Article

Prognostic Value of Renal Venous Involvement in Renal Carcinoma

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Abstract

A series of 108 renal tumour nephrectomies carried out between 1975 and 1984 was studied to determine the prognostic statistical significance of the relationship between venous involvement and various pathological features. Tumour size, spread, histological grade and lymph node involvement were compared between V0 tumours (58%), V1 (32%) and V2 tumours (10%). Actuarial 5-year survival rates revealed a poor prognosis with venous involvement (V0 66%, V1 27%, V2 33%). Tumours larger than 10 cm with perirenal spread and of higher histological grade were significantly related to venous involvement. Survival between renal vein involvement and inferior vena caval extension was statistically similar, but it was influenced by tumour size and higher grade. Perirenal spread and nodal involvement were poor indicators.

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... Pour certains, cet envahissement de la paroi de la veine cave semble pouvoir être corrélé à un diamètre du thrombus de plus de 40 mm et ainsi être suspecté en préopératoire par les examens morphologiques [22]. Néanmoins, certains auteurs constatent une dissémination métastatique [7, 8] ou un envahissement locorégional [10, 11], patients n'ayant aucune extension locorégionale ou générale décelable, ce qui souligne l'importance des examens morphologiques préopératoires. ...
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Ce travail vise à analyser les résultats de la néphrectomie avec thrombectomie atrio-cave sous circulation extracorporelle (CEC) chez sept patients ayant un cancer du rein avec envahissement cave supra-diaphragmatique et de discuter les indications opératoires. Sept patients, six hommes et une femme dont l’âge varie entre 46ans et 65ans, ont été opérés d'un cancer du rein avec extension atrio-cave. L’écho-doppler a toujours permis la mise en évidence de l'extension veineuse mais la limite supérieure du thrombus était formellement identifiée par l'examen tomodensitométrique quatre fois, et par la résonance magnétique nucléaire dans tous les cas. Tous les patients ont été opérés sous CEC à cœur battant en normothermie. Un seul décès postopératoire est survenu. La durée du séjour en réanimation a été de 4,5 jours. Cinq patients ont eu à distance une dissémination métastatique. Cinq malades ont eu une médiane de survie de 11,5 mois (de 7 à16). Un malade a subi une métastasectomie pulmonaire 6 mois après la néphrectomie. L'exérèse des thrombi atrio-caves a été facilitée par la CEC avec une mortalité et une morbidité postopératoires acceptables mais les résultats à distance ont été décevants. Cette intervention ne peut être proposée qu'aux patients n'ayant aucune extension locorégionale et générale décelable, ce qui souligne l'importance des examens morphologiques préopératoires.
Article
IntroductionL’extension tumorale renale a la veine cave inferieure (VCI) et a l’oreillette droite (OD) est generalement l’evolution naturelle des carcinomes a cellules claires [1]. Ce thrombus neoplasique envahit la VCI dans 4 a 10 % des cas [2-4] et atteint l’OD dans 2 % des cas [4, 5].Sa prise en charge necessite une approche agressive associant une nephrectomie a une ablation du thrombus neoplasique cavo-atrial sous circulation extracorporelle (CEC) [4, 6], voire parfois [...]
Article
Renal cell carcinoma represents a 2,5-3% of all neoplastic processes, usually seen un patients older than 50 years. 60-75% are resectable at diagnosis, representing local or metastatic advanced disease the rest of them. This tumor tends to spread intravascularly, leading to tumoral thrombosis within the inferior caval vein (ICV) and renal vein 4-10% and 21-35% of cases, respectively.As the only efective treatment is surgical resection, preoperative determining of the thrombus extension is crucial. Thus, an accurate radiological study including ultrasound, doppler sonography, computed tomography and/or Magnetic Resonance, is key for these patients.We present a 49 year-old patient with renal cell carcinoma and associated tumoral thrombosis in inferior caval vein and left renal vein; we provide the most significant figures, explaining its most characteristic radiological findings.
Article
Renal carcinoma with cavo-atrial involvement. Surgical management using cardiopulmonary bypass without circulatory arrest.Study aim: The study aim was to report results of nephrectomy with resection of cavo atrial thrombus in 6 patients with a renal carcinoma and supra-diaphragmatic vena cava extension and to discuss limits of the surgical indications.Patients and method: Six patients, five adults (mean age: 57±10 years) and a four-year old girl, were operated on for a renal cell carcinoma with supra-diaphragmatic vena cava extension. The venous extension was detected in all cases by abdominal ultrasonography. The superior extent of the thrombus was effectively visualized by CT scan in three cases, and by ultrasonography and magnetic resonance imaging in all cases. All the patients were operated on, using cardio-pulmonary bypass, without circulatory arrest, four in normothermia, two in moderate hypothermia at 28 °C.Results: Hospital mortality was 0%. Average intensive care unit stay was 3.8 days. During the following period, all the patients developed metastastic disease. Mean survival rate of the five adult patients who had loco-regional invasion was 9.4 months (range: 6 to 19). The young girl underwent a wedge excision of two pulmonary metastases one year later and was still alive 7 years later.Conclusions: With cardio-pulmonary bypass, surgical resection of cavo-atrial thrombi may be performed with a low mortality and morbidity rate but late results were disappointing. Surgery should be limited to patients without loco-regional invasion or distant metastatic disease, and therefore accurate preoperative staging is mandatory.
Article
Historically the presence of a thrombus in vena cava was associatted with worse prognosis in patients with renal cell carcinoma, and the effective of surgery limited. However a extensive tumor thrombi can be present without evidence of lymph node and distant metastasis, an aggressive surgical approach with curative intent is justified.We retrospectively reviewed 25 patients with renal cell carcinoma and thrombus in vena cava and they underwent radical nephrectomy and thrombectomy. The IRM allowed to know the level of the thrombus into vena cava in all patients: 56% level I, 8% level II, 26% level III. There were 14 pT3b, 8 pT3c, 3 pT4, and 48% N+. The rate of complications was 36% and there were 4 perioperative death (16%).Patients without lymph node and no distant metastasis had a mean survival of 64% 46%, 37% to 2,3,4 years respectively. Patients with lymph node invasive an distant metastasis the prognosis was poor. We no noted correlation between level thrombus and prognosis.
Article
Renal cell carcinoma has marked tendency to spread into renal vein, inferior vena cava and right side of heart. Extension of tumour thrombus into these veins will alter the surgical approach. We have compared the CT scan with Colour flow Doppler ultrasound in detecting venous tumour thrombus in renal vein and inferior vena cava. This cross-sectional study included 30 adult patients presenting with renal tumour. Patients of either gender were included in the study. Non probability convenience sampling was used. All patients underwent colour flow Doppler ultrasound and CT scan with contrast to asses the renal vein and inferior vena cava. The results were confirmed by intra operative findings and histopathology. The data was analyzed using SPSS version 12. Out of 30 patients, 20 (66%) were males and 10 (34%) female. The tumour was predominantly on the right side (60%), as was renal venous tumour thrombus (44%). Inferior vena cava was involved in 4 cases predominantly due to right sided tumours. The sensitivity of Doppler ultrasound in detecting renal venous tumour thrombus (88% on right and 100% on left side) was higher than CT scan (63% on right and 60% on left side). Doppler ultrasound was also superior to CT scan in detecting vena caval thrombus. The overall sensitivity of Doppler sonography was higher than CT scan in detecting tumour extension into renal veins and inferior vena cava. Therefore, it can be used as a complementary tool in equivocal cases.
Article
Our objective was to evaluate the accuracy of color Doppler sonography for assessing tumor thrombus extension into the renal veins, the inferior vena cava, and the right side of the heart in patients with renal cell carcinoma. Over the past 4.5 years, 44 patients with 46 renal cell carcinomas were examined with color Doppler sonography for the presence and extent of tumor thrombus in the renal veins, the inferior vena cava, and the right side of the heart. Examinations were performed after an equivocal CT scan in 34 patients and as a primary imaging technique in 10. Color Doppler sonographic findings were correlated with surgical-pathologic findings or findings from autopsies performed within 3 months of the Doppler study. Seven patients were excluded: two because of poor technical quality caused by body habitus and five because pathologic correlation was performed more than 3 months after the color Doppler sonographic examination. The remaining 39 renal vein and 37 caval Doppler examinations constituted the study material. Criteria used for the diagnosis of tumor thrombus included distention of the renal vein or the inferior vena cava by echogenic material and partial or complete absence of flow detected with color Doppler sonographic examination. Sixteen of 39 renal veins evaluated had pathology-proven tumor thrombus. Color Doppler sonography was 87% accurate with a sensitivity of 75%, a specificity of 96%, a positive predictive value of 92%, and a negative predictive value of 85%. In two false-positive cases, involvement was limited to intrarenal veins, causing no change in the surgical approach. Five of 37 inferior venae cavae evaluated had proven involvement by tumor thrombus. Color Doppler sonography was 100% accurate in assessing the presence and extent of inferior vena caval involvement by tumor thrombus. Extension into the right atrium and ventricle that was shown by this technique was proven by surgery in one case. The overall accuracy for detecting venous involvement for both the renal veins and the inferior vena cava was 93%, the sensitivity was 81%, and the specificity was 98%. In patients with renal cell carcinoma, color Doppler sonography appears to be fairly accurate in assessing tumor extension into the renal veins, the inferior vena cava, and the right side of the heart. Although CT is the primary imaging technique for staging renal cell carcinoma, color Doppler sonography may be used as a complementary technique for assessing venous extension in patients with an equivocal CT examination.
Article
Renal cell carcinoma represents a 2.5-3% of all neoplastic processes, usually seen un patients older than 50 years. 60-75% are resectable at diagnosis, representing local or metastatic advanced disease the rest of them. This tumor tends to spread intravascularly, leading to tumoral thrombosis within the inferior caval vein (ICV) and renal vein 4-10% and 21-35% of cases, respectively. As the only effective treatment is surgical resection, preoperative determining of the thrombus extension is crucial. Thus, an accurate radiological study including ultrasound, doppler sonography, computed tomography and/or Magnetic Resonance, is key for these patients. We present a 49 year-old patient with renal cell carcinoma and associated tumoral thrombosis in inferior caval vein and left renal vein; we provide the most significant figures, explaining its most characteristic radiological findings.
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Historically the presence of a thrombus in vena cava was associated with worse prognosis in patients with renal cell carcinoma, and the effective of surgery limited. However a extensive tumor thrombi can be present without evidence of lymph node and distant metastasis, an aggressive surgical approach with curative intent is justified. We retrospectively reviewed 25 patients with renal cell carcinoma and thrombus in vena cava and they underwent radical nephrectomy and thrombectomy. The IRM allowed to know the level of the thrombus into vena cava in all patients: 56% level I, 8% level II, 26% level III. There were 14 pT3b, 8 pT3c, 3 pT4, and 48% N+. The rate of complications was 36% and there were 4 perioperative death (16%). Patients without lymph node and no distant metastasis had a mean survival of 64% 46%, 37% to 2, 3, 4 years respectively. Patients with lymph node invasive an distant metastasis the prognosis was poor. We no noted correlation between level thrombus and prognosis.
Article
We determined the prognostic significance of renal vein or inferior vena caval (IVC) extension in patients with nonmetastatic renal cell carcinoma (RCC) or oncocytoma undergoing surgery. The charts of patients undergoing radical or partial nephrectomy from 1989 to 2001 for nonmetastatic RCC or oncocytoma were retrospectively reviewed. A total of 1082 patients (1120 renal units) underwent radical (850 renal units) or partial (270 renal units) nephrectomy. Renal vein extension was present in 60 patients (65.9%) and IVC extension was present in 31 (34.1%). The histological type associated with an increased risk of renal vein/IVC extension was conventional (80 of 702 cases, p <0.0001) and histological types with a decreased risk were oncocytoma (0 of 117, p = 0.00052) and papillary histology (0 of 146, p <0.0001). The 5-year actuarial recurrence-free probability was 59%, 65% and 91% in patients with IVC extension, renal vein extension and no renal vein or IVC extension, respectively. Larger tumor size, nodal metastases and conventional histology were associated with an increased risk of recurrence (RR = 3.38, 95% CI 2.53 to 4.51 for a doubling in size, RR = 9.97, 95% CI 5.51 to 18.1 and RR 3.78, 95% CI 2.15 to 6.65) as well as death (RR = 1.44, 95% CI 1.20 to 1.74 for a doubling in size, RR = 5.39, 95% CI 2.86 to 10.2 and RR = 1.56, 95% CI 1.09 to 2.24, respectively). Conventional RCC is associated with an increased risk, and oncocytoma and papillary histology are associated with a decreased risk of renal vein or IVC extension. Renal vein or IVC extension alone does not impart a worse prognosis independent of tumor size, nodal status and histology.
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The prognostic significance of morphologic parameters was evaluated in 103 patients with renal cell carcinoma diagnosed during 1961--1974. Pathologic material was classified as to pathologic stage, tumor size, cell arrangement, cell type and nuclear grade. Four nuclear grades (1--4) were defined in order of increasing nuclear size, irregularity and nucleolar prominence. Nuclear grade was more effective than each of the other parameters in predicting development of distant metastasis following nephrectomy. Among 45 patients who presented in Stage I, tumors classified as nuclear grade 1 did not metastasize for at least 5 years, whereas 50% of the higher grade tumors did so. Moreover, among Stage I tumors there was a significant difference in subsequent metastatic rate between nuclear grades 1 and 2. There was an apparent positive relationship between cell type and metastatic rate; clear cell tumors were less aggressive than predominantly granular cell tumors (metastatic rate 38% versus 71%). This relationship in part a function of the nuclear grade: only 5% of grade 3 and 4 tumors consisted of clear cells, whereas such high grades were seen in 57% of granular cell tumors. The size of the primary correlated well with the stage at the time of surgery. However, with the exception of extremely large and small tumors, the size was not useful in predicting the subsequent course of patients treated for Stage I tumors. Nuclear grade was the most significant prognostic criterion for the outcome of Stage I renal cell carcinoma.
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In lifetesting, medical follow-up, and other fields the observation of the time of occurrence of the event of interest (called a death) may be prevented for some of the items of the sample by the previous occurrence of some other event (called a loss). Losses may be either accidental or controlled, the latter resulting from a decision to terminate certain observations. In either case it is usually assumed in this paper that the lifetime (age at death) is independent of the potential loss time; in practice this assumption deserves careful scrutiny. Despite the resulting incompleteness of the data, it is desired to estimate the proportion P(t) of items in the population whose lifetimes would exceed t (in the absence of such losses), without making any assumption about the form of the function P(t). The observation for each item of a suitable initial event, marking the beginning of its lifetime, is presupposed. For random samples of size N the product-limit (PL) estimate can be defined as follows: List and label the N observed lifetimes (whether to death or loss) in order of increasing magnitude, so that one has \(0 \leqslant t_1^\prime \leqslant t_2^\prime \leqslant \cdots \leqslant t_N^\prime .\) Then \(\hat P\left( t \right) = \Pi r\left[ {\left( {N - r} \right)/\left( {N - r + 1} \right)} \right]\), where r assumes those values for which \(t_r^\prime \leqslant t\) and for which \(t_r^\prime\) measures the time to death. This estimate is the distribution, unrestricted as to form, which maximizes the likelihood of the observations. Other estimates that are discussed are the actuarial estimates (which are also products, but with the number of factors usually reduced by grouping); and reduced-sample (RS) estimates, which require that losses not be accidental, so that the limits of observation (potential loss times) are known even for those items whose deaths are observed. When no losses occur at ages less than t the estimate of P(t) in all cases reduces to the usual binomial estimate, namely, the observed proportion of survivors.
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The BJC is owned by Cancer Research UK, a charity dedicated to understanding the causes, prevention and treatment of cancer and to making sure that the best new treatments reach patients in the clinic as quickly as possible. The journal reflects these aims. It was founded more than fifty years ago and, from the start, its far-sighted mission was to encourage communication of the very best cancer research from laboratories and clinics in all countries. The breadth of its coverage, its editorial independence and it consistent high standards, have made BJC one of the world's premier general cancer journals. Its increasing popularity is reflected by a steadily rising impact factor.
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Part I of this report appeared in the previous issue (Br. J. Cancer (1976) 34,585), and discussed the design of randomized clinical trials. Part II now describes efficient methods of analysis of randomized clinical trials in which we wish to compare the duration of survival (or the time until some other untoward event first occurs) among different groups of patients. It is intended to enable physicians without statistical training either to analyse such data themselves using life tables, the logrank test and retrospective stratification, or, when such analyses are presented, to appreciate them more critically, but the discussion may also be of interest to statisticians who have not yet specialized in clinical trial analyses.
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The Erlangen system of histologic grading of the degree of malignancy of renal cell cancers (188 cases) is described. It takes into consideration the type of cell and pattern of the tumor and differentiates between grades 1, 2, and 3. Grade 1 tumors include: renal cell cancers of solid pattern consisting of clear cells, and adenomas of doubtful malignancy and questionably benign Grawitz tumors (Zollinger). Grade 3 are: tumors of exclusively glandular or glandular papillary pattern; tumors which show at least in one low power field (64x) exclusively dark cells; tumors with sarcoma like areas. All other malignant parenchymal tumors are classified as grade 2. Grade 1 was observed in 10%, grade 2 in 51% and grade 3 in 39% of cases. The difference in the 5 yr survival rates between grade 3 and grades 1 and 2 tumors is statistically significant.
Article
The original tumour node metastases system of clinical staging was not applicable to renal parenchymal tumors, because the 3 principal clinically demonstrable parameters were not of reliable significance. The size is of very limited value for staging and for prognosis. The urographic distortion can be very slight in a very advanced tumor on the one hand or very marked in a very benign tumor. The mobility can be a decisive factor only if it is definitely limited or if it is fixed. It is very doubtful if a solely clinical classfication into T1 to T4 is possible at all. However, the arteriographic changes could be used as a factor in prognosis, and the histological grading is certainly of value in estimating the prognosis. The following classification of stages of renal tumor extension proposed: Stage A: intracapsular stage; the tumor must have its own pseudocapsule complete (i.e. no perforation). Stage B: the tumor invasion is confined to the kidney tissue; it is not outside the kidney. Stage C: the tumor has some signs of involvement of surrounding structures such as perforation of the fibrous capsule and perirenal invasion, lymph node involvement or renal vein involvement to Stage D: distant metastases are present. The value of this anatomical classification can be seen from 200 cases followed for more than 5 yr after operation.
Article
Preoperative axial computerized tomography scans in 163 patients with renal cell carcinoma were reviewed to assess the predictive value for the diagnosis of regional lymph node metastases. Computerized tomography was falsely negative in 5 patients: 2 had metastatic lymph nodes in the renal hilus adjacent to the primary tumor measuring 2 and 2.5 cm., and 3 had micrometastases in nodes of less than 1 cm. In 43 patients enlarged lymph nodes with a diameter of 1 to 2.2 cm. (median 1.4 cm.) were diagnosed on the preoperative scan and this was confirmed at nephrectomy and pathologically. In 18 of these 43 patients (42%) histological study showed metastases of the renal cell carcinoma in the enlarged lymph nodes. In the other 25 patients (58%) the enlarged nodes showed only inflammatory changes and/or follicular hyperplasia. This finding was significantly more frequent in patients with tumor involvement of the renal vein and tumor necrosis (p = 0.0044). We conclude that the sensitivity of preoperative computerized tomography is good for the detection of enlarged lymph nodes in patients with renal cell cancer (95%). However, significant lymph node enlargement frequently may be caused by inflammatory changes, especially in the presence of tumor necrosis. This radiological finding should not be misinterpreted as metastatic disease, unless it has been proved cytologically by fine needle aspiration.
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The purpose of the study documented in this article was to reevaluate the prognostic value of tumor size, cytologic grading, and histologic pattern in patients with renal carcinoma. One hundred and eighty-six renal carcinomas were histologically graded. In 175 cases clinical follow-up information was obtained. It was found that for 5 years of survival there are essentially two prognostic groups. The first group includes tumors with solid patterns and clear cells, tumors with granular cells without field, and tumors with a papillary pattern or oncocytic cells. This group has a much better than the second group of tumors, which have either a large number of granular cells with field or a sarcomatoid or stratified pattern. It was also observed that for prognostic evaluation the histologic pattern was a better parameter than size and cytologic grading.
Article
Morphologic parameters were correlated with survival in 121 renal cortical neoplasms including 116 carcinomas and five oncocytomas. An increasing nuclear grade was generally correlated with a significant decrease in disease-free survival although no statistical difference was found between nuclear Grade 1 and 2 tumors. Similarly, a higher stage at diagnosis predicted a shorter disease-free survival. Renal vein invasion adversely affected prognosis only for high nuclear grade carcinomas. Papillary and spindled carcinomas, independent of nuclear grade, were associated with a significant decrease in disease-free survival compared to tumors with a solid pattern. Patients with large neoplasms (greater than 10 cm) had a significantly worse disease-free survival than patients with tumors 10 cm or less. The prognostic significance of tumor cell type is less clear. Patients with oncocytomas had the best disease-free survival compared with patients with tumors of other cell types. However, the difference in survival was not statistically significant for low-grade tumors, suggesting that nuclear grade rather than cell type may be the more important determinant.
Article
From July 2, 1971 to April 1, 1985, 47 patients (median age 63 years) with renal cell cancer extending into the renal vein or inferior vena cava were evaluated and treated. Two-thirds of the tumors occurred in men and three-fourths were found in the right kidney. Of the 44 patients operated on 35 had no evidence of preoperative metastatic disease at operation. The patients were divided into ideal, favorable and unfavorable subgroups. The adjusted 5 and 10-year survival rates in the former 2 groups (32 patients) were 68.8 and 60.2 per cent, respectively. In contrast, 12 patients with nodal involvement or metastases had an adjusted median survival time of 1.2 years with no survival extending beyond 4.8 years. We believe that an extended operation for renal cell cancer with involvement of the vena cava is warranted and provides reasonable long-term survival in properly selected patients.
Article
Three hundred twenty-six patients treated at New York University from 1970 to 1982 were studied for survival in relationship to surgical stage, type of therapy, and pathologic characterization of the primary tumor. At the time of diagnosis 25.5 per cent of tumors were Stage I, 15 per cent Stage II, 28.5 per cent Stage III, and 31 per cent Stage IV. The retrospective study showed that patients with tumor confined within the capsule achieved the highest five- and ten-year survivals of 88 per cent and 66 per cent, respectively. Survivals decreased as tumor invaded perirenal fat (67% and 35%) or regional lymph nodes (17% and 5%). Tumor invasion into the renal vein alone did not significantly change five-year survival (84%) but lowered ten-year survival to 45 per cent. Patients with metastases at the time of nephrectomy did poorly regardless of site of metastases or kind of adjuvant therapy, except for those managed by surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis, e.g., size below 5 cm in diameter, lack of invasion of collecting system, perirenal fat or regional lymph nodes, and predominance of clear or granular cells growing into a recognizable histologic pattern.
Article
The records of 24 patients with renal cell carcinoma involving the inferior vena cava who were free of metastatic disease at presentation were reviewed retrospectively. The over-all 2-year survival for the group was 45.8 per cent, with a mean survival of 38.9 months. When the group was analyzed according to the level of extension of the vena caval thrombus marked differences in the rate of survival and of incidence of local progression of disease were found. The 10 patients with an infrahepatic vena caval thrombus had a 2-year survival rate of 80 per cent and a mean survival of 61.4 months. Two patients (20 per cent) had extension of tumor into the perinephric fat and none had involvement of the regional lymph nodes. The 14 patients with a vena caval thrombus extending to the level of the hepatic veins or beyond had a 2-year survival rate of 21 per cent and a mean survival of 22.9 months. Tumor was present in the regional lymph nodes and/or perinephric fat in 9 of these patients (64 per cent). These results suggest that the level of vena caval involvement by tumor thrombus in patients with renal cell carcinoma has prognostic significance.
Article
Of 426 operatively removed renal cell carcinomas, macroscopic vein invasion was proven in 197 cases, i.e. 46.2%. The inferior vena cava contained tumor in 4.0%, the trunk of the renal vein in 24.4%, and in 18.1% only the major branches of the renal vein were found invaded. In 132 patients (31.0%) with tumor-free major renal branches, vein invasion could be demonstrated histologically. Statistically significant correlations could be found comparing renal vein invasion and other pathological parameters as histological grade, tumor diameter, local spread and lymphatic metastases. Proof of renal vein invasion affects prognosis: age-corrected 5-year survival rates amounted to 33.6 +/- 8.5% in macroscopically determined vein invasion; 62.3 +/- 11.9% in histologically determined vein invasion, and 89.0 +/- 10.3% without vein invasion. Vein invasion should be subdivided into an only histological and a macroscopical group of evidence, because significantly different survival rates will result. Therefore, an exact definition of the UICC classification criteria and a standardized usage are necessary and should be kept in mind for the next issue of the UICC classifications.
Article
Of 18 patients with renal cell carcinoma extending into the inferior vena cava 16 underwent radical nephrectomy with either venacavotomy and tumor thrombectomy or vena cava resection. Of 8 patients with no evidence of metastasis at the time of surgery 4 (50 per cent) are free of cancer for a mean duration of 93 months. Of 8 patients with known preoperative metastasis 7 died with cancer after a mean survival of 12 months. Operative mortality was 6.2 per cent and morbidity was minimal.
Article
The prognostic significance of morphologic parameters was evaluated in 103 patients with renal cell carcinoma diagnosed during 1961--1974. Pathologic material was classified as to pathologic stage, tumor size, cell arrangement, cell type and nuclear grade. Four nuclear grades (1--4) were defined in order of increasing nuclear size, irregularity and nucleolar prominence. Nuclear grade was more effective than each of the other parameters in predicting development of distant metastasis following nephrectomy. Among 45 patients who presented in Stage I, tumors classified as nuclear grade 1 did not metastasize for at least 5 years, whereas 50% of the higher grade tumors did so. Moreover, among Stage I tumors there was a significant difference in subsequent metastatic rate between nuclear grades 1 and 2. There was an apparent positive relationship between cell type and metastatic rate; clear cell tumors were less aggressive than predominantly granular cell tumors (metastatic rate 38% versus 71%). This relationship in part a function of the nuclear grade: only 5% of grade 3 and 4 tumors consisted of clear cells, whereas such high grades were seen in 57% of granular cell tumors. The size of the primary correlated well with the stage at the time of surgery. However, with the exception of extremely large and small tumors, the size was not useful in predicting the subsequent course of patients treated for Stage I tumors. Nuclear grade was the most significant prognostic criterion for the outcome of Stage I renal cell carcinoma.
Article
Survival rates and various prognostic factors were studied in 89 patients between 20 and 40 years old who underwent nephrectomy for renal adenocarcinoma between 1950 and 1978. Although rare, renal carcinoma in young adults seems to follow a course similar to the disease seen in older patients. Among 18 suspected prognostic factors 2 are strongly and independently associated with survival. These are the pathologic stage of the tumor and preoperative weight loss. Several other prognostic variables show a statistically significant association with survival. These include the presence of preoperative fever, duration of symptoms, tumor cell type, microhematuria on admission to the hospital, tumor grade and sex. However, advanced statistical techniques demonstrate that the association of these variables with survival can be accounted for mostly by their close correlation with the stage of the tumor. Certain variables show no prognostic significance. These included the diameter of the tumor, age of the patient, presence or absence of gross hematuria, flank pain, palpable mass, arterial hypertension, sedimentation rate and side or site of the tumor.
Article
A series of 88 cases of renal cell carcinoma treated by radical nephrectomy is presented showing a statistically significant improvement in the 3,5 and 10-year survival rates. This increased survival rate is due to 3 factors: 1) early ligation of the renal artery and vein, 2) complete removal of the perinephric envelope and 3) surgical extirpation of the lymphatic field. Prognosis is directly related to the stage and grade of the tumor. Some ancillary aids in the preoperative prognostic evaluation of the tumor are suggested and discussed.
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