Solidifying prognosis after surgery for renal cell carcinoma.

Abstract

Dason and colleagues from Dublin, Ireland have added an interesting series to the canon of nephrectomy outcomes, and have further validated and solidified the prognostic implications of stage, grade and histology in renal cell carcinoma (RCC). 1 Newer series such as this one have renewed value in that they may provide a window into RCC outcomes in an era when the peculiarities of the small renal mass (SRM) have gained prominence. 2 The increasing incidence of RCC, attributed in large part to increased abdominal imaging, has typically accompanied a downward stage migration, with smaller incident masses and the expectation of lower stage and grade. Surgical series of SRM pathology have confirmed that a decreasing size of tumour is associated with increased benign diagnosis, and lower markers of aggressiveness. 3 These expectations are not met here, as the increasing surgical volume is accompanied by unchanged tumour size and stage, while grade decreased as might be expected. This finding stirs the mind into seeking a biological rationale to explain it, and indeed the authors concede that reasons are not particularly obvious. The tertiary care environment may play a role here, as referral patterns might distill more challenging cases toward these centres, while smaller or more favourable masses are handled outside. The preponderance of SRMs has also paralleled the introduction of thermal ablation techniques, active surveillance and watchful waiting due to competing risks, so smaller or more indolent-behaving masses may be