TNM T3a renal cell carcinoma: adrenal gland involvement is not the same as renal fat invasion

Integrative Analysis of Peripheral Blood Indices for the Renal Sinus Invasion Prediction of T1 Renal Cell Carcinoma: An Ensemble Study Using Machine Learning-Assisted Decision-Support Models

Purpose

Renal sinus invasion is an attributive factor affecting the prognosis of renal cell carcinoma (RCC). This study aimed to construct a risk prediction model that could stratify patients with RCC and predict renal sinus invasion with the help of a machine learning (ML) algorithm.

Patients and Methods

We retrospectively recruited 1229 patients diagnosed with T1 stage RCC at the Baotou Cancer Hospital between November 2013 and August 2021. Iterative analysis was used to screen out predictors related to renal sinus invasion, after which ML-based models were developed to predict renal sinus invasion in patients with T1 stage RCC. The receiver operating characteristic curve (ROC), decision curve analysis (DCA), and clinical impact curve (CIC) were performed to evaluate the robustness and clinical practicability of each model.

Results

A total of 21 candidate variables were shortlisted for model building. Iterative analysis screened that neutrophil to albumin ratio (NAR), hemoglobin level * albumin level * lymphocyte count/platelet count ratio (HALP), prognostic nutrition index (PNI), body mass index*serum albumin/neutrophil-lymphocyte ratio (AKI), NAR, and fibrinogen (FIB) concentration (NARFIB), platelet to lymphocyte ratio (PLR), and R.E.N.A.L score was related to renal sinus invasion and contributed significantly to ML-based algorithm. The areas under the ROC curve (AUCs) of the random forest classifier (RFC) model, support vector machine (SVM), eXtreme gradient boosting (XGBoost), artificial neural network (ANN), and decision tree (DT) ranged from 0.797 to 0.924. The optimal risk probability of renal sinus invasion predicted was RFC (AUC = 0.924, 95% confidence interval [CI]: 0.414–1.434), which showed robust discrimination for identifying high-risk patients.

Conclusion

We successfully develop practical models for renal sinus invasion prediction, particularly the RFC, which could contribute to early detection via integrating systemic inflammatory factors and nutritional parameters.

Update on the Role of Imaging in Clinical Staging and Restaging of Renal Cell Carcinoma Based on the AJCC 8th Edition, From the AJR Special Series on Cancer Staging

This article reviews the essential role of imaging in clinical staging and restaging of renal cell carcinoma (RCC). To completely characterize and stage an indeterminate renal mass, renal CT or MRI without and with IV contrast administration is recommended. The critical items for initial clinical staging of an indeterminate renal mass or of a known RCC according to the TNM staging system are tumor size, renal sinus fat invasion, urinary collecting system invasion, perinephric fat invasion, venous invasion, adrenal gland invasion, invasion of the perirenal (Gerota) fascia, invasion into other adjacent organs, the presence of enlarged or pathologic regional (retroperitoneal) lymph nodes, and the presence of distant metastatic disease. Larger tumor size is associated with higher stage disease and invasiveness, lymph node spread, and distant metastatic disease. Imaging practice guidelines for clinical staging of RCC, as well as the role of renal mass biopsy, are highlighted. Specific findings associated with response of advanced cancer to antiangiogenic therapy and immunotherapy are discussed, as well as limitations of changes in tumor size after targeted therapy. The accurate clinical staging and restaging of RCC using renal CT or MRI provides important prognostic information and helps guide the optimal management of patients with RCC.

[Criteria for an improved prognostic stratification in category pT renal carcinoma]

Asymptomatic renal carcinomas are usually small and localized and thus, for the assessment of pT, precise criteria are required, able to identify the initial phases of a local extension and correlate them with current prognostic prospects. Various studies and consensus meetings have defined precisely how to measure tumoral nodules (solid, cystic and multiple). Furthermore, they have distinguished tumoral extension to the renal sinus, which has a worse prognosis, from that to the perirenal adipose tissue. They have also analyzed the clinical significance of invasion of the sinus vessels, the hilar veins and parenchymal vascular retroinvasion. Our aim is to revise and update the criteria of the different pT subcategories and consider those morphological aspects which could be clinically significant and that are not currently included in the TNM classification.

Prognostic value of perirenal and/or sinus fat infiltration in patients with pT3a renal cell carcinoma: A multicentre cohort study. LARCG Group

INTRODUCTION AND OBJECTIVES

The objective of this study is to evaluate overall survival (OS), cancer-specific survival (CSS), relapse-free survival, local and distant (LRFS and DRFS, respectively) rates in patients with pT3a renal cell carcinoma (RCC) considering the perirenal and/or sinus fat infiltration (FI) as prognostic factors.

MATERIALS AND METHODS

Retrospective cohort of patients with pT3a RCC who underwent radical or partial nephrectomy. The data were extracted from the LARCG (Latin American Renal Cancer Group) database. The demographic, clinical, pathological and surgical variables were evaluated. FI was divided into 4 groups (vein, perirenal, sinus and both fats infiltration). The Kaplan Meier and Cox regression curves were performed.

RESULTS

293 patients were included in the study. The mean age was 61.4 years. The median follow-up was 21 months (r: 1-194). CSS, RFS, LRFS and DRFS estimated at 3 years in the group of both fats' infiltration were 53.1, 45.1, 58.7 and 51.6 months, respectively, and always statistically lower than the rest (P˂0.005). In the multivariate analysis, the infiltration of both fats significantly increased specific mortality, overall and local relapse with respect to vein infiltration (HR: 4.5, 2.42 and 8.08, respectively). The Fuhrman grade and renal pelvis infiltration were independent predictors of CSS and RFS.

CONCLUSIONS

Infiltration of both fats increases the risk of overall and local relapse in pT3a RCC. In the same way, it is associated with a lower cancer-specific survival and should be considered as a factor of poor prognosis.

Renal cell carcinoma staging: pitfalls, challenges, and updates

Renal cell carcinoma (RCC) is unusual among cancers in that it often grows as a spherical, well-circumscribed mass. Increasing tumour size influences the pathological pT stage category within pT1 and pT2, with cutoffs of 40, 70 and 100 mm; however, with increasing size also comes a sharp increase in the likelihood of renal sinus or renal vein tributary invasion, such that clear cell RCC rarely reaches 70 mm without invading one of these. To clarify some previous challenges in assigning tumour stage, the American Joint Committee on Cancer 2016 tumor-node-metastasis classification has removed the requirements than vein invasion be recognised grossly and that vein walls contain muscle for the diagnosis of vein invasion. Renal pelvis invasion has also been added as an additional route to pT3a. Multinodularity or finger-like extensions from a renal mass should be viewed with great suspicion for the possibility of vein or renal sinus invasion, and, as tumour size increases to over 40-50 mm, thorough sampling of the renal sinus interface should always be undertaken. With increasing interest in adjuvant therapy in renal cancer, the pathologist's role in RCC staging will continue to be an important prognostic parameter and a tool for selection of patients for enrolment in clinical trials.

Classic SRY-box protein SOX7 functions as a tumor suppressor regulating WNT signaling and is methylated in renal cell carcinoma

SOX7 (SRY-related high mobility group box 7), a high mobility group protein, is reported to be down-regulated in several cancer types, which indicates an important role in tumorigenesis; however, its biologic role in renal cell carcinoma (RCC) pathogenesis remains unknown. We studied the alterations and functions of SOX7 in RCC. We detected its broad expression in multiple human normal tissues, including kidney, but frequent down-regulation in RCC cell lines and primary tumors. Promoter CpG methylation seems to directly mediate SOX7 silencing in RCC cells, which could be reversed by demethylation treatment. SOX7 methylation was detected in primary RCC tumors, but rarely in normal kidney tissues. Restoration of SOX7 in silenced 786-O and A498 RCC cell lines inhibited their cell growth by inducing G₀/G₁ arrest, whereas SOX7 knockdown promoted RCC cell proliferation. We also found that SOX7 silencing resulted in the activation of WNT signaling and the induction of epithelial to mesenchymal transition. In conclusion, the current study demonstrates that SOX7 is frequently inactivated by promoter CpG methylation in RCC and functions as a tumor suppressor by regulating WNT signaling.-Wang, L., Fan, Y., Zhang, L., Li, L., Kuang, G., Luo, C., Li, C., Xiang, T., Tao, Q., Zhang, Q., Ying, J. Classic SRY-box protein SOX7 functions as a tumor suppressor regulating WNT signaling and is methylated in renal cell carcinoma.

Prognostic heterogeneity in T3aN0M0 renal cell carcinoma according to the site of invasion

PURPOSE

We investigated the influence of the site of invasion on recurrence and survival in patients with pT3aN0M0 renal cell carcinoma (RCC).

MATERIALS AND METHODS

We reviewed the data of 266 patients with pT3aN0M0 RCC who underwent nephrectomy and divided them into the following 5 groups according to the site of invasion: perinephric invasion (PNI), sinus fat invasion (SFI), PNI and SFI without renal vein invasion (RVI) (i.e., PNI+SFI), RVI, and RVI with PNI and/or SFI (RVI+PNI±SFI). Subgroup analysis was performed to verify the differences in prognosis according to the extent of renal vein invasion using Cox regression models.

RESULTS

A total of 111 patients (41.7%) experienced recurrence and 59 patients (22.2%) died of disease during follow-up (median = 58.1mo; interquartile range: 37.2-86.5). Patients with RVI showed significantly poorer outcomes than those with fat invasion in terms of 5-year recurrence-free survival (34.3% vs. 62.2%, P<0.001) and cancer-specific survival (62.8% vs. 84.1%; P<0.001). In multivariate analysis, RVI was an independent prognostic factor for recurrence and survival. In 94 patients with RVI, the 5-year recurrence-free survival rates were 50.0%, 33.9%, and 8.9% for the thrombus-only, the vascular wall invasion with negative surgical margin, and the vascular wall invasion with positive surgical margin groups, respectively (P<0.001), and the cancer-specific survival rates were 82.3%, 56.6%, and 20.0%, respectively (P<0.001). Wall invasion was the only independent prognostic factor for cancer-specific survival in these patients.

CONCLUSIONS

Patients with pT3aN0M0 RCC with RVI have a significantly poorer prognosis than those with fat invasion. The prognosis differs according to the extent of RVI. Wall invasion should be considered a negative prognostic indicator in patients with T3a RCC.

The Difference in Prognosis between Renal Sinus Fat and Perinephric Fat Invasion for pT3a Renal Cell Carcinoma: A Meta-Analysis

Background

In the current Tumour-Node-Metastasis (TNM) classification system for renal cell carcinoma (RCC), both renal sinus fat invasion (SFI) and perinephric fat invasion (PFI) are defined as T3a, suggesting that the prognosis should be similar for the two pathologic findings. Several studies, however, have reported a worse prognosis for SFI in patients with a T3a tumor. In order to compare the prognosis of these two pathologic findings (SFI versus. PFI) in a more comprehensive way, this meta-analysis was performed.

Methods

To identify relevant studies, Medline, Embase, Cochrane Library, and Scopus database were searched from the inception until October 2014. A meta-analysis was performed using Review Manager 5.2 and STATA 11. Pooled Odds ratio (OR) and/or hazard ratio (HR) with 95% confidence interval (CI) were calculated to examine the risk or hazard association.

Results

A total of 6 studies including 1031 patients qualified for analysis. T3a RCC patients with SFI were significantly associated with poor cancer specific survival(CSS) (HR: 1.47, 95% CI: 1.19–1.83; P<0.001) compared to those with PFI. In T3aNx/N0M0 subgroup, SFI patients also showed a worse prognosis than those with PFI (CSS, HR: 1.94, 95% CI: 1.21–3.12; P = 0.006). T3a RCC patients with SFI had higher Furhman grade, greater possibility of lymph node metastasis, sarcomatoid differentiation and tumour necrosis. Main limitation is the relatively small number of included studies.

Conclusion

The present meta-analysis suggested that SFI is associated with worse CSS in patients with pT3a RCC. However, due to the small number of included studies, future studies with a large sample size are required to further verify our findings.

The Role of Adrenalectomy in Renal Cancer

CONTEXT

Since the 1960s, routine ipsilateral adrenalectomy (IA) has been considered an integral step in the removal of renal tumors as a part of a radical nephrectomy. However, recent data from the past decade have narrowed the indications for adrenalectomy and called into question the need for adrenalectomy at all in the treatment of renal cell carcinoma (RCC).

OBJECTIVE

We sought to identify the role of adrenalectomy in the treatment of RCC. Specifically, we wanted to answer the following questions: What is the incidence of ipsilateral adrenal involvement by cancer? How reliable is preoperative imaging? What is the rate of ipsilateral and contralateral metachronous recurrence? And finally, what are the potential noncancer sequelae from unnecessary removal of the adrenal gland?

EVIDENCE ACQUISITION

A systematic literature search of Embase, PubMed, Cochrane, and Ovid Medline was performed to identify studies evaluating the role of adrenalectomy during RCC surgery. Only articles published in English from the years 2000-2015 were included. Case reports, articles about primary adrenal tumors, letters to the editor, and surgical technique papers were excluded.

EVIDENCE SYNTHESIS

We found little evidence to suggest that routine IA is associated with a higher risk of short-term surgical or medical complications. We did not find evidence that IA is associated with improved cancer control. Tomographic preoperative imaging of the adrenal gland demonstrating no cancer involvement is rarely wrong (<1% of the time), and the few adrenal lesions missed on imaging can often be identified intraoperatively. Some evidence indicates that IA may be associated with worse long-term survival. Adrenalectomy rates have been decreasing in recent years, reflecting a changing practice pattern.

CONCLUSIONS

IA at the time of kidney surgery for a renal mass should be performed only if radiographic or intraoperative evidence indicates adrenal gland involvement.

PATIENT SUMMARY

We sought to define the role of adrenalectomy in patients with kidney cancer. Although there are not high-quality studies to answer this question definitively, we conclude that the adrenal gland should be spared unless there is clinical evidence of adrenal involvement.

Clinical and prognostic factors for renal parenchymal, pelvis, and ureter cancers in SEER registries: collaborative stage data collection system, version 2

BACKGROUND

The American Joint Committee on Cancer's (AJCC) 7th edition cancer staging manual reflects recent changes in cancer care practices. This report assesses changes from the AJCC 6th to the AJCC 7th edition stage distributions and the quality of site-specific factors (SSFs).

METHODS

Incidence data for renal parenchyma and pelvis and ureter cancers from 18 Surveillance, Epidemiology, and End Results (SEER) registries were examined, including staging trends during 2004-2010, stage distribution changes between the AJCC 6th and 7th editions, and SSF completeness for cases diagnosed in 2010.

RESULTS

From 2004 to 2010, the percentage of stage I renal parenchyma cancers increased from 50% to 58%, whereas stage IV and unknown stage cases decreased (18% to 15%, and 10% to 6%, respectively). During this period, the percentage of stage 0a renal pelvis and ureter cancers increased from 21% to 25%, and stage IV and unknown stage tumors decreased (20% to 18%, and 7% to 5%, respectively). Stage distributions under the AJCC 6th and 7th editions were about the same. For renal parenchymal cancers, 71%-90% of cases had known values for 6 required SSFs. For renal pelvis and ureter cancers, 74% of cases were coded as known for SSF1 (WHO/ISUP grade) and 47% as known for SSF2 (depth of renal parenchymal invasion). SSF values were known for larger proportions of cases with reported resections.

CONCLUSIONS

Stage distributions between the AJCC 6th and 7th editions were similar. SSFs were known for more than two-thirds of cases, providing more detail in the SEER database relevant to prognosis.

Clinicopathologic patterns of adult renal tumors in Pakistan

BACKGROUND

Renal cancer is a serious public health problem which may be under reported and registered in our setup, since the Karachi cancer registry documented only 43 cases out of 4,268 incident cancer cases over 3 year duration. Therefore we aimed to determine the clinicopathologic characteristics of adult renal tumors in our setup.

MATERIALS AND METHODS

The study was conducted in histopathology department, Liaquat National Hospital and included total of 68 cases of adult renal tumors over 4 years. Detailed histopathologic characteristics of tumors were analyzed.

RESULTS

Mean age of patients was 56.4 (18-84) years. Renal cell carcinoma (RCC) was the most common cell type (78%) cases; followed by transitional/urothelial carcinoma (12.5%), leiomyosarcoma (4.7%), oncocytoma (1.6%), squamous cell carcinoma (1.6%) and high grade pleomorphic undifferentiated sarcoma (1.6%). Among 50 RCC cases; 62% were conventional/clear cell RCC (CCRCC) type followed by papillary RCC(PRCC), 24%; chromophobe RCC(CRCC), 6% and sarcomatoid RCC(SRCC), 8%. Mean tumor size for RCC was 7.2 cm. Most RCCs were intermediate to high grade (60% and 40% respectively). Capsular invasion, renal sinus invasion, adrenal gland involvement and renal vein invasion was seen in 40%, 18%, 2% and 10% of cases respectively.

CONCLUSIONS

We found that RCC presents at an earlier age in our setup compared to Western populations. Tumor size was significantly larger and most of the tumors were of intermediate to high grade. This reflects late presentation of patients after disease progression which necessitates effective measures to be taken in primary care setup to diagnose this disease at an early stage.

The ISUP system of staging, grading and classification of renal cell neoplasia

There have been significant changes in the staging, classification and grading of renal cell neoplasia in recent times. Major changes have occurred in our understanding of extra-renal extension by renal cell cancer and how gross specimens must be handled to optimally display extra-renal spread. Since the 1981 World Health Organization (WHO) classification of renal tumors, in which only a handful of different entities were reported, many new morphological types have been described in the literature, resulting in 50 different entities reported in the 2004 WHO classification. Since 2004, further new entities have been recognized and reported necessitating an update of the renal tumor classification. There have also been numerous grading systems for renal cell carcinoma with Fuhrman grading, the most widely used system. In recent times, the prognostic value and the applicability of the Fuhrman grading system in practice has been shown to be, at best, suboptimal. To address these issues and to recommend reporting guidelines, the International Society of Urological Pathology (ISUP) undertook a review of adult renal neoplasia through an international consensus conference in Vancouver in 2012. The conduct of the conference was based upon evidence from the literature and the current practice amongst recognized experts in the field. Working groups selected to deal with key topics evaluated current data and identified points of controversy. A pre-meeting survey of the ISUP membership was followed by the consensus conference at which a formal ballot was taken on each key issue. A 65% majority vote was taken as consensus. This review summarizes the outcome and recommendations of this conference with regards to staging, classification and grading of renal cell neoplasia.

Prognostic factors in renal cell carcinoma: analysis of 227 patients treated at the Brazilian National Cancer Institute

PURPOSE

We evaluated the role of several prognostic factors in predicting death and/or progressive disease in patients with renal cell carcinoma.

MATERIALS AND METHODS

Between 2004 and 2010, 227 consecutive patients with renal cell carcinoma underwent radical nephrectomy at our Institute. All histological specimens were examined by the same pathologist. We considered certain histological parameters, including histological subtype, conventional Fuhrman grade, presence of sarcomatoid features, adrenal gland infiltration, invasion of the perinephric fat, vascular embolization, collecting system invasion, presence or absence of tumour necrosis (0 %, 1 % to 49 %, or 50 % or greater) and regional lymph node metastasis.

RESULTS

Variables significantly associated with death and/or progressive disease on univariate analysis were histological subtype (p = 0.006), Fuhrman grade (p < 0.0001), tumor necrosis (p = 0.009), perinephric fat invasion (p = 0.002), vascular embolization (p = 0.0002), presence of lymph node involvement (p < 0.002), tumor size (p = 0.0006), TNM stage (p < 0.00001) and presence of metastasis (p < 0.00001). In the multivariable model histological subtype, tumor necrosis, lymph node involvement and presence of metastasis were independent risk factors for disease-free survival (p = 0.011, 0.042, 0.025 and p < 0.0001, respectively).

CONCLUSION

Histological subtype, tumor necrosis, lymph node involvement and presence of metastasis proved to be independent prognostic factors for disease-free survival. Therefore, the presence and rate of tumor necrosis should always be informed by the pathologist and lymphadenectomy should be performed in all patients.

Application of the revised Tumour Node Metastasis (TNM) staging system of clear cell renal cell carcinoma in eastern China: advantages and limitations

This study was designed to evaluate whether the revised 2010 Tumour Node Metastasis (TNM) staging system could lead to a more accurate prediction of the prognosis of renal cell carcinoma (RCC) patients. A total of 1216 patients who had undergone radical nephrectomy or partial nephrectomy for RCC from 2003 to 2011 were enrolled. All of the patients had pathologically confirmed clear cell RCC (ccRCC). All cases were staged by both the 2002 and 2010 TNM staging systems after pathological review, and survival data were collected. Univariate and multivariate Cox regression models were used to evaluate cancer-specific survival (CSS) and progression-free survival (PFS) after surgery. Continuous variables, such as age and tumour diameter, were calculated as mean values and standard deviations (s.d.) or as median values. Survival was calculated by the Kaplan-Meier method, and the log-rank test assessed differences between groups. Statistically significant differences in CSS and PFS were noted among patients in T3 subgroups using the new 2010 staging system. Therefore, the revised 2010 TNM staging system can lead to a more accurate prediction of the prognosis of ccRCC patients. However, when using the revised 2010 staging system, we found that more than 92% of patients (288/313) with T3 tumours were staged in the T3a subgroup, and their survival data were not significantly different from those of patients with T2b tumours. In addition, T2 subclassification failed to independently predict survival in RCC patients.

Comparison of the 2002 and 2010 TNM classification systems regarding outcome prediction in clear cell and papillary renal cell carcinoma

AIMS

  A novel version of the tumour-node-metastasis (TNM) classification system for renal cell carcinoma (RCC) was introduced in 2010, although the prognostic significance with regard to different histological subtypes has not been explored. Therefore, the aim of our study was to compare the predictive ability of the 2002 and 2010 versions of the TNM classification system for clear cell and papillary RCC.

METHODS AND RESULTS

  Data from 2263 consecutive clear cell and 309 papillary RCC patients, operated at a single tertiary academic centre, were evaluated. According to TNM 2010, statistically significant differences for cancer-specific survival (CSS) were observed for pT1a versus pT1b (P < 0.001) and pT3a versus pT3b (P < 0.004) in clear cell RCC; and pT1b versus pT2a (P = 0.002) and pT3b versus pT3c (P = 0.046) in papillary RCC. The c-index for CSS in clear cell RCC was 0.74 and 0.73, and in papillary RCC 0.79 and 0.78, for the 2002 and 2010 versions of the TNM classification system, respectively.

CONCLUSIONS

  According to our data, the predictive ability of the 2010 version of the TNM classification system regarding CSS is not superior to the 2002 version, either in clear cell or in papillary RCC.

[Partial versus radical nephrectomy for renal cell carcinoma involving peri renal fat. Oncological and functional outcomes]

PURPOSE

In the latest guidelines of the European Association of Urology, partial nephrectomy was a reference standard in tumors less than 7cm confined to the kidney. The invasion of the perirenal fat and therefore dissection in a potentially tumor tissue with an increased risk of recurrence.

MATERIAL

From 1995 to 2009, we retrospectively evaluated the oncological outcomes of partial versus radical nephrectomy in tumors with local extension beyond the boundaries of the kidney, without adrenal involvement or metastatic lymph node extension. We evaluated the histological factors influencing the prognostic.

RESULTS

A total of 43patients have been included (ten partial and 33radical nephrectomy). We did not found any significant difference in terms of specific and recurrence-free survival between partial and radical nephrectomy in tumor invading the perirenal fat (P=0.739 and P=0.683 respectively). Factors influencing the prognosis were the Fuhrman grade (P=0.010), the invasion of the urinary tract (P=0.017) and the presence of a positive surgical margin (P=0.041). The renal function was better after partial nephrectomy. The complication rate was similar between partial and radical nephrectomy.

CONCLUSION

The perirenal fat invasion by kidney tumor did not impact the oncological outcomes of partial versus radical nephrectomy with better functional outcomes for partial nephrectomy.

Validation of the 2009 TNM Classification for Renal Cell Carcinoma: Comparison with the 2002 TNM Classification by Concordance Index

PURPOSE

To assess the validity of the 2009 TNM classification for renal cell carcinoma (RCC) and compare its ability to predict survival relative to the 2002 classification.

MATERIALS AND METHODS

We identified 1,691 patients who underwent radical nephrectomy or partial nephrectomy for unilateral, sporadic RCC between 1989 and 2007. Cancer-specific survival was estimated by the Kaplan-Meier method and was compared among groups by the log-rank test. Associations of the 2002 and 2009 TNM classifications with death from RCC were evaluated by Cox proportional hazards regression models. The predictive abilities of the two classifications were compared by using Harrell's concordance (c) index.

RESULTS

There were 234 deaths from RCC a mean of 38 months after nephrectomy. According to the 2002 primary tumor classification, 5-year cancer-specific survival was 97.6% in T1a, 92.0% in T1b, 83.3% in T2, 61.9% in T3a, 51.1% in T3b, 40.0% in T3c, and 33.6% in T4 (p for trend<0.001). According to the 2009 classification, 5-year cancer-specific survival was 83.2% in T2a, 83.8% in T2b, 62.6% in T3a, 41.1% in T3b, 50.0% in T3c, and 26.1% in T4 (p for trend<0.001). The c index for the 2002 primary tumor classification was 0.810 in the univariate analysis and increased to 0.906 in the multivariate analysis. The c index for the 2009 primary tumor classification was 0.808 in the univariate analysis and increased to 0.904 in the multivariate analysis.

CONCLUSIONS

Our data suggest that the predictive ability the 2009 TNM classification is not superior to that of the 2002 classification.

Staging of renal cell carcinoma: Current concepts

The most important and widely utilized system for providing prognostic information following surgical management for renal cell carcinoma (RCC) is currently the tumor, nodes, and metastasis (TNM) staging system. An accurate and clinically useful staging system is an essential tool used to provide patients with counseling regarding prognosis, select treatment modalities, and determining eligibility for clinical trials. Data published over the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate predictive prognostic factors. Staging systems have also evolved with an increase in the understanding of RCC tumor biology. Molecular tumor biomarkers are expected to revolutionize the staging of RCC by providing more effective prognostic ability over traditional clinical variables alone. This review will examine the components of the TNM staging system, current staging modalities including comprehensive integrated staging systems, and predictive nomograms, and introduce the concept of molecular staging for RCC.

Independent validation of the 2010 American Joint Committee on Cancer TNM classification for renal cell carcinoma: results from a large, single institution cohort

PURPOSE

In 2010 the American Joint Committee on Cancer updated the renal cell carcinoma TNM classification. Without independent validation of the new classification its predictive ability for cancer specific survival and generalizability remains unknown. In this setting we determined the predictive ability of the 2010 TNM classification compared to that of the 2002 classification.

MATERIALS AND METHODS

Using the nephrectomy registry at our institution we retrospectively reviewed the records of 3,996 patients with unilateral or bilateral synchronous renal cell carcinoma treated with radical nephrectomy or nephron sparing surgery between 1970 and 2006. Cancer specific survival was estimated using the Kaplan-Meier method and predictive ability was evaluated using the concordance index.

RESULTS

There were 1,165 deaths (29.1%) from renal cell carcinoma a median of 1.9 years after surgery compared to a median followup of 7.4 years for survivors. The estimated 10-year cancer specific survival rate was 96%, 80%, 66%, 55%, 36%, 26%, 25% and 12% for patients with 2010 primary tumor classifications of pT1a, pT1b, pT2a, pT2b, pT3a, pT3b, pT3c and pT4, respectively (p <0.001). The multivariate concordance index for the 2002 and 2010 TNM classifications was 0.848 and 0.850, respectively.

CONCLUSIONS

The new 2010 classification remains a robust predictor of cancer specific survival compared to the 2002 classification by dividing pT2 lesions into pT2a and pT2b, reclassifying ipsilateral adrenal involvement as pT4, reclassifying renal vein involvement as pT3a and simplifying nodal involvement as pN0 vs pN1. However, the 2010 TNM classification showed only modest improvement in predictive ability compared to the 2002 classification.

Surgical approach and the use of lymphadenectomy and adrenalectomy among patients undergoing radical nephrectomy for renal cell carcinoma

OBJECTIVES

We assessed the influence of tumor size and surgical approach on the use of lymphadenectomy and adrenalectomy with radical nephrectomy.

METHODS

We evaluated patients with renal cell carcinoma (RCC) enrolled in the U.S. Kidney Cancer Study, a case-control study in the metropolitan areas of Detroit and Chicago from 2002 to 2007. We identified patients who underwent open (ORN) or laparoscopic radical nephrectomy (LRN). We used medical records and Surveillance, Epidemiology, and End Results (SEER) data to determine the proportion of patients who underwent lymphadenectomy or adrenalectomy. Bivariate analyses were performed to evaluate associations between tumor size, surgical approach, and receipt of lymphadenectomy or adrenalectomy.

RESULTS

We identified 730 patients who underwent ORN (427, 58%) or LRN (303, 42%) for RCC from 2002 to 2007. Among this group, 11% and 24% underwent lymphadenectomy or adrenalectomy, respectively. Lymphadenectomy was more common among patients treated from an open surgical approach (14.1% ORN vs. 5.9% LRN, P < 0.01); this difference was most pronounced for cases with tumors between 4 and 7 cm (15.9% vs. 2.9%, P = 0.01). Patients treated with ORN were also more likely to undergo adrenalectomy, with the greatest discrepancy among cases with tumors ≤ 4 cm (21.7% vs. 11.4%, P < 0.01).

CONCLUSIONS

Among patients undergoing radical nephrectomy for RCC, the use of lymphadenectomy and adrenalectomy is relatively uncommon and varies by tumor size and surgical approach. With an increasing number of patients with small tumors, the diffusion of laparoscopy, and the emergence of clinical trials evaluating systemic adjuvant therapies, our findings highlight important considerations for optimizing surgical management of patients with RCC.

Prognostic impact of muscular venous branch invasion in localized renal cell carcinoma cases

PURPOSE

Beginning with the 2002 American Joint Committee on Cancer staging system, renal sinus muscular venous branch invasion has prognostic equivalence with renal vein invasion in renal cell carcinoma cases. To validate this presumed equivalence we compared patients with isolated muscular venous branch invasion to those with renal vein invasion and those with no confirmed vascular invasion.

MATERIALS AND METHODS

From routine cataloging at our institution we identified 500 patients who underwent partial or radical nephrectomy from 2003 to 2008. After excluding patients with metastasis or noncortical renal cell carcinoma pathology we identified 85 with positive muscular venous branch invasion (+). The 259 patients with pT1-2 muscular venous branch (-) invasion and the 71 with renal vein (+) invasion served as comparison groups. We used a multivariate Cox model to control for tumor characteristics using the Kattan renal cell carcinoma nomogram.

RESULTS

On multivariate analysis the risk of recurrence in the pT1-2 muscular venous branch invasion (-) group was lower than in the muscular venous branch invasion (+) group (HR 0.06, 95% CI 0.02-0.18, p < 0.001). Patients with renal vein invasion (+) had a recurrence rate similar to that in those with muscular venous branch invasion (+) (HR 0.80, 95% CI 0.39-1.65, p = 0.6). The overall survival rate was higher in the muscular venous branch invasion (-) group than in the other groups.

CONCLUSIONS

Patients with muscular venous branch invasion have an outcome inferior to that in patients with pT1-2 disease. This confirms the adverse prognosis of muscular venous branch invasion and supports pathological up-staging. The prognosis of muscular venous branch invasion is similar to that of renal vein invasion, although we cannot exclude the possibility of a difference. Our findings underscore the importance of close patient followup and careful pathological assessment of the nephrectomy specimen.

[Significance of ipsilateral adrenalectomy in surgery for renal cell carcinoma]

PURPOSE

The aim of this study is to analyze the incidence of involvement of ipsilateral adrenal gland from renal cell carcinoma and assess the actual significance of ipsilateral adrenalectomy at nephrectomy.

PATIENTS AND METHODS

From 1981 to 2007, 588 patients were diagnosed as having renal cell carcinoma pathologically at our institution. Of those patients, we retrospectively reviewed the clinicopathologic data in the 426 renal cell carcinoma patients who were eligible for evaluation. Of the 426 patients, 193 (AD group) and the remaining 233 (AS group) underwent radical or partial nephrectomy with or without adrenalectomy, respectively.

RESULTS

Five patients (2.6%) of AD group had adrenal involvement and all of them presented T4 and/or M1 disease. The three patients presented direct involvement of adrenal gland, while metastasis in the remaining 2. All the 5 patients had disease progression after surgery and 4 of them died of disease. The remaining one patient, in whom interferon showed a remarkable response, has been alive with disease for 31 months. The ipsilateral adrenal gland was abnormal on preoperative computed tomography (CT) in 8 patients (1.8%), of whom, 4 had adrenal involvement. One of the five adrenal involvements was overlooked by CT. Thus, in this study, CT showed 80% sensitivity, 98% specificity, 99% negative predictive value and 50% positive predictive value. The 18 patients (7.7%) in AS group later developed nodal and/or visceral metastasis, while no solitary ipsilateral adrenal recurrence was observed in this group.

CONCLUSIONS

Ipsilateral adrenal involvement from renal cell carcinoma is rare, especially after the adrenal-sparing surgery. It is concluded that concomitant adrenalectomy appears to give a very limited therapeutic benefit in this

Prognostic factors in renal cell carcinoma

PURPOSE

Renal cell carcinoma (RCC) is a very heterogeneous disease with widely varying prognosis. An accurate knowledge of the individual risk of disease progression and mortality after treatment is essential to counsel patients, plan individualized surveillance protocols and select patients for adapted treatment schedules and new clinical trials.

METHODS

A systematic review of the literature on prognostic factors of localized and metastatic RCC was performed.

RESULTS

Prognostic factors in RCC include anatomical (TNM classification, tumor size), histological (Fuhrman grade, histologic subtype), clinical (symptoms and performance status), and molecular features. All these features are not perfectly accurate when used alone. Therefore an increasing number of prognostic models or nomograms that include several combined prognostic features have been designed in order to improve predictive accuracy. UCLA Integrated Staging System (UISS) and the Mayo Clinic's SSIGN score are the two most used prognostic models for localized RCC. In the setting of metastatic RCC the classical anatomical and histological tumor features have little predictive value. However, accurate prognostic models have been designed to predict response to therapy, and progression-free and overall survival. The two most used tools to predict response to immunotherapy are the model designed by the French Group of Immunotherapy and the Motzer's model. The advent of tyrosine kinase inhibitors and antiangiogenic drugs have deeply changed the treatment of metastatic RCC. Predictive tools that are adapted to the modern targeted therapies are now needed.

CONCLUSION

There is increasing knowledge on prognostic factors of localized and metastatic RCC. Several predictive models have been developed by combining different prognostic features and are valuable tools for patient counseling, treatment decision-making and trial design. Further research is needed to assess whether the combination of classical prognostic factors with molecular features and information from gene and protein expression profiling can increase the predictive accuracy of the current prognostic models.

Reassessing the current UICC/AJCC TNM staging for renal cell carcinoma

CONTEXT

The outcome prediction for renal cell cancer (RCC) remains controversial, and although many parameters have been tested for prognostic significance, only a few have achieved widespread acceptance in clinical practice. The TNM staging system defines local extension of the primary tumour (T), involvement of regional lymph nodes (N), and presence of distant metastases (M).

OBJECTIVE

This review focuses on reassessing the current TNM staging system for RCC.

EVIDENCE ACQUISITION

A literature search in English was performed using the National Library of Medicine database and the following keywords: renal cell cancer, kidney neoplasm, and staging. We scrutinized 1952 references, and 62 were selected for review based on their pertinence, study size, and overall contribution to the field.

EVIDENCE SYNTHESIS

The prognostic significance of tumour size for localized RCC has been investigated in a large number of studies. As a consequence, many modifications of the TNM staging system were primarily made to the size cut points between stage I and II tumours. The latest three revisions of the TNM system are systematically reviewed. For the heterogeneous group of locally advanced RCCs, involving different anatomic structures surrounding the kidney, the situation is still the subject of controversial scientific dispute. In detail, perirenal fat invasion, direct infiltration of the ipsilateral adrenal gland, invasion of the urinary collecting system, infiltration of renal sinus fat, and vena cava and renal vein thrombosis are disputed. Finally, staging of lymph node metastases and distant metastatic disease is discussed.

CONCLUSIONS

Special emphasis should be put on renal sinus invasion for stage evaluation. Retrospective studies relying on material collected at a time when no emphasis was placed on adequate sampling of the renal sinus should be treated with caution. In view of new treatment opportunities, the current TNM staging system of RCC and any other staging system must be dynamic.

Advances and controversies in grading and staging of renal cell carcinoma

Despite the considerable progress made in our understanding of the pathogenesis, genetics, and pathology of renal cell carcinoma (RCC), difficulties remain relating to the prediction of clinical outcome for individual cases. Although there is evidence to show that high-grade tumors have a poorer prognosis when compared to those of low grade, debate remains regarding the predictive value of grading, especially for those tumors classified into the intermediate grades. Numerous composite morphologic and nuclear grading systems have been proposed for RCC and although that of the Fuhrman classification have achieved widespread usage, the validity of the grading criteria of this classification has been questioned. In addition, there are few studies that have attempted to validate the Fuhrman system for RCCs beyond that of the clear cell subtype. Recent studies have indicated that grading of papillary RCC should be based on nucleolar prominence alone and that the components of the Fuhrman grading classification do not provide prognostic information for chromophobe RCC. Independent of tumor grade, the prognostic importance of tumor stage for RCC is well recognized. The Union Internationale Contre le Cancer/American Joint Committee for Cancer Staging and End Results Reporting TNM staging system is now in its sixth edition (2002) and recent refinements have focused on defining size cut points that will identify apparently localized tumors that will develop recurrence and/or metastases despite attempted curative surgery. In parallel with these studies it has been shown that infiltration of the renal sinus is an important prognostic factor, being observed in almost all tumors >7 cm in diameter. Questions remain as to the appropriate stratification of regional extension of RCC, as defined in the T3 tumor-staging category. Recent modifications to this category have been suggested combining the level of infiltration of the venous outflow tract with the presence or absence of infiltration of the adrenal gland and/or perirenal fat. Similarly, the utility of classifying lymph node involvement by tumor is debated, although it is well recognized that lymph node infiltration is associated with a poor prognosis. Although the current TNM classification does provide useful prognostic information it would appear that further modifications are justified to enhance the predictive value of staging for RCC.

Epidemiology, clinical staging, and presentation of renal cell carcinoma

The increasing incidence of renal cell carcinoma over the past 2 decades can be partly explained by the expanding use of abdominal imaging. As a result, the most incident renal cancers today are small, localized, and asymptomatic. However, the well-documented rise in all stages of RCC calls into question the nature of these asymptomatic lesions. The expected "screening effect" of detecting RCC when it is small and localized, with subsequent decreases in disease-specific mortality, has not been observed. Disease-specific mortality is actually rising, especially in African American patients. Effective interventions aimed at reducing obesity, hypertension, and smoking may help in reducing the incidence of RCC in the future.