Nephron-sparing surgery for renal cell carcinoma: clinicopathologic features predictive of patient outcome

doi:10.1016/S0090-4295(03)00489-8

Urology

Volume 62, Issue 4, October 2003, Pages 641-646

https://doi.org/10.1016/S0090-4295(03)00489-8 Get rights and content

Abstract

Objectives

To determine the clinicopathologic features associated with outcome in patients with sporadic renal cell carcinoma (RCC) treated with nephron-sparing surgery.

Methods

We studied 344 patients treated with nephron-sparing surgery between 1970 and 2000. The pathologic features of the tumors were reviewed by two urologic pathologists who recorded the histologic subtype, 2003 TNM stage, tumor size, and grade. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method, and log-rank tests were used to compare the outcome by histologic subtype. Univariate Cox proportional hazards models were fit to assess the associations between the clinicopathologic features and death from RCC, distant metastases, and local recurrence.

Results

The CSS rate at 5 and 10 years for patients with clear cell RCC was 94.4% and 91.5%, respectively. In contrast, the CSS rate at 5 and 10 years for patients with papillary or chromophobe RCC was 99.0%, because only 1 patient died of papillary RCC and no patient died of chromophobe RCC (P = 0.029). Among the patients with localized clear cell RCC, tumor stage and grade were significantly associated with death from RCC and metastases. Grade was significantly associated with local recurrence for clear cell RCC, but not for papillary RCC.

Conclusions

In our series of patients with RCC treated with nephron-sparing surgery, patients with clear cell RCC had a significantly worse CSS than did patients with papillary and chromophobe RCC. Tumor stage and grade were associated with outcome among patients with localized clear cell RCC. These findings are similar to the results for patients with localized clear cell RCC treated with radical nephrectomy.

Section snippets

Patient selection

The Mayo Clinic Institutional Review Board reviewed and approved this study protocol. There were a total of 650 patients whose first operation between 1970 and 2000 was a nephron-sparing procedure. Of these, 608 patients had pathologic material available for review; 442 patients (72.7%) had RCC, 159 (26.2%) had benign lesions, and 7 (1.2%) had transitional cell carcinoma. We concentrated on the 442 patients with RCC for the analysis. Patients with familial, von Hippel-Lindau or tuberous

Results

Of the 344 patients, 225 (65.4%) had clear cell, 96 (27.9%) had papillary, 21 (6.1%) had chromophobe, and 1 (0.3%) had collecting duct RCC. One patient (0.3%) had an RCC tumor that could not be classified into one of these four groups. The clinical, surgical, and pathologic features for the three most common histologic subtypes are summarized in Table I. A Kaplan-Meier curve comparing the CSS among the three most common histologic subtypes is shown in Figure 1. Because only 1 patient died of

Comment

NSS is increasingly being used as a surgical option in the treatment of patients with RCC. The increased use of imaging techniques for nonspecific complaints has resulted in an increase in the frequency of incidentally discovered small renal masses. For example, the rate of NSS for incidental, organ-confined tumors at the Mayo Clinic increased from 14% between 1970 and 1994 to 35% between 1995 and 2000. Several studies have indicated that patients with RCC who undergo NSS have similar CSS to

Conclusions

Our results indicate that patients with papillary or chromophobe RCC treated with NSS have an excellent CSS. In addition, tumor stage and nuclear grade are important prognostic features among patients with localized clear cell RCC treated with NSS. This information is important for preoperative decision making, patient counseling, and surveillance and supports the use of NSS as an option in managing localized renal masses.

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Patients with early-stage renal cell carcinoma (RCC) are considered to be eligible donors. Although preliminary experience in using kidneys of specific pathologic types, mainly those with small renal masses (SRMs), have been established, multiorgan utilization of the same donor with SRMs is limited.
One deceased donor whose left-side kidney was diagnosed with Fuhrman grade I RCC was included. The tumor mass in the kidney was removed through partial nephrectomy according to the gold standard. Then, 3 transplant surgeries were performed, in which 1 recipient accepted kidney transplant after tumor exeresis, 1 simultaneous heart-kidney (the contralateral one) transplant, and 1 liver transplant. Recipients were followed up according to our standard protocol for renal cancers. (All allografts were allocated in compliance with the Declaration of Helsinki and the Declaration of Istanbul.)
After 32 months, no radiographic findings showed any morphologic changes of the lesion, and all patients were in good condition, with neither tumor recurrence nor allograft rejection or infection. No complaints such as pain, oliguria, dyspnea, nausea, or fatigue were recorded.
To the best of knowledge, this initial work takes the lead in elaborating the organ utilization of multiorgan donors with SRMs. We hope the experience will provide support for cross discussion concerned with multiorgan transplant from tumor-affected donors in clinical practices, further expand the donor pool and address the donor shortage problem.
Papillary renal cell carcinoma: Review
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Kidney cancer is the 13th most common malignancy globally, and the incidence is rising. Papillary renal cell carcinoma is the second most common subtype, comprising 10-15% of renal cell carcinomas. Though the histologic features of this subtype were initially described in the 1990’s, our understanding of the genetic and molecular characteristics of this disease have rapidly evolved over the past decade. In this review, we summarize the contemporary understanding of the clinical, morphologic, radiographic, and genetic characteristics of papillary renal cell carcinoma, as well as clinical considerations, current options for management, and prognosis.
Classification of Histologic Patterns of Pseudocapsular Invasion in Organ-Confined Renal Cell Carcinoma
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A standardized histologic definition and classification of patterns of renal tumor pseudocapsular invasion (RTPI) in renal cell carcinoma (RCC) is not available. The aim of the present study was to propose a classification of RTPI patterns and assess their correlation with other pathologic features and prognosis.
The renal tumor pseudocapsule was assessed by 2 expert genitourinary pathologists on the histologic slides of 190 specimens from radical nephrectomy performed for organ-confined (pT1-pT2) RCC. The histologic patterns of RTPI were classified and described. The association between the RTPI patterns and other pathologic features was assessed. The Kaplan-Meier method was used to calculate the survival functions, and Cox regression models were used to assess the predictors of cancer-specific survival.
RTPI was classified into 2 main histologic patterns (expansive and infiltrative). Expansive and infiltrative RTPI was observed in 39.5% and 51.6% of cases, respectively. A significant association between the RTPI pattern and Fuhrman grade (P = .006) and RCC histologic subtype (P = .034) was detected. Patients with infiltrative pseudocapsular invasion had significantly poorer 5- and 10-year cancer-specific survival rates than patients with expansive invasion or no invasion (93.6% vs. 98.9% and 84.9% vs. 93%, respectively; P = .039). The presence of infiltrative pseudocapsular invasion was a significant predictor of cancer-specific survival (hazard ratio 4.38, 95% confidence interval 1.04-20.27).
An expansive and an infiltrative RTPI pattern can be described. In our study, patients with organ-confined RCC and an infiltrative RTPI pattern had a greater risk of cancer-specific death and might require stricter postoperative surveillance strategies.
Significance of Pathologic T3a Upstaging in Clinical T1 Renal Masses Undergoing Nephrectomy
2015, Clinical Genitourinary Cancer
Citation Excerpt :
We also found that the histologic subtype, especially CC, was a predictor of upstaging. This finding also seems to be congruent with the current data because CC generally seems to behave more aggressively and lead to worse survival rates than either the chromophobe or papillary subtypes.17-19 The presence of PSMs was highly predictive of pathologic upstaging in our cohort.
The objectives of the present study were to report the incidence of pathologic T3a upstaging in a contemporary cohort of patients with clinical stage T1 (cT1) renal tumors treated with partial or radical nephrectomy; investigate the clinical outcomes; and identify the predictors associated with pathologic upstaging.
From a single-institution, institutional review board–approved renal tumor database of 945 patients, we identified 610 patients who had undergone surgery for a cT1 renal mass. Data for 494 patients were available for analysis. Of these, 66 lesions had been pathologically upstaged to T3a after surgery and 428 had not. The oncologic follow-up data and clinical and pathologic features were recorded, and multivariable logistic regression analysis was performed to identify the risk factors for pT3a upstaging, controlling for age, gender, body mass index, and nephrectomy type.
The cT1 tumors of 66 patients (13.3%) were upstaged to pT3a after surgery. Of these 66 patients, 44 (66.7%) had undergone partial and 22 (33.3%) radical nephrectomy. The median follow-up period was 50 months. No patient with upstaging developed recurrence, and all were disease free at their last follow-up visit. On multivariable analysis, tumor size > 4 cm (odds ratio [OR], 3.766; 95% confidence interval [CI], 1.417-10.011; P < .008), clear cell histologic features (OR, 4.461; 95% CI, 1.498-13.461; P < .007), and positive surgical margins (hazard ratio, 5.118; 95% CI, 2.088-12.547; P < .0001) were associated with upstaging.
Of the cT1 lesions in 66 patients, 13% were pathologically upstaged after surgery. The patients with larger tumors, clear cell histologic features, and positive surgical margins were at the greatest risk of upstaging. However, after an intermediate follow-up period, pathologic upstaging did not appear to result in worsened oncologic outcomes.
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To evaluate the pathological characteristics of peritumoral capsule (PC) and the prognostic effect of capsule penetration on tumor recurrence in patients treated with tumor enucleation for clinically intracapsular renal cell carcinomas (RCCs).
PC status was analyzed in 304 consecutive patients with single intracapsular RCC. Degree and side of capsule penetration if present were evaluated. Mean (median, range) follow-up was 49 months (46, 25–69). Local recurrence rate, progression-free survival (PFS), and cancer-specific survival were the main outcomes. Statistical analyses included the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression models.
Overall, 51% of RCCs had intact PC and free from neoplastic invasion (PC−), 34.9% had capsular penetration on the parenchymal side (PCK), and 14.1% had tumor invasion on the perirenal fat tissue side (PCF). None of the patients had positive surgical margins. The 5-year PFS rates for tumors PC−, PCK, and PCF were 97.5%, 96.7%, and 77.1%, respectively (P<0.0001).
The multivariate Cox model showed PCF to be the sole significant independent predictor of PFS, whereas patients who had PCK did not present a significant increased risk in developing recurrence.
Tumor enucleation is an oncologically safe nephron-sparing surgery technique. PCF is a significant and independent predictor of tumor recurrence in patients with clinically intracapsular RCCs scheduled for nephron-sparing surgery. PCK does not predict the risk of recurrence.
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Adult urologyNephron-sparing surgery for renal cell carcinoma: clinicopathologic features predictive of patient outcome

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Patient selection

Results

Comment

Conclusions

Urology

Mayo Clin Proc

Urology

J Urol

J Urol

Urology

J Urol

J Urol

J Urol

J Urol

J Urol

Adult urology
Nephron-sparing surgery for renal cell carcinoma: clinicopathologic features predictive of patient outcome