant disease attending a large oncological center. Eighty per cent of hypercalcemias were of obvious malignant etiology. Hypercalcemia was most frequent in multiple myeloma, renal carcinoma, squamocellular carcinomas of different sites and breast cancer. Most patients had advanced metastasized disease. In 80% of those with solid tumors malignant hypercalcemia was associated with bone metastases. Serum calcium could almost invariably be reduced by treatment, and active treatment was associated with a more favorable prognosis. One year actuarial survival of patients with malignant hypercalcemia was 31%.

Renal cell carcinoma with unusual metastasis to the gallbladder

Gallbladder involvement in patients with renal cell carcinoma (RCC) is extremely rare. We present a report of a 61-year-old man with a synchronous RCC metastasis to the gallbladder presenting as an intraluminal polypoid mass simulating primary gallbladder carcinoma. Enhanced abdominal computed tomography demonstrated a well-enhanced polypoid lesion in the gallbladder. Intraoperative rapid pathological examination of the gallbladder tumor showed clear cell-type cancerous cells. Microscopically, tumor cells of both the resected kidney and gallbladder had round uniform nuclei, clear cytoplasm, and well-defined cytoplasmic borders, forming alveolar patterns. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), which is usually positive in primary clear cell carcinoma of the gallbladder. Therefore, the final diagnosis was RCC with a synchronous gallbladder metastasis.

Osseous metastasis from renal cell carcinoma: "flow-void" sign at MR imaging

PURPOSE

To characterize the appearance and determine the importance of the "flow-void" sign on magnetic resonance (MR) images of patients with osseous metastasis from renal cell carcinoma.

MATERIALS AND METHODS

Three musculoskeletal radiologists retrospectively and independently reviewed the medical records of 16 patients who had undergone MR imaging and in whom 20 osseous metastatic lesions from renal cell carcinoma had been diagnosed on the basis of clinical and radiologic findings. They assessed the MR images for the presence and frequency of the flow-void sign--multiple dot-like or tubular structures with low signal intensity. They then compared these findings on MR images with the corresponding areas on available images obtained with radiography (n = 16), computed tomography (CT) (n = 6), and digital subtraction angiography (n = 3) and with the results of histopathologic analysis for the same patient group. They noted the location, diameter, and appearance of the lesion and the flow-void sign, as well as variations in signal intensity within the lesion and among lesions. Statistical analysis was performed to determine the level of interobserver agreement.

RESULTS

Radiographic findings and the level of signal intensity on MR images were nonspecific for diagnosis of osseous metastasis from renal cell carcinoma. The flow-void sign was identified at the lesion core or margin with a mean frequency of 76.7% by the three observers (in 15, 16, and 15 of 20 lesions, by observers 1, 2, and 3, respectively). Most of these areas of low signal intensity were tubular structures of less than 3 mm in diameter; in three lesions, they measured 5-8 mm in diameter. In 14 lesions, these structures corresponded to dilated blood vessels or veins identifiable on CT images (six lesions) or digital subtraction angiographic images (four lesions) or at histopathologic analysis (four lesions). The flow-void sign on MR images corresponded to vessels depicted on the CT scans available for six lesions and on the angiographic images available for four lesions.

CONCLUSION

Observation of the flow-void sign in lesions depicted on musculoskeletal MR images may prove helpful for diagnosing osseous metastasis from renal cell carcinoma and for treatment planning, especially in patients with occult or forgotten primary renal tumor.

Allogeneic stem cell transplantation for renal cell carcinoma

Although the prognosis for patients with metastatic kidney cancer remains poor, a number of promising immunotherapeutic approaches for the treatment of metastatic disease have been developed over the past decade. The response of some patients to cytokines such as interleukin-2 and interferon-alpha, and more recently, vaccination with dendritic cell/tumor fusions has laid the ground work for ongoing immune-based investigational approaches. Allogeneic stem cell transplantation is a potent form of immunotherapy capable of delivering potentially curative immune-mediated anti-tumor effects against a number of different hematological malignancies. Knowledge of renal cell carcinoma's unusual susceptibility to immune attack has led to the hypothesis that tumor rejection, mediated through immunocompetent donor T-cells, might be generated against this solid tumor following the transplantation of an allogeneic immune system. Although clinical trials are early and ongoing, the recent observation of metastatic disease regression following non-myeloablative stem cell transplantation has identified renal cell carcinoma as being susceptible to a graft-versus-tumor effect. Disease responses following such therapy have ranged from partial to complete and have been observed even in patients who have failed conventional cytokine based strategies. This article reviews the design, methodology and early clinical results of studies investigating the use of allogeneic stem cell transplantation in metastatic renal cell carcinoma.

Differential inhibition of renal cancer cell invasion mediated by fibronectin, collagen IV and laminin

Invasion of tumor cells into the extracellular matrix is an essential step in the formation of metastases in renal cancer. Cell adhesion molecules such as beta(1)-integrins, which bind to the RGD sequence (arginine-glycine-asparagine) and CD44 are involved in this process. We examined the invasion of a renal carcinoma cell line (CCF-RC1) into the extracellular matrix compounds fibronectin, collagen IV and laminin and the effect of TGFbeta and IFNgamma on this process. The inhibitory effect of an antibody against the beta(1)-subunit of integrins (CD29), as well as a pentapeptide including the RGD sequence, was also evaluated. A micro-chemotaxis chamber, including a polycarbonate membrane with a pore diameter of 8 microm, was used for quantification of cell migration. The addition of the extracellular matrix compounds fibronectin, laminin and collagen IV resulted in a 5-10-fold increase in invasion. This increased invasion depends strongly on the presence of beta(1)-integrins, shown by the use of an antibody against CD29 or a RGD including peptide which inhibit the cell migration by approximately 88%. CD44 is less involved in collagen IV dependent migration and almost no influence of CD44 was observed on a fibronectin and laminin dependent migration. TNFalpha and IFNgamma did not significantly influence the expression of CD29 or CD44, and no alteration in tumor cell migration was observed. These results show that the invasion of renal cancer cells is differentially regulated by compounds of the extracellular matrix, whereby fibronectin seems to be the most critical factor. The molecular interactions in this process are strongly dependent on beta(1)-integrins and the corresponding amino acid sequence RGD.

Metastatic renal cell carcinoma with concurrent inferior vena caval invasion: long-term survival after combination therapy with radical nephrectomy, vena caval thrombectomy and postoperative immunotherapy

PURPOSE

We report our experience using aggressive multimodal therapy in a high risk group of patients with metastatic renal cell carcinoma and concurrent inferior vena caval extension.

MATERIALS AND METHODS

We retrospectively reviewed the records of all patients in our kidney cancer database who had metastatic renal cell carcinoma and tumor thrombus extension into the inferior vena cava at the initial diagnosis. Patients were included in the study if they underwent radical nephrectomy and inferior venal caval thombectomy, and immunotherapy was planned for the postoperative period. Tumor size and grade, metastatic sites, level of vena caval extension, surgical complications and overall survival were obtained from the medical records. The primary end point analyzed was overall survival.

RESULTS

We identified 31 cases of metastatic renal cell cancer with extensive disease and vena caval extension. Of the patients 23% had an isolated lung metastasis, and 53% had metastasis in the lung and at other sites. The remaining patients had involvement primarily at nonpulmonary metastatic sites, including lymph node in 38%, soft tissue in 13%, liver in 29% and bone in 10%. Average blood loss during nephrectomy was 3,200 cc (median 2,100) and the rate of major complications was 12%. Of the patients 80% underwent the full course of surgery and postoperative immunotherapy. At a mean followup of 18 months (34 for survivors) 26% of the patients are alive. Actuarial overall 5-year survival of the group was 17%. Tumor thrombus level did not correlate with overall survival, while immunotherapy, tumor grade and metastatic site provided significant prognostic information. In patients with an isolated pulmonary metastasis the 5-year survival rate was 43%, while in those with low grade tumors it was 52%.

CONCLUSIONS

In contrast to the poor results of surgery only in patients with renal cell carcinoma and concurrent inferior venal caval invasion, reasonable 5-year survival may be achieved after combined aggressive surgery and immunotherapy. Patients in whom metastasis was limited to the lungs and those with grade 1 to 2 tumors had a better prognosis. With careful planning and experienced immunotherapists therapy may be completed in the majority of this high risk group of patients.

Renal cell carcinoma: a paradigm of lanthanic disease

Renal cell carcinoma is characterized by varied and sometimes obscure manifestations, which include unusual metastatic sites and paraneoplastic and vascular syndromes. In this review, uncommon metastatic sites and their clinical significance are discussed, particularly the thyroid, nasal structures, vagina, and gastrointestinal sites. Paraneoplastic syndromes appear to be related predominantly to cytokines or immunologic mechanisms. Vascular syndromes are related to the tendency of the tumor to spread by direct venous extension and to complications related to the vascularity of the tumor or its metastases. The recognition of unusual manifestations of renal cell carcinoma is important because these syndromes may lead to the diagnosis. Moreover, paraneoplastic syndromes and vascular findings may not indicate unresectability or incurability.

Localization of monoclonal antibody CC49 in colonic metastasis from renal cell carcinoma

We report a rare case of solitary metastasis from renal cell carcinoma which manifested as a primary colonic tumour 5 years after nephrectomy. A monoclonal antibody CC49 (anti-TAG-72 antibody), used in Radioimmunoguided Surgery, was found to localize in the tumour. Pathological examination revealed metastasis of renal cell carcinoma in the colon. Immunohistochemistry with CC49 showed moderate staining of the colonic mucosa around the metastasis with no reaction in the tumour itself. Based on this case and other published studies, we conclude that TAG-72, the antigen manifested in many adenocarcinomas, can be up-regulated and expressed in normal colonic mucosa adjacent to another tumour as a result of stimulations, such as cytokine release, in response to this tumour.

Nephrectomy and vena caval thrombectomy in patients with metastatic renal cell carcinoma

OBJECTIVES

To report out experience with performing nephrectomy and vena caval thombectomy in patients with metastatic renal cell carcinoma.

METHODS

A retrospective review was performed of 15 patients who underwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites of metastases included lungs (n = 8), bone (n = 3), bulky retroperitoneal or mediastinal lymph nodes (n = 2), liver (n = 1), and contralateral adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score of 0, 11 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months.

RESULTS

Median operative time was 6.5 hours and median hospitalization was 10 days. Two patients required re-exploration for postoperative hemorrhage. There were no perioperative deaths. Four patients underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperatively. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 110). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months (range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Ten of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapid progression at 2 and 5 months after surgery and the other 2 at 17 and 42 months.

CONCLUSIONS

Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furthermore, in patients receiving biologic therapy, nephrectomy may enable a better quality of life and prolonged survival.

Adjuvant radiation or systemic therapy for renal cell carcinoma: A brief review

Several clinical trials have been performed in which radiation therapy or systemic therapy have been given to patients in an attempt to reduce relapse following nephrectomy for renal cell carcinoma. Since only randomized trials can give valid information about the value of adjuvant therapy as compared with surgery alone, this short review evaluates critically the randomized trials that have been performed. Four randomized trials of radiation therapy given pre- or postoperatively suggest an overall detrimental effect on survival because of toxicity. Randomized trials of medroxyprogesterone acetate and of interferon-α have shown no benefit. There is current interest in the potential benefit of adjuvant treatment with other biological modifiers such as interleukin-2, but adjuvant therapy of any type should only be given in the context of a well-designed, randomized clinical trial.

Hypercalcemia and urologic malignancies

Hypercalcemia may be a manifestation of a variety of disorders including hyperparathyroidism, hypervitaminosis D, sarcoidosis, multiple myeloma, hyperthyroidism, acute osteoporosis, metastatic bone disease, and a number of primary malignancies. Hypercalcemia may be seen in as many as 1.5% of all patients with malignant disease, with or without bony metastases. The neoplasms most commonly associated with hypercalcemia include carcinoma of the lung (all cell types), breast cancer, squamous cell carcinomas, hematologic malignancies, and renal cell carcinoma. Observation of a number of instances of hypercalcemia attendant on urologic malignancies prompts the brief report of 4 characteristic cases with documentation of response to therapy. Management of severe and debilitating hypercalcemia is emphasized. Urologists should be aware of new agents available for such treatment.

The impact of adjuvant nephrectomy on multimodality treatment of metastatic renal cell carcinoma

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: an institutional review

BACKGROUND

Solitary metastases from a primary renal cell carcinoma (RCC) occur in < 10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented.

MATERIALS AND METHODS

Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970-1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded.

RESULTS

Metastases were intrathoracic (n = 20), intracranial (n = 7), and intraabdominal or in the extrapleural chest wall soft tissue (n = 10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival.

CONCLUSION

A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances.

Solitary brain metastasis 13 years after removal of renal adenocarcinoma

We report a case of a patient who developed a single brain metastasis to the cerebellum 13 years after removal of a renal adenocarcinoma. The cerebellar metastasis was removed twice due to local recurrence one year after the first operation. The patient is alive and doing well 18 months after the second neurosurgical procedure. The metastasis was not associated with any other evidence of disease. Brain metastasis may present many years after removal of kidney adenocarcinoma and when not associated with other evidence of disease their operative treatment may carry a good prognosis.

The value of postoperative irradiation in renal cell cancer

This is a retrospective analysis of 147 evaluable patients, with histologically proven renal cell carcinoma, who were referred to our center between 1977 through 1988. All patients with disease limited to the kidney underwent nephrectomy. Post-operative megavoltage irradiation, with a median dose of 46 Gy, was given to 56 patients, using parallel opposing portals, or multiple field technique. Five and 10 year actuarial survivals in irradiated patients (Rt+) were 50 and 44%, respectively, and in non-irradiated patients (Rt-) 40 and 32%, respectively. The disease recurred locally in a total of 19 patients; 16 had tumor bed recurrence and three had scar recurrence. Local recurrence by stage was as follows: T2 N0M0: RT+ 0/17, RT- 2/28; T3 N0M0: RT+ 4/37 (10%), RT- 11/30 (37%) (p less than 0.05); T4 N0M0: RT+ 1/2, RT- 1/5. Two of the local recurrences in irradiated patients developed in a surgical scar which was not included in the treatment volume. Significant toxicity developed in three patients (5%). It is concluded that post-operative irradiation can reduce local recurrence rate in T3 N0M0 renal cell carcinoma. It is recommended that the surgical scar should always be included in the treatment volume and irradiated to a full dose.

Alpha-interferons: impact on survival of patients with renal cell carcinoma

We studied the effect of treatment on tumour response and survival of 76 evaluable patients with renal cell carcinoma, treated in this unit over a 12-year period. For the purpose of this study patients were classified into three groups according to the treatment they received: (a) 22-patients were evaluable for treatment with alpha-interferons; (b) 20 for treatment with immune modulation, other than interferon; (c) 34 patients received hormone treatment, chemotherapy or had no systemic treatment. Objective tumour regressions were observed only among patients who received interferon. No difference in overall survival from first diagnosis or from diagnosis of Stage IV disease could be demonstrated in these three groups. Alpha-Interferons are the first agents to induce clinically meaningful and reproducible regression of metastases in renal cell carcinoma. This treatment, however, has not been shown to have a major impact on survival.

The incidence and prognostic significance of humoral hypercalcemia in renal cell carcinoma

This retrospective study was conducted to evaluate the incidence and prognostic significance of humoral hypercalcemia in 218 renal cell carcinoma patients during the last 20 years. Of 218 patients 20 (9.2%) were hypercalcemic, with serum calcium levels ranging from 10.7 to 16.0 mg./dl. The respective incidence of humoral hypercalcemia was 3% in patients with stage I, 5.9% with stage II, 14.1% with stage III and 18.9% with stage IV disease without bone metastasis. The survival curves between the hypercalcemic and eucalcemic groups among stages I to III cancer patients showed no statistical significance (p greater than 0.05). The survival curve deteriorated significantly in stage IV cancer patients with humoral hypercalcemia (p less than 0.005), with a median survival of 45.0 +/- 39.7 days versus 286.4 +/- 27.6 days in eucalcemic patients. No specific correlation was found between pathological cell type and humoral hypercalcemia.

Management and prognostic significance of hypercalcemia in renal cell carcinoma

A retrospective study was conducted to evaluate the prognostic significance of hypercalcemia associated with renal cell carcinoma and the efficacy of different treatment modalities. Twenty-seven of 160 (16.8%) patients with renal cell carcinoma were found to have tumor-induced hypercalcemia: 24 had Stage IV disease, 1 Stage III disease, and 2 Stage I disease. There was no evidence of bone metastasis in 13 of 27 (48%) patients. A total of 89 episodes of acute hypercalcemia were treated: 36 episodes resulted in a complete response ([CR] calcium levels returning to normal), 24 partial response ([PR] calcium decrease greater than 1 mg/dL, but above normal) and 29 negligible response ([NR] calcium decrease less than 1 mg/dL) to treatment modalities used. One patient with Stage I disease and 3 with Stage IV disease underwent nephrectomies resulting in 2 CR and 1 PR. There was a complete response (CR) to mithramycin in 7 of 10 (70%) acute hypercalcemic episodes, to furosemide and mithramycin in 12 of 20 (60%), to steroids or furosemide and steroids in 3 of 7 (43%), to hydration in 4 of 13 (31%), and to furosemide in 7 of 25 (28%). The response rates to phosphates, indomethacin, and calcitonin were low but involved a small number of patients. Survival in 24 patients with Stage IV disease was 5-239 days (av 87.3 days). There was essentially no survival difference between patients who had an initial calcium elevation less than or greater than 13 mg/dL. We conclude that mithramycin is more effective in controlling acute hypercalcemia secondary to renal cell carcinoma than furosemide or hydration. Steroids appear to be effective but our experience was limited. Surprisingly, the degree of calcium elevation did not show a significant correlation with survival.

Interferon therapy of metastatic renal cell cancer

There is no curative therapy for metastatic or recurrent renal cell carcinoma (RCC). Almost three-quarters of such patients die of their malignancy in 1 year and less than 5% of such patients are alive at 3 years. Few patients respond to hormonal therapy or chemotherapy, and when responses occur, they are usually brief and partial with little impact on survival. Interferon therapy in metastatic RCC has been associated with response rates of approximately 15-20%, and tumor regression has been demonstrated in patients treated with both partially purified and, more recently, recombinant interferon. Analysis of published trials shows no clear dose-response relationship; however, the highest therapeutic index appears associated with a daily dosage of 5-10 million units. The time to response is variable and may occasionally be prolonged; however, some patients have durations of response exceeding 12 months. Although nephrectomy may be associated with higher response rates, review of available data indicates that nephrectomy has frequently been an eligibility criteria, and indeed there are adequate descriptions of responses in patients that have not undergone this procedure. Patients with pulmonary metastases have the highest response rate. Recently, laboratory and clinical investigations of interferons and several chemotherapeutic agents, notably vinblastine, suggest synergy, but further data is needed to confirm these findings. The role of interferon therapy in improving survival is unknown. There is little doubt, however, that symptomatic patients who respond to interferon therapy may show improvement in their quality of life and prolongation of survival.

Sarcomatoid renal cell carcinoma. A treatable entity

Of 920 patients with histologically confirmed renal cell carcinoma (RCC) seen at University of Texas M. D. Anderson Hospital over a 10-year period, 44 (4.8%) had the sarcomatoid variant. The authors show that, although sarcomatoid RCC has as common denominators with classic RCC in certain epidemiologic parameters such as age and sex, its biologic behavior is different. It is more malignant, has a higher metastatic rate, ultimate recurrence in localized disease which translates to a shorter survival time. Metastasis at presentation, advanced age (older than 59 years) and female sex were a associate with a worse prognosis. This entity is characterized by a high incidence of bone metastasis at presentation (48%) and by a tendency toward pathologic bone fractures. All of the untreated patients died very soon after diagnosis (median, 3.8 months), whereas all of the patients treated with the various systemic modalities initiated only in the presence of metastatic disease survived significantly longer (median, 13.0 months). Of the eight patients who were treated with doxorubicin HCI chemotherapy regimens two (on CYVADIC) showed complete responses and are the only survivors (50, 65 months). Four patients treated with interferon had the longest median survival (41.0 months). These results suggest that CYVADIC chemotherapy should be combined with interferon in this entity. Since surgery is not curative in early stages of sarcomatoid RCC, adjuvant therapy with those agents should be considered.

Phase II trial of misonidazole (MISO) and cyclophosphamide (CYC) in metastatic renal cell carcinoma

In animal models pre-treatment with misonidazole, a hypoxic cell radiosensitizer, enhances the antineoplastic effects of alkylating agent chemotherapy. Laboratory data suggest that hypoxic tumor cells may be more resistant to chemotherapy because of suboptimal drug delivery, reduced rates of cell division, or because hypoxia confers relative drug resistance. The therapeutic potential depends on the tumor type, doses of radiosensitizer and alkylating agent, the time interval between drug administration, and the ratio of sensitization of normal and malignant tissues. A Phase II trial of misonidazole and cyclophosphamide was initiated by the Eastern Cooperative Oncology Group to determine the response rate and toxicity in patients with metastatic renal cell cancer. Patients received 5 gm/m2 of misonidazole intravenously two hr before 1200 mg/m2 of cyclophosphamide every 3 wk. Patients with prior chemotherapy or radiotherapy received 1000 mg/m2 of cyclophosphamide. Misonidazole was discontinued after a total dose of 15 gm/m2. The median total misonidazole dose was 23.5 gm (range 4.5-34.5 gm). The median number of cyclophosphamide cycles was 2 (range 1-12). Of the 30 patients evaluable for response, only one patient had an objective partial response. Twenty-nine patients had stable or progressive disease. One patient remains on cyclophosphamide after 9 mo. Estimated median survival is 4.8 mo. There have been no lethal toxicities; however, 9 patients (25%) experienced life-threatening leukopenia and an additional 42% experienced severe hematologic toxicity. Eight patients had WBC less than 1000 on days 7-14 of cycle 1. Thrombocytopenia and grade 3 anemia occurred in 1 and 2 patients, respectively. Moderate or severe nausea and vomiting occurred in 47% and 19% of patients, respectively. Only 3 patients experienced severe neurotoxicity. Four additional patients had moderate neurotoxicity. In summary, misonidazole in this dosing schedule does not enhance the antitumor activity of cyclophosphamide in renal cell carcinoma.

DNA content and prognosis in renal cell carcinoma. A comparison between primary tumors and metastases

Deoxyribonucleic acid (DNA) content was retrospectively determined by single-cell cytophotometry in primary tumors and corresponding metastases from 32 patients with renal cell carcinoma. In 15 of the primary tumors a diploid/near diploid and in 17 an aneuploid DNA content was found. A diploid/near diploid DNA pattern was revealed in 10 metastases and 22 were aneuploid. By comparing the DNA content in the primary tumors with their metastases, 13 of 32 showed a clear divergency, which might illustrate tumor cell heterogeneity of renal cell carcinoma. The DNA pattern showed a close correlation to morphologic grading. A correlation between DNA content in the metastases and survival time was found. Patients, with diploid/near diploid metastases survived significantly longer than those with aneuploid DNA contents (mean, 31.1 and 11.5 months, respectively; P = 0.004). In contrast to this, no correlation was found between DNA content in the primary tumors and survival time.

Regression of metastatic renal cell carcinoma: a case report and literature review

The literature provides few examples of regression of documented metastatic renal cell carcinoma. We report a case of cytologically documented pulmonary metastases from a renal cell carcinoma, which resolved following nephrectomy and hormonal therapy. The patient has been followed for 6 years without evidence of recurrence.

Prognostic significance of the DNA content in renal cell carcinoma

The DNA content in renal cell carcinoma as an indicator of prognosis was studied retrospectively in 55 patients without distant metastases at operation. Two groups of patients were selected, differing with respect to survival. Thirty-three patients survived for at least 10 years and 22 succumbed to the disease within four years. DNA measurements in morphologically identified tumor cells were performed in histological sections by single cell cytophotometry. The tumor cells of the surviving patients had a DNA content comparable to that of normal cells. A diploid/near diploid DNA content was the dominant feature in 32 of these 33 tumors. The remaining patient had a tumor with a tetraploid/near tetraploid DNA value. In contrast, all tumors from the non-surviving patients had abnormally increased DNA content, indicating a high degree of aneuploidy in these tumors. The results suggest that DNA content may be superior to other clinical and microscopical parameters as a prognostic indicator.

Value of routine radionuclide bone scans in renal cell carcinoma

Radionuclide bone scans were obtained as part of the routine evaluation of 85 patients with renal cell carcinoma. Twenty-nine patients (34%) were found to have metastatic disease at presentation. Bone scans were abnormal in 27 of these 29 patients for a sensitivity of 93 per cent; of the remaining 56 without metastatic disease, 48 had normal bone scans for a specificity of 86 per cent. In all patients whose abnormal bone scans indicated metastatic disease, there were either clinical signs (bone pain), laboratory findings (elevated alkaline phosphatase), or routine radiographic procedures (chest roentgenogram, intravenous pyelogram, or angiogram) suggesting disease metastatic to bone. Although bone scanning was useful for confirming clinically or radiographically suspected metastatic disease, it did not influence the staging of the renal cell carcinoma in any patient. We therefore conclude that bone scans should be used to confirm the presence and to determine the extent of osseous metastases in patients with renal cell carcinoma but are unnecessary as a routine staging procedure.

Urine cytology in the detection of renal adenocarcinoma

Whereas urine cytology has proved to be of considerable diagnostic value for nonpapillary urothelial carcinoma, carcinoma in situ, and high-grade urothelial tumors, controversy has arisen over the accuracy of cytology in the diagnosis of renal neoplasms. To establish the reliability of urine cytology as a detection technique, 436 urine specimens from 59 patients with histologically proven renal adenocarcinoma were examined. Malignant cells in urinary sediment were found in 121 (27.75%) specimens from 31 (52.54%) patients. Seven of 20 (35%) patients with Stage I tumor showed neoplastic cells in 16 (16.5%) of 97 urinary samples. Positive cytologic features were found in 36.9% of 84 urinary specimens from 7 (50%) of 14 patients with tumors smaller than 5 cm. Using only imaging methods, the renal neoplasm was diagnosed in 58 (98.3%) cases. Urine cytology is, therefore, of little value in the diagnostic evaluation of known renal masses and in the detection of early-stage disease. In the current series there was not a single case with positive cytologic findings in which radiology did not reveal the tumor. The cytologic examination of the urinary sediment is unreliable in the diagnosis of radiologically unresolved cases of renal neoplasms. In 15 patients (44%) who had cancer cells in the urine the neoplasm had not invaded the renal pelvis. In 36% of patients with negative urine cytologic findings the renal pelvis was involved by renal adenocarcinoma. In the current study the desquamation of neoplastic cells in the urinary stream did not depend on tumor invasion of the renal pelvis. Based on the assumption that the primary objective of a screening procedure is to achieve an adequate sensitivity for early detection of disease, the results led the authors to conclude that the use of urine cytology as a possible screening test of renal adenocarcinoma is futile. Factors in the current study that diminished the practical value of cytologic examination of urinary sediment included the large number of specimens without malignant cells and the insensitivity of the procedure in diagnosing early renal adenocarcinoma of limited extent. Although this is the largest series reported, the number of cases considered was limited and further detailed studies are mandatory to definitively clarify the value of urine cytology in detecting renal adenocarcinoma.

Infarction-nephrectomy for metastatic renal carcinoma. Southwest oncology group study

Thirty patients with metastatic renal cell cancer were treated by renal infarction, followed by delayed nephrectomy. All cases were collected over an eighteen-month period, with a minimum follow-up of one year. There were no complete remissions and only one partial remission, which lasted twenty-one months before progression of disease. Three patients had stable disease for at least six months, but eventually all patients showed evidence of progression. After tumor progression was documented patients were treated with intramuscular medroxyprogesterone acetate (Depo-Provera) 800 mg per week. No patient responded to this therapy. Overall, a 28 per cent one-year survival and a seven-month median survival were realized, which is similar to other series in which no therapy or palliative nephrectomy was performed. We conclude that infarction and nephrectomy is not an effective modality in the treatment of metastatic renal cell carcinoma. In addition, medroxyprogesterone was not shown to be significantly active against renal cancer in this study.

The role and value of surgery in metastatic renal adenocarcinoma: a retrospective clinical study of 106 nephrectomized cases

The results of treatment of 106 consecutive nephrectomized cases with metastatic renal adenocarcinoma were analyzed. Over 50% of the patients were dead at 1 year and more than 80% at 2 years from the first metastases. The corresponding 5-year survival rate was 7.3%. Fourteen patients demonstrated a response to radiotherapy, hormonal therapy, cytotoxic drugs, or active specific immunotherapy. The 5-year survival rate of the responders was 14.3% from the first metastases. The 5-year survival rate for 22 patients presenting with only one metastasis was 32%. The corresponding figure for patients presenting with multiple metastases was 1%. Complete excision of metastases was possible in 12 patients, whose 5-year survival rate was 58.3%. All patients with solitary metachronous metastases completely excised lived 5 years or more. It seems that a small number of metastatic renal adenocarcinomas are slow-growing tumors that may simulate a favorable effect of a therapy, but at the same time such disease with nephrectomy, usually with minor tumor burden, in fact may also react better to the treatment, and this feature can cause difficulties in judging the value of any therapy in metastatic renal adenocarcinoma.

Problems of the indications of radiotherapy in renal tumours after radical nephrectomy

The complex therapy of renal tumours is discussed. While pointing to the advances in this field over the last decade, the fact is emphasized that it is primarily in the radicality of the operations were progress has been achieved. Radiotherapy is viewed with a critical eye. Its hazards are illustrated by observations of four lethal cases consecutive to complications of postoperative irradiations, which had been administered without any need when malignant changes were no longer present.

Metastatic renal-cell carcinoma presenting as a cutaneous horn

Renal-cell carcinoma develops as an insidious neoplasm, frequently metastasizing to the skin. Cutaneous manifestations vary regarding morphology and sites of predilection. A patient was recently seen demonstrating a metastasis from a renal neoplasm. The lesion was unusual in that it grossly resembled a cutaneous horn. Dermatologists should continue to be alert to the possibility of renal tumor metastasis when evaluating cutaneous tumors.

Culture of peripheral monocytes in vitro in patients with renal cell carcinoma: a possible prognostic indicator

An in vitro assay has been applied in 23 patients with renal cell carcinoma. A mononuclear cell-rich fraction was cultured from peripheral blood of patients with renal cell carcinoma. The number of monocytes maturing into macrophages was quantitated over a period of 7 days. Monocyte maturation was significantly lower in patients with renal cell carcinoma than in normal individuals. Of 10 patients tested both pre- and post-nephrectomy, 8 patients showed clinical improvement after surgery. In all 8, the posttreatment macrophage yield improved significantly from the pretreatment values to approach normal values. In 2 patients found to have metastasis postoperatively, the macrophage yield continued below normal levels. Our results suggest that the in vitro maturation of macrophages from mononuclear cells may parallel clinical events.

[Hypocalcemia in malignant diseases]

Hypercalcemia accompanies often malignant diseases. The majority of cases of malignancy complicated by hypercalcemia is induced by metastases involving bone, hypercalcemia may also accompany localised tumors. Various hormones have been implicated in the genesis of malignant hypercalcemia: ectopic secretion of parathyroid hormone by tumor or orthotopic secretion by concomitant primary hyperparathyroidism, prostaglandin activating osteoclasts, production of hypercalcemic factor other than these hormones. This review summarizes current knowledge about endocrine-mediated mechanisms which produce hypercalcemia and about its frequency and mechanism in different types of tumors.

Cost effective analysis of prenephrectomy radioisotope scans in renal cell carcinoma

To evaluate the cost-effectiveness of liver and bone isotope scans, results of scans were reviewed in 60 patients with renal cell carcinoma. In no patient did the results of the scans influence or change the treatment plan. Routine utilization of radioisotope scans as part of the preoperative evaluation of patients with renal cell carcinoma should be discouraged.

Metastatic renal cell carcinoma presenting as shoulder arthritis

Three patients with previously undiagnosed renal cell carcinoma presented with complaints of shoulder pain secondary to tumor metastases involving the clavicle or upper humerus. In two patients, bone scintigraphy and/or gallium scintigraphy demonstrated the primary renal lesion. One patient had been treated with anti-inflammatory drugs and intra-articular steroid injections for presumed arthritis before the cause of the symptoms was recognized. Review of the literature reveals that renal cell carcinoma frequently metastasizes to bones of the shoulder girdle, and that presenting complaints may relate to osseous metastases. Careful evaluation should be carried out before patients with shoulder pain are treated for presumed arthritis.