Factors Affecting Survival After Surgery for Locally Advanced RCC
Asymptomatic presentation, T3 low-grade tumors, and negative lymph nodes are associated with better progression-free and overall survival.
Patients who have no symptoms at presentation with T3 low-grade tumors and negative lymph nodes experience favorable survival following resection of locally-advanced, non-metastatic renal cell carcinoma (RCC), a recent retrospective study finds.
Investigators led by Paul Russo, MD, a urologic oncology surgeon at Memorial Sloan Kettering Cancer Center in New York, reviewed the medical records of 802 patients at the center who had nephrectomy (74% radical nephrectomy, 26% partial nephrectomy) for non-metastatic stage T3 or T4 RCC from 1989 to 2012. Most had open surgery with or without adrenalectomy or lymphadenectomy. The researchers focused on survival following surgical management of the disease, excluding patients receiving adjuvant treatment.
RCC progressed in 189 patients and 104 patients died from the disease, according to results published in the Journal of Urology (2015;193:1911-1917). The researchers determined that the following factors were significantly linked to progression-free and overall survival: symptoms at presentation, American Society of Anethesiologists (ASA) classification, tumor stage, histological subtype, grade, and lymph node status.
The overall 10-year progression-free survival (PFS) rate among patients with clear-cell RCC was 65%, but it differed by AJCC tumor classifications. The PFS rate was 72% in patients with T3 tumors compared with 23% in those with T4 tumors. The 10-year PFS rate was 76% for patients with low-grade clear-cell tumors compared with 55% for patients with high-grade clear-cell tumors.
A high ASA classification was associated not only with worse overall survival but also with disease progression. “Many mechanisms have been proposed for this observation, including a proneoplastic state due to chronic immunosuppression related to renal failure associated uremia,” the investigators suggested.
Compared with patients who had T3 tumors, those who had T4 tumors had a 2.7 times increased risk of disease progression and a 3.4 times increased risk of death, in multivariable analysis. Patients who had local or systemic symptoms at presentation had a 2.3 times and 1.6 times increased risk of progression and death, respectively. Patients with positive lymph nodes had a 3.1 times and 1.5 times increased risk of progression and death compared with patients who had negative lymph nodes. Patients with high-grade tumors had a 62% and 48% increased risk of progression and death compared with those who had low-grade tumors.
The researchers also highlighted a trend toward “more selective use” of adrenalectomy over the years. “Our current practice is to perform adrenalectomy for bulky tumors and in patients with radiographic or intraoperative evidence of adrenal involvement,” they stated. Use of lymphadenectomy increased, especially among younger patients and those with large tumors.