Discovery Of Metastasis Research Articles

Prognostic analysis of 152 patients with distant metastasis after intensity-modulated radiotherapy for nasopharyngeal carcinoma.

The aim of this study was to analyze the prognostic factors for nasopharyngeal carcinoma (NPC) patients with distant metastasis after intensity-modulated radiotherapy (IMRT), and to provide a further basis for clinical treatment options. One hundred and fifty-two NPC patients with distant metastasis after IMRT from January 2006 to December 2017 were included in this study and reviewed for analysis. The patients were followed up for a median time of 43 months. The survival rate was calculated and compared using the Kaplan-Meier method and log-rank tests, respectively. The Cox risk ratio model was used for univariate and multivariate analyses. Among all patients, the median interval from treatment completion to distant metastasis was 11.3 months. The median post-metastasis survival was 14 months, and the 1-, 2-, and 3-year survival rates were 60.4%, 40.2%, and 27.6%, respectively. Through univariate analysis, we found that overall survival was related to lymph node (N) staging at diagnosis, whether induction chemotherapy was utilized, the interval time from initial radiotherapy completion to distant metastasis, with/without liver metastasis, and whether chemotherapy or palliative radiotherapy were utilized after metastasis discovery. Cox regression results showed that liver metastasis, multi-organ metastasis, chemotherapy after metastasis, and the time from radiotherapy completion to distant metastasis were independent prognostic factors for patient survival. The prognosis of NPC patients with distant metastasis after IMRT was related to the time from radiotherapy completion to distant metastasis, liver and multi-organ metastasis, and whether adjuvant chemotherapy was administered. Both adequate adjuvant chemotherapy and palliative radiotherapy could potentially prolong the patients' survival.

Disruption of LTBP4 Induced Activated TGFβ1, Immunosuppression Signal and Promoted Pulmonary Metastasis in Hepatocellular Carcinoma.

IntroductionThe current prognosis of hepatocellular carcinoma (HCC) is unsatisfactory due to high rates of recurrence and metastasis, which has led to research focused on the discovery of metastasis genes.MethodsIn this study, we combined in silico analysis and in vitro transwell experiments to identify a metastasis gene. Then, we used an in vivo experiment to validate the metastasis. Furthermore, a series of experiments such as FACS, Western blot, and ELISA were applied to explore the function of the metastasis gene.ResultsLTBP4 (latent transforming growth factor beta binding protein 4) was confirmed as a metastasis gene, whose expression levels are correlated with the overall survival rate of HCC patients. We further showed that the knockout of LTBP4 in an HCC cell line increased cell proliferation, activated the cell cycle, and induced metastasis events. Moreover, we proved that LTBP4-KO could increase the percentage of active TGFβ1 secreted by HCC cell lines, as well as the recruitment of MDSCs (myeloid-derived suppressor cells) by active TGFβ1 (transforming growth factor beta 1), which further inhibited CD8+ T cell proliferation and activated the immune suppression signal.ConclusionOur results demonstrate that the LTBP4-TGFβ1-MDSCs axis is a critical pathway for the immune suppression signals of HCC primary tumors.

Comparative study of endoscopic and surgical ampullectomy for benign ampullary lesions

Purpose: To evaluate and compare the results of endoscopic and surgical ampullectomy for presumed benign lesions (adenoma, us ≤ T1N0). Material and method: From 2007 to 2017, 65 patients were eligible for ampullectomy. The criteria studied were: morbidity, mean length of stay (LOS), definitive histology, complete resection, follow-up, recurrence, distant complications and the complete treatment rate (mean complete resection and no recurrence). Results: In the endoscopy group, 40 were eligible, 35 ampullectomy were performed, 5 were sent to surgeon: the morbidity was 10%; the LOS was 3.3 days; 9 patients had no adenomatous lesions on the definitive histology; 30% resection was R1, 0% was R2; average follow-up was 17 months; recurrence rate was 19%; biliary stenosis rate was 2%; complete treatment rate of 53%. In the surgical group, 30 were eligible (Initially 25 + 5 sent by endoscopists), 22 ampullectomy were performed, 7 were convert to pancreatoduodenectomy, 1 abstention (discovery of metastasis): morbidity was 35%; LOS was 10 days; 6 patients had invasive adenocarcinoma; 14% of the resection was R1, 5% was R2; average follow-up was 28 months; recurrence rate of 4%; biliary stenosis rate was 8%; complete treatment rate of 93%. Conclusion: The short-term and long-term results of patients undergoing endoscopic or surgical ampullectomy are different. The lesions are less severe, with simpler suites in endoscopy group. The lesions are more severe, with more morbid sequels, but with a better rate of complete treatment and better long-term results for surgical ampullectomy group.

Profile of Secondary Bone Cancer in Brazzaville

Objectives: To report an epidemiology study and prognosis for metastatic bone tumor. Methodology: It was a descriptive, transversal study on records of patients hospitalized in Rheumatology and Oncology-Radiotherapy departments of the University Teaching Hospital of Brazzaville, Congo from 1 January 2005 to 31 July 2011 (7 years and 6 months). The diagnosis of bone metastasis was made because of the existence of bone pain, or pathological fracture, or bone swelling and a bone-condensing or mixed or osteolytic radiological image. The anatomo-pathological evidence was made after biopsy of the bone lesion or primary cancer. 3687 patients were hospitalized for active cancer, among them 81 had documented bone metastasis. Results: There were 60 men (74.1%) and 21 women (25.9%) with a sex ratio of 2.85. The average age was 53 years, ranging from 3 to 80 years. 75% of patients were more or equal to 50 years old at the discovery of the bone metastasis. Bone pain was the main mode of discovery (67.9% of cases). However, in 6.2% of cases, it was discovered incidentally. The metastasis was bone condensing in 50.7% of cases, osteolytic in 40.7% and mixed in 8.6%. They were unifocal in 25.9% and multifocal in 74.1% of cases. The Primary cancer most frequently found was that of the prostate in 55.6% of cases, breast in 20.7% and rhabdomyosarcoma in 4.9%. In 6.2% of cases, the primary site of cancer was unknown. The average survival was 25 months. Conclusion: The clinical and radiological presentation remains classic. Cancer of the prostate and breast are the main neoplasia responsible for bone metastasis in our series. The discovery of metastasis remains a major evolutionary step of cancer.

Self-Expanding Metal Stents (SEMS) for Preoperative Biliary Decompression in Patients with Resectable and Borderline-Resectable Pancreatic Cancer: Outcomes in 241 Patients

Obstructive jaundice caused by distal biliary obstruction can present in up to 70 % of patients with localized cancer of the head of the pancreas. The aim of this study was to report our experience in using self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head. We performed a retrospective study evaluating patients from two tertiary referral centers. Two-hundred and forty-one patients with resectable and borderline resectable pancreatic carcinoma underwent ERCP with metal biliary stent placement between September 2006 and August 2011. We assessed the effectiveness of SEMS to adequately decompress the biliary tree, procedural success, patient survival, stent patency, and stent-related complications. Two-hundred and forty-one patients were evaluated [123 male, mean age (± SD) 67.4 ± 9.8 years; resectable 174, borderline resectable 67]. Patients with borderline-resectable cancer underwent neoadjuvant therapy and restaging before possible curative surgery. Successful placement of a metal biliary stent was achieved in all patients and improved jaundice. Patients were followed for mean duration of 6.3 months. The overall survival was 49 % at 27 months. Fourteen (5.8 %) patients experienced stent occlusion; the mean time to stent occlusion was 6.6 (range 1-20) months. Immediate complications included: post-ERCP pancreatitis (n = 14), stent migration (n = 3), and duodenal perforation (n = 3). Long-term complications included stent migration (n = 9) and hepatic abscess (n = 1). A total of 144/174 patients deemed to have resectable cancer at time of diagnosis underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22/67 patients with borderline-resectable cancer underwent curative surgery. SEMS should be considered for patients with obstructive jaundice and resectable or borderline resectable pancreatic cancer, especially if surgery is not planned immediately as a result of preoperative chemoradiation. These stents appear to be safe and effective.

Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy

Most patients with locally advanced esophageal cancer requiring neoadjuvant therapy have significant dysphagia. To report our experience in using a fully covered self-expandable metal stent (FCSEMS) to treat malignant dysphagia and for maintenance of nutritional support during neoadjuvant therapy. Retrospective study. Two tertiary-care referral centers. This study involved 55 patients with locally advanced esophageal cancer (50 adenocarcinoma, 5 squamous cell carcinoma). Forty-three patients were men, and the mean age was 65.8 years. EUS followed by FCSEMS placement. Procedural success, dysphagia scores, patient weights, stent migration, and stent-related complications. All stents were successfully placed. Tumors were located in the middle esophagus (n = 10) and distal esophagus (n = 45). The mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively; P < .001). Patients maintained their weights at 1 month follow-up when compared with baseline (153 and 149 pounds, respectively; P = .58). Immediate complications included chest discomfort in 13 patients; 2 patients required stent removal because of intractable pain. One patient had stent removal because of significant acid reflux. Stent migration occurred at some point in 17 of 55 patients (31%). There was a delayed perforation in 1 patient. Because of disease progression or the discovery of metastasis after neoadjuvant therapy, only 8 of 55 patients underwent curative surgery. Retrospective study. Placement of FCSEMSs in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. FCSEMSs appear to be effective for palliating dysphagia. Migration was not associated with injury or harm to the patient and usually represented a positive response to neoadjuvant therapy. Few patients undergoing stenting in this situation ultimately undergo surgery because of disease progression or poor operative candidacy.

Long‐term outcomes of distant metastasis from differentiated thyroid carcinoma

The aim of this study was to identify the prognostic factors of long-term survival and optimal therapeutic protocol for patients with distant metastasis secondary to differentiated thyroid carcinoma (DTC). A retrospective review of 1665 patients with DTC treated at a regional tertiary hospital in Taiwan between 1986 and 2010 was performed. Among them, 207 patients were found to have distant metastasis. For a long-term outcome survey, 126 patients that had received at least 5 years (mean 9·6 ± 5·2 years) of follow-up after the diagnosis of distant metastasis were analysed for this study. Prognostic factor analysis included age, sex, histology, disease stage, type of surgical procedure, site of metastatic foci, (131) I avidity of tumour, thyroglobulin (Tg) level and accumulated therapeutic dose of radioiodine (RAI). The mean age at diagnosis of distant metastasis was 46·4 ± 17·2 years. The female-to-male ratio was 2·1:1. The 10- and 15-year survival rates were 70·6% and 64·9%, respectively. The independent predictors of survival were younger age, surgical dissection of neck lymph nodes (LNs) and low TSH-stimulated Tg level (<400 μg/l) at the discovery of metastasis. Most cases of resolved (131) I-avid disease (79·2%) and disease-free remission (87·5%) received a cumulative dose no >600 mCi of (131) I. The mean cumulative doses of (131) I in both deceased and living patients were similar. The prognosis of patients with distant metastasis from DTC within this study was found to be favourable. Survival may be improved by surgical dissection of neck LNs, but repeated (131) I therapy >600 mCi is not advised unless there is a high probability that it would benefit the patient.

Utility or futility of prognostic scoring systems for colorectal liver metastases in an era of advanced multimodal therapy

Objectives To assess the general applicability of prognostic scores for colorectal liver metastases (CRLM). Methods Review of English language studies from 1980 to 2008 (Medline and Embase). Search keywords included “Colorectal neoplasms”, “liver metastases”, “liver resection”, “prognostic scoring system”. Results Six scoring systems and fourteen prognostic factors within these studies were identified. No prognostic factor was common in all scoring methods. Five scores retained the number of metastases as a prognostic factor. Size of metastases and time between the onset of the primary tumor and the discovery of metastases were present in four scores. Three scores predicted 5-year survival using carcinoembryonic antigen (CEA) and R1 resection. Only two scores were assessed preoperatively. Successive scoring methods had improved predictive accuracy compared to earlier systems. However, their applicability in general populations remains debatable. An evaluation of the scores applicability to different patient populations demonstrated that the models were minimally effective in predicting disease-specific survival and recurrence, suggesting that stratification of patients by clinical and pathologic factors alone, may be clinically unreliable and not applicable for selection of patients for surgery. Conclusion The utility of prognostic models on general populations is inconsistent. Current clinicopathologic factors may be inadequate to determine disease prognosis in CRLM. Future attempts to develop prognostic scores should include additional biologic and clinical variables, and be validated in larger populations.

Renal Cell Carcinoma Metastases to Bone After a 33-Year Remission

Renal cell carcinoma accounts for 2% of all cancers. Metastases to bone occur 35% to 40% of the time, second in prevalence of metastases only to the lungs. These metastases are highly destructive, hypervascular tumors known to be difficult to manage. This article reports a unique case in which a patient was disease free for 33 years from initial nephrectomy for treatment of primary renal cell carcinoma to discovery of metastatic disease to the pelvis. Search for an unknown primary was performed, consisting of a complete blood count, chemistry, alkaline phosphatase, calcium, serum and urine protein electrophoresis, immunoglobulin levels, prostate specific antigen, liver function tests, bone scan, and chest, abdomen, and pelvis computed tomography scans. This workup was negative for any other primary source of malignancy, and the patient's remaining kidney was found to be free from any tumor burden. The patient successfully underwent excisional biopsy of the lesion, which proved to be vascular in nature, consistent with the final pathology of renal cell carcinoma. The longest amount of time from completion of treatment for the primary renal cell carcinoma to discovery of the first metastatic disease has previously been reported at 22.3 years. Mean interval between primary treatment and discovery of metastases has been defined as 3.0+/-5.4 years. This article highlights the need for advanced medical workup as well as maintaining a high clinical suspicion in patients with remote histories of primary malignancies who present with bony lesions.

Malignant pituitary corticotroph adenomas: report of two cases and a comprehensive review of the literature

Corticotroph pituitary carcinomas are tumors, defined by the presence of distant metastases that determine their poor prognosis. The diagnosis and therapy of malignant corticotroph adenomas remains a clinical challenge. The molecular mechanisms of malignant transformation of pituitary adenomas are unclear, although they are believed to arise in an adenoma-to-carcinoma sequence. We describe two cases of malignant Cushing's disease with metastases in liver and bone, respectively. The primary pituitary tumors were treated by a combination of radiotherapy and transsphenoidal surgery, but recurred several times in both patients. The time interval between the diagnosis of Cushing's disease and the discovery of metastases was 32 and 17 years, respectively. In the first case the patient died within 6 months after diagnosis of metastasis, whereas the second patient is alive at a follow-up of 2 years after the discovery of the metastasis. Furthermore, we reviewed all available cases of corticotroph pituitary carcinomas reported in the literature and analyzed their clinical features and therapeutical management. In conclusion, frequent relapses of Cushing's disease, aggressive growth of macroadenoma, Nelson's syndrome after adrenalectomy or persistently high ACTH levels should prompt the clinician to consider the possibility of pituitary corticotroph carcinomas.

Procarbazine, Lomustine, Vincristine Combination may be Effective in Adult Medulloblastoma Patients with Systemic Metastases

Medulloblastoma is an aggressive malignant central nervous system tumor that commonly arises from the cerebellum. In adults medulloblastomas are very rare, accounting for <1% of all adult brain tumors. In contrast to other CNS tumors, medulloblastoma has a rate of about 5–10% to metastasize extracranially. With the current therapy options median survival after the discovery of metastases is 9.5 months in adults [1]. We present a case of medulloblastoma who has recurred with bone and lymph node metastases and has been successfully treated with a combination of procarbazine, lomustine, and vincristine. A 22-year-old man presented with a progressively increasing headache for 3 months. He was free of any other complaints or any neurologic symptoms. Physical examination revealed no specific finding. Cranial magnetic resonance imaging (MRI) showed a mass at the left posterior fossa of the cranium. The mass was totally excised and histopathological diagnosis was desmoplastic medulloblastoma, WHO grade 4. The patient was treated with craniospinal axis radiation therapy and he had no symptoms and findings of recurrences for 2 years. The patient developed back pain 2 years after the completion of primary treatment. On physical exami

Increased expression of tenascin in pheochromocytomas correlates with malignancy.

Tenascin is a significant extracellular matrix glycoprotein, which is upregulated in various neoplasias and pathologic processes. Pheochromocytomas are rare tumors of the sympathoadrenal system, whose malignancy is almost impossible to predict. There are no histologic or chemical markers available that would define the malignant behavior of these tumors, except the discovery of metastases. In our search for new markers, we investigated the immunohistochemical expression of tenascin in a large number of pheochromocytomas and paragangliomas. Seven tumors were metastasized and were thus considered malignant. Normal adrenal medulla was tenascin negative. A striking difference was seen between malignant and benign pheochromocytomas. All malignant pheochromocytomas expressed stromal tenascin strongly or moderately, whereas most benign pheochromocytomas (28 of 37, 70%) showed no or only weak immunopositivity. The staining was strong or moderate also in 13 of 28 (46%) of the tumors that showed histologically suspicious features, here called borderline tumors. Paragangliomas showed a more heterogeneous staining pattern, and no significant difference was found between benign and malignant paragangliomas. To our knowledge, this is the first study to demonstrate the expression of tenascin in pheochromocytomas and particularly the enhanced expression in malignant pheochromocytomas. We therefore suggest that tenascin may be associated with the malignant transformation and metastasis of pheochromocytomas. It is also a potential marker predicting more aggressive behavior in pheochromocytomas.

MACROSCOPIC HEMATURIA AS AN INITIAL MANIFESTATION OF CARCINOMA OF THE COLON

Secondary neoplasms of the prostate are rare and usually diagnosed at autopsy.' The primary tumor is most commonly of hematological origin or it emanates from an adjacent organ.2 A number of cases have been reported in which the primary tumor was diagnosed after the discovery of metastasis to the prostate. We report an unusual case of previously unknown colon cancer of which the initial manifestation was hematuria due to prostatic metastasis. CASE REPORT An 82-year-old man was hospitalized due to macroscopic hematuria. History was significant for transurethral prostatectomy 3 years previously with benign histology. Physical examination demonstrated a hard and nodular prostate. Serum prostate specific antigen was 3 ng./ml. (normal less than 4). Cystoscopy showed an irregular prostatic urethra and urine cytology revealed malignant adenoid type cells. The patient underwent transurethral prostatectomy. Histopathological evaluation showed well differentiated mucin producing adenocarcinoma that was probably metastatic from the colon. Staining was positive for carcinoembryonic antigen and negative for prostatic acid phosphatase (see figure). Colonoscopy showed 2 polypoid tumors in the right colon that were histologically diagnosed as well differentiated adenocarcinoma of the colon.

Orchidectomy followed by radiotherapy in 176 stage I and II testicular seminoma patients: benefits of a 10-year follow-up study

Results are presented for 176 patients with stage I and II primary testicular seminoma treated at the Dr. Daniel den Hoed Cancer Center (DDHCC) between 1975 and 1985. The median follow-up time was 7 years and 4 months. One-hundred and seventy-four (99%) of these patients were treated primarily with radiotherapy after extensive staging. According to the Royal Marsden Staging Classification, 132 patients (75%) were stage I, 8 (5%) were stage IIA, 21 (12%) were stage IIB, 9 (5%) were stage IIC and for 6 stage II patients a further subdivision was not possible. At 5 years the actuarial relapse-free survival and the actuarial survival were 95 and 99%, respectively, for stage I, and 77 and 91% for stage II. Prophylactic irradiation of the mediastinum has not been performed for stage II patients. Five stage II patients relapsed in the mediastinum. Four out of these five relapses were cured with chemotherapy, and in one case, in combination with radiotherapy, at the time of relapse. These results indicated that prophylactic irradiation of the mediastinum appeared to be unnecessary for stage II patients. Tumour markers were not useful in the discovery of metastases. Five years after treatment no relapses were seen. Therefore, it is proposed that a maximum follow-up of 5 years is sufficient to measure disease-free survival.

Synovial sarcoma metastatic to the mandible: Report of two cases

While tumor metastasis to the mandible is considered rare, its true incidence probably is underreported for several reasons. First, the historical rarity of this manifestation of malignancy may result in a lowered index of suspicion on the part of clinicians; radiographic and radionuclide bone surveys done during metastatic workups seldom include separate views of the jaws. Second, asymptomatic or mildly symptomatic lesions may be overlooked in cancer patients, or may be thought to be odontogenic or benign in nature. Finally, patients may die before jaw metastases become apparent, and postmortem examinations rarely include the mandible. The discovery of metastasis may signal a change in prognosis that can affect both oncologic treatment planning and patient management. A mandibular lesion may provide the first indication that a known primary cancer has spread or that generalized metastatic disease is progressing. It can indeed be the very first sign of an occult malignancy. Metastasis is one of the major causes of treatment failure in clinical oncology. 1 For these reasons, the importance of careful clinical and radiographic investigation of apparent dental aberrations in cancer patients cannot be overstated. The following report describes, in two patients, the metastasis of a very rare soft-tissue sarcoma to the mandible, and its presentation, diagnosis, clinical course, and outcome.

Extracranial metastases of medulloblastoma in adults: literature review.

A consecutive series of 30 cases of extracranial medulloblastoma metastases in adults is analysed. The majority of the patients were males with a 3:1 male/female ratio. Bone was the most frequent site of metastases in adults (77%) and children (78%), followed by lymph nodes (33%) in both children and adults. Lung metastases were more common in adults (17%), but liver metastases occurred more frequently in children (15%). Possible routes of spread and development of metastases are discussed, with special emphasis on the role of shunts in tumour seeding. Distant extracranial metastatic spread of medulloblastoma occurs at the rate of 7.1%. Mean interval between operation of the primary tumour and the discovery of metastases was shorter in children (20 months) than in adults (36 months). Survival after the discovery of metastases was also shorter in children (5 months) than in adults (9.5 months). Shunts were associated with an earlier appearance of metastases and with a poorer prognosis. A detailed review of the literature of 119 cases of medulloblastoma with extracranial metastases is provided.

Long-term Survival Following Nodal Metastases from Basal Cell Carcinoma

A case of long-term survival with metastatic basal cell carcinoma to regional lymph nodes is presented. The literature has been briefly reviewed. When a metastatic basal cell carcinoma is discovered, the average survival is only 8 to 10 months. The patient in this case report has been followed for 10 years from the initial metastatic discovery and 7 years from the last metastatic surgery by one of the authors. There has been no evidence of recurrent disease. The topic of metastatic basal cell carcinoma is detailed in this report.

Evaluation of Prostate-Specific Antigen in Prostate Cancer

Prostate-specific antigen (PSA) was assayed retrospectively in 131 prostate cancer patients. Pretreatment levels at primary tumor diagnosis were above 5 ng/ml in 13/16 (81%) of stage B and C patients and in 28/28 (100%) of stage D (D1 and D2) patients. At the discovery of metastasis in treated patients, they were above this value in 12/17 (71%) of patients. To determine the value of PSA assays when physical exams were negative, 52 patients were reevaluated at a maximum interval of 12 months as a function of their initial PSA concentration. When the initial PSA was negative, there was no clinical evolution during the next 6 months; when PSA was positive, patients had a 55% risk of progression in the next 4 months. All PSA assays were coupled with prostatic acid phosphatase (PAP) measurements. No PAP values were positive when PSA was negative.

Intraoperative echotomographic diagnosis in abdominal and neurosurgery.

In many clinics, intraoperative sonography is used as a routine method in general surgery as well as in neurosurgery. The availability of sterilizable applicators in diverse shapes and sizes enables the optimal approach to the site to be examined. In processes involving the liver, the pancreas, the kidneys, or the brain, ultrasonic examination, together with an exact topographic localization, proved to be helpful in determining the dimensions of an altered structure. In patients with colorectal carcinoma, the discovery of metastases that had not been previously detected by percutaneous sonography proves the necessity of regular intraoperative ultrasonic examination to augment staging accuracy in tumor surgery.

Prognostic Factors in Metastatic Renal Carcinoma

We reviewed 181 cases of metastatic renal carcinoma treated from 1973 to 1982 to characterize the factors associated with prolonged survival. Cumulative survival from the date of first known metastasis was analyzed with respect to the patient age, sex, interval free of disease, performance status, site of metastasis and nephrectomy. Survival for the entire group was 73 per cent at 6 months, 48 per cent at 1 year and 9 per cent at 5 years. Age and sex did not influence survival. Improved survival was correlated with long interval free of disease between nephrectomy and discovery of metastases, normal performance status, metastases limited to the lung parenchyma and removal of the primary tumor. The effect of nephrectomy on survival was not separable from effects of patient selection. The subgroup of patients with the favorable characteristics had longer survival than was reported previously for advanced renal carcinoma (50 per cent at 3 years, median 24 months). These patients may be appropriate candidates for more aggressive therapy. These factors should be considered in the analysis of results of future clinical trials on metastatic renal carcinoma.