RESUMEN
PURPOSE: We determined clinical and pathological predictors of positive bone scans and computerized tomography (CT) in patients with biochemical recurrence after radical prostatectomy (RP). MATERIALS AND METHODS: A retrospective analysis of patients treated with RP at West Los Angeles Veterans Affairs Medical Center and University of California-Los Angeles Medical Center was performed to identify men with biochemical recurrence. All postoperative bone scans and pelvic CT following recurrence and prior to the initiation of hormone ablation therapy were reviewed. Preoperative clinical variables, pathological findings, serum prostate specific antigen (PSA) at postoperative imaging and postoperative PSA doubling time were compared between patients with positive and negative imaging study results. RESULTS: A total of 128 patients with biochemical recurrence after RP who had postoperative pelvic CT or bone scans available were identified. A total of 97 bone scans were obtained, of which 11 (11%) were positive, and 71 CT scans were obtained, of which 5 (7%) were positive. Men with PSA doubling time less than 6 months were at increased risk of a positive bone scan (26% vs 3%) or positive CT (24% vs 0%) relative to men with longer PSA doubling time. In men with PSA doubling time less than 6 months the risk of a positive study highly depended on PSA at the time of imaging. In men with PSA less than 10 ng/ml the incidence of a positive study was 0% for pelvic CT and 11% for bone scan. In men with PSA greater than 10 ng/ml the risk of a positive study was 57% for pelvic CT and 46% for bone scan. In men with PSA doubling time greater than 6 months no clear relationship to PSA was seen, although the number of patients with a positive study was extremely low (positive bone scans 3% and positive CT 0%). However, none of the 6 imaging studies performed in men with PSA doubling times greater than 6 months and a markedly elevated PSA of 20 to 90 ng/ml was positive. CONCLUSIONS: The risk of detecting metastatic disease by bone scan or pelvic CT in men with biochemical recurrence following RP with PSA doubling time greater than 6 months is low despite marked PSA increases up to 90 ng/ml. In men with PSA doubling time less than 6 months the risk of detecting metastatic disease markedly increases when PSA is greater than 10 ng/ml. These results have important implications for the timing of imaging in patients with biochemical recurrence following RP.
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Neoplasias Óseas/diagnóstico , Neoplasias Óseas/secundario , Antígeno Prostático Específico/sangre , Prostatectomía , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/patología , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Próstata/cirugía , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Insuficiencia del TratamientoRESUMEN
PURPOSE: We outline the biology, prognosis and role of immunotherapy for renal cell carcinoma with gross venous tumor thrombus. MATERIALS AND METHODS: A total of 207 patients with unilateral renal cell carcinoma and tumor thrombus into the renal vein (107) and inferior vena cava (100) who underwent nephrectomy and thrombectomy were compared with 607 without tumor thrombus. RESULTS: At diagnosis 77 patients (37%) had N0M0 disease and 130 (63%) had lymph node (N+) or distant (M1) metastases. Compared with nontumor thrombus cases tumor thrombus was associated with more advanced stage, N+ (26% versus 12%), M1 (54% versus 31%) disease, higher grade and Eastern Cooperative Oncology Group performance status. In N0M0 cases with inferior vena caval tumor thrombus capsular penetration, collecting system invasion and extension into the hepatic vein were more important prognostic variables then the level of inferior vena caval thrombus. In patients with confined N0M0 tumors mean 2 and 5-year survival +/- SD was 83% +/- 8.8% and 72% +/- 10.7% in those with inferior vena caval tumor thrombus, and 90% +/- 9.4% and 68% +/- 16.1% in those with renal vein tumor thrombus, similar to the 93.4% +/- 1.7% and 81 +/- 3.1% rates, respectively, in those without thrombus who had no recurrence within 6 months after nephrectomy. Of patients with M1 disease in whom cytoreductive surgery was done those with and without thrombus showed a similar response to immunotherapy. When there was inferior vena caval and renal vein thrombus, mean 2-year survival was higher after nephrectomy and immunotherapy than after nephrectomy alone (41% +/- 9% and 52% +/- 7% versus 32% +/- 13% and 45% +/- 7%), immunotherapy alone (0% and 13% +/- 12%, respectively) and no treatment (0%). CONCLUSIONS: Renal cell carcinoma with tumor thrombus is associated with worse characteristics. Local tumor extension has greater prognostic importance than the level of inferior vena caval tumor thrombus. Survival is fair in patients with truly confined N0M0 disease and thrombus. The combination of surgery and immunotherapy has a role in thrombus cases. Our data provide the rationale for a prospective study of adjuvant immunotherapy after surgery in N0M0 cases with extensive tumor thrombus.
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Carcinoma de Células Renales/patología , Inmunoterapia , Neoplasias Renales/patología , Células Neoplásicas Circulantes , Nefrectomía , Venas Renales/patología , Vena Cava Inferior/patología , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/terapia , Venas Hepáticas/patología , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/terapia , Análisis Multivariante , Invasividad Neoplásica , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia , TrombectomíaRESUMEN
PURPOSE: We characterized the histopathological features and clinical behavior of unclassified renal cell carcinoma and compared the prognostic outcome in patients with unclassified and conventional (clear cell) renal cell carcinoma. MATERIALS AND METHODS: A total of 31 patients with unclassified renal cell carcinoma are included in the kidney cancer database at our institution. Another 317 matched patients with clear cell carcinoma were used for comparing demographic, clinical, pathological and survival data. RESULTS: The incidence of unclassified renal cell carcinoma was 2.9%. At initial diagnosis 29 patients (94%) with unclassified and 264 (83%) with clear cell renal cell carcinoma had metastatic disease (p = 0.143). Compared with the clear cell variety unclassified disease was associated with larger tumors (p = 0.005), increased risk of adrenal gland involvement (25% of cases, p = 0.0001), direct invasion to adjacent organs (42%, p = 0.00001), bone (52%, p = 0.022), regional (52%, p = 0.0042) and nonregional lymph node (41%, p = 0.03) metastases. Nephrectomy was less likely to be attempted or completed in unclassified renal cell carcinoma cases (61%, p = 0.00007). Unclassified histology was a significant indicator for poor prognosis on multivariate analysis (p <0.0001). Median survival in patients with unclassified renal cell carcinoma was 4.3 months. Nephrectomy alone did not confer any survival advantage in these cases (p = 0.1086), while immunotherapy did (p = 0.008). The combination of nephrectomy and immunotherapy yielded improved survival over immunotherapy alone (p = 0.0356) but patients with unclassified renal cell carcinoma were significantly less likely than those with clear cell disease to be eligible for immunotherapy regimens (p = 0.05). CONCLUSIONS: Unclassified renal cell carcinoma is associated with distinct and highly aggressive biological behavior, and poor clinical outcome. Whenever feasible, immunotherapy with nephrectomy is warranted.
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Carcinoma de Células Renales/patología , Neoplasias Renales/patología , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales/clasificación , Carcinoma de Células Renales/secundario , Carcinoma de Células Renales/terapia , Femenino , Humanos , Inmunoterapia , Neoplasias Renales/clasificación , Neoplasias Renales/terapia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Invasividad Neoplásica , Nefrectomía , PronósticoRESUMEN
PURPOSE: We examined whether cytoreductive nephrectomy in patients with venous tumor thrombus and metastatic disease is associated with more complications than in those with thrombus without metastatic disease. MATERIALS AND METHODS: Between 1989 and 2000, 74 patients with renal vein extension, 87 with inferior vena caval extension and 491 without tumor thrombus underwent nephrectomy at our institution. Metastatic and nonmetastatic renal vein extension in 51 and 23 cases, inferior vena caval extension in 54 and 33, and nontumor thrombus in 171 and 320, respectively, were compared for symptoms at presentation, surgical data, mortality and complications. RESULTS: For nonmetastatic and metastatic inferior vena caval extension presenting symptoms, hospital stay, surgical time and the number of patients undergoing thoraco-abdominal incision, lymph node dissection, venacavotomy alone for thrombus and adrenal sparing surgery were similar. Five patients with thrombus died intraoperatively or postoperatively, including 3.1% with and 0.8% without thrombus (p = 0.03), while 3 had metastatic (2.3%) and 2 (2.6%) had nonmetastatic disease. The rate of postoperative complications was higher in thrombus cases overall but there was no difference in nonmetastatic and metastatic disease with thrombus. On multivariate analysis inferior vena caval thrombus (odds ratio 10.5), adjacent organ resection due to locally advanced tumor (odds ratio 6), partial nephrectomy (odds ratio 3.8), regional lymph node involvement (odds ratio 1.7) and lower preoperative hemoglobin (odds ratio 1.6) were independent variables predicting bleeding requiring transfusion. Inferior vena caval thrombus (odds ratio 1.7) and adjacent organ resection (odds ratio 2) were also associated with nonhemorrhagic complications. Systemic metastasis was not an independent risk factor in either analysis. CONCLUSIONS: To our knowledge there are no published data comparing surgical complications in patients with metastatic and nonmetastatic renal cell carcinoma who have gross tumor thrombus. Cytoreductive surgery in patients with thrombus and metastasis is not associated with an increase in the extent of surgery, morbidity or mortality compared with their counterparts with nonmetastatic disease.