BACKGROUND Mortality rates from kidney cancer have continued to rise despite increases in the detection of smaller renal tumors and rates of renal operations. To explore factors associated with this treatment-outcome discrepancy, we evaluated how changes in tumor size have affected disease progression in patients following nephrectomy for localized kidney cancer. Furthermore, we sought to identify factors that are associated with disease progression and overall patient survival following resection for localized kidney cancer. METHODS We identified 1,618 patients with localized kidney cancer treated by nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) from 1989 to 2004. Patients were categorized by year of operation: 1989–1992, 1993–1996, 1997–2000, and 2001–2004. Tumor size was classified according to the following strata: <2 cm, 2 to 4 cm, 4 to 7 cm, and >7 cm. Progression was defined as the development of local recurrence or distant metastases. Five-year progression-free survival (PFS) was calculated for patients in each tumor size strata, according to year of operation, using the Kaplan-Meier method. Patient, tumor, and surgery related characteristics associated with PFS and overall survival (OS) were explored using univariable analysis and all significant variables were retained in a multivariable Cox regression analysis. RESULTS Overall, the number of nephrectomies increased for all tumor size categories from 1989 to 2004. A tumor size migration was evident during this period, as the proportion of patients with tumors <2 cm and 2 to 4 cm increased while those with tumors >7 cm decreased. 179 patients (11%) developed disease progression after nephrectomy. Local recurrence occurred in 16 (1%) and distant metastases in 163 (10%). When 5-year PFS was calculated for each tumor size strata according to 4-year cohorts, trends in PFS did not improve nor differ significantly over time. Compared to historical cohorts, patients in more contemporary cohorts were more likely to undergo partial, as opposed to radical, nephrectomy and less likely to have a concomitant lymph node dissection and adrenalectomy. Multivariable analysis showed that pathologic stage and tumor grade were associated with disease progression while patient age and tumor stage were associated with overall patient survival. CONCLUSIONS Despite an increasing number of nephrectomies and a size migration towards smaller tumors, trends in 5-year PFS and OS did not improve nor differ significantly over time. These findings require further research to identify causative mechanisms and argue for a re-evaluation of the current treatment paradigm of surgically removing solid renal masses upon initial detection and consideration of active surveillance for patients with select renal tumors.

OBJECTIVE To examine the effect of radical nephrectomy (RN) with adjacent organ and structure resection on survival, as invasion of adjacent organs in patients with renal cell carcinoma (RCC) is rare. PATIENTS AND METHODS After institutional review board approval, we reviewed our database and statistically analysed of patients with pathological stage T3 or T4 RCC who had RN and resection of a contiguous organ or structure. RESULTS We identified 38 patients of 2464 (1.5%) who had RN with adjacent organ or structure resection. The median (interquartile range) size of the mass was 11 (8–14) cm, and the follow‐up 13 (5–33) months. Most patients (68%) were pT4 stage and had conventional clear cell carcinoma (95%). Fourteen patients (37%) had positive surgical margins. The liver (10) was the most commonly resected adjacent organ or structure. Only one patient remains alive with no evidence of disease at 5 years, while three are currently alive with disease. Overall, 34 of 38 patients (90%) ultimately died from disease at a median (range) of 11.7 (5.4–29.2) months after surgical resection. The surgical margin status was the only statistically significant factor for recurrence and death (P = 0.006). CONCLUSIONS The prognosis for patients with advanced RCC and adjacent organ or structure involvement is extremely poor and similar to that of patients with metastatic disease. These patients should be thoroughly counselled about the impact of surgical management and considered for entry into neoadjuvant or adjuvant clinical trials with new targeted systemic agents.

With the widespread use of abdominal imaging, there has been a substantial increase in the detection of incidental, small renal masses. This change has resulted in a downward trend in the size and stage of tumors being detected, and a corresponding increase in the number of renal cortical tumors amenable to partial nephrectomy. Based solely on a size criterion of 7 cm or less (pT1), nearly 70% of all patients with newly diagnosed kidney tumors are eligible for partial nephrectomy. Here, we briefly review the current rationale for partial nephrectomy and provide insight into advances in the technique of open partial nephrectomy. In addition to describing in detail the surgical techniques used at our institution, we also report the outcomes of our series of open partial nephrectomies performed via a mini-flank incision above the 11th rib. We believe that this approach offers a safe, practical and easily adoptable alternative to traditional open partial nephrectomy and laparoscopic partial nephrectomy.

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