Reassessment of American Joint Committee on Cancer Staging for Stage III Renal Cell Carcinoma With Nodal Involvement: Propensity Score Matched Analyses of a Large Population-Based Study

Abstract

Background: To assess the role of nodal involvement in stage III renal cell carcinoma (RCC) according to the American Joint Committee on Cancer (AJCC) 8th staging system. We compared the survival outcomes of RCC patients with pT 1−3 N 1 M 0 disease and those with pT 3 N 0 M 0 or stage IV (stratified as pT 4 N any M 0 and pT any N any M 1) disease in a large population-based cohort. Methods: A cohort of 3,112 eligible patients with RCC was identified from the Surveillance, Epidemiology, and End Results (SEER) database, registered between January 2004 and December 2015. Kaplan-Meier and Cox proportional hazards models were used to evaluate the overall survival (OS), and cancer-specific survival (CSS). The prognostic value of the modified stage for pT 1−3 N 1 M 0 disease was assessed by nomogram-based analyses. Propensity score matching (PSM) was used to adjust for potential baseline confounding. Results: Patients with pT 1−3 N 1 M 0 disease showed similar survival outcomes (median OS 41.0 vs. 38.0 months, P = 0.77; CSS 45.0 vs. 39.0 months, P = 0.59) to pT 4 N any M 0 patients, whereas the significantly better survival outcome was found for pT 3 N 0 M 0 patients. After PSM, comparable survival rates were observed between pT 1−3 N 1 M 0 group and pT 4 N any M 0 group, which were still significantly worse than the survival of pT 3 N 0 M 0 patients. The modified stage IIIA (pT 3 N 0 M 0), IIIB (pT 1−3 N 1 M 0 , pT 4 N any M 0), and IV (pT any N any M 1) showed higher predictive accuracy than AJCC stage system in the nomogram-based analyses (concordance index: 0.70 vs. 0.68, P < 0.001 for OS; 0.71 vs. 0.69, P < 0.001 for CSS). Conclusions: The pT 1−3 N 1 M 0 RCC might be reclassified as stage IIIB together with pT 4 N any M 0 disease for better prediction of prognosis, further examination and validation are warranted.

To Be or “Node” to Be: Nodal Disease and the Role of Lymphadenectomy in the Treatment of Renal Cell Carcinoma

“…Furthermore, LND provides important staging, prognostic, and counseling value, which based on recent studies has drastic survival outcomes. 3,29,30 The onus of creating a more accurate TNM staging system will need to be a multidisciplinary effort in order to provide physicians with reliable information for counseling patients and accurately stratifying patients within clinical trials and standard of care practice.…”

“…Like Yu et al, our data shows that Stage III node-positive disease (22.7%; 95% CI: 20.6%-24.9%) and Stage IV RCC patients and (15.6%; 95% CI: 11.1%-23.8%) have similar 5-year survival rates. Recently, Han et al used the Surveillance, Epidemiology, and End Results (SEER)database performed a similar analysis to compare survival outcomes for patients with pT1-3N1M0 to pT3N0M0 and pT1-3N0M1 RCC 30. Using propensity score matching to adjust for baseline confounders, patients with Stage III nodal-positive had similar OS and cancer-specific survival (CSS) to patients with Stage IV disease (median OS 41.0 vs. 38.0 months, p=0.77; CSS 45.0 vs. 39.0 months, p=0.59).…”

Role of lymphadenectomy during primary surgery for kidney cancer

“…Srivastava et al analyzed 8988 patients with RCC who underwent RN and retroperitoneal LND and showed that pN1 stage III disease was inferior to pN0 stage III and was similar to stage IV disease with respect to OS [41]. Similarly, several studies have also shown that stage III disease patients had similar survival estimates, such as OS and CSS than stage IV patients [42,43].…”