Validation of an Integrated Staging System Toward Improved Prognostication of Patients With Localized Renal Cell Carcinoma in an International Population

Risk models for recurrence and survival after kidney cancer: a systematic review

OBJECTIVE

To systematically identify and compare the performance of prognostic models providing estimates of survival or recurrence of localized renal cell cancer (RCC) in patients treated with surgery with curative intent.

MATERIALS AND METHODS

We performed a systematic review (PROSPERO CRD42019162349). We searched Medline, EMBASE and the Cochrane Library from 1 January 2000 to 12 December 2019 to identify studies reporting the performance of one or more prognostic model(s) that predict recurrence-free survival (RFS), cancer-specific survival (CSS) or overall survival (OS) in patients who have undergone surgical resection for localized RCC. For each outcome we summarized the discrimination of each model using the C-statistic and performed multivariate random-effects meta-analysis of the logit transformed C-statistic to rank the models.

RESULTS

Of a total of 13 549 articles, 57 included data on the performance of 22 models in external populations. C-statistics ranged from 0.59 to 0.90. Several risk models were assessed in two or more external populations and had similarly high discriminative performance. For RFS, these were the Sorbellini, Karakiewicz, Leibovich and Kattan models, with the UCLA Integrated Staging System model also having similar performance in European/US populations. All had C-statistics ≥0.75 in at least half of the validations. For CSS, they the models with the highest discriminative performance in two or more external validation studies were the Zisman, Stage, Size, Grade and Necrosis (SSIGN), Karakiewicz, Leibovich and Sorbellini models (C-statistic ≥0.80 in at least half of the validations), and for OS they were the Leibovich, Karakiewicz, Sorbellini and SSIGN models. For all outcomes, the models based on clinical features at presentation alone (Cindolo and Yaycioglu) had consistently lower discrimination. Estimates of model calibration were only infrequently included but most underestimated survival.

CONCLUSION

Several models had good discriminative ability, with there being no single 'best' model. The choice from these models for each setting should be informed by both the comparative performance and availability of factors included in the models. All would need recalibration if used to provide absolute survival estimates.

Outcome after PSMA-PET/CT-based salvage radiotherapy for nodal recurrence after radical prostatectomy

Purpose

Nodal recurrent prostate cancer (PCa) represents a common state of disease, amenable to local therapy. PSMA-PET/CT detects PCa recurrence at low PSA levels. The aim of this study was to evaluate the outcome of PSMA-PET/CT-based salvage radiotherapy (sRT) for lymph node (LN) recurrence.

Methods

A total of 100 consecutive patients treated with PSMA-PET/CT-based salvage elective nodal radiotherapy (sENRT) for LN recurrence were retrospectively examined. Patients underwent PSMA-PET/CT scan due to biochemical persistence (bcP, 76%) or biochemical recurrence (bcR, 24%) after radical prostatectomy (RP). Biochemical recurrence-free survival (BRFS) defined as PSA < post-RT nadir + 0.2 ng/ml and distant metastasis-free survival (DMFS) were calculated using the Kaplan–Meier method and uni- and multivariate analysis was performed.

Results

Median follow-up was 37 months. Median PSA at PSMA-PET/CT was 1.7 ng/ml (range 0.1–40.1) in patients with bcP and 1.4 ng/ml (range 0.3–5.1) in patients with bcR. PSMA-PET/CT detected 1, 2, and 3 or more LN metastases in 35%, 23%, and 42%, respectively. Eighty-three percent had only pelvic, 2% had only paraaortic, and 15% had pelvic and paraaortic LN metastases. Cumulatively, a total dose converted to EQD2_1.5 Gy of 66 Gy (60–70 Gy) was delivered to the prostatic fossa, 70 Gy (66–72 Gy) to the local recurrence, if present, 65.1 Gy (56–66 Gy) to PET-positive lymph nodes, and 47.5 Gy (42.4–50.9 Gy) to the lymphatic pathways. Concomitant androgen deprivation therapy (ADT) was administered in 83% of patients. One-, 2-, and 3-year BRFS was 80.7%, 71.6%, and 65.8%, respectively. One-, 2-, and 3-year DMFS was 91.6%, 79.1%, and 66.4%, respectively. In multivariate analysis, concomitant ADT, longer ADT duration (≥ 12 vs. < 12 months) and LN localization (pelvic vs. paraaortic) were associated with improved BRFS and concomitant ADT and lower PSA value before sRT (< 1 vs. > 1 ng/ml) with improved DMFS, respectively. No such association was seen for the number of affected lymph nodes.

Conclusions

Overall, the present analysis shows that the so far, unmatched sensitivity and specificity of PSMA-PET/CT translates in comparably high BRFS and DMFS after PSMA-PET/CT-based sENRT for patients with PCa LN recurrence. Concomitant ADT, duration of ADT, PSA value before sRT, and localization of LN metastases were significant factors for improved outcome.

Development and Validation of a Nomogram Predicting the Prognosis of Renal Cell Carcinoma After Nephrectomy

Objective

To develop and validate a nomogram for predicting the overall survival (OS) of renal cell carcinoma (RCC) patients after nephrectomy.

Materials and Methods

In total, 488 patients with RCC who underwent nephrectomy at the Urology Department of the First Hospital of Shanxi Medical University between January 2013 and December 2018 were randomly divided into a development cohort (n = 344) and a validation cohort (n = 144). The development cohort was used to build a prediction model, and the validation cohort was used for validation. Single-factor and multifactor analyses were carried out with R software, and the nomogram, calibration chart, ROC curve and C index were constructed.

Results

The median follow-up time of the development and validation cohorts was 34 months. The total 3-year and 5-year survival rates of the development cohort were 93.3% and 91.6%, respectively; those of the validation cohort were 92.4% and 91.0%, respectively. Cox univariate analysis of the development cohort showed that age, type 2 diabetes mellitus (T2DM), smoking history, type of surgery, T stage, N stage, M stage and Fuhrman nuclear grade were prognostic factors for OS in RCC patients undergoing nephrectomy. Cox multivariate analysis showed that T2DM, smoking history and T stage were independent prognostic factors for OS in RCC patients undergoing nephrectomy (P < 0.05). According to the univariate and multivariate analyses, a nomogram was constructed. In the development cohort, the C index of predicted OS was 0.875 (95% CI, 0.820-0.930). The calibration curve of the 3-year and 5-year survival rates showed that the predicted value of the nomogram was consistent with the actual observed value. The area under the 3-year and 5-year survival ROC curves was 0.861 and 0.901, respectively. In the validation cohort, the C index was 0.880 (95% CI, 0.778-0.982). The calibration curve of the 3-year and 5-year survival rates showed that the predicted value of the nomogram was consistent with the actual observed value. The area under the 3-year and 5-year survival ROC curves was 0.813 and 0.799, respectively.

Conclusion

We developed and verified a new and accurate nomogram with available clinicopathological data that can effectively predict the OS of RCC patients after nephrectomy.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : prise en charge du cancer du reinFrench ccAFU guidelines – Update 2018–2020: Management of kidney cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article.

Is there a role for adjuvant therapy after surgery in "high risk for recurrence" kidney cancer? An update on current concepts

Background

Although surgical resection remains the standard of care for localized kidney cancers, a significant proportion of patients experience systemic recurrence after surgery and hence might benefit from effective adjuvant therapy. So far, several treatment options have been evaluated in adjuvant clinical trials, but only a few have provided promising results. Nevertheless, with the recent development of targeted therapy and immunomodulatory therapy, a series of clinical trials are in progress to evaluate the potential of those novel agents in the adjuvant setting. In this paper, we provide a narrative review of the progress in this field, and we summarize the results from recent adjuvant trials that have been completed.

Methods

A literature search was conducted. The primary search strategy at the medline, Cochrane reviews, and http://ClinicalTrials.gov/databases included the keywords "adjuvant therapy," "renal cell carcinoma," and "targeted therapy or/and immunotherapy."

Conclusions

Data from the s-trac study indicated that, in the "highest risk for recurrence" patient population, disease-free survival was increased with the use of adjuvant sunitinib compared with placebo. The assure trial showed no benefit for adjuvant sunitinib or sorafenib in the "intermediate- to high-risk" patient population. The ariser (adjuvant girentuximab) and protect (adjuvant pazopanib) trials indicated no survival benefit, but subgroup analyses in both trials recommended further investigation. The inconsistency in some of the current results can be attributed to a variety of factors pertaining to the lack of standardization across the trials. Nevertheless, patients in the "high risk of recurrence" category after surgery for their disease would benefit from a discussion about the potential benefits of adjuvant treatment and enrolment in ongoing adjuvant trials.

Treatment of renal cell carcinoma: Current status and future directions

Answer questions and earn CME/CNE Over the past 12 years, medical treatment for renal cell carcinoma (RCC) has transitioned from a nonspecific immune approach (in the cytokine era), to targeted therapy against vascular endothelial growth factor (VEGF), and now to novel immunotherapy agents. Multiple agents-including molecules against vascular endothelial growth factor, platelet-derived growth factor, and related receptors; inhibitors of other targets, such as the mammalian target of rapamycin and the MET and AXL tyrosine-protein kinase receptors; and an immune-checkpoint inhibitor-have been approved based on significant activity in patients with advanced RCC. Despite these advances, important questions remain regarding biomarkers of efficacy, patient selection, and the optimal combination and sequencing of agents. The purpose of this review is to summarize present management and future directions in the treatment of metastatic RCC. CA Cancer J Clin 2017;67:507-524. © 2017 American Cancer Society.

The value of complementing administrative data with abstracted information on smoking and obesity: A study in kidney cancer

INTRODUCTION

Variables, such as smoking and obesity, are rarely available in administrative databases. We explored the added value of including these data in an administrative database study evaluating the association of statin use with survival in kidney cancer.

METHODS

We linked administrative data with chart-abstracted data on smoking and obesity for 808 patients undergoing nephrectomy for kidney cancer. Base models consisted of variables from administrative databases (age, sex, year of surgery, and different measures of comorbidity [to compare their sensitivity to smoking and obesity data]); extended models added chart-abstracted data. We compared coefficients for statin use with overall (OS) and cancer-specific survival (CSS), and used the c-statistic and net reclassification improvement (NRI) to compare predications of five-year survival obtained from Cox proportional hazard models.

RESULTS

The coefficient for statin use changed minimally following addition of abstracted data (<6% for OS, <2% for CSS). Base models performed similarly for OS, with c-statistics of 0.75 (95% confidence interval [CI] 0.72-0.79) for Charlson score and 0.73 (95% CI 0.69-0.78) for John Hopkins Aggregated Diagnosis Groups score. After including abstracted data, c-statistics modestly improved (change <0.02); CSS demonstrated similar findings. NRIs were 0.210 (95% CI 0.062-0.297) and 0.186 (-0.031-0.387) when using the Charlson score, and 0.207 (0.068-0.287) and 0.197 (0.007-0.399) when using the Aggregated Diagnosis Groups score, for OS and CSS, respectively.

CONCLUSIONS

The inclusion of data on smoking and obesity marginally influences survival models in kidney cancer studies using administrative data.

Follow-up imaging in the first two years after nephrectomy for T1 RCC: Over-use or necessary care?

Objective:

We sought to study patterns of imaging for follow-up after surgery for stage T1 renal cell carcinoma (RCC) at a single institution. We hypothesised that there would be significant variation in the use of surveillance imaging.

Methods and materials:

We evaluated the two-year follow-up of 317 consecutive patients undergoing radical or partial nephrectomy who were found to have pT1 RCC. Follow-up imaging data were collected. Surgical characteristics and tumour pathology data were analysed via a Poisson regression model to evaluate the incidence rate ratio for frequency of imaging based on each variable. Logistic regression was used to evaluate factors correlated with concordance with current imaging guidelines.

Results:

A total of 1016 imaging exams were performed after surgery on 268 patients. These studies identified four tumour recurrences: two local and two lung. The overall recurrence rate was 1.49%. Three recurrences were found within a two-year postoperative window, and one was recorded on the patient’s last clinic note after two years. Of 66 imaging exams with findings suspicious for recurrence, 62 were found to be false positives. All statistical analyses on a subgroup of 162 patients with full two-year follow-up failed to demonstrate any correlation between clinicopathologic variables and the frequency of abdominal imaging or concordance with current imaging guidelines.

Conclusions:

Frequent follow-up imaging studies were obtained despite a low recurrence rate. There was a high rate of false-positive findings on routine exams. No clinicopathologic criteria were identified that were correlated with increased imaging frequency.

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.

Renal cell carcinoma

The treatment of renal cell carcinoma (RCC) has changed greatly over the past 15 years. Progress in the surgical management of the primary tumor and increased understanding of the molecular biology and genomics of the disease have led to the development of new therapeutic agents. The management of the primary tumor has changed owing to the realization that clean margins around the primary lesion are sufficient to prevent local recurrence, as well as the development of more sophisticated tools and techniques that increase the safety of partial nephrectomy. The management of advanced disease has altered even more dramatically as a result of new agents that target the tumor vasculature or that attenuate the activation of intracellular oncogenic pathways. This review summarizes data from prospective randomized phase III studies on the surgical management and systemic treatment of RCC, and provides an up to date summary of the histology, genomics, staging, and prognosis of RCC. It describes the management of the primary tumor and offers an overview of systemic agents that form the mainstay of treatment for advanced disease. The review concludes with an introduction to the exciting new class of immunomodulatory agents that are currently in clinical trials and may form the basis of a new therapeutic approach for patients with advanced RCC.

Patterns of recurrence and surveillance strategies for renal cell carcinoma following surgical resection

Renal cell carcinoma (RCC) remains one of the most lethal urologic malignancies, with up to 40% of patients eventually dying of cancer progression. Despite advances in the diagnosis, staging and treatment of patients with RCC, approximately a third of patients who undergo surgery for clinically localized RCC will suffer a recurrence. Timely identification of recurrences following surgical extirpation is imperative in the treatment of these patients. RCC is known to metastasize through hematogenous routes of spread to distant organ sites and via lymphatic channels to regional lymph nodes. The path of tumor escape is associated with diverse clinical outcomes and a unique tumor biology. A consensus on surveillance regimens for patients following surgical resection of localized disease is lacking. The most extensively used system for providing prognostic information regarding survival and recurrence of disease has historically been the tumor-node-metastasis (TNM) classification system. As a result, most contemporary surveillance protocols have tailored follow-up regimens according to stage-based stratifications. Numerous studies have recently demonstrated that certain clinical and histopathological factors can improve the prediction of tumor recurrence. The incorporation of these prognostic factors into stage-based stratification models should be better than stage alone in attempting to provide a rational approach to identifying treatable recurrences while minimizing unnecessary exams and tests, as well as patient anxiety. Advances in the understanding of the pathogenesis, behavior and molecular biology of RCC have paved the way for developments that may enhance early diagnosis and prognostication, and improve survival for patients. Lastly, molecular markers should, in the future, revolutionize surveillance protocols for RCC by tailoring follow-up to specific molecular classifications.

Outcomes and prognosis in advanced renal cell carcinoma

Breakthroughs in understanding the pathogenesis of renal cell carcinoma have led to recent therapeutic advances in this disease. However, the US FDA approval of sunitinib and sorafenib (and soon temsirolimus) after successful Phase III trials must also be attributed to the work of clinical investigators over the past decade defining the outcomes and major prognostic factors in patients with advanced renal cell carcinoma. Those past studies have been critical in providing a context for the interpretation of future trials with novel agents, optimizing patient selection for specific therapeutic approaches and identifying appropriate variables for patient stratification on randomized trials. This review will focus on studies that define the outcome and prognosis in advanced renal cell carcinoma.

Identification of a 4-microRNA signature for clear cell renal cell carcinoma metastasis and prognosis

Renal cell carcinoma (RCC) metastasis portends a poor prognosis and cannot be reliably predicted. Early determination of the metastatic potential of RCC may help guide proper treatment. We analyzed microRNA (miRNA) expression in clear cell RCC (ccRCC) for the purpose of developing a miRNA expression signature to determine the risk of metastasis and prognosis. We used the microarray technology to profile miRNA expression of 78 benign kidney and ccRCC samples. Using 28 localized and metastatic ccRCC specimens as the training cohort and the univariate logistic regression and risk score methods, we developed a miRNA signature model in which the expression levels of miR-10b, miR-139-5p, miR-130b and miR-199b-5p were used to determine the status of ccRCC metastasis. We validated the signature in an independent 40-sample testing cohort of different stages of primary ccRCCs using the microarray data. Within the testing cohort patients who had at least 5 years follow-up if no metastasis developed, the signature showed a high sensitivity and specificity. The risk status was proven to be associated with the cancer-specific survival. Using the most stably expressed miRNA among benign and tumorous kidney tissue as the internal reference for normalization, we successfully converted his signature to be a quantitative PCR (qPCR)-based assay, which showed the same high sensitivity and specificity. The 4-miRNA is associated with ccRCC metastasis and prognosis. The signature is ready for and will benefit from further large clinical cohort validation and has the potential for clinical application.

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.

Predicting cancer-control outcomes in patients with renal cell carcinoma

PURPOSE OF REVIEW

An increasing number of models are becoming available for patients with either suspected or established renal cell carcinoma (RCC) of various stages. In this review, we propose a systematic approach to the assessment of the quantity of the existing predictive and prognostic models.

RECENT FINDINGS

Only one model was designed to distinguish between malignant or benign histology prior to nephrectomy and another tool attempts to discriminate between low-grade and high-grade histology. Four tools predict the natural history of RCC using preoperative tumor characteristics. Postnephrectomy recurrence can be predicted with four tools. Finally, mortality predictions can be quantified with 21 predictive tools. Although several of these tools are validated, formal tests were performed in surprisingly few such models.

SUMMARY

Multiple models can be applied to nephrectomy candidates, to patients treated with nephrectomy, or to individuals with metastatic RCC regardless of nephrectomy status. For newly diagnosed and untreated patients, these tools can guide the clinician with respect to treatment selection. For patients treated with nephrectomy, they can assess the risk of recurrence and/or mortality and can guide the type and frequency of follow-up considerations. Finally, for patients with metastatic RCC, the models can provide the best estimate of remaining life expectancy. Unfortunately, virtually no data are available to model the prognosis of patients subjected to surveillance or nonextirpative treatment models.

Renal cell carcinoma: risk assessment and prognostic factors for newly diagnosed patients

Surgical management of renal cell carcinoma is the most effective treatment for patients with localized disease. In patients with advanced renal cell carcinoma, immune modulation-based therapies are typically used to improve cancer-specific survival. Similar to most cancers, tumor grade and stage are linked to the tumor's biologic potential. Integrating these factors with patients' performance status can help predict their long-term disease-free survival, the likelihood of tumor recurrence, and the median time to failure following surgery and immunotherapy. A novel integrated staging system and a postoperative renal cell carcinoma specific nomogram, along with standardized quality of life assessments have been shown to be useful clinical tools to aid in patient counseling, determining optimal follow-up imaging protocols, and identifying patients who might benefit from early enrollment in adjuvant therapy protocols. This article offers clinicians a review and summary of the most recent evidence-based research related to risk assessment among patients with newly diagnosed renal cell carcinoma.

A preoperative prognostic model for patients treated with nephrectomy for renal cell carcinoma

BACKGROUND

Currently two pretreatment prognostic models with limited accuracy (65-67%) can be used to predict survival in patients with localized renal cell carcinoma (RCC).

OBJECTIVE

We set out to develop a more accurate pretreatment model for predicting RCC-specific mortality after nephrectomy for all stages of RCC.

DESIGN, SETTING, AND PARTICIPANTS

The data originated from a series of prospectively recorded contemporary cases of patients treated with radical or partial nephrectomy between 1984 and 2006. Model development was performed using data from 2474 patients from five centers and external validation was performed using data from 1972 patients from seven centers.

MEASUREMENTS

The probability of RCC-specific mortality was modeled using Cox regression. The significance of the predictors was confirmed using competing risks analyses, which account for mortality from other causes.

RESULTS AND LIMITATIONS

Median follow-up in patients who did not die of RCC-specific causes was 4.2 yr and 3.5 yr in the development and validation cohorts, respectively. The freedom from cancer-specific mortality rates in the nomogram development cohort were 75.4% at 5 yr after nephrectomy and 68.3% at 10 yr after nephrectomy. All variables except gender achieved independent predictor status. In the external validation cohort the nomogram predictions were 88.1% accurate at 1 yr, 86.8% accurate at 2 yr, 86.8% accurate at 5 yr, and 84.2% accurate at 10 yr.

CONCLUSIONS

Our model substantially exceeds the accuracy of the existing pretreatment models. Consequently, the proposed nomogram-based predictions may be used as benchmark data for pretreatment decision making in patients with various stages of RCC.

Proposal of an improved prognostic classification for pT3 renal cell carcinoma

PURPOSE

The prognostic accuracy of the current TNM 2002 staging system for locally advanced renal cell carcinoma has been questioned. To contribute to the development of a more accurate classification for this stage of disease we assessed the correlation between patterns of invasion in the pT3 category and outcomes in a large multi-institutional series.

MATERIALS AND METHODS

Pathological data and clinical followup on 513 pT3 renal cell carcinoma cases treated with radical nephrectomy between 1983 and 2005 at 3 Italian academic centers were retrospectively reviewed. Cause specific survival rates were calculated with the Kaplan-Meier method and multivariate analysis was performed using the Cox proportional hazards regression model.

RESULTS

Estimated overall 5-year cause specific survival was 50.1% at a median followup of 61.5 months in survivors. The current TNM classification was not a significant outcome prognosticator. Patients with a tumor invading only the perirenal or sinus fat were at lowest risk for death from the disease. Patients at intermediate risk had tumors with invasion of the venous system alone. Simultaneous perirenal fat and sinus fat invasion or perirenal fat and vascular invasion as well as adrenal gland involvement characterized high risk tumors. Low risk tumors could be further divided into 2 groups with different outcomes based on a size cutoff of 7 cm. Our classification was a significant predictor of survival on multivariate analysis as well as M stage, N stage, Fuhrman grade and tumor size.

CONCLUSIONS

We confirm that the prognostic usefulness of the current 2002 TNM system for pT3 renal cell carcinoma is limited. We have identified 4 groups of tumors with distinct patterns of invasion and significantly different survival probabilities in this category. Large prospective series are needed to validate these findings.

Impact of comorbidity on overall survival in patients surgically treated for renal cell carcinoma

OBJECTIVES

Although the classification of cancer has traditionally focused on the gross and microscopic characteristics of the tumor, the overall health of patients can affect their survival. Because patients with renal cell carcinoma often have other medical conditions, we explored the effect of preexisting medical disease on survival after radical and partial nephrectomy.

METHODS

From January 1995 to August 2003, the comorbidity status of 697 patients with nonmetastatic renal cell carcinoma who had undergone radical or partial nephrectomy was prospectively coded using the Adult Comorbidity Evaluation-27. Histopathologic review of all slides was performed according to the 2004 World Health Organization scheme. Other variables analyzed included age, sex, ethnicity, pathologic stage, Fuhrman grade, and tumor size. The effect of these factors on overall survival (OS) was analyzed using Cox proportional hazards regression model.

RESULTS

The median follow-up was 32.2 months for survivors and 36.5 months for all patients. The OS rate at 1, 3, and 5 years was 92.0% (641 patients), 75.3% (525 patients), and 52.7% (367 patients), respectively. Univariate analyses demonstrated that age, comorbidity, tumor size, Fuhrman grade, and pathologic stage were significant predictors of OS. Multivariate analysis revealed that age (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.10 to 1.82, P = .0067), comorbidity (HR 1.37, 95% CI 1.16 to 1.63, P = .0002), pathologic stage (HR 1.97, 95% CI 1.60 to 2.41, P < .0001), and grade (HR 1.83, 95% CI 1.28 to 2.59, P = .0008) predicted for OS.

CONCLUSIONS

The results of this study have demonstrated that comorbidity is an independent prognostic factor for OS in patients with renal cell carcinoma. Capturing the comorbidity information using validated instruments can improve the preoperative evaluation of patients by providing more accurate prognostic information.

Risk stratification and prognostication of renal cell carcinoma

OBJECTIVES

To review the most recent data on prognostic factors and describe the characteristics and prognostic accuracy of the most important prognostic systems available to predict the risk of recurrence, progression, and mortality in patients with renal cell carcinoma (RCC).

METHODS

The study was based on a non-systematic review of literature.

RESULTS

Clinical (performance status, and mode of presentation), anatomical (size and extension of the primary tumor, lymph node involvement, and distant metastasis), and histological factors (histological subtypes, nuclear grade, and tumor necrosis) are the most largely evaluated prognostic factors in RCC. Valuable prognostic accuracy has been shown for several laboratory parameters (erythrocyte sedimentation rate, platelet count, serum calcium, hemoglobin, and lactate dehydrogenase levels) and a few genetical and molecular markers (CAIX, B7-H1, and B7-H4). A few integrating systems have been proposed and validated, integrating both clinical and pathological (UCLA Integrating Staging Systems, Kattan nomogram, and Sorbellini nomogram) or only pathological variables (SSIGN score).

CONCLUSIONS

Several large and methodologically consistent studies have been published. The chance to integrate the data derived from each prognostic factor into prognostic algorithms and scores has allowed improving significantly the stratification of the prognosis of patients with RCC. The currently available prognostic systems can be further improved through the inclusion of molecular and genetic variables. Integrating prognostic systems should be used to design randomized controlled trials (RCTs), which will evaluate the efficacy of the new-targeted therapies in either neoadjuvant, adjuvant, or salvage treatments of patients with RCC.

Mathematical models for prognostic prediction in patients with renal cell carcinoma

OBJECTIVES

The objectives of this study are to catalogue all models developed to predict survival of RCC patients and to identify the ones to be used in different situations.

METHODS

A systematic review was performed searching with a free text and MeSH strategy 3 electronic databases. For each model, the following parameters were identified: number, features of the patients; evaluation endpoints; clinical and/or pathological variables included; concordance indexes (cI).

RESULTS

The research retrieved 156 records. Eleven articles proposed new models, 5 articles external validations. We retrieved 2 mathematical models including clinical variables only (Yaycioglu, cI 0.651; Cindolo, cI 0.672); 2 algorithms including also pathological variables (SSIGN, cI 0.819; UISS, cI 0.79-0.84), 5 nomograms (Kattan, cI 0.76-0.86; Sorbellini, cI 0.82; Kim 2004, cI 0.79, Kim 2005, cI 0.68; Karakiewicz, cI 0.86); 2 algorithms for patients with metastatic disease (Motzer, Leibovich).

CONCLUSIONS

The SSIGN was the most accurate algorithm for conventional RCC, while the UISS allowed the evaluation of patients regardless of tumor histotype. The Sorbellini nomogram is applicable only for patients with conventional RCC, while the Kattan and Karakiewicz nomograms also provide information for other histotypes. Metastatic patients can be evaluated with Leibovich and Motzer algorithms. Two models combine molecular markers and clinical features (Kim 2004-2005).

Expression levels of the mitochondrial IAP antagonists Smac/DIABLO and Omi/HtrA2 in clear-cell renal cell carcinomas and their prognostic value

PURPOSE

Numerous molecular parameters are thought to be implicated in renal cell carcinoma (RCC) tumor biology and may therefore reflect the malignant potential of individual tumors. Their investigation may thus help to improve the postoperative management of RCC patients. This study characterized the mRNA expression levels and evaluated the prognostic effect of the mitochondrial inhibitor of apoptosis antagonists Smac/DIABLO and Omi/HtrA2 in tumor tissue from clear-cell RCC patients.

METHODS

The relative gene expression (RGE) was analyzed by real-time RT-PCR in tumor tissue obtained from 85 patients (median follow-up: 47 months) following surgical treatment. Expression data was correlated to clinico-pathological variables and outcome.

RESULTS

The RGE of Smac/DIABLO was lowest in patients with primary metastases, intermediate in those who progressed to metastatic disease, and highest in those who did not develop metastases during follow-up (P=0.006). Expression levels of Smac/DIABLO and Omi/HtrA2 were strongly correlated with each other (Pearson coefficient 0.90). Recurrence-free and tumor-specific survival was shorter in patients with low Smac/DIABLO levels (P=0.019 and P=0.001) as well as in those with low Omi/HtrA2 tumor expression (P=0.033 and P=0.032). Contrary to Omi/HtrA2, low Smac/DIABLO levels were still predictive of a reduced time to recurrence (hazard rate 5.31; 95% CI: 1.16-24.21) and tumor-specific survival (hazard rate 4.24; 95% CI: 1.22-14.77) in explorative multivariate analysis.

CONCLUSIONS

The mRNA expression levels of the mitochondrial IAP antagonists Smac/DIABLO and Omi/HtrA2 are strongly inter-correlated, but do not relate to tumor stage or grade of RCC. Our data suggest that expression of Smac/DIABLO, but not Omi/HtrA2, is inversely associated with outcome of RCC patients.

Predicting cancer-control outcomes in patients with renal cell carcinoma

PURPOSE OF REVIEW

Several novel treatment modalities have been introduced for patients across all renal cell carcinoma stages. Observation or a variety of minimally invasive approaches can be applied to small renal masses. Conversely, aggressive loco-regional resections may be performed for locally advanced disease. Cytoreductive partial nephrectomy has become an alternative to radical nephrectomy. Finally, targeted therapies improve cancer control in unresectable or metastatic renal cell carcinoma. The variety of modes and stages at presentation and the number of treatment options may render medical decision-making highly complex. Various prognostic models and nomograms can assist with treatment decision-making in patients with renal cell carcinoma.

RECENT FINDINGS

The multivariable risk-factor approach to renal cell carcinoma-specific mortality has been pioneered. In 1999 was proposed a multivariate model for prediction of individual survival in patients with metastatic renal cell carcinoma. Since then several prenephrectomy and postnephrectomy models have been developed. These models can be distinguished according to their target populations, discriminant properties (accuracy of predictions) and confirmed validity within independent cohorts.

SUMMARY

We give a comparative outline of these model characteristics within existing tools. Our work provides the clinician with a complete list of such tools, including comparisons of their relative advantages and disadvantages.

A Review on Follow-Up Strategies for Renal Cell Carcinoma after Nephrectomy

OBJECTIVES

To provide a comprehensive review of the evidence supporting the necessity for follow-up after nephrectomy for renal cell carcinoma.

METHODS

We searched the Medline, MeSH, EMBASE, and Cochrane databases using the terms "renal cell cancer," "kidney neoplasm," "follow-up," "surveillance," "prognosis," and "staging" to look for human/English language/Randomized Controlled Trials/Clinical trials/Review articles/Meta-analysis/Practiced Guidelines, and Editorials.

RESULTS

No consensus currently exists on surveillance guidelines after radical or partial nephrectomy for renal cell carcinoma. The rationale for follow-up strategies is to detect local recurrence or metastatic disease and to allow appropriate treatment. Most of the surveillance protocols recommend various follow-up strategies for all tumour stages. The emphasis on follow-up should be during the first 3-5 yr after nephrectomy. There is no consensus about which investigations should be performed and at what intervals. Most surgeons rely on symptom enquiry, physical examination, chest x-ray, and computed tomography scanning. A protocol based on the stage of the initial tumour is adapted by the majority of the investigators. Patients should be followed similarly after radical or partial nephrectomy on the basis of stage-oriented protocols. The combination of various prognostic factors requires further validation over stage-based protocols. There is a paucity of guidelines in the literature regarding follow-up for patients with hereditary forms of renal cell carcinoma.

CONCLUSIONS

Current guidelines for follow-up are based on observational and case studies. While this fact precludes a high level of evidence-based guidelines, we have to conclude that this is the best available evidence to date.

Expression of the apoptosis inhibitor livin in renal cell carcinomas: correlations with pathology and outcome

Livin has recently been identified as a member of the inhibitor of apoptosis family expressed in several types of cancer but not in most benign tissues. Expression levels of livin were associated with prognosis in various malignancies, but livin expression and its prognostic relevance have not been evaluated in renal cell carcinomas (RCC). In a cohort of 152 RCC patients, we analyzed the relative expression of livin and its splicing variants by real-time RT-PCR and Western blot in tumor and adjacent normal renal tissue specimens. Livin expression was detected in 59 (38.8%) of 152 RCC specimens but in none of the normal samples. Both splicing variants were present in the livin-positive RCC specimens. Livin expression levels did not correlate with pathological or clinical parameters and were not predictive of patient outcome. Our findings suggest that livin expression in RCC is not of prognostic relevance. Further studies to clarify the role of livin expression in RCC and its potential value as a target for immune-mediated tumor destruction are warranted.

Multi-institutional validation of a new renal cancer-specific survival nomogram

PURPOSE

We tested the hypothesis that the prediction of renal cancer-specific survival can be improved if traditional predictor variables are used within a prognostic nomogram.

PATIENTS AND METHODS

Two cohorts of patients treated with either radical or partial nephrectomy for renal cortical tumors were used: one (n = 2,530) for nomogram development and for internal validation (200 bootstrap resamples), and a second (n = 1,422) for external validation. Cox proportional hazards regression analyses modeled the 2002 TNM stages, tumor size, Fuhrman grade, histologic subtype, local symptoms, age, and sex. The accuracy of the nomogram was compared with an established staging scheme.

RESULTS

Cancer-specific mortality was observed in 598 (23.6%) patients, whereas 200 (7.9%) died as a result of other causes. Follow-up ranged from 0.1 to 286 months (median, 38.8 months). External validation of the nomogram at 1, 2, 5, and 10 years after nephrectomy revealed predictive accuracy of 87.8%, 89.2%, 86.7%, and 88.8%, respectively. Conversely, the alternative staging scheme predicting at 2 and 5 years was less accurate, as evidenced by 86.1% (P = .006) and 83.9% (P = .02) estimates.

CONCLUSION

The new nomogram is more contemporary, provides predictions that reach further in time and, compared with its alternative, which predicts at 2 and 5 years, generates 3.1% and 2.8% more accurate predictions, respectively.

Grading Systems in Renal Cell Carcinoma

PURPOSE

We reviewed updated literature data concerning several issues of renal cell carcinoma grading systems.

MATERIALS AND METHODS

We performed a nonsystematic review of the literature. Data were identified by a MEDLINE search using a strategy including MeSH and free text protocols. From the MEDLINE search we collected 184 records.

RESULTS

Although the original study was published in 1982, the independent predictive value of nuclear grades was only revealed in 2000 by the team from University of California-Los Angeles. Subsequently further data from our group and the group at the Mayo Clinic reconfirmed those findings, although similar cancer specific survival probabilities were noted among different grades. The prognostic relevance of nuclear grade justified the inclusion of that variable in algorithms and nomograms predictive of cancer specific survival, such as those provided by University of California-Los Angeles, the Mayo Clinic and Memorial Sloan-Kettering Cancer Center. Despite the routine clinical use of nuclear grade, several drawbacks have affected grading systems, such as interobserver and intra-observer reproducibility, and variability of the cancer specific survival probabilities stratified by grade. Several studies showed that intra-observer and interobserver agreement with regard to grade are only moderate with up shifting in all series. That issue might be due to the heterogeneity of renal cell carcinoma as well as to the lack of consensus about the minimal size of high grade tumor to be considered significant. Moreover, recent data underscore the role of histological subtypes.

CONCLUSIONS

Grade is one of the most powerful prognostic factors in patients with renal cell carcinoma. The Fuhrman grading system is currently most widely used by pathologists in Europe and the United States. However, there is still a need for better standardization of nuclear criteria to improve interobserver reproducibility and a major consensus should be achieved by uropathologists.

The follow-up management of non-metastatic renal cell carcinoma: definition of a surveillance protocol

OBJECTIVE

To define a follow-up protocol based on the University of California Los Angeles Integrated Staging System (UISS) for patients undergoing surgery for N0M0 renal cell carcinoma (RCC).

PATIENTS AND METHODS

The clinical records of patients treated with radical surgery for N0/NXM0 RCC and monitored through periodic follow-up studies (> or =24 months in disease-free patients) were reviewed retrospectively from 1399 patients surgically treated for renal neoplasms between 1983 and 2005. Each case was assigned a UISS risk category; recurrence features, time and site were recorded. In particular, recurrence sites were categorized into local, renal (ipsilateral or contralateral) and distant (single-site or disseminated).

RESULTS

The records were reviewed of 814 patients with a mean follow-up of 75.6 months. UISS risk categories were distributed as follows: high-risk (HR) 17.2%, intermediate-risk (IR) 51.6% and low-risk (LR) 31.2%. Disease-free survival rates at 5 years were 63.9%, 88.3% and 96.5% (log-rank test P < 0.001), respectively. The disease recurred in 193 patients (23.7%), at distant sites (73.0% of recurrences), locally (11.9%), in the contralateral kidney (10.9%) and in the ipsilateral kidney (4.1%). There was a significant correlation between UISS category and risk of distant or local (both P < 0.001) recurrences, whereas there was no correlation of recurrences in the operated kidney (P = 0.372) or contralateral kidney (P = 0.898).

CONCLUSIONS

The prognostic accuracy and applicability of the UISS for distant and local recurrences is confirmed, whereas renal relapses have an independent course. A follow-up scheme tailored to the recurrence patterns observed in each UISS risk group is recommended.

Adjuvant Therapy of Renal Cell Carcinoma

Metastatic renal cell carcinoma (RCC) has a highly variable natural history and carries a dismal prognosis. Unlike many other tumors, RCC is generally unresponsive to cytotoxic, hormonal, and radiation adjuvant therapies after cytoreductive surgery. Different modalities of treatment have been tried and tested with modest success. Until recently, only immunotherapies such as interleukin-2 and interferon-alpha have been shown to provide a response, albeit in a minority of patients and often with severe treatment-associated toxicities. Other adjuvant therapies, such as active specific immunotherapy with Bacillus Calmette-Guerin and autologous renal tumor cell vaccines, have not provided alternative solutions. Recent approaches include heat-shock protein peptide complex 96 vaccine and cG250 monoclonal antibody therapy. Novel targeted therapies have been developed using our knowledge of the molecular genetics that belie RCC. This culminated in sorafenib and sunitinib, the first Food and Drug Administration-approved drugs for RCC in more than a decade in the United States. The future will see further trials being carried out in the development of targeted therapies with emphasis placed on patient selection. Staging systems will need to be updated to integrate molecular biomarkers, which could potentially act not just as diagnostic and prognostic predictors, but also as tools for appropriate patient selection for treatment. In the future, this could potentially lead us to our ultimate goal of personalized medicine.

External validation of the Mayo Clinic Stage, Size, Grade and Necrosis (SSIGN) score to predict cancer specific survival using a European series of conventional renal cell carcinoma

PURPOSE

We validated the Mayo Clinic SSIGN score in an independent European sample of patients who were surgically treated for conventional RCC.

MATERIALS AND METHODS

In our kidney cancer database we identified 388 patients who were treated with radical or partial nephrectomy for conventional RCC between 1986 and 2000. Associations of the pathological features studied with death from RCC were evaluated using the log rank test and Cox proportional hazards regression model. The predictive ability of competing models was evaluated using the c index.

RESULTS

Median followup in the 290 patients who were alive at last followup was 5 years (range 5 months to 17 years). The estimated cancer specific survival rate 5 years following surgery was 81.3%. All features that comprise the SSIGN score except tumor size were significantly associated with death from RCC in a multivariate setting, resulting in a c index of 0.90. The median SSIGN score in the 388 patients studied was 3 (range 0 to 15). The c index in a model containing the clear cell SSIGN score was 0.88. Five-year cancer specific survival rates in patients with a score of 0 to 2, 3 to 4, 5 to 6, 7 to 9 and 10 or more were 100.0%, 90.5%, 63.6%, 46.8% and 0%, respectively.

CONCLUSIONS

We provide the first external validation of the Mayo Clinic SSIGN score for conventional RCC. This simple algorithm resulted in a high degree of prognostic accuracy.

Comparison of predictive accuracy of four prognostic models for nonmetastatic renal cell carcinoma after nephrectomy: a multicenter European study

BACKGROUND

The objective of the current study was to compare, in a large multicenter study, the discriminating accuracy of four prognostic models developed to predict the survival of patients undergoing nephrectomy for nonmetastatic renal cell carcinoma (RCC).

METHODS

A total of 2404 records of patients from 6 European centers were retrospectively reviewed. For each patient, prognostic scores were calculated according to four models: the Kattan model, the University of California at Los Angeles integrated staging system (UISS) model, the Yaycioglu model, and the Cindolo model. Survival curves were estimated by the Kaplan-Meier method and compared by the log-rank test. Discriminating ability was assessed by the Harrell c-index for censored data. The primary end point was overall survival (OS), and the secondary end points were cancer-specific survival (CSS) and disease recurrence-free survival (RFS).

RESULTS

At last follow-up, 541 subjects had died of any causes, with a 5-year OS rate of 80%. The 5-year CSS and RFS rates were 85% and 78%, respectively. All models discriminated well (P < 0.0001). The c-indexes for OS were 0.706 for the Kattan nomogram, 0.683 for the UISS model, and 0.589 and 0.615 for the Yaycioglu and Cindolo models, respectively. The Kattan nomogram was found to improve discrimination substantially in the UISS intermediate-risk patients.

CONCLUSIONS

The current study appears to better define the general applicability of prognostic models for predicting survival in patients with nonmetastatic RCC treated with nephrectomy. The results suggest that postoperative models discriminate substantially better than preoperative ones. The Kattan model was consistently found to be the most accurate, although the UISS model was only slightly less well performing. The Kattan model can be useful in the UISS intermediate-risk patients.

Role of molecular markers in the diagnosis and therapy of renal cell carcinoma

Recent advances in the understanding of the pathogenesis, behavior, and molecular biology of renal cell carcinoma (RCC) have paved the way for developments that may enhance early diagnosis, better predict prognosis, and improve survival. Reliable predictive factors are essential for the stratification of patients into clinically meaningful categories that can be used to provide patients with counseling regarding prognosis, select treatment modalities, and determine eligibility for clinical trials. The TNM (tumor, nodes, metastasis) staging system is currently the most extensively used staging system for RCC, but it has undergone systematic revisions as a result of emerging data. Comprehensive integrated staging systems that combine important clinical and pathological variables have been created in an attempt to improve prognostication. Although staging has improved with the development of integrated systems, the incorporation of molecular tumor markers are expected to revolutionize the staging of RCC. This article reviews the important molecular markers in RCC to date and discusses their role in the diagnosis, prognostication, and therapy of patients with RCC.

Renal cell carcinoma 2005: new frontiers in staging, prognostication and targeted molecular therapy

PURPOSE

Renal cell carcinoma (RCC) has traditionally been staged using a purely anatomical staging system. Although current staging systems provide good prognostic information, data published in 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 and predictive prognostic factors not currently included in traditional staging systems. This review highlights such controversies and provides an update on current staging modalities, prognostic factors and targeted molecular therapy for RCC.

MATERIALS AND METHODS

A comprehensive review of the peer reviewed literature was performed on the topic of current staging modalities, validated prognostic factors, predictive nomograms, molecular markers and targeted molecular therapy for RCC.

RESULTS

A staging system for malignant disease such as RCC uses various characteristics of tumors to stratify patients into clinically meaningful categories, which can be used to provide patients with counseling regarding prognosis, select treatment modalities and determine eligibility for clinical trials. The TNM staging system is currently the most extensively used one. However, it has undergone recent systematic revision due to rapidly emerging data from longer patient followup. The identification of various histological and symptomatic factors has led groups at many centers to develop more comprehensive staging systems that integrate these factors and include patients with metastatic and local disease. While integrated staging systems have improved RCC staging, the recent discovery of molecular tumor markers is expected to revolutionize RCC staging in the future and lead to the development of new therapies based on molecular targeting.

CONCLUSIONS

Staging systems for RCC serve as a valuable prognostic tool. Several new patient and tumor characteristics have been reported to be important prognostic factors and they have been integrated into current staging systems. In addition, the field of RCC is rapidly undergoing a revolution led by molecular markers and targeted therapies. With this information urologists will be updated with the most current and comprehensive staging strategies, and be provided with a glimpse of the molecular and patient specific staging and treatment paradigms that will in our opinion transform the future management of this malignancy.