Survival rates after resection for localized kidney cancer: 1989 to 2004

Abstract

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.

Onco-Nephrology

“…Despite equivalent cancer outcomes with reduced morbidity and possibly, mortality of partial nephrectomy, unnecessary radical nephrectomies are still being performed. In tertiary care centers, 30%-65% of solitary cortical tumors are resected by partial nephrectomy; however, partial nephrectomy is used only 7% of the time for the same tumors in the community (10,11). One explanation advanced for this troubling trend is that surgeons have converted from open to laparoscopic radical nephrectomies rather than from open radical nephrectomies to partial nephrectomies (12).…”

Intraoperative Conversion From Partial to Radical Nephrectomy at a Single Institution From 2003 to 2008

“…6,7 Although renal function is maximally preserved by PN, patients scheduled for PN are at risk for intraoperative conversion to RN, which places them at risk for CKD and its complications. Careful patient selection is required to identify those who will benefit from surgical intervention vs those who can be observed and avoid the risks of surgery.…”

Radiation therapy following targeted therapy in oligometastatic renal cell carcinoma

“…Over the past decade, research on RCC treatment has been focused on the development and implementation of targeted drugs (16), including TKIs, monoclonal antibodies and mammalian target of rapamycin inhibitors. These drugs have significantly changed the management of RCC and prolonged progression-free survival (17).…”