Prognostic factors for disease progression in patients with renal cell carcinoma

IntroductionMore than 40% of patients with renal cell carcinoma present with disease progression after surgery. The objective of the current study was to identify a clinically useful set of prognostic factors that would correlate significantly with the capacity of progression.Material and methodsThe authors studied 252 patients with renal cell carcinoma who underwent radical nephrectomy. Followup ranged from 12-246 months (median 36 months). Several morphologic parameters of the tumors were considered. DNA content was analyzed by flow cytometry and tumor size was determined from the surgical specimen. A Cox proportional hazards regression model was used to identify significant independent prognostic factors for disease progression.ResultsA total of 224 out of 252 were available for suitable histograms. Of the 224 patients, 95 (42,4%) were aneuploid tumors, 106 (47,2%) were organ-confined renal cell carcinoma and 87 (39,74%) presented disease progression. At 5 and 10 years of followup, disease free survival was found to be 66,31% and 62,23%, respectively. Univariate analysis revealed that DNA ploidy, Furhman grade and stage (TNM) had a statistically significant predictive value for disease progression. Survival univariate analysis found a worse probability of survival for aneuploid tumors, grade III-IV tumors, non organ-confined tumors and conventional and undiferentiated tumors. Using multivariate survival analyses, Furhman grade, stage (TNM) and DNA ploidy were the only independent prognostic factors. So, the probability of death for aneuploid tumor was 1,7 times higher than for diploid tumors.ConclusionsStage, DNA content and Furhman grade were the only significant independent predictors of disease progression. Tumoral size and histological type did not provide more additional information.     

Evaluation of PD-L1 (E1L3N, 22C3) expression in venous tumor thrombus is superior to its assessment in renal tumor in predicting overall survival in renal cell carcinoma

BackroundRenal cell carcinoma (RCC) frequently invades renal vein forming neoplastic thrombus. The expression of immune checkpoint receptors in RCC was addressed in multiple studies, but little is known about the expression and prognostic significance of programmed death ligand-1 in tumor thrombus.Material and methodsThe study aimed to evaluate the expression of PD-L1 within venous tumor thrombus and primary tumor using 2 independent antibody clones (22c3 and E1L3N) and to assess its value in predicting overall survival (OS) in the subgroup of patients with RCC and renal vein thrombus.ResultsEighty-two patients with RCC and venous tumor thrombus that underwent nephrectomy were enrolled. The expression of PD-L1 was assessed utilizing tissue microarrays separately on tumor cells (TCs) and tumor-infiltrating lymphocytes (TILs). The frequency of PD-L1 expression on TCs and TILs varied between tumor and thrombus compartments and was dependent on the antibody clone used. The expression of PD-L1 on TCs and/or TILs was associated with worse OS irrespectively of the antibody and the analyzed compartment. Nevertheless, the best prognostic performance was noted for the combined assessment of PD-L1 expression on TCs and TILs in venous tumor thrombus with the use of 22c3 antibody. The multivariable Cox regression model predicting OS incorporated PD-L1 22c3 in venous tumor thrombus (hazards ratio [HR] = 3.64, 95% confidence interval [CI] = 1.63–8.14, P = 0.002) and nodal status (HR = 2.88, 95% CI = 1.18–7.03, P = 0.02).ConclusionsPD-L1 may become a valuable tool for prognostic purposes in this specific subgroup of patients and be incorporated into the respective models qualifying for adjuvant treatment.     

Determinants of outcomes after resection of renal cell carcinoma with venous involvement

Purpose

To determine the outcomes and to identify prognostic variables determining mortality and recurrence after surgery for renal cell cancer (RCC) with venous involvement.

Methods

Retrospective evaluation of the medical records of 132 patients with RCC and tumor thrombi treated at Johns Hopkins Hospital (1997?C2008) was done. Kaplan?CMeier analysis was used to determine survivals. Uni- and multivariate Cox proportional analysis was done to identify predictors for recurrence, all-cause mortality (ACM) and cancer-specific mortality (CSM).

Results

Mean follow-up was 30.3 (0.03?C159.5) months. Sixty-four (48.5?%) patients had renal vein thrombus (Group 1), 55 (41.7?%) had subdiaphragmatic inferior vena cava (IVC) tumor thrombus (Group 2), while 13 (9.8?%) had involvement of IVC above diaphragm or atrial extension (Group 3). IVC thrombus was more common from the right-sided tumors. Patients with higher thrombus levels had more blood loss and complicated and longer hospital stay. Thrombus level was not found to be a predictor of recurrence, ACM and CSM. One- and three-year recurrence-free survivals for non-metastatic patients were 69 and 53?%. Tumor size (p?=?0.015), grade (p?=?0.007) and venous wall invasion (p?=?0.027) were predictors for recurrence. Five-year overall survival was 48, 35 and 13?% for 3 groups, respectively. Presence of distant metastasis (p?=?0.032), size (p?=?0.002), histology (p?=?0.020) and grade (p?=?0.013) were predictors of ACM. Five-year cancer-specific survival was 65, 43 and 36 for 3 groups, respectively. Tumor size (p?=?0.001) and distant metastasis at presentation (p?=?0.025) were the predictors of CSM.

Conclusions

Tumor thrombus level does not predict recurrence or mortality in RCC with venous involvement. Survival is determined by inherent aggressiveness of the cancer manifested by tumor size, grade and distant metastasis at presentation.     

关于肝癌消融治疗学科建设的若干思考

目的分析影响TACE治疗中晚期肝癌生存期的因素。方法回顾性分析67例中晚期肝癌接受TACE术患者的临床资料,采用Kaplan-Meier及Log-rank分析影响预后的因素,Cox比例风险回归模型进行多因素分析。结果全组患者中位生存期12个月(95%CI:7.82,16.17),1、2、3年生存率分别为44.78%(30/67)、13.43%(9/67)和5.97%(4/67)。单因素预后分析显示:既往有无射频治疗、有无动静脉瘘、BCLC分期、有无门静脉癌栓、ECOG评分、远处转移、ALT、后继索拉菲尼治疗情况与中晚期肝癌患者的预后有关(P0.05);多因素预后分析显示远处转移及门静脉癌栓与中晚期肝癌患者预后有关(B0,P0.05)。结论合并远处转移及门脉癌栓是中晚期肝癌患者预后的独立影响因素。     

Population based analysis of survival in patients with renal cell carcinoma and venous tumor thrombus

ObjectivesTo identify prognostic factors for renal cell carcinoma (RCC) with venous tumor thrombus (VTT) and determine the significance of thrombus level on survival.Materials and methodsPatients within the Surveillance, Epidemiology, and End Results (SEER) database with RCC and VTT were identified and included if managed surgically. The Kaplan-Meier method and Cox regression analyses were performed to identify factors associated with disease-specific survival.ResultsA total of 1,875 patients met the inclusion criteria. One-year survival for patients undergoing surgery was 60% for patients with metastases and 90% for those without. Factors associated with worse survival included larger tumor size (HR 1.2, 95% CI 1.0–1.4), medullary, collecting duct, or sarcomatoid histology (HR 2.2, 95% CI 1.5–3.3), Fuhrman grade 3 (HR 2.2, 95% CI 1.5–3.3) or grade 4 (HR 2.9, 95% CI 1.8–4.5) tumors, positive lymph nodes (HR 1.5, 95% CI 1.0–2.0), and metastases (HR 3.5, 95% CI 2.6–4.8). Thrombus level above the diaphragm (T3c) was not significantly associated with worse survival (HR 1.4, 95% CI 0.8–2.5).ConclusionsIn this large, population-based study of patients with RCC and VTT, we identify several disease-specific factors strongly associated with cancer-specific mortality. After controlling for adverse prognostic factors, thrombus level was not associated with worse outcome.     

Natural history of untreated renal cell carcinoma with venous tumor thrombus

ObjectivesThe natural history of untreated renal cell carcinoma (RCC) with venous tumor thrombus (VTT) is poorly characterized. We aimed to describe the natural history of this disease, and to identify prognostic factors associated with disease-specific survival.Materials and methodsWe identified patients in the Surveillance, Epidemiology, and End Results (SEER) database with untreated renal cell carcinoma and venous tumor thrombi. Disease-specific median and 1-year survival rates were determined, and disease-free survival curves were plotted using the Kaplan-Meier method. Multivariable Cox regression analyses were performed to identify factors associated with disease-specific and overall survival in this patient group.ResultsOf 2,265 patients with RCC and VTT, 390 (17%) underwent no treatment; 278 (71%) patients died during follow-up; of these, 243 deaths (87%) were due to RCC. Median and 1-year disease-specific survival for this group was 5 months and 29%, respectively. On multivariable analysis, the extent of tumor thrombus (HR 1.7 for T3c vs. T3b, 95% CI 1.0–2.7) and the presence of metastases (HR 3.1 for M+ vs. M0, 95% CI 1.7–5.5) were most strongly associated with disease-specific mortality.ConclusionsPrognosis is poor for the majority of untreated patients with RCC and VTT. Supradiaphragmatic thrombi and distant metastases are adverse prognostic factors in this patient group. This information is important when counseling patients as to the risk and benefits of surgical vs. nonoperative management of RCC and VTT.     

Long-term Survival in Patients Undergoing Radical Nephrectomy and Inferior Vena Cava Thrombectomy: Single-Center Experience

Background

Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management.

Objective

To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy.

Design, setting, and participants

We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed.

Measurements

Disease-free survival (DFS) and disease-specific survival (DSS) were studied.

Results and limitations

The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p = 0.03). However, when analyzed in two groups—supradiaphragmatic and infradiaphragmatic—there was no significant difference in DSS (P = 0.14). On univariate analysis, metastasis at presentation, non–clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p = 0.03), metastasis at presentation (p < 0.01), and non–clear-cell histology (p = 0.03) were independent prognostic factors on multivariate analysis.

Conclusions

Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non–clear-clear cell histology are significant prognostic factors influencing DSS.     

Prognostic significance of extent of venous tumor thrombus in patients with non-metastatic renal cell carcinoma: Results from a Canadian multi-institutional collaborative

PurposeThe prognostic significance of level of venous tumor thrombus (VTT) extension in patients with non-metastatic renal cell carcinoma (RCC) has been controversial. The aim of this study was to examine the prognostic significance of VTT extent in patients who underwent surgery for non-metastatic RCC.Materials and MethodsThe Canadian Kidney Cancer information system database was used to identify patients who underwent surgery for non-metastatic RCC and VTT from January 2011 to December 2019. Association between VTT level and recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) was examined. Univariable and multivariable analyses were performed to estimate predictors of survival.ResultsOut of 6,340 patients during the study period, 228 patients (3.6%) had VTT. VTT was level 0 in 84 (37%), level I to II in 112 (49%), and level III to IV in 33 (14%) patients as per the Mayo Clinic classification. Median age was 65.4 years (interquartile range [IQR] 57.6–72.2) and 169 (74.1%) were male. After a median follow-up of 21.2 months, VTT level did not significantly impact the RFS, CSS, or OS. For VTT level 0, I to II, and III to IV, there was no significant difference in estimated 5-year RFS (31%, 23%, and 30.5%; P > 0.05), CSS (70%, 69%, and 55%; P > 0.05) and OS (64%, 66%, and 50%; P > 0.05). Adjusting for known prognostic factors, thrombus level was not associated with risk of recurrence or death.ConclusionIn a large, multi-institutional cohort of patients undergoing surgery for non-metastatic RCC with tumor thrombus, thrombus extent was not independently associated with recurrence or death.     

Renal cell carcinoma with tumor thrombus extension: biology,role of nephrectomy and response to immunotherapy

PURPOSE: We outline the biology, prognosis and role of immunotherapy for renal cell carcinoma with gross venous tumor thrombus. MATERIALS AND METHODS: A total of 207 patients with unilateral renal cell carcinoma and tumor thrombus into the renal vein (107) and inferior vena cava (100) who underwent nephrectomy and thrombectomy were compared with 607 without tumor thrombus. RESULTS: At diagnosis 77 patients (37%) had N0M0 disease and 130 (63%) had lymph node (N+) or distant (M1) metastases. Compared with nontumor thrombus cases tumor thrombus was associated with more advanced stage, N+ (26% versus 12%), M1 (54% versus 31%) disease, higher grade and Eastern Cooperative Oncology Group performance status. In N0M0 cases with inferior vena caval tumor thrombus capsular penetration, collecting system invasion and extension into the hepatic vein were more important prognostic variables then the level of inferior vena caval thrombus. In patients with confined N0M0 tumors mean 2 and 5-year survival +/- SD was 83% +/- 8.8% and 72% +/- 10.7% in those with inferior vena caval tumor thrombus, and 90% +/- 9.4% and 68% +/- 16.1% in those with renal vein tumor thrombus, similar to the 93.4% +/- 1.7% and 81 +/- 3.1% rates, respectively, in those without thrombus who had no recurrence within 6 months after nephrectomy. Of patients with M1 disease in whom cytoreductive surgery was done those with and without thrombus showed a similar response to immunotherapy. When there was inferior vena caval and renal vein thrombus, mean 2-year survival was higher after nephrectomy and immunotherapy than after nephrectomy alone (41% +/- 9% and 52% +/- 7% versus 32% +/- 13% and 45% +/- 7%), immunotherapy alone (0% and 13% +/- 12%, respectively) and no treatment (0%). CONCLUSIONS: Renal cell carcinoma with tumor thrombus is associated with worse characteristics. Local tumor extension has greater prognostic importance than the level of inferior vena caval tumor thrombus. Survival is fair in patients with truly confined N0M0 disease and thrombus. The combination of surgery and immunotherapy has a role in thrombus cases. Our data provide the rationale for a prospective study of adjuvant immunotherapy after surgery in N0M0 cases with extensive tumor thrombus.     

Caval tumor thrombus volume influences outcomes in renal cell carcinoma with venous extension

IntroductionSurgery for renal cell carcinoma with tumor thrombus has a high potential morbidity rate, and the current classification system based on proximal tumor thrombus level (TTL) has not been shown to consistently predict outcomes.AimTo assess the prognostic value of inferior vena cava tumor thrombus volume (IVC-TV) for determining the perioperative complications as well as with survival end points.MethodsFrom June 2001 to June 2012, we identified 147 patients who underwent radical nephrectomy with venous thrombi. In total, 66 patients had IVC involvement and available imaging for review. IVC-TV was measured by cross-sectional area and height measurement for each axial slice. Linear, logistic models and Cox proportional hazard was used for analysis.ResultsMedian IVC-TV was 16.5 cm³, and 18 patients had TTL≥III. In total, 57 Clavien I–V complications were documented in 32 patients including 3 deaths. On multivariate analysis, age>65 years, American Society of Anesthesiologists>3, and IVC-TV>15 cm³ were independent predictors for perioperative complications. Disease progression (PoD) occurred in 78% of patients, and metastatic disease (hazard ratio [HR] = 3.33, P<0.01) and non–clear cell histology (HR = 2.98, P = 0.02) were independent predictors of PoD. Median time to death was 16 months (interquartile range: 5.2–42.9). On Cox regression analysis, metastatic disease, non–clear cell histology, IVC-TV>15 cm³, and TTL III/IV were significantly associated with overall survival. As a preoperative variable, IVC-TV>15 cm³ was shown to be an independent predictor of PoD (HR = 2.3, P = 0.01) and overall survival (HR = 2.21, P = 0.03).ConclusionIVC-TV has value as a prognostic indicator, which is superior to TTL in the setting of renal cell carcinoma with IVC venous thrombus.     

腹腔镜手术治疗肾癌伴静脉癌栓的初步经验

目的探讨腹腔镜手术(包括普通腹腔镜和机器人辅助腹腔镜)在治疗肾癌伴静脉癌栓患者中的安全性和有效性。 方法回顾性分析上海长征医院2016年2月至2018年12月期间共18例接受腹腔镜手术(包括普通腹腔镜和机器人辅助腹腔镜)的肾癌伴静脉癌栓患者的临床资料。其中男14例、女4例;年龄32～77岁,平均(59.7±10.1)岁;术前肌酐53～147 μmol/L,平均(94.2±26.2)μmol/L。静脉癌栓Mayo分级：0级5例、Ⅰ级6例、Ⅱ级7例。普通腹腔镜手术6例、机器人辅助腹腔镜手术12例;左侧肾癌6例、右侧肾癌12例。 结果所有患者手术均顺利完成,无中转开腹。术中均采用经腹腔途径,具体手术步骤根据癌栓分级、肿瘤方向而有所不同;手术时间165～615 min,平均(295.2±123.7)min;术中出血量100～1 500 ml,平均(458.3±431.8)ml;术中输血6例。术后病理：透明细胞癌13例、乳头状细胞癌4例、肾嫌色细胞癌与嗜酸性细胞肿瘤的混合肿瘤1例。18例患者均获随访,随访1～34个月,平均14个月,其中1例术后20个月死亡。 结论腹腔镜手术(包括普通腹腔镜和机器人辅助腹腔镜)对肾癌伴静脉癌栓患者,特别是Ⅱ级及以下的癌栓患者,是安全、有效的治疗方法。但具体的手术方案需结合患者的肿瘤位置、癌栓分级及术者腹腔镜手术熟练度来制订,从而使患者得到最大的收益。     

Survival prognostic factors valuation on a series of 202 patients with surgical treatment of renal cell carcinoma

ObjectivesTo describe renal cell carcinoma prognostic factors and set up the relationship with survival rates in this neoplasm. Likewise we show epidemiologic, clinical, diagnosis and therapeutic facts.Material and methodWe review 202 patients underwent surgical treatment for renal cell carcinoma and the following features were recorded: gender, age and presenting symptoms, especially incidentally discovered tumors; tumor-related factors like TNM tumor stage, tumor grade and venous involvement; therapy-related recorded were surgical techniques and cytokine-based therapy.Results60% of the patients showed organ-confined disease, 10% of patients with renal cell carcinoma presented with nodal positive disease and 7% with systemic metastases. 42% of patients presenting incidental tumor, with survival rates substantially better than that for symptomatic patients. 42% of patients with nodal positive disease presented systemic metastases at diagnosis, and 30% at surveillance. Systemic metastases portend a particularly poor prognosis for patients with renal cell carcinoma, with 12-months survival rates that 0%. Patients with cytokine-related therapy for metastatic disease presented 24-months survival rates that 20%.ConclusionsRenal cell carcinoma remains a major source of mortality, basically at advanced disease (nodal positive disease or systemic disease), without a clear improvement of survival rates despite the newer therapy modalities.     

Grading Chromophobe Renal Cell Carcinoma: Evidence for a Four-tiered Classification Incorporating Coagulative Tumor Necrosis

BackgroundAlthough grading systems have been proposed for chromophobe renal cell carcinoma (ChRCC), including a three-tiered system by Paner et al (Paner GP, Amin MB, Alvarado-Cabrero I, et al. A novel tumor grading scheme for chromophobe renal cell carcinoma: prognostic utility and comparison with Fuhrman nuclear grade. Am J Surg Pathol 2010;34:1233–40), none have gained clinical acceptance, and the World Health Organization (WHO) currently recommends against grading ChRCC.ObjectiveTo validate a previously published grading scheme and propose a scheme that includes tumor necrosis.Design, setting, and participantsA total of 266 patients who underwent nephrectomy for nonmetastatic ChRCC between 1970 and 2012 were reviewed for ChRCC grade according to the Paner system and coagulative tumor necrosis.Outcome measurements and statistical analysisAssociations with cancer-specific survival (CSS) were evaluated using Cox proportional hazard regression models and summarized with hazard ratios (HRs).Results and limitationsTwenty-nine patients died from RCC; the median follow-up was 11.0 (interquartile range 7.9–15.9) yr. ChRCC grade according to the Paner system was significantly associated with CSS, including the difference in outcome between grade 1 and 2 tumors. Among patients with grade 2 tumors, the presence of tumor necrosis helped delineate patients with worse CSS. As such, the Paner system was expanded to four tiers separating grade 2 into those with and without tumor necrosis. HRs for associations of the proposed grade 2, 3, and 4 tumors with CSS were 4.63 (p = 0.007), 17.8 (p < 0.001), and 20.9 (p < 0.001), respectively. The study is limited by the lack of multivariable analysis including additional pathologic features.ConclusionsThe expansion of a previously reported ChRCC grading system from three to four tiers by the inclusion of tumor necrosis helps further delineate patient outcome and can, therefore, enhance patient counseling following surgery. It also aligns the number of ChRCC grades with the WHO/International Society of Urologic Pathology four-tiered grading systems for clear cell and papillary RCC.Patient summaryChromophobe renal cell carcinoma is the third most common type of renal cancer, and unlike other renal cancers, there is no accepted prognostic grading system. In this study, we found that a grading system that included a pathologic feature of tumor necrosis could better define outcomes for patients with chromophobe renal cell carcinoma.     

肝动脉化疗栓塞术治疗原发性肝细胞癌预后影响因素分析

目的分析肝动脉化疗栓塞术(TACE)治疗原发性肝细胞癌(HCC)的预后影响因素。方法回顾性分析326例接受TACE治疗的HCC患者的资料。采用Kaplan-Meier法计算患者1、2、3年累积生存率,分别以Log-rank检验及Cox比例风险模型进行预后相关单因素及多因素分析。结果患者1、2、3年累积生存率分别为73.90%、40.20%、22.20%,中位生存期21个月。单因素分析显示,甲胎蛋白(AFP)、γ-谷氨酰转肽酶(GGT)、肿瘤最大径、肿瘤数目、肝功能Child-Pugh分级、巴塞罗那临床肝癌(BCLC)分期、门静脉癌栓、动静脉瘘、远处转移为影响HCC患者预后的相关因素(P均0.05)。多因素分析显示,AFP、GGT、肿瘤最大径、肿瘤数目、BCLC分期、动静脉瘘为HCC患者预后的独立影响因素(P均0.05)。结论影响TACE治疗HCC患者预后的独立因素包括AFP、GGT、肿瘤最大径、肿瘤数目、BCLC分期及动静脉瘘。     

A new classification for hepatocellular carcinoma with hepatic vein tumor thrombus

BackgroundHepatic vein tumor thrombus (HVTT) is a significant poor risk factor for survival outcomes in hepatocellular carcinoma (HCC) patients. Currently, the widely used international staging systems for HCC are not refined enough to evaluate prognosis for these patients. A new classification for macroscopic HVTT was established, aiming to better predict prognosis.MethodsThis study included 437 consecutive HCC patients with HVTT who underwent different treatments. Overall survival (OS) and time-dependent receiver operating characteristic (ROC) curve area analysis were used to determine the prognostic capacities of the new classification when compared with the different currently used staging systems.ResultsThe new HVTT classification was defined as: type I, tumor thrombosis involving hepatic vein (HV), including microvascular invasion; type II, tumor thrombosis involving the retrohepatic segment of inferior vena cava; and type III, tumor thrombosis involving the supradiaphragmatic segment of inferior vena cava. The numbers (percentages) of patients with types I, II, and III HVTT in the new classification were 146 (33.4%), 143 (32.7%), and 148 (33.9%), respectively. The 1-, 2-, and 3-year OS rates for types I to III HVTT were 79.5%, 58.6%, and 29.1%; 54.8%, 23.3%, and 13.8%; and 24.0%, 10.0%, and 2.1%, respectively. The time-dependent-ROC curve area analysis demonstrated that the predicting capacity of the new HVTT classification was significantly better than any other staging systems.ConclusionsA new HVTT classification was established to predict prognosis of HCC patients with HVTT who underwent different treatments. This classification was superior to, and it may serve as a supplement to, the commonly used staging systems.     

Valor pronóstico de la invasión microvascular en la predicción de la supervivencia en el carcinoma de células renales

ObjectiveTo assess microvascular tumor invasion and other clinical and histological parameters as potential prognostic factors in surgically treated renal cell carcinoma.Materials and methodsSurgical specimens from 238 consecutive patients who underwent radical or partial surgery between 1990 and 2006 were retrospectively evaluated. The series included clinically localized or metastatic renal cell carcinoma (pT1-4; N0-1; M0-1). Disease-free and cancer-specific survival assessments were the end points with median follow-up of 75 months (range 1-189 months). Variables studied included: age, sex, tumor size, TNM 2010 classification, Fuhrman grade, histological subtype and microvascular tumor invasion.ResultsMicrovascular tumor invasion was observed in 79 patients (33,2%) and was significantly associated with age (P = .010), tumor size (P = .000), Fuhrman grade (P = .000), pT stage 2010 (P = .000), N stage 2010 (P = .000) and M stage 2010 (P = .000). Multivariate analyses determined that sex, Fuhrman grade, pT stage 2010 and histological subtipe were independent prognostic factors of disease-free survival, while sex, Fuhrman grade, pT stage 2010, M stage 2010, histological subtype and microvascular invasion were prognostic factors for cancer-specific survival.ConclusionsOur study shows that microvascular tumor invasion is an independent prognostic factor for cancer-specific survival in surgically treated patients with renal cell carcinoma.     

Impact of the neutrophil-to-lymphocyte ratio as a surgical prognostic factor in renal cell carcinoma with inferior-vena-cava tumor thrombus

BackgroundThe aim of this study is to evaluate the efficacy of radical nephrectomy with thrombectomy and to identify the prognostic factors for patients with renal cell carcinoma (RCC) and inferior vena cava tumor thrombus (IVCTT). The role of the neutrophil-to-lymphocyte ratio (NLR), which has been reported to be a useful prognostic predictor for various solid cancers, was also investigated.MethodsFifty-five patients with RCC and IVCTT who underwent radical nephrectomy and thrombectomy in our hospital were retrospectively analyzed. The relationship between clinical characteristics and surgical outcome was examined using the Kaplan–Meier method. Univariate and multivariate analyses were carried out to determine the prognostic factors.ResultsThe median follow-up time after surgery was 44.2 months. Twenty-seven patients died of RCC, and 4 died of other disease at last follow-up. There were no patients with postoperative pulmonary embolism (PE) or deaths from PE. The median cancer-specific survival (CSS) and overall survival (OS) were 81.0 (95% confidence interval [CI]: 42.0–103.2) and 69.0 (95% CI: 34.3–81.5) months, respectively. Significant prognostic factors for CSS were distant metastasis (p = 0.045) and NLR ≥ 2.9 (p = 0.009). The only independent predictor for OS was the NLR ≥ 2.9 (p = 0.034).ConclusionsA high preoperative NLR level was an independent poor prognostic factor influencing CSS and OS of patients with RCC and IVCTT who underwent radical nephrectomy and thrombectomy. The NLR may be an available biomarker that helps with preoperative risk stratification.     

肾癌伴静脉癌栓外科治疗的疗效观察

目的探讨外科治疗肾癌伴静脉癌栓患者的预后。方法自1994年8月至2004年7月共33例患者行肾癌根治术及静脉癌栓取出术,其中男性26例、女性7例,中位年龄60岁(20~82岁)。肾静脉癌栓15例,下腔静脉癌栓Ⅰ级(肝下水平)9例、Ⅱ级(肝后水平)5例、Ⅲ级(肝上水平)1例、Ⅳ级(右心房水平)3例。采用Kaplan-Meier方法进行生存分析。结果29例患者得到随访,14例死亡,平均生存(16·4±2·9)个月(1~42个月),15例存活,平均随访(17·3±4·6)个月(3~67个月)。1例患者术后第2天死亡,3例失访。5年生存率为16%。肾静脉癌栓患者平均生存(49·9±9·8)个月,明显高于Ⅰ级下腔静脉癌栓患者的(16·7±1·9)个月(P<0·05)。结论肾癌根治性切除加癌栓取出术是治疗肾癌伴静脉癌栓的有效方法,肾静脉癌栓患者的预后好于腔静脉癌栓患者。     

Prognostic significance of pseudocapsule status in patients with metastatic renal cell carcinoma treated with tyrosine kinase inhibitors

BackgroundWe sought to determine whether pseudocapsule (PS) features have prognostic implications in patients with metastatic renal cell carcinoma (mRCC).MethodsWe retrospectively reviewed 231 patients diagnosed with mRCC and treated with tyrosine kinase inhibitors; 188 patients with data available regarding the tumor-parenchyma interfacial PS of the primary tumor were enrolled for analysis. PS status was evaluated as intact (grade 0), merely involved (grade 1), penetrated (grade 2), and absent (grade 3). We applied the Kaplan-Meier method and Cox regression model to assess the survival impact.ResultsOf the 188 patients, 19 (10.1%), 61 (32.4%), 96 (51.1%) and 12 (6.4%) had grade 0, 1, 2 and 3 PS, respectively. PS status was significantly associated with histology (P=0.0206), venous tumor embolus (P=0.0511), microvascular invasion (P=0.0108) and microsatellite formation (P=0.0097). Patients without a PS had the worst overall survival (OS), with a 3-year OS rate of 12.7%, whereas the OS rates for grades 0, 1 and 2 were 78.8%, 50.8% and 43.6%, respectively. Adjusted by other variables, grade 3 and grade 2 PS gave rise to a much higher risk of death across the cohort [hazard ratio (HR) =5.217, P=0.0182; HR =3.765, P=0.0281, respectively]. Sarcomatoid change was also an independent factor for OS (HR =2.932, P=0.0075). In contrast, microsatellite formation was not associated with survival in the cohort.ConclusionsPS status has prognostic implications for OS in metastatic renal cancer. The absence of the PS and sarcomatoid change are two pathological features related to an extremely poor prognosis.