21 research outputs found
1076 Independent validation of the 2010 TNM staging system for renal cell carcinoma : does it improves predictive accuracy in cancer-specific mortality compared to 2002 TNM?
No full textINTRODUCTION AND OBJECTIVES
The 2009 TNM staging system provided several changes in pT classification: pT2 stage is splitted in pT2a (10 cm); patients with tumor thrombus invading the renal vein are classified as pT3a; infiltration of the wall of the vena cava as pT3c; direct invasion of the adrenal gland is inserted in pT4 stage. Moreover all nodal involvement is classified as pN1. We aimed to analyze wether the new TNM staging system is more accurate than the 2002 TNM classification in predicting the risk of cancer-specific mortality (CSM).
GoMETHODS
We retrospectively analyzed data of 14040 consecutive patients who underwent radical nephrectomy or nephron-sparing surgery for RCC, between 1987 and 2008. The Kaplan-Meier method and univariable and multivariable Cox regression analyses were used to determine the effect of the 2002 TNM and of the new TNM staging system on CSM. Finally, we compared the accuracy of the 2002 TNM and of the 2009 TNM staging system calculation the area under the ROC curve. Mantel-Haentzel test evaluated the differences in predictive accuracy between the two different classification.
GoRESULTS
Median follow-up was 63 months (2-290). According to 2002 TNM staging system, no difference was found in survival between pT3c and pT4 patients at univariable analyses. According to the 2009 TNM staging system, pT3c and pT4 patients showed similar survival. The predictive accuracy of pT 2002 and pT2009 was 73.7 and 73.9%, respectively, at univariable analysis. At multivariable Cox regression analysis, both 2002 pT and the new pT classification resulted as independent predictors of the risk of CSM, after adjusting for distant metastases and nodal involvement. Finally, the model including 2002 TNM and the new TNM staging system showed similar accuracy in predicting CSM (AUC= 80.5 vs 80.6%; p=0.89).
GoCONCLUSIONS
in the TNM 2009, the reclassification in pT2a and pT2b disease seems to really distinguish two groups of patients with different prognosis, as well as in case of pT3a, pT3b and pT3c subgroup of patients. However, no difference was found in CSM between pT3c and pT4 patients according to both 2002 and 2009 TNM classification. The new TNM staging system is an accurate tool to predict CSM, but does not improve accuracy in predicting patient outcomes with respect to the 2002 TNM staging system. Further improvement in patient risk stratification will be required
Prognostic effect of sarcomatoid dedifferentiation in patients with surgically treated renal cell carcinoma: a matched-pair analysis.
No full textThe aim of this study was to assess the prognostic relevance of SD in patients with RCC.Among 8126 RCC patients surgically treated at 12 academic centers (members of the Collaborative Research on Renal Neoplasms Association [CORONA] project), 316 patients (3.9\%) had SD with sarcomatoid areas comprising at least 10\% of the tumor tissue. After propensity score-based matched-pair analysis, 281 with and 281 matched RCC patients without SD remained available for direct comparison of cancer-specific survival (CSS). Median follow-up was 36.5 months (interquartile range, 15-82). Uni- and multivariable Cox proportional hazards regression analyses were performed to assess the prognostic value of parameters.In univariable analysis, there was no difference in CSS between patients with or without SD (1 and 5 years CSS, 79\% vs. 83\% and 59\% vs. 64\%, respectively; hazard ratio, 1.21; P = .16). Multivariable analysis in patients with SD identified metastatic dissemination at the time of surgery, pT-stage, nodal status, and tumor size as independent predictors of CSS. This study was limited by its retrospective multicenter design and lack of central histopathological review.Sarcomatoid dedifferentiation was not an independent predictor of CSS in surgically treated RCC patients in the present matched-pair series. Because pathology reports form the basis on which study specimens are selected for further studies, which are clearly needed to advance our understanding of the prognostic value of SD in RCC, it is imperative that pathologists reliably report on absence or presence and the estimated percentage of a coexisting sarcomatoid component
Evaluation of the prognostic significance of perirenal fat invasion and tumor size in patients with pT1-pT3a localized renal cell carcinoma in a comprehensive multicenter study of the CORONA project. Can we improve prognostic discrimination for patients with stage pT3a tumors?
No full textBackground The current TNM system for renal cell carcinoma (RCC) merges perirenal fat invasion (PFI) and renal vein invasion (RVI) as stage pT3a despite limited evidence concerning their prognostic equivalence. In addition, the prognostic value of PFI compared to pT1-pT2 tumors remains controversial. Objective To analyze the prognostic significance of PFI, RVI, and tumor size in pT1-pT3a RCC. Design, setting, and participants Data for 7384 pT1a-pT3a RCC patients were pooled from 12 centers. Patients were grouped according to stages and PFI/RVI presence as follows: pT1-2N0M0 (n = 6137; 83.1%), pT3aN0M0 + PFI (n = 1036; 14%), and pT3aN0M0 (RVI ± PFI; n = 211; 2.9%). Intervention Radical nephrectomy or nephron-sparing surgery (NSS) (1992-2010). Outcome measurements and statistical analysis Cancer-specific survival was estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional-hazards regression models, as well as sensitivity and discrimination analyses, were used to evaluate the impact of clinicopathologic parameters on cancer-specific mortality (CSM). Results and limitations Compared to stage pT1-2, patients with stage pT3a RCC were significantly more often male (59.4% vs 53.1%) and older (64.9 vs 62.1 yr), more often had clear cell RCC (85.2% vs 77.7%), Fuhrman grade 3-4 (29.4% vs 13.4%), and tumor size >7 cm (39.1% vs 13%), and underwent NSS less often (7.5% vs 36.6%; all p < 0.001). According to multivariate analysis, CSM was significantly higher for the PFI and RVI ± PFI groups compared to pT1-2 patients (hazard ratio [HR] 1.94 and 2.12, respectively; p < 0.001), whereas patients with PFI only and RVI ± PFI did not differ (HR 1.17; p = 0.316). Tumor size instead enhanced CSM by 7% per cm in stage pT3a (HR 1.07; p < 0.001) with a 7 cm cutoff yielding the highest prediction accuracy. Conclusions Since the prognostic impact of PFI and RVI on CSM seems to be comparable, merging both as stage pT3a RCC might be justified. Enhanced prognostic discrimination of stage pT3a RCC appears to be possible by applying a tumor size cutoff of 7 cm within an alternative staging system. Patient summary Prognosis prediction for patients with localized renal cell carcinoma up to stage pT3a can be enhanced by including tumor size with a cutoff of 7 cm as an additional parameter in the TNM classification system
Collecting system invasion and Fuhrman grade but not tumor size facilitate prognostic stratification of patients with pT2 renal cell carcinoma
No full textTumor size did not have a significant influence on cancer specific survival in pT2 tumors, neither continuously applied nor based on various cutoff values. To enhance prognostic discrimination, multifactorial staging systems including pathological features should be implemented. The prognostic relevance of the variable subsuming Fuhrman grade and collecting system invasion should be considered for future evaluation
Do we need new high-risk criteria for surgically treated renal cancer patients to improve the outcome of future clinical trials in the adjuvant setting? : results of a comprehensive analysis based on the multicenter CORONA database
No full textBackground: Since there is still an unmet need for potent adjuvant strategies for renal cancer patients with high progression risk after surgery, several targeted therapies are currently evaluated in this setting. We analyzed whether inclusion criteria of contemporary trials (ARISER, ASSURE, SORCE, EVEREST, PROTECT, S-TRAC, ATLAS) correctly identify high-risk patients.
Methods: The study group comprised 8873 patients of the international CORONA-database after surgery for non-metastatic renal cancer without any adjuvant treatment. Patients were divided into potentially eligible high-risk and assumable low-risk patients who didn't meet inclusion criteria of contemporary adjuvant clinical trials. The ability of various inclusion criteria for disease-free survival (DFS) prediction was evaluated by Harrell's c-index.
Results: During a median follow-up of 53 months 15.2% of patients experienced recurrence (5-year-DFS 84%). By application of trial inclusion criteria, 24% (S-TRAC) to 47% (SORCE) of patients would have been eligible for enrollment. Actual recurrence rates of eligible patients ranged between 29% (SORCE) and 37% (S-TRAC) opposed to <10% in excluded patients. Highest Hazard Ratio for selection criteria was proven for the SORCE-trial (HR 6.42; p < 0.001), while ASSURE and EVEREST reached the highest c-index for DFS prediction (both 0.73). In a separate multivariate Cox-model, two risk-groups were identified with a maximum difference in 5-year-DFS (94% vs. 61%).
Conclusion: Results of contemporary adjuvant clinical trials will not be comparable as inclusion criteria differ significantly. Risk assessment according to our model might improve patient selection in clinical trials by defining a high-risk group (28% of all patients) with a 5 year-recurrence rate of almost 40%
Impact of clinical and histopathological parameters on disease specific survival in patients with collecting duct renal cell carcinoma: Development of a disease specific risk model
No full textPurpose: Collecting duct renal cell carcinoma is a rare, aggressive histological subtype of renal cell carcinoma. Since few groups have evaluated the oncological prognosis in these patients based on clinical and pathological parameters, we assessed parameters prognostic for disease specific mortality.
Materials and Methods: From a cohort of 14,047 patients with renal cell carcinoma we retrieved the records of 95 with collecting duct renal cell carcinoma at a total of 16 European and American centers of the CORONA (Collaborative Research on Renal Neoplasms Association) and SATURN (Surveillance and Treatment Update Renal Neoplasms) projects, and another 2 centers. Multivariable Cox regression analysis was applied to determine the influence of parameters on disease specific mortality. Median followup was 48.1 months (IQR 24-103).
Results: The disease specific survival rate at 1, 2, 5 and 10 years was 60.4%, 47.3%, 40.3% and 32.8%, respectively. American Society of Anesthesiologists (ASA) score 3-4, tumor size greater than 7 cm, stage M1, Fuhrman grade 3-4 and lymphovascular invasion independently predicted disease specific mortality. Based on these parameters, patients were divided into 26 (27%) at low, 13 (14%) at intermediate and 56 (59%) at high risk with a 5-year disease specific survival rate of 96%, 62% and 8%, respectively (bootstrap corrected c-index 0.894, 95% CI 0.820-0.967, p < 0.001).
Conclusions: While patients with collecting duct renal cell carcinoma are commonly diagnosed at advanced stage and have poor prognosis after surgery, a subset has excellent survival. Histopathological features can help risk stratify patients based on the described, highly accurate risk model to predict disease specific mortality, facilitating patient counseling and risk based clinical decision making for adjuvant therapy and clinical trial inclusion
Assessing the accuracy and generalizability of the preoperative and postoperative Karakiewicz nomograms for renal cell carcinoma: results from a multicentre European and US study.
No full textTo assess the accuracy and generalizability of the pre- and postoperative Karakiewicz nomograms for predicting cancer-specific survival (CSS) in patients with renal cell carcinoma (RCC). This retrospective study included 3231 patients from European and US centres, who were treated by radical or partial nephrectomy for RCC between 1992 and 2010. Prognostic scores for each patient were calculated and the primary endpoint was CSS. Discriminating ability was assessed by Harrell's c-index for censored data. The 'validation by calibration' method proposed by Van Houwelingen was used for checking the calibration of covariate effects. Calibration was graphically explored. Local and systemic symptoms were present in 23.2% and 9.1% of the patients, respectively. The median follow-up (FU) was 49 months. At the last FU, 408 cancer-related deaths were recorded, Kaplan-Meier estimates of CSS (with 95% confidence intervals [CIs]) at 5 and 10 years were 0.86 (0.84-0.87) and 0.77 (0.75-0.80), respectively. Both nomograms discriminated well. Stratified c-indices for CSS were 0.784 (95% CI 0.753-0.814) for the preoperative nomogram, and 0.842 (95% CI 0.816-0.867) for the postoperative one, with a significant difference between the two values (P < 0.001). The covariate-based predictions on our data for both nomograms were valid. The calibration plots showed no relevant departures from ideal predictions. The results suggest that the postoperative Karakiewicz nomogram discriminates substantially better than the preoperative one. These nomogram-based predictions may be used as benchmark data for pretreatment and postoperative decision-making in patients at various stages of RCC. © 2013 BJU International
Impact of clinical and histopathological parameters on disease specific survival in patients with collecting duct renal cell carcinoma: development of a disease specific risk model
No full textPURPOSE:
Collecting duct renal cell carcinoma is a rare, aggressive histological subtype of renal cell carcinoma. Since few groups have evaluated the oncological prognosis in these patients based on clinical and pathological parameters, we assessed parameters prognostic for disease specific mortality.
MATERIALS AND METHODS:
From a cohort of 14,047 patients with renal cell carcinoma we retrieved the records of 95 with collecting duct renal cell carcinoma at a total of 16 European and American centers of the CORONA (Collaborative Research on Renal Neoplasms Association) and SATURN (Surveillance and Treatment Update Renal Neoplasms) projects, and another 2 centers. Multivariable Cox regression analysis was applied to determine the influence of parameters on disease specific mortality. Median followup was 48.1 months (IQR 24-103).
RESULTS:
The disease specific survival rate at 1, 2, 5 and 10 years was 60.4%, 47.3%, 40.3% and 32.8%, respectively. American Society of Anesthesiologists (ASA) score 3-4, tumor size greater than 7 cm, stage M1, Fuhrman grade 3-4 and lymphovascular invasion independently predicted disease specific mortality. Based on these parameters, patients were divided into 26 (27%) at low, 13 (14%) at intermediate and 56 (59%) at high risk with a 5-year disease specific survival rate of 96%, 62% and 8%, respectively (bootstrap corrected c-index 0.894, 95% CI 0.820-0.967, p <0.001).
CONCLUSIONS:
While patients with collecting duct renal cell carcinoma are commonly diagnosed at advanced stage and have poor prognosis after surgery, a subset has excellent survival. Histopathological features can help risk stratify patients based on the described, highly accurate risk model to predict disease specific mortality, facilitating patient counseling and risk based clinical decision making for adjuvant therapy and clinical trial inclusion
