Adrenal Invasion Research Articles

Preoperative Computed Tomography Imaging Accurately Identifies Adrenal Gland Involvement In Patients With Renal Masses

ObjectiveTo determine the frequency of adrenal gland involvement (AGI) in patients with renal cell carcinoma (RCC) and assess the ability of preoperative computed tomography (CT) imaging to predict AGI prior to radical nephrectomy (RN). MethodsWe retrospectively identified 90 patients who underwent RN with concomitant ipsilateral adrenalectomy (CIA) between 2019 and 2021 at our institution. We reviewed the preoperative CT findings and final pathology reports to assess AGI and determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative CT imaging. ResultsFive patients (5.5%) had AGI on pathological analysis. On preoperative CT, eight patients had CT findings suspicious of AGI. All five patients with pathological AGI were identified preoperatively yielding a sensitivity of 100%. Pathological analysis in all patients who did not demonstrate AGI on imaging showed no adrenal invasion, yielding a negative predictive value of 100%. High-grade tumors were significantly associated with AGI (84.4% vs. 33.6%, p = 0.02). Patients with AGI had larger tumor size when compared with those without AGI on final pathology (10 cm vs. 6.89 cm, p = 0.07). ConclusionsThe overall incidence of AGI in patients with RCC is low. Preoperative CT can accurately identify those with AGI and can thus prevent unnecessary CIA during RN.

Laparoscopic Portal Vein Ligation and Embolization During First-Stage Hepatectomy for Initially Unresectable Colorectal Liver Metastases.

Two-stage hepatectomy (TSH) is the only treatment for the patients with multiple bilobar colorectal liver metastases (CRMs) who are not candidates for one-step hepatectomy because of insufficient future remnant liver volume and/or impaired liver function.1-5 Although laparoscopic approaches have been introduced for TSH,6-8 the postoperative morbidity and mortality remains high because of the technical difficulties during second-stage hepatectomy.9,10 The authors present a video of laparoscopic TSH with portal vein (PV) ligation and embolization, which minimizes adhesions and PV thrombosis risk in the remnant liver, thereby facilitating second-stage hepatectomy. Three patients with initially unresectable bilateral CRMs received a median of chemotherapy 12 cycles, followed by conversion TSH. After right PV ligation, laproscopic PV embolization was performed by injection of 100% ethanol into the hepatic side of the right PV using a 23-gauge winged needle. After PV embolization, a spray adhesion barrier (AdSpray, Terumo, Tokyo, Japan)11 was applied. During the first stage of hepatectomy, two patients underwent simultaneous laparoscopic colorectal resection (left hemicolectomy and high anterior resection). In the initial hepatectomy, two patients underwent two limited hepatectomies each, and one patient underwent six hepatectomies in the left lobe. After hepatectomy, all the patients underwent right PV embolization. During the second stage, two patients underwent open extended right hepatectomy (right adrenalectomy was performed because of adrenal invasion in one patient), and one patient underwent laparoscopic extended right hepatectomy. No postoperative complications occurred in the six surgeries. Laparoscopic TSH with PV embolization is recommended for safe completion of the second hepatectomy.

High-grade B-cell Lymphoma Initially Presenting with Dysphagia, Upper Gastrointestinal Bleeding, and Adrenal Invasion

Abstract Gastric high-grade B-cell lymphoma (HGBL) with adrenal gland invasion is a rare clinical entity with few cases reported in the literature. Patients usually present with nonspecific symptoms that lead to delays in the diagnosis, initiation of treatment, and prognosis. In this report, we present a case of a middle-aged woman in her 60s who presented with shortness of breath, dysphagia, early satiety, and melena. Further investigations confirmed the presence of an ulcerated gastric mass with invasion to the left adrenal gland, and histopathological and molecular studies of the gastric mass confirmed the diagnosis of B-Cell Lymphoma with MYC and BCL-6 rearrangements, a rare aggressive lymphoma subtype known as HGBL. Consequently, she was started on R-CHOP-21 chemotherapy protocol with good outcomes and resolution of the mass on repeat imaging; the current report aimed to emphasize the importance of recognizing unusual presentations of HGBL, especially gastric HGBL, which will help in early recognition, treatment, and prognosis.

Renal cell carcinoma T staging: Diagnostic accuracy of preoperative contrast-enhanced computed tomography.

Renal cell carcinoma (RCC) accounts for 1-2% of all malignancies and is the most common renal tumor in adults. Imaging studies are used for diagnosis and staging. Tumor-Node-Metastasis staging strongly affects prognosis and management, while contrast-enhanced computed tomography (CECT) is regarded as a standard imaging technique for local and distant staging. The present study aimed to evaluate the accuracy of CECT for the preoperative staging of RCC by using surgical and pathological staging as the reference methods. This single-center prospective study was conducted between October 2019 and November 2021. The preoperative abdominal CT scans of patients suspected of having RCC were reviewed. Imaging data were collected, including tumor side and size, and perinephric fat invasion. Intraoperative notes were recorded, including the operation type, perinephric fat invasion, renal vein (RV) or inferior vena cava (IVC) tumor extension, and surrounding organ invasion. pathological data were collected on tumor size, RCC type, presence of clear margins, presence of renal capsule or perinephric fat invasion, renal sinus or pelvicalyceal system (PCS) invasion, segmental or main RV extension, and the involvement of Gerota's fascia and nearby organs. Preoperative CECT revealed that 42 out of 59 tumors had a greater maximum diameter than the pathological specimen, with an overall disparity of 0.25 cm. The specificity of CT for the detection of tumor invasion of the perinephric and renal sinus fat and PCS was 95%, and the sensitivity ranged from 80 to 88%. CT had an 83% sensitivity and a 95 specificity in detecting T4 stage cancer, with a 100% specificity for adrenal invasion. The concordance between radiographic and histological results for RV and IVC involvement was high, with specificities of 94 and 98%, and sensitivities of 80 and 100%, respectively. Overall accuracy for correct T staging was 80%. In conclusion, CECT is accurate in the local T staging of RCC, with high sensitivity and specificity for estimating tumor size and detecting extension to nearby structures and venous invasion.

Clinical Outcome of RAMPS for Left-Sided Pancreatic Ductal Adenocarcinoma: A Comparison of Anterior RAMPS versus Posterior RAMPS for Patients without Periadrenal Infiltration.

Radical antegrade modular pancreatosplenectomy (RAMPS) is considered an effective procedure for left-sided pancreatic ductal adenocarcinoma (PDAC). However, whether there are differences in perioperative outcomes, pathologies, or survival outcomes between anterior RAMPS (aRAMPS) and posterior RAMPS (pRAMPS) has not been reported previously. We retrospectively reviewed and compared the demographic, perioperative, histopathologic, and survival data of patients who underwent aRAMPS or pRAMPS for PDAC. We also compared these two groups among patients without periadrenal infiltration or adrenal invasion. A total of 112 aRAMPS patients and 224 pRAMPS patients were evaluated. Periadrenal infiltration, neoadjuvant treatment, and concurrent vessel resection were more prevalent in the pRAMPS group. After excluding patients with periadrenal infiltration, 106 aRAMPS patients were compared with 157 pRAMPS patients. There were no significant differences between the aRAMPS and pRAMPS groups in the pathologic tumor size, resection margin, proportion of tangential margin in the R1 resection, and number of harvested lymph nodes. The median overall survival and disease-free survival also did not differ significantly between the two groups. We cautiously suggest that pRAMPS will not necessarily provide more beneficial histopathologic outcomes and survival rates for left-sided PDAC cases without periadrenal infiltration. If periadrenal infiltration is not suspected, aRAMPS alone should be sufficiently effective.

Compare Fuhrman Nuclear and Chromophobe Tumor Grade on Chromophobe RCC.

BackgroundChromophobe renal cell carcinoma (chRCC) has a favorable prognosis. Due to irregular nuclei and nuclear pleomorphism, chRCC has a high Fuhrman nuclear grade (FNG). The chromophobe tumor grade (CTG) is a novel three-tier grading system that has been reported to be a better prognosticator than the traditional FNG. We compared the two nuclear grading systems in terms of patients’ clinical outcomes.Patients and MethodWe performed this retrospective chart review of all patients with chRCC from 2000 to 2017. All pathologic features and CTG and FNG results were re-evaluated.ResultEighteen patients’ records were reviewed with a mean follow-up of 70.6 months. The nuclear grading distribution was as follows: FNG 2, 56%; FNG 3, 39%; FNG 4, 5%; CTG 1, 78%; CTG 2, 17%; and CTG 3, 6%. Only one patient died. This patient had adrenal invasion, lung metastasis, sarcomatoid change and tumor necrosis, and the tumor was graded as FNG 4 and CTG 3. Overall survival was associated with both FNG and CTG.ConclusionChromophobe RCC was associated with a low rate of cancer-specific death and sarcomatoid differentiation. Both FNG and CTG were associated with overall survival.

Risk Factors for Adrenal Invasion in Renal Cell Carcinoma

Risk Factors for Adrenal Invasion in Renal Cell Carcinoma

Significance of TNM staging, Demographic and Histologic Features in Predicting the Prognosis of Renal Cell Carcinoma

Background : The aim of this study was to evaluate the prognostic significance of clinical, demographic and detailed histopathological parameters in renal cell carcinoma (RCC).Methods : A total of 102 patients who underwent partial or radical nephrectomy for a renal mass between 2008 and 2013 were evaluated retrospectively. Fuhrman grade, TNM stage, macroscopic satellite tumor nodule formation, histopatho-logical subtype, renal vein invasion (RVI), necrosis, microvessel invasion (MVI), sarcomatoid differentiation and overall survival (OS) were evaluated to determine prognostic factors.Results : The 102 patients consisted of 73 with clear cell tumor, 15 with papillary tumor, 12 with chromophobe tumor and 2 collecting duct RCC cases. A statistically negative relationship was observed between increasing age and OS when the patients were grouped as above and under 40 years of age. There was no statistical relationship between OS and his-topathological subtype, adrenal gland invasion, and lymph node metastasis. The risk of death was 10-fold increased in patients with stage 4 tumor compared to patients with stage 1 tumor. Statistically significant macroscopical parameters for OS were satellite tumor nodule presence, Fuhrman grade, tumor size, renal sinus and perinephric fat invasion, distant metastasis, and RVI. The risk of death was 13-fold higher in cases with sarcomatoid differentiation. There was a strong correlation between the presence of a satellite tumor nodule, necrosis, sarcomatoid differentiation and the tumor stage. A statistically negative correlation was observed between OS and the MVI, sarcomatoid differentiation, and necrosis. Conclusion : We found the Fuhrman grade, tumor size, renal sinus and perinephric fat invasion, distant metastasis, RVI, MVI, sarcomatoid differentiation, necrosis and satellite tumor nodule to be all statistically significant parameters for OS. The addition of other variables to the TNM stage and grade may improve the prediction of outcomes for RCC patients.

Prognostic Outcomes and Risk Factors for Patients with Renal Cell Carcinoma and Venous Tumor Thrombus after Radical Nephrectomy and Thrombectomy: The Prognostic Significance of Venous Tumor Thrombus Level.

Introduction. To evaluate the prognostic outcomes and risk factors for renal cell carcinoma (RCC) patients with venous tumor thrombus in China. Materials and Methods. We reviewed the clinical information of 169 patients who underwent radical nephrectomy and thrombectomy. Overall and cancer-specific survival rates were analyzed. Univariate and multivariate analyses were used to investigate the potential prognostic factors. Results. The median survival time was 63 months. The five-year overall survival and cancer-specific survival rate were 53.6% and 54.4% for all patients. For all patients, significant survival difference was only observed between early (below hepatic vein) and advanced (above hepatic vein) tumor thrombus. However, significant differences existed between both RV/IVC and early/advanced tumor thrombus groups in N0M0 patients. Multivariate analysis demonstrated that higher tumor thrombus level (p = 0.016, RR = 1.58), N (p = 0.013, RR = 2.60), and M (p < 0.001, RR = 4.14) stages and adrenal gland invasion (p = 0.001, RR = 4.91) were the most significant negative prognostic predictors. Conclusions. In this study, we reported most cases of RCC patients with venous extension in China. We proved that patients with RCC and venous tumor thrombus may have relative promising long-term survival rate, especially those with early tumor thrombus.

Cytoplasmic PAR-3 protein expression is associated with adverse prognostic factors in clear cell renal cell carcinoma and independently impacts survival.

Clear cell renal cell carcinomas (ccRCCs) represent 70% of renal cancers, and several clinical and histolopathological factors are implicated in their prognosis. We recently demonstrated that the overexpression of PAR-3 protein encoded by the PARD3 gene could be implicated in renal oncogenesis. The object of this work was to study the association of intratumoral PAR-3 expression with known prognostic parameters and clinical outcome. In this aim, PAR-3 expression was assessed by immunohistochemistry in ccRCC tumors of 101 patients from 2003 to 2005. The immunostaining of PAR-3 was scored either as membranous (mPAR-3) or as both membranous and cytoplasmic (cPAR-3). Cytoplasmic PAR-3 was significantly associated with worse histopathological and clinical prognostic factors: Fuhrman grades 3 and 4, tumor necrosis, sarcomatoid component, adrenal invasion, renal and hilar fat invasion, eosinophilic component, a noninactivated VHL gene, higher tumor grade, lymph node involvement, metastasis, and worse clinical Eastern Cooperative Oncology Group and S classification scores. After multivariate analysis, 2 parameters were independently associated with cPAR-3: necrosis and eosinophilic components. In addition, cPAR-3 patients had shorter overall and progression-free survivals independently from strong prognostic validated factors like metastases. A cytoplasmic expression of PAR-3 is therefore implicated in worse clinical and pathological cancer features in ccRCC and could be useful to identify patients with high-risk tumors.

The accuracy of multidetector Computed Tomography for preoperative staging of renal cell carcinoma

The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) in the preoperative staging of renal cell carcinoma (RCC). We retrospectively reviewed the clinical and pathological records of 312 patients with RCC who underwent staging MDCT before surgery. Radiographic findings were compared to the findings at surgery and pathological examination. All staging used 2009 updated TNM classification. The difference in tumor size between radiographic and pathological findings was 0.21 cm. In T1a group, the difference was 0.33 cm. Agreement between MDCT and histopathological findings was moderate for T staging (Kappa = 0.469), fair for N staging (Kappa = 0.322), and excellent for M staging (Kappa = 0.932). The sensitivity and specificity of MDCT in detecting perinephric fat invasion were 32.26% and 85.87%, in detecting tumor thrombosis were 84% and 100%, in detecting adrenal gland invasion were 60% and 95.79%, in detecting lymph node involvement were 50% and 96.36%, in detecting distant metastasis were 100% and 99.67%, respectively. In regard to stage grouping, 237 of 314 patients were correctly staged by MDCT, with an overall accuracy of 75.48%. MDCT with a dynamic contrast protocol is able to delineate RCC with high accuracy. However, a great portion of tumors were overstaged by MDCT because of overestimation of tumor size and poor visualization of infiltration of the perinephric fat. In addition, nodal metastatic lesion evaluation relies on node size only and remains a difficult task.

Practical issues and pitfalls in staging tumors of the genitourinary tract

Accurate staging of tumors involving the genitourinary tract is critical to determine appropriate management options and subsequent clinical outcome for patients. The staging protocols, however, continue to evolve and are under constant revision and change. The new 2010 American Joint Committee on Cancer/Tumor Nodes and Metastasis (AJCC/TNM) staging system of the prostate, bladder, kidney, and testis is now recommended. Although the protocols are relatively straightforward, this article focuses on some practical issues and occasional pitfalls that may be encountered when staging cancers of the genitourinary tract. Specific issues that will be addressed include issues and pitfalls in radical prostatectomy specimens (substaging of pT2 tumors, extraprostatic extension, bladder neck invasion, positive surgical margins, seminal vesicle involvement, no residual tumor identified), cystectomy/cystoprostatectomy specimens (extravesicular extension and prostatic stromal invasion), nephrectomy specimens (renal sinus invasion, ipsilateral adrenal gland invasion, renal vein involvement, multifocal tumors), and orchiectomy specimens (pseudoangiolymphatic invasion of friable tumors, rete testis invasion, and spermatic cord invasion/metastasis). In addition, pitfalls in both prostate (extraprostatic extension, seminal vesicle/ejaculatory duct involvement in needle core biopsies, and quantification of tumor volume in transurethral resection specimens) and bladder (tumors with inverted growth pattern, muscularis propria invasion, extravesicular extension) biopsy interpretations that may have an impact on staging are also addressed.

840 CAN IT BE POSSIBLE TO SPARE THE ADRENAL GLAND AT RADICAL NEPHRECTOMY IN CHILDREN DIAGNOSED OF WILMS' TUMOR?

You have accessJournal of UrologyPediatrics: Stones/Tumors1 Apr 2012840 CAN IT BE POSSIBLE TO SPARE THE ADRENAL GLAND AT RADICAL NEPHRECTOMY IN CHILDREN DIAGNOSED OF WILMS' TUMOR? Jeman Ryu, Jongwon Kim, Sungchan Park, and Kun Suk Kim Jeman RyuJeman Ryu Seoul, Korea, Republic of More articles by this author , Jongwon KimJongwon Kim Seoul, Korea, Republic of More articles by this author , Sungchan ParkSungchan Park Ulsan, Korea, Republic of More articles by this author , and Kun Suk KimKun Suk Kim Seoul, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.931AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Wilms' tumor is most common renal neoplasm in children. Radical nephrectomy is the generally recommended treatment of choice as a part of multi-disciplinary therapy. However, there is no definite clinical guideline for ipsilateral adrenalectomy when performing radical nephrectomy for the treatment of Wilms' tumor. Therefore we aimed to confirm whether patients with Wilms' tumor could be treated with ipsilateral adrenal sparing nephrectomy. METHODS Between 1992 and 2010, 51 patients with histologically confirmed Wilms' tumor undergoing radical nephrectomy were analyzed in this study. Patient age, clinical symptom, size and laterality of tumor, and adrenal invasion of tumor on abdominal computed tomography (CT) or ultrasound were reviewed as preoperative data and pathologic stage, renal capsule invasion, adrenal invasion, lymphovascular invasion, and complete resection were reviewed postoperatively. RESULTS Of the 51 patients, 27 (53%) were male and 24 (47%) were female. The mean age was 39 months and the mean follow up duration was 73.7 months. Preoperative clinical symptoms included abdominal palpable mass (62.7%), abdominal discomfort (9.8%), and gross hematuria (27.5%). Tumor involved unilaterally in 49 and bilaterally in 2. The mean size of renal mass was 10.1cm on preoperative CT (74.5%) or ultrasound (25.5%). Six patients (11.8%) who had pulmonary metastasis received neoadjuvant chemotherapy (Vincristine, Dactinomycin, and Cyclophosphamide). Pathologic stage was: I-25 (49%), II-8 (15.7%), III-7 (13.7%), IV-9 (17.6%), and V-2 (4%). Renal capsule invasion in 13 and lymphovascular invasion in 4 were observed, but adrenal invasion was not identified in all nephrectomy specimens. Complete resection rate was 80% and adjuvant chemotherapy was performed following radical nephrectomy in all 51 patients. CONCLUSIONS Adrenal involvement is not likely in patients with Wilms' tumor, and adrenalectomy is unnecessary in all cases eventually. These results suggest that unconditional ipsilateral adrenalectomy during radical nephrectomy for the treatment of Wilms' tumor could be avoided. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e342-e343 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeman Ryu Seoul, Korea, Republic of More articles by this author Jongwon Kim Seoul, Korea, Republic of More articles by this author Sungchan Park Ulsan, Korea, Republic of More articles by this author Kun Suk Kim Seoul, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

腎癌患者350例の予後検討による2009年TNM分類の評価

To validate 2009 TNM classification (7th edition) of renal cell carcinoma (RCC), we reevaluated our RCC database depends on 6th and 7th TNM staging and analyzed a prognostic divergence between subgroups. A study population of 350 patients with RCC was retrospectively reviewed based on the TNM classification both 6th and 7th editions. Cause-specific survival (CSS) in each group was estimated using Kaplan-Meier method. Applying the new TNM system, 336 patients were divided into pT1a 131, pT1b 105, pT2a 31, pT2b 13, pT3 a 38, pT3b 3, pT3c 0, pT4 14. Previously pT3b-staged 11 cases with renal vein involvement without vena caval extension were included into pT3a. Due to the positive direct invasion into the adrenal gland, previously pT3-staged six patients were changed to pT4. Kaplan-Meier curves revealed no significant differences in CSS between each a/b subgroups from pT1 to pT3. Particularly, no significant statistical value was recognized between pT2a and pT2b subgroups. Patients with direct adrenal invasion tended to show a less favorable prognosis than those with invasion beyond Gerota. (1) pT2 subdivision does not affect prognostic value. (2) Population imbalance is enhanced due to the pT 3 reclassification. (3) Direct adrenal invasion is compatible with pT4 category.

IJU this issue

Mototsugu Oya M.D., Associate Editor In this issue, I would like to focus on “degenerative” and “regenerative” medicine. The degenerative issue is renal cell carcimoma (RCC) arising in end-stage kidneys. Whether RCC arising in patients under hemodialysis (HD) is the same as or different from non-HD RCC in terms of oncogenesis is an important issue to be resolved. The most important molecule related to RCC oncogenesis is von Hippel-Lindau disease tumor suppressor gene. The mutation of the gene is observed both in sporadic non-HD patients and HD patients. In contrast, in pathological aspects, RCC arising in HD patients occasionally have different types of cancer tissues (described by Tickoo SK et al. cited #25 in Takagi's paper). This suggests a distinctly different oncogenic pathway. The most different feature, I believe, is that HD-related RCC are multifocal in contrast to the non-HD, which is single (unifocal). Multifocal tumors can arise in susceptible, pre-oncogenic tissues. For example, liver cancer arises from hepatitis virus-infected tissues that are susceptible to cancer. Takagi et al. described the clinical characteristics of RCC in HD patients in a single institution. They showed that bilateral occurrence did not influence the likelihood of death from cancer, suggesting de novo primary events rather than the metastases of the contralateral primary. Interestingly, a longer duration before surgery was an unfavorable prognosis. This suggests that the accumulation of molecular alteration in end-stage kidneys is related to progression of the cancer as well as the initiation. Molecular pathogenesis needs to be elucidated in this malignant phenotype of long HD-associated RCC. Venous extension or tumor thrombus is a feature of RCC that is rarely observed in other cancers. The 7th edition of UICC changed the T3 classification. The cephalad extent of the tumor was divided into three parts, namely, renal vein, inferior vena cava (IVC) below the diaphragm and IVC above the diaphragm, and assigned T3a, T3b and T3c. Nagata et al. assessed the revision of UICC using the clinical data in their institution retrospectively. Their Kaplan–Meier curves were clearly separated accordingly. They concluded that the new classification could be valid in Japan. T category in RCC is complex, as compared with other cancers. For example, T factor in bladder cancer is simply the extent of the invasion. In determining the T of RCC, tumor size, perinephric invasion, adrenal invasion and venous involvement should be evaluated. The 7th edition of UICC is not perfect. Based on accumulating publications, T factor might be changed in the future. Regenerative medicine is one of the main topics at present. Obinata et al. used a unique cell transplantation system named adipocyte-derived dedifferentiated fat (DFAT) cells to treat stress urinary incontinence (SUI) in a rat model. DFAT cells are easily isolated from a small amount (approximately 1 g) of subcutaneous adipose tissue and differentiated to smooth muscle-like cells by adding transforming growth factor-β1. A cross-section of the urethra showed a marked difference in terms of the thickness of the muscle layers in the DFAT-injected rats. As mentioned in the Editorial Comment by Pastor-Navarro, this injured model is not a permanent model. SUI is a permanent injury as a result of labor during childbirth. She mentioned a need for a permanent injury model to validate the results. I believe DFAT is easy and can be applicable to clinical use. However, several issues should be clarified. How and how long are the dedifferentiated muscle-like cells maintained in the tissues? How is the injected DFAT distributed and how about the injured muscle cells? An easy method that is replicable by other researchers can survive in regenerative medicine. To explore an easy way is a short cut to clinical use. None declared.

Management of the Adrenal Gland During Partial Nephrectomy

Nephron sparing surgery is an increasingly used alternative to Robson's radical nephroadrenalectomy. The indications for adrenalectomy in patients undergoing partial nephrectomy are not clearly defined and some surgeons perform it routinely for large and/or upper pole renal tumors. We analyzed initial management and oncological outcomes of adrenal glands after open partial nephrectomy. Institutional review board approval was obtained for this study. During partial nephrectomy the ipsilateral adrenal gland was resected if a suspicious adrenal nodule was noted on radiographic imaging, or if intraoperative findings indicated direct extension or metastasis. Concomitant adrenalectomy was performed in 48 of 2,065 partial nephrectomies (2.3%). Pathological analysis revealed direct invasion of the adrenal gland by renal cell carcinoma (1), renal cell carcinoma metastasis (2), other adrenal neoplasms (3) or benign tissue (42, 87%). During a median followup of 5.5 years only 15 patients underwent subsequent adrenalectomy (0.74%). Metachronous adrenalectomy was ipsilateral (10), contralateral (2) or bilateral (3), revealing metastatic renal cell carcinoma in 11 patients. Overall survival at 5 years in patients undergoing partial nephrectomy with or without adrenalectomy was 82% and 85%, respectively (p = 0.56). Adrenalectomy should not be routinely performed during partial nephrectomy, even for upper pole tumors. We propose concomitant adrenalectomy only if a suspicious adrenal lesion is identified radiographically or invasion of the adrenal gland is suspected intraoperatively. Using these criteria adrenalectomy was avoided in more than 97% of patients undergoing partial nephrectomy. Even using such strict criteria only 13% of these suspicious adrenal nodules contained cancer. The rarity of metachronous adrenal metastasis and the lack of an observable benefit to concomitant adrenalectomy support adrenal preservation during partial nephrectomy except as previously outlined.

Renal Sinus Fat Invasion in pT3a Clear Cell Renal Cell Carcinoma Affects Outcomes of Patients Without Nodal Involvement or Distant Metastases

According to the 2002 American Joint Committee on Cancer TNM classification, perinephric and renal sinus fat invasion are classified as pT3a renal cell carcinoma. However, only a few studies have assessed the impact of sinus fat invasion on patient survival and with controversial results. We analyzed the impact of sinus fat invasion on cancer specific survival in a cohort of patients with pT3a clear cell renal cell carcinoma. We retrospectively analyzed data on 115 consecutive patients treated with open radical nephrectomy for unilateral, sporadic pT3a clear cell renal cell carcinoma at our department from 1989 to 2006. All pathological specimens were rereviewed by a single uropathologist. The prognostic role of sinus fat invasion in cancer specific survival was assessed by Cox proportional hazards regression models. Ten patients had direct ipsilateral adrenal invasion and were excluded from analysis. A total of 105 patients with clear cell renal cell carcinoma were evaluated. Median followup was 38 months. In the overall population sinus fat invasion did not reach independent predictive status in terms of cancer specific survival on multivariate Cox regression analysis after adjusting for age, performance status, tumor dimension, tumor grade, synchronous metastases, nodal involvement, sarcomatoid differentiation and coagulative necrosis. In the subset of patients with pNx/pN0 M0 (83) the actuarial 5-year cancer specific survival was 71.9% and 45.5% for those with perinephric fat invasion only and sinus fat invasion, respectively (p = 0.025). Sinus fat invasion achieved an independent predictive role on multivariable Cox regression analysis (p = 0.048, HR 2.06). Sinus fat invasion in clear cell renal cell carcinoma significantly affects cancer specific survival in patients without nodal or distant metastases. However, sinus fat invasion is not associated with worse cancer specific survival in cases of metastatic disease.

Prognostic Value of Renal Vein and Inferior Vena Cava Involvement in Renal Cell Carcinoma

BackgroundThe prognostic significance of venous tumor thrombus extension in patients with renal cell carcinoma (RCC) is a matter of many controversies in the current literature. ObjectiveTo evaluate the prognostic role of inferior vena cava (IVC) involvement in a large series of pT3b and pT3c RCCs. Design, setting, and participantsA total of 1192 patients from 13 European institutions underwent a radical nephrectomy for pT3b and pT3c RCC between 1982 and 2003. The patients were evaluated in a retrospective manner. Age, gender, clinical symptoms, Eastern Cooperative Oncology Group (ECOG) performance status, TNM stage, tumor size, adrenal invasion, perinephric fat invasion, histological type, and Fuhrman grade were reviewed. The log-rank and Cox uni- and multivariate regression analyses were used to evaluate prognostic factors for overall survival. MeasurementsOverall survival and prognostic factors for overall survival in patients with RCC extending to the renal vein (RV) or to the IVC. Results and limitationsThe median follow-up was 61.4 mo (56.3–66.5 mo). The mean age was 63.2 yr. The mean tumor size was 8.9cm. Group 1 (Gr 1) included 933 patients with a renal vein tumor thrombus (78.3%), Group 2 (Gr 2) included 196 patients with a subdiaphragmatic IVC tumor thrombus (16.4%), and Group 3 (Gr 3) included 63 patients with a supradiaphragmatic IVC tumor thrombus (5.3%). Median survival was 52 mo for Gr 1, 25.8 mo for Gr 2, and 18 mo for Gr 3. In univariate analysis, Gr 1 had a significantly better overall survival than Gr 2 (p<0.001) and Gr 3 (p≤0.001). No significant difference in survival was noted between Gr 2 and Gr 3 (p=0.613). Prognostic factors for overall survival in univariate analysis were clinical symptoms (p<0.001), tumor size (p<0.001), perinephric fat invasion (p<0.001), Fuhrman grade (p<0.001), histological type (p=0.021), lymph node invasion (p<0.001), and distant metastasis (p<0.001). Independent prognostic factors in multivariate analysis were tumor size (p=0.013), perinephric fat invasion (p=0.003), lymph node invasion (p<0.001), distant metastasis (p<0.001), and IVC invasion (p=0.008). ConclusionsThe level of tumor thrombus in the IVC does not significantly affect long-term overall survival in patients with renal cell carcinoma. The overall survival was statistically different for patients with a tumor thrombus in the RV compared to those with IVC involvement. This has to be considered for the next revision of the TNM system, and the pT3b and pT3c stages have to be redesigned.

Reappraisal of T3N0/NxM0 renal cell carcinoma: significance of extent of fat invasion, renal vein invasion, and adrenal invasion

T3 renal cell carcinoma (RCC) is a heterogeneous group of tumors that are substaged based on perirenal or sinus fat invasion, adrenal invasion, and renal vein invasion. To evaluate whether the extent of fat invasion (minimal versus extensive) and direct adrenal gland invasion, renal vein invasion with or without concurrent fat invasion has a similar prognosis, we retrospectively reviewed 198 T3N0/NxM0 RCCs in a single academic tertiary hospital. Fat invasion was subdivided as minimal (< or =5 mm into the fat) or extensive (>5 mm) invasion. Direct adrenal invasion was defined as contiguous involvement of ipsilateral adrenal gland. Among the 198 T3 RCCs, minimal and extensive fat invasions were identified in 57 and 61 cases, respectively; renal vein invasion and direct adrenal invasion were seen in 66 and 14 cases. The patients' average age was 62.9 years, and 145 patients were male and 53 were females. The 2-year and 5-year survival rates were 85% and 56% for minimal fat invasion, 76% and 70% for extensive fat invasion, and 55% and 32% for renal vein invasion, respectively. There was no difference of survival in patients with T3b (renal vein invasion) RCC stratified by presence or absence of concurrent fat invasion. The 2-year and 5-year survival rates for adrenal invasion were 31% and 21%, respectively, which was significantly worse than that of fat or renal vein invasion. Multivariate analysis showed that nuclear grade, sarcomatoid differentiation, and subgrouping of pT3 RCC (fat invasion, renal vein invasion, and adrenal invasion) remained independent predictors of patient's overall survival. In conclusion, our study shows that T3 RCCs with minimal or extensive perinephric fat invasion has a similar prognosis and is significantly more favorable than that of renal vein invasion regardless of presence or absence of concurrent fat invasion. In contrast, tumors with adrenal gland invasion carry a far worse prognosis than perinephric fat or renal vein invasion and thus supporting a separate stage category.

Prognostic Significance of Perinephric Fat Infiltration and Tumor Size in Renal Cell Carcinoma

It is controversial that perinephric fat infiltration has an impact on survival in patients with renal cell carcinoma. Therefore, we evaluated the influence of perinephric fat infiltration and tumor size on patient survival. We retrospectively reviewed the medical records of 783 and 77 patients with pT1-2 (cN0M0) and pT3a (cN0M0) renal cell carcinoma, respectively. Sporadic unilocular noncystic renal cell carcinoma was included. Univariate and multivariate analyses of prognostic factors, including perinephric fat infiltration, on cancer specific and disease-free survival were performed. Median followup was 56.0 months after surgery. Patients with pT1-2 and pT3a tumors had a 5-year cancer specific survival rate of 96.1% and 84.9%, and a 5-year disease-free survival rate of 93.4% and 74.7%, respectively (each p <0.01). Age, tumor size and Fuhrman nuclear grade were independent prognostic factors for cancer specific and disease-free survival, whereas perinephric fat infiltration was significant only for disease-free survival. However, perinephric fat infiltration had a significant effect on cancer specific survival in patients with pT3a tumors more than 7 cm (p = 0.001). In contrast, patients with pT3a tumors 7 cm or less had cancer specific and disease-free survival similar to that of patients with pT2 tumors. Recurrence of pT3a tumors greater than 7 cm was observed in 44% of patients but in only 14.6% of those with pT3a tumors 7 cm or less (p = 0.029). In contrast to the recurrence of tumors 7 cm or less, recurrence of pT3a tumors more than 7 cm usually developed at multiple sites with a large tumor burden and it progressed rapidly. Consequently 85% of patients with recurrence of pT3a tumors larger than 7 cm died of renal cell carcinoma compared with 33% of those with recurrence of pT3a tumors 7 cm or less (p = 0.001). In pT3a renal cell carcinoma tumor size was the strongest prognostic factor of disease-free and cancer specific survival. Perinephric fat infiltration was an independent prognostic factor for disease-free survival but not for cancer specific survival due to the less aggressive behavior of small (7 cm or less) pT3a tumors after recurrence. Tumor size and perinephric fat infiltration should be included in T3a renal cell carcinoma staging.