Retroperitoneal Lymph Node Recurrence Research Articles

Retroperitoneal lymph node recurrence of epithelial ovarian cancer: Prognostic factors and treatment outcome

ObjectiveTo evaluate the treatment outcome and survival of patients with epithelial ovarian cancer recurrence isolated to the retroperitoneal lymph nodes compared to intraperitoneal spread. MethodsA retrospective cohort study including women with recurrence of epithelial ovarian, cancer, who were treated at a single medical center, between 2000 and 2015. Patients were classified into three groups according to the site of recurrence: intraperitoneal only, retroperitoneal lymph nodes only, and both. Response to treatment was assessed by the RECIST criteria. ResultsOut of 135 patients in our cohort, 66 were diagnosed with intraperitoneal recurrence, 30 with retroperitoneal lymph node recurrence and 39 with combined site recurrence. The clinical, pathological and surgical characteristics were similar among all groups, besides CA-125 which was significantly lower in the retroperitoneal recurrence group at diagnosis, end of treatment and recurrence. The median follow-up period was 45.8 months. Overall survival (OS) and post relapse survival (PRS) were significantly higher in the retroperitoneal recurrence group vs. the intraperitoneal and combined site recurrence groups. (OS – 93.07, 47.9 and 41.7 months, respectively, p < .001, PRS – 68.57, 29.67 and 19.7 months, respectively, p < .001). On cox's regression analysis, retroperitoneal recurrence was found to be an independent prognostic factor for survival. ConclusionsThe site of recurrence has significant prognostic value regarding PRS and OS. Patients with recurrence limited to the retroperitoneal lymph nodes have a favourable prognosis with median survival longer than 5 years.

Laparoscopic Cytoreduction for Isolated Retroperitoneal Lymph Node Recurrence in Gynecologic Malignancies: Experience of Hospital Italiano of Buenos Aires, Argentina

Laparoscopic Cytoreduction for Isolated Retroperitoneal Lymph Node Recurrence in Gynecologic Malignancies: Experience of Hospital Italiano of Buenos Aires, Argentina

Oncological control associated with surgical resection of isolated retroperitoneal lymph node recurrence of renal cell carcinoma.

To evaluate the outcome of patients after surgical resection of isolated retroperitoneal lymph node (RPLN) recurrence of renal cell carcinoma (RCC) using a multicentre international cohort. In all, 50 patients were identified who underwent resection of isolated RPLN recurrence of RCC at four institutions after nephrectomy for pTany Nany M0 disease. Progression-free (PFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Cox proportional hazards regression models were used to assess the association of clinicopathological characteristics with disease progression. The median (interquartile range, IQR) age at resection was 57.0(50.0-62.5)years. The median (IQR) time to RPLN recurrence after nephrectomy was 12.6(6.9-39.5)months, with no significant difference in median time to RPLN recurrence between patients with N+ disease at nephrectomy (10.7[6.5-24.6]months) and those with Nx/pN0 disease at nephrectomy (13.7[8.7-44.2]months) (P = 0.66). The median (IQR) size of the RPLN recurrence before resection was 2.6(1.9-5)cm. The most common site for RPLN recurrence was within the interaortocaval region (34%). The median (IQR) follow-up after RPLN resection for patients alive at last follow-up was 28.0(13.7-51.2)months. During follow-up, 26 patients developed RCC recurrence, at a median (IQR) of 9.9(4.0-18.5)months after RPLN resection. Of those who developed a secondary recurrence, disease was again isolated to the retroperitoneum in seven patients. In all, 11 patients subsequently died, including 10 who died from disease. The median PFS after RPLN resection was 19.5months, with a 3- and 5-year PFS of 40.5% and 35.4%, respectively. We also found that RPLN recurrence at ≤12months after nephrectomy was associated with a significantly inferior median PFS (12.3months) compared with RPLN recurrence at >12months after nephrectomy (47.6 months; P = 0.003). Moreover, on multivariate analysis, a shorter time to recurrence remained associated with a significantly increased risk for subsequent disease progression (hazard ratio 3.51; P = 0.005). Surgical resection of isolated RPLN recurrence from RCC may result in durable cancer control in appropriately selected patients. Recurrence at ≤12months after nephrectomy was associated with a significantly increased risk of progression after resection, underscoring the importance of this variable for risk stratification. Thus, we recommend that, in the setting of isolated RPLN recurrence of RCC (in patients without precluding comorbidities), careful consideration with the patients and medical oncology colleagues be undertaken about the relative and individualised benefits of surgical resection, systemic therapy, and surveillance.

CT-guided permanent 125I seed interstitial brachytherapy for recurrent retroperitoneal lymph node metastases after external beam radiotherapy

To evaluate the feasibility, efficacy, and safety of permanent (125)I seed interstitial brachytherapy reirradiation in patients with retroperitoneal lymph node recurrence under CT guidance. Seventeen patients with 19 retroperitoneal lymph node recurrence after external beam radiotherapy underwent CT-guided (125)I seed implant brachytherapy from October 2007 to August 2014. Treatment for all patients was preplanned using a three-dimensional radiation therapy planning system 3-5days before brachytherapy; dosimetry verification was performed immediately after brachytherapy. The actuarial D90 (dose delivered to 90% of the target volume) was 100-198Gy (median, 126.5Gy). In 9 patients, pain intensity decreased to mild pain 1-3weeks after brachytherapy. Pain-free survival ranged 2-15months (median, 5months; 95% confidence interval [CI]: 0.1, 9.9). The overall response rate was 19 of 19 (100%). The median local control time was 15months (95% CI: 2.3, 27.7). The 6-, 12-, and 24-month local control rate was 88.0%, 63.2%, and 42.1%, respectively. Twelve patients (70.6%) developed distant metastases and died. Two patients (11.8%) are alive with distant metastases but no evidence of local recurrence. Three patients (17.6%) are alive with no evidence of local recurrence. Median overall survival was 10months (95% CI: 5.7, 14.3); the 1- and 2-year survival rates were 38.1% and 15.3%, respectively. No major complications related to the procedure occurred during or after brachytherapy. Reirradiation with CT-guided permanent (125)I seed interstitial brachytherapy is feasible, safe, and effective as pain relief or salvage treatment for patients with recurrent retroperitoneal lymph nodes.

Incorporation of radiotherapy in the multidisciplinary treatment of isolated retroperitoneal lymph node recurrence from colorectal cancer.

This article was designed to study the clinical outcomes and prognostic factors following radiotherapy (RT) in the multidisciplinary management of isolated retroperitoneal lymph node (RPLN) recurrence of colorectal cancer. We identified 52 patients treated consecutively with tumor-directed RT for isolated RPLN recurrence. Twenty-five patients received upfront RT (Group 1). Twenty-seven patients received RT after systemic therapy. The deferred RT was administered either to locally controlled tumors (Group 2, n=17) or to locally progressive tumors in RPLNs (Group 3, n=10). The median overall survival and progression-free survival were 41 and 13months, respectively, with a median follow-up time of 34months. Survival was not significantly different among three groups. Local recurrence (32/52) was predominant and occurred earlier than distant metastasis (31/52). Two-thirds of the local recurrences (21/32) involved outfield recurrence, which was mostly in the cranial direction (15/21) from the upper margin of the RT volume. Repeated RT successfully salvaged a substantial number of patients. A shorter disease-free interval, low-dose radiation, and a tumor location above the renal vein were independent risk factors for local recurrence (all P<0.05). A large gross tumor volume was an independent risk factor for distant metastasis (P=0.037). No acute or late RT-related toxicity ≥ grade 3 occurred. Our analysis suggests that both upfront RT and deferred RT incorporated into multidisciplinary management are potentially effective treatment strategies. We found that gross tumor volume, tumor location, and disease-free interval are important prognostic factors and should be taken into consideration to decide the timing of RT.

OP3-08 SURGICAL OUTCOMES IN THE MANAGEMENT OF ISOLATED NODAL RECURRENCES: A MULTICENTER INTERNATIONAL RETROSPECTIVE COHORT

You have accessJournal of UrologyOutstanding Posters: Oncology1 Apr 2014OP3-08 SURGICAL OUTCOMES IN THE MANAGEMENT OF ISOLATED NODAL RECURRENCES: A MULTICENTER INTERNATIONAL RETROSPECTIVE COHORT Christopher M. Russell, Wassim Kassouf, Patrick Espiritu, David D. Buethe, Michael Poch, Wade J. Sexton, Julio M. Powsang, Simon Tanguay, Armen Aprikian, Michael Hanzly, Thomas Schwaab, and Philippe Spiess Christopher M. RussellChristopher M. Russell More articles by this author , Wassim KassoufWassim Kassouf More articles by this author , Patrick EspirituPatrick Espiritu More articles by this author , David D. BuetheDavid D. Buethe More articles by this author , Michael PochMichael Poch More articles by this author , Wade J. SextonWade J. Sexton More articles by this author , Julio M. PowsangJulio M. Powsang More articles by this author , Simon TanguaySimon Tanguay More articles by this author , Armen AprikianArmen Aprikian More articles by this author , Michael HanzlyMichael Hanzly More articles by this author , Thomas SchwaabThomas Schwaab More articles by this author , and Philippe SpiessPhilippe Spiess More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2329AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES 10 - 24% of patients treated surgically for local renal cell carcinoma (RCC) will experience a post-surgical recurrence, which poses a therapeutic challenge as surgical resection represents the only potentially curative option. Isolated nodal recurrence represents a subset of locoregional recurrence, yet to be described in detail, which may demonstrate a unique disease course and response to surgical intervention. METHODS Upon IRB approval a retrospective chart review at three independent institutions, identified 36 patients surgically treated for isolated nodal recurrence of RCC between 1993 and 2012. Of those, 22 met inclusion criteria of pTanyNanyM0 disease at initial nephrectomy and pTanyN1M0 disease at time of recurrence. Clinical, pathological, and radiological characteristics were reviewed. Progression free survival (PFS) was estimated using the Kaplan-Meier method. RESULTS At diagnosis the median age was 57 years (range 10-76) years. Overall median time to primary recurrence following nephrectomy was 31.5 months. Median size of nodal recurrence by radiographic imaging was 2.6 cm (range 1.5-10.2). Following resection of isolated nodal recurrence, 10 patients (45%) developed a secondary recurrence at a median of 10.2 months (range 2.5-47.6), and 2 (9%) succumbed to their disease. Neither pathologic staging nor positive lymph node density correlated with increased risk of secondary recurrence. There were no recorded intraoperative complications, mean estimated blood loss was 325 mL (range 20-1250), and median length of stay was 5 days (range 2-16). Overall median PFS was 12.7 months, and was 24.8 months in T(1-2) tumors, 9.9 months in T3 tumors, 13.4 months in clear cell recurrences, and 17.6 months in non-clear cell recurrences. Median follow-up in our cohort was 22.3 months (range 12.5-45.7). CONCLUSIONS Surgical resection represents the best curative option for patients presenting with isolated retroperitoneal lymph node recurrence of RCC, and a durable PFS following surgery is attainable in many patients regardless of initial tumor stage or histology of recurrence. As such all patients free of precluding comorbidities should be considered for complete surgical resection by an experienced genitourinary surgeon. Also of note, despite similar survival statistics, tumors with a clinical stage ≥ T3 exhibited a general trend to develop secondary recurrence sooner than their T1 and T2 counterparts, suggesting that these patients may require more aggressive monitoring in the initial post-operative period. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e854 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Christopher M. Russell More articles by this author Wassim Kassouf More articles by this author Patrick Espiritu More articles by this author David D. Buethe More articles by this author Michael Poch More articles by this author Wade J. Sexton More articles by this author Julio M. Powsang More articles by this author Simon Tanguay More articles by this author Armen Aprikian More articles by this author Michael Hanzly More articles by this author Thomas Schwaab More articles by this author Philippe Spiess More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Surgical Outcomes in the Management of Isolated Nodal Recurrences: A Multicenter, International Retrospective Cohort

We report a multicenter international cohort representing what is toour knowledge the largest surgical experience with managing isolated retroperitoneal nodal recurrence of renal cell carcinoma, a unique subset of locoregional disease, yet to be described in detail. Patients with isolated nodal recurrence of pTanyN+M0 disease after nephrectomy were identified by retrospective chart review at 3 independent institutions. Progression-free survival was estimated by the Kaplan-Meier method and used to compare survival outcomes between primary T(1-2)N(any)M0 and T3N(any)M0 tumors as well as clear cell and nonclear cell histology renal cell carcinoma. A total of 22 patients met study inclusion criteria. Median time to localpostoperative recurrence was 31.5 months (IQR 12.9-43.3). After resection of isolated nodal recurrence 10 patients (46%) had a secondary recurrence at amedian of 11.2 months (IQR 8.1-18.4), of whom 2 (9%) died of the disease. Overall median progression-free survival was 12.7 months, including 24.8 months for T(1-2)N(any)M0 tumors, 9.9 months for T3N(any)M0 tumors, and13.4 and 17.6 months for clear and nonclear cell renal cell carcinoma, respectively. Surgical resection represents the best curative option for patients who present with isolated retroperitoneal lymph node recurrence of renal cell carcinoma. Durable postoperative progression-free survival is attainable in many patients regardless of histology or clinical TNM stage. In addition, our cohort showed a lower renal cell carcinoma related mortality rate than in previous series of local metastasis. As such, all patients free of precluding comorbidities should be considered candidates for complete surgical resection performed by an experienced genitourinary surgeon.

Prognostic significance of tumor location and superficial urothelial bladder carcinoma history in patients with ureteral urothelial carcinoma treated with radical nephroureterectomy

To investigate the significance of tumor location and superficial urothelial bladder carcinoma (UBC) history on oncological outcomes in patients treated with radical nephroureterectomy (RNU) for ureteral urothelial carcinoma (UC). One hundred and thirty-two patients treated with RNU for ureteral UC between January 1999 and July 2010 were retrospectively analyzed. Recurrence probabilities and survival rates were analyzed, stratified by tumor location and superficial UBC history. Comparison of patients with proximal, middle, and distal ureteral UC showed that percentage of bladder recurrence was 13.3, 14.7, and 25.0 %, respectively (P = 0.285); retroperitoneal (tumor bed or lymph node) recurrence was 26.7, 14.7, and 27.9 % (P = 0.319); and contralateral recurrence was 0, 2.9, and 0 % (P = 0.234). Comparison of patients with and without history of superficial UBC revealed that percentage of bladder recurrence was 15.4 and 20.2 %, respectively (P = 0.681); retroperitoneal recurrence was 15.4 and 25.2 % (P = 0.433); and contralateral recurrence was 0 and 0.84 % (P = 0.740). Using multivariable Cox regression analyses, there were no significant differences of recurrence-free survival (RFS) and cancer-specific survival (CSS) with regard to neither tumor location nor superficial UBC history (RFS: P = 0.282 and 0.762, CSS: P = 0.272 and 0.818, respectively). Tumor location and history of superficial UBC could not be used to predict oncological outcomes of patients who underwent RNU for ureteral UC. Therefore, operative strategies or postoperative surveillance should not be affected by tumor location or history of superficial UBC.

Ovarian Metastasis Is Associated with Retroperitoneal Lymph Node Relapses in Women Treated for Colorectal Peritoneal Carcinomatosis

To analyze the patterns of recurrence and the prognostic impact of ovarian metastases (OM) in a population of women with colorectal peritoneal carcinomatosis (CRPC) treated with curative intent. Data from all consecutive women with CRPC who underwent curatively intended complete cytoreductive surgery (CRS) plus intraperitoneal chemotherapy at our institution were retrieved from a prospective database. A bilateral oophorectomy or a complementary unilateral oophorectomy was systematically performed during CRS. From 1994 to 2009, among 105 women who underwent CRS plus intraperitoneal chemotherapy for CRPC, 62 (60 %) had OM. Women with and without OM had comparable peritoneal cancer index (PCI) scores (10 vs. 12, respectively, p = 0.09). After a median follow-up of 60 (range 5-145) months, median overall survival of women with OM did not differ statistically from that of women without OM (respectively, 36 and 40 months; p = 0.75). Relapses occurred in 82 % of the patients, distributed similarly between the two groups except for retroperitoneal lymph node recurrence, which occurred in 19 patients (18 %), including 18 with OM. The only predictive factor for a retroperitoneal relapse was a history of OM (p = 0.0012). Retroperitoneal lymph node recurrence seems to be linked to OM originating from colorectal cancer and could worsen the prognosis. A systematic lymphadenectomy could be evaluated in women with isolated OM or very limited peritoneal carcinomatosis to analyze the incidence of invaded lymph nodes and study its potential benefit on survival.

Use of laparoscopy as an alternative to computed tomography (CT) and positron emission tomography (PET) scans for the detection of recurrence in patients with gastric cancer: a pilot study

This study aimed to evaluate laparoscopy as a diagnostic method for detecting recurrence in patients with advanced gastric cancer. Diagnostic laparoscopy was performed for 12 patients with insufficient evidence of intraabdominal gastric cancer recurrence by computed tomography or positron emission tomography. By comparing laparoscopic observations with conventional radiologic results, the diagnostic accuracy of laparoscopy was assessed. In 11 (92%) of 12 cases of recurrence not diagnosed by imaging studies, laparoscopic examination confirmed the case as a recurrence. Using diagnostic laparoscopy, retroperitoneal lymph node recurrence was confirmed in two patients, peritoneal seeding nodules in five patients, and recurrent masses invading the mesocolon in two patients. Two patients had no definitive recurrence grossly but were confirmed as recurrence cases by washing cytology during the laparoscopic procedure. One patient had a duodenal stump recurrence. No patients experienced operation-related morbidity. Laparoscopy is a safe and feasible method for detecting recurrence with acceptable accuracy. This approach provides more accurate information than conventional imaging methods.

Curative Chemoradiotherapy for Isolated Retroperitoneal Lymph Node Recurrence of Colorectal Cancer

Abstract Purpose To investigate the efficacy of curative chemoradiotherapy for isolated retroperitoneal lymph node recurrence of colorectal cancer. Materials and methods Twenty-two colorectal cancer patients who received three-dimensional conformal radiotherapy ( n =20) or helical tomotherapy ( n =2) for isolated retroperitoneal lymph node recurrence were analyzed retrospectively. Radiation dose was 55.8Gy in 31 fractions or 63Gy in 35 fractions, and 60Gy in 20 fractions by helical tomotherapy. All patients received concurrent chemotherapy and 16 (72.7%) received adjuvant chemotherapy. Results The treatment response was complete in 13 (59.1%), partial in 6 (27.3%), and stable in 3 (13.6%) patients. Median follow-up for 11 (50%) surviving patients was 32months (range, 27–61). The 3- and 5-year overall survival rates were 64.7% and 36.4%, and median overall survival was 41months. Recurrences developed in 15 (68.2%) patients; outside the retroperitoneum in 13. The 3- and 5-year recurrence-free survival rates were 34.1% and 25.6%, and median recurrence-free survival was 20months. Response and adjuvant chemotherapy were significant prognostic factors for overall survival. Gastrointestinal toxicity⩾Grade 3 was not observed. Conclusions Definitive chemoradiotherapy is an effective salvage treatment for isolated retroperitoneal lymph node recurrence of colorectal cancer without severe complications.

Curative chemoradiotherapy for isolated retroperitoneal lymph node recurrence of colorectal cancer

Purpose To investigate the efficacy of curative chemoradiotherapy for isolated retroperitoneal lymph node recurrence of colorectal cancer. Materials and methods Twenty-two colorectal cancer patients who received three-dimensional conformal radiotherapy ( n = 20) or helical tomotherapy ( n = 2) for isolated retroperitoneal lymph node recurrence were analyzed retrospectively. Radiation dose was 55.8 Gy in 31 fractions or 63 Gy in 35 fractions, and 60 Gy in 20 fractions by helical tomotherapy. All patients received concurrent chemotherapy and 16 (72.7%) received adjuvant chemotherapy. Results The treatment response was complete in 13 (59.1%), partial in 6 (27.3%), and stable in 3 (13.6%) patients. Median follow-up for 11 (50%) surviving patients was 32 months (range, 27–61). The 3- and 5-year overall survival rates were 64.7% and 36.4%, and median overall survival was 41 months. Recurrences developed in 15 (68.2%) patients; outside the retroperitoneum in 13. The 3- and 5-year recurrence-free survival rates were 34.1% and 25.6%, and median recurrence-free survival was 20 months. Response and adjuvant chemotherapy were significant prognostic factors for overall survival. Gastrointestinal toxicity ⩾ Grade 3 was not observed. Conclusions Definitive chemoradiotherapy is an effective salvage treatment for isolated retroperitoneal lymph node recurrence of colorectal cancer without severe complications.

Metronomic Cyclophosphamide and Vinblastine in Refractory Lymphoma

Full Abstract Introduction A recent phase I report drew attention to the effectiveness of metronomic (daily low-dose oral) CPA and I.V. vinblastine in refractory Hodgkin disease. 1 We used this combination in a patient with Hodgkin lymphoma and extensive prior treatment. The regimen was adapted to include rituximab for another patient who was unfit for R-CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone plus rituximab) therapy due to prior myocardial infarction. Case 1 A 56-year-old patient had first-line chemotherapy for Hodgkin lymphoma stage IVB in 2004, treated with ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine). A year later a recurrence was treated with stem cell transplantation. He presented in February 2008 with extensive bone metastases, for which 45 Gy radiotherapy was given, also with curative intent. In April 2008 we started with metronomic chemotherapy (cyclophosphamide 50 mg + methylprednisolone 32 mg per day orally, vinblastine 3 mg/m 2 intravenously [I.V.] 1 × per week) for retroperitoneal lymph node recurrence. This treatment was well tolerated. After 9 months of treatment, there were no lymph nodes detectable on computed tomography scan. Complete remission now lasts > 3 months. Case 2 An 81-year-old farmer had a myocardial infarction 40 years ago. He presented with cutaneous involvement and axillary lymph node. Biopsy showed a cutaneous involvement by B-cell diffuse large-cell lymphoma. International Prognostic Index score was low. Ejection fraction was 42%. The same chemotherapy was applied (cyclophosphamide 50 mg/d and methylprednisolone 32 mg per day, vinblastine I.V. days 1, 8, 15), but on day 22 of the 28-day cycle, we applied rituximab 375 mg/m 2 . The patient had a complete remission after 4 months of treatment. Conclusion These data confirm the effectiveness of this well-tolerated regimen in refractory lymphoma as well as in a lymphoma patient unfit for anthracyclines. Reference Young S, Whissell M, Noble JC. Phase II clinical results involving treatment with low-dose daily oral cyclophosphamide, weekly vinblastine, and rofecoxib in patients with advanced solid tumors. Clin Cancer Res 2006; 12; 3092-9.

POD-6.09: Retroperitoneal Lymph Node Recurrence in Patients with Transitional Cell Carcinoma of Upper Urinary Tract

Radical nephroureterectomy and bladder cuff resection is the standard treatment modality in patients with transitional cell carcinoma of upper urinary tract (UUT-TCC). However, the indications and roles of lymphadenectomy are uncertain. In this study, we investigated the patterns of retroperitoneal lymph node recurrence in patients with UUT-TCC following nephroureterectomy without lymphadenectomy.

Surgical Resection of Isolated Retroperitoneal Lymph Node Recurrence of Renal Cell Carcinoma Following Nephrectomy

Durable survival has been reported following the resection of solitary metachronous metastasis of renal cell carcinoma at sites including the lung, bone and adrenal. We report our experience with resection of isolated retroperitoneal lymph node recurrence. Patients who underwent surgical resection of isolated metachronous recurrence of renal cell carcinoma in the retroperitoneal lymph nodes following radical nephrectomy for pT(any)N(any)M0 tumors were identified (group 1). Progression-free and cancer specific survival were estimated using the Kaplan-Meier method and compared to survival in patients who had pT(any)N+M0 disease at nephrectomy (group 2) and in patients who underwent complete resection of a solitary metachronous metastasis at other sites (group 3). A total of 15 patients underwent resection of isolated retroperitoneal lymph node recurrence of renal cell carcinoma. Median time from nephrectomy to resection was 10.3 months (range 3 to 159). No patient received systemic therapy before resection. Recurrence was asymptomatic in all except 1 patient. No intraoperative or postoperative mortality occurred. Six patients subsequently died of renal cell carcinoma at a median of 18 months (range 6 to 33.6) following resection. Median progression-free survival in groups 1 to 3 was 9.1, 8.7 and 15.6 months, while median cancer specific survival was 33.3, 20.8 and 46.9 months, respectively. Resection of isolated retroperitoneal lymph node recurrence may be associated with survival rates approaching those of resection of solitary metastasis at other sites. The decreased time to progression relative to patients with resected metastasis at other sites likely reflects the aggressive biology of nodal disease.

A SCORING ALGORITHM TO PREDICT SURVIVAL FOR PATIENTS WITH METASTATIC CLEAR CELL RENAL CELL CARCINOMA: A STRATIFICATION TOOL FOR PROSPECTIVE CLINICAL TRIALS

We developed a clinically useful scoring algorithm to predict cancer specific survival for patients with clear cell metastatic renal cell carcinoma (RCC). We studied 727 patients treated with radical nephrectomy for clear cell RCC from 1970 to 2000 who had distant metastases at nephrectomy (285) or in whom metastases subsequently developed (442). A scoring algorithm to predict cancer specific survival was developed using the regression coefficients from a Cox proportional hazards model. There were 606 deaths from clear cell RCC at a median of 1.0 years (range 0 to 14) following metastatic RCC. Constitutional symptoms at nephrectomy (+2), metastases to the bone (+2) or liver (+4), metastases in multiple simultaneous sites (+2), metastases at nephrectomy (+1) or within 2 years of nephrectomy (+3), complete resection of all metastatic sites (-5), tumor thrombus level I to IV (+3), and the primary pathological features of nuclear grade 4 (+3) and histological tumor necrosis (+2) were significantly associated with death from RCC. All patients started with a score of 0 and points were added or subtracted as indicated in parentheses. Cancer specific survival rates at 1 year were 85.1%, 72.1%, 58.8%, 39.0%, and 25.1%, respectively, for patients with scores of -5 to -1, scores of 0 to 2, scores of 3 to 6, scores of 7 or 8, and scores of 9 or more. This scoring algorithm can be used to predict cancer specific survival for patients with metastatic clear cell RCC.

Small cell carcinoma of the ovary with hypercalcemia causes severe pancreatitis and altered mental status

Background Small cell carcinoma of the ovary is a rare, highly malignant tumor that often exhibits a paraneoplastic hypercalcemia. Case A 27-year-old female presented with pancreatitis and altered mental status with hypercalcemia. Further investigation revealed a left ovarian mass and a small cell carcinoma of the ovary, hypercalcemic type was found. Hysterectomy with bilateral salpingo-oophorectomy was performed, and the patient underwent chemotherapy with carboplatin and paclitaxel. Hypercalcemia resolved after tumor resection. The patient has retroperitoneal lymph node recurrence at 16 months. Conclusion Paraneoplastic hypercalcemia may result in pancreatitis and delirium. Small cell carcinoma of the ovary should be considered under these circumstances.

LACK OF RETROPERITONEAL LYMPHADENOPATHY PREDICTS SURVIVAL OF PATIENTS WITH METASTATIC RENAL CELL CARCINOMA

Patients with metastatic renal cell carcinoma have a reported 5-year survival of 0% to 20%. The ability to predict which patients would benefit from nephrectomy and interleukin-2 (IL-2) therapy before any treatment is initiated would be useful for maximizing the advantage of therapy and improving the quality of life. A retrospective analysis of the x-rays and charts of patients treated at the National Institutes of Health Surgery Branch between 1985 and 1996, who presented with metastatic renal cancer beyond the locoregional area and the primary tumor in place, was performed. Preoperative computerized tomography or magnetic resonance imaging, or radiological reports if no scans were available, were used to obtain an estimate of the volume of retroperitoneal lymphadenopathy. Operative notes were used to evaluate whether all lymphadenopathy was resected or disease left in situ, or if any extrarenal resection, including venacavotomy, was performed. Mean survival rate was calculated from the time of nephrectomy to the time of death or last clinical followup. If patients received IL-2 therapy, the response to treatment was recorded. Mean survival and response rate for IL-2 were compared among patients in 3 separate analyses. Patients without preoperatively detected lymphadenopathy were compared with those with at least 1 cm.3 retroperitoneal lymphadenopathy. Also, the patients who had detectable lymphadenopathy were divided into subgroups consisting of all resected, incompletely resected, unresectable and unknown if all disease was resected. Each subgroup was compared with patients without detectable preoperative lymphadenopathy. Patients with less than were compared to those with greater than 50 cm.3 retroperitoneal lymphadenopathy. Patients undergoing extrarenal resection at nephrectomy (complex surgery) due to direct invasion of the tumor into another intra-abdominal organ were compared with those undergoing radical nephrectomy alone, regardless of lymph node status. Statistical analysis was done with the Mantel-Cox test for comparison of survival on Kaplan-Meier curves and with Fisher's exact test for response rates for IL-2. A total of 154 patients with metastatic renal cell carcinoma underwent cytoreductive nephrectomy as preparation for IL-2 based regimens. There were 82 patients with metastatic renal cell carcinoma and no preoperative retroperitoneal lymphadenopathy who survived longer (median 14.7 months) than the 72 with lymphadenopathy (median 8.5, p = 0.0004). Patients with incompletely resected, unresectable or an unknown volume resected had decreased survival compared to those with no retroperitoneal lymphadenopathy. A multivariate analysis of survival was performed evaluating the known prognostic indicators, performance status and tumor burden, as represented by the number of organs involved with metastases, and the new prognostic factor, lymphadenopathy. Lymphadenopathy was more closely associated with survival than performance status, and appeared to be a new prognostic variable. Patients with and without retroperitoneal lymphadenopathy at initial presentation had similar rates for treatment with IL-2 (54% for both groups). Of the 82 patients with no lymphadenopathy 11 (13%) had long-term survival greater than 5 years. Of the 6 complete responses to IL-2, 5 occurred in this group. Only 1 other patient with incompletely resected retroperitoneal lymphadenopathy survived longer than 5 years. No significant difference in survival was seen between patients who did or did not undergo complex surgery. Patients who presented with metastatic renal cancer and retroperitoneal lymphadenopathy had a shorter survival than those with no detectable retroperitoneal lymphadenopathy. It is warranted to continue to perform complex extrarenal resection during nephrectomy since no significant difference in the response rate for IL-2 or mean survival compared with those of patients undergoing nephrectomy alone is currently detectable.

Retroperitoneal node biopsy in paratesticular rhabdomyosarcoma

Retroperitoneal lymph node dissection (RPLND) was used in 121 Intergroup Rhabdomyosarcoma Study (IRS) III patients with nonmetastatic paratesticular (PT) rhabdomyosarcoma (RMS) to assess retroperitoneal lymph node (RPLN) involvement so as to determine the need for x-ray therapy (XRT). Clinical node evaluation (CNE) was accomplished by a computed tomography (CT) scan in 105 and a sonogram in six. Pathological node evaluation (PNE) was performed in 113: lymphadenectomy (9 bilateral, 85 unilateral) and biopsy in 19. Vincristine and actinomycin D were used for 1 year postoperatively in 89%; all patients who had positive PNE received RPLN XRT. This study compares CNE with PNE and evaluates predictors of relapse and survival. Findings: There were clinically negative nodes (cN0) in 81% of the 121 patients. Among cN0 patients, 14% had positive nodes (pN1). Of the clinically positive (cN1) patients, 94% had pN1. RPLN relapse occurred in only two of the 121 patients. Initially both had cN0 and one had PNE that was negative. For all 121 patients, the 5-year survival was 91%. For cN0 patients, the 5-year survival was 96% compared with 69% for cN1 patients ( P < .001). Among the children in whom treatment failed, nodes were cN1 in 5 of 11 (45%) compared with 15 of 107 (14%) in those whose treatment did not fail ( P < .008). Conclusions: (1) Results of RPLN imaging studies were negative in 81% of patients with PT RMS (specificity 99%, sensitivity 57%). (2) RPLN recurrence is uncommon (even when RPLN are initially involved) if regional XRT and appropriate chemotherapy are used. (3) RPLN biopsy is not necessary to confirm positivity in patients with clinically positive nodes. (4) Node positivity is associated with decreased patient survival and helps identify patients who have an increased risk for relapse and death.