Tumor Scoring Systems Research Articles

A rational analysis of the commonly used renal tumor scoring systems in predicting surgical outcomes of cystic renal masses

Objective: To explore the predictive effect of the renal tumor scoring system on the surgical outcomes of cystic renal masses (CRMs). Methods: A retrospective analysis was performed on the data of 234 patients who received robotic-assisted partial nephrectomy (RAPN) treatment in the First Affiliated Hospital of Xi'an Jiaotong University from January 2018 to June 2020. And 31 cases had cystic renal masses (CRM) and 203 cases had solid renal masses (SRM). The propensity score of patients was calculated by logistic regression model, and 1∶2 matching was performed by the nearest neighbor method. The changes in perioperative indexes and long-term estimated glomerular filtration rate (eGFR) in CRM group and SRM group were compared. The CRM group and SRM group were stratified according to the complexity grading of R.E.N.A.L. score and PADUA score, respectively, to compare the difference in the achievement rate of ideal surgical outcome between the two groups, and analyze the predictive factors affected. The CRM diameter was stratified with 4 cm as the cut-off value (CRM1 group with a diameter<4 cm, CRM2 group with a diameter≥4 cm), and the surgical results were compared with the matched SRM1 group and SRM2 group. Results: In the matching cohort, the CRM group comprised 29 patients with a mean age of (48.7±10.8) years, of which 22 (75.9%) were males. The SRM group included 58 patients with a mean age of (50.4±10.2) years, of which 41 (70.7%) were males, with no statistically significant difference (all P>0.05). The warm ischemia time (WIT) [M (Q1,Q3)] in the CRM group was longer than that in the SRM group [23(18, 25) vs. 19(17, 25) min, P=0.040]. The operation time (OT) [M (Q1,Q3)] in the CRM group was also longer than that of the SRM group [130(100, 150) vs. 107.5(86.25, 120) min, P=0.006]. The change in serum creatinine before and after the operation [M (Q1,Q3)] was higher in the CRM group than in the SRM group [15(9, 23) vs 11.5(6, 16.75) μmol/L, P=0.030]. The ideal surgical outcomes were achieved in 7 patients (24.1%) in the CRM group and 36 patients (62.1%) in the SRM group. The number of patients achieving ideal surgical outcomes in R.E.N.A.L. intermediate complex surgery and PADUA advanced complex surgery in the SRM group were 24 (58.5%) and 15 (51.7%), respectively, which were higher than those in the CRM group 6 (27.3%) and 1 (5.9%) respectively (P<0.05). Preoperative eGFR (OR=0.758, 95%CI: 0.719-0.799) and the nature of the tumor (CRM as reference, OR=4.883, 95%CI: 1.550-15.378) were influencing factors for achieving the ideal surgical outcome. Subgroup analysis showed that eGFR changes before and after surgery and the estimated blood loss (EBL) in the CRM2 group were higher than those in the SRM2 group, and WIT and OT were longer than those in the SRM2 group (all P<0.05). The EBL and WIT of the CRM1 group were shorter than those of the CRM2 group (P<0.05). Conclusion: The surgical risk of RAPN in complex CRMs with a maximum diameter of≥4 cm is higher than the risk of RAPN in SRM with equivalent R.E.N.A.L. and PADUA scores.

Evaluation of a novel Re-VASC score to differentiate malignant and benign T1a renal masses.

e16548 Background: Early characterization of renal cell carcinoma (RCC) is pertinent for cancer prognosis and patient treatment. However, characterization of renal masses as benign or malignant on computed tomography (CT) remains a difficult clinical challenge. Angiogenesis plays a major role in RCC progression and assessing neovascularity in tumor-burdened kidneys with Re-VASC scoring has been shown to aptly predict tumor pathology and staging. In the current study, we evaluated if Re-VASC can reliably differentiate between malignant T1a ( &lt; 4cm) RCC and benign T1a renal masses. Methods: All eligible patients had a diagnosis of T1a from pathologic or clinical evaluation. The inclusion criteria for malignant masses included a diagnosis of RCC by pathology after partial or radical nephrectomy. Our T1a benign group was comprised of patients with a diagnosis of a non-malignant renal mass (angiomyolipoma or oncocytoma) established via histopathology or CT imaging (fat containing lesions). Re-VASC score was calculated on axial preoperative contrast enhanced CT utilizing the system described below: 0 = No visible neovascularization 1 = visualized single new vessel &lt; 3mm in diameter 2 = visualized single new vessel ≥3mm in diameter 3 = visualized multiple new vessels &lt; 3mm in diameter 4 = visualized multiple new vessels and at least one vessel ≥3mm in diameter. Results: A total of 64 benign and 69 malignant T1a tumors were included. Comparison of the two groups demonstrated no significant differences with regards to age, sex, ASA, and BMI. The average Re- VASC scores was 0.159 and 0.753 for benign and malignant masses respectively (p &lt; 0.001). Additionally, the tumor size for benign masses was 2.373 and for malignant masses was 2.546 (p = 0.210). There was no significant difference in Re-VASC score between the contralateral kidneys of malignant and benign kidney masses (p &lt; 0.508). Additionally, the sensitivity, specificity and positive predictive values were 26%, 86% and 74% respectively, when utilizing a Re-VASC score of 1 as a cutoff for malignancy. Conclusions: Our results show a significantly higher Re-VASC score in T1a malignant tumors and T1a benign tumors. While biopsy remains the gold standard for confirmation of malignant tumors such as RCC, radiological evaluation with tumor scoring systems like Re-VASC may offer a useful clinical decision-making tool in a less-invasive manner. Because renal biopsy carries non-negligible risk of complications, reducing volume of biopsies among low-risk patients may lead to better overall care. The Re-VASC score shows potential as a confirmatory test with a specificity of 86%. We would like to apply the Re-VASC score to an expanded multi-center trial, in order to assess its translatability to the general population.

Pediatric Adrenocortical Neoplasms: A Study Comparing Three Histopathological Scoring Systems.

Adrenocortical neoplasms are rare in childhood. Their histopathological categorization into benign and malignant is often challenging, impacting further management. While the AFIP/Wieneke scoring system is widely used for the prognostic classification of these tumors, it has limitations. Few other tumor scoring systems have evolved over the past few years. These have been validated in adults but not yet in pediatric patients. We evaluated a cohort of pediatric adrenocortical neoplasms to assess the applicability of AFIP/Wieneke criteria and the recently introduced Helsinki score and reticulin algorithm in predicting clinical outcomes. A tumor was considered 'clinically aggressive' in the presence of any of the following: metastases, recurrence, progressive disease, or death due to disease. Cases without any such event were considered 'clinically good'. Event-free survival time was the duration from the date of clinical presentation to any post-operative adverse event. For overall survival analysis, the endpoint was either the last follow-up or death due to disease.Using ROC curve analysis, the obtained cut-off Helsinki score of 24 could stratify the cases into two prognostically relevant groups. Survival analysis showed significant differences in the event-free and overall survival of these two groups of patients, validating the proposed cut-off. None of the three histopathological scoring systems could predict an unfavorable outcome with 100% accuracy. All showed a sensitivity of ≥ 80%, with the reticulin algorithm achieving 100% sensitivity. The specificity and accuracy of the AFIP/Wieneke criteria were the lowest (62.5% and 73.08%, respectively). While the Helsinki score (at the cut-off score of 24) and the reticulin algorithm had similar accuracy rates (80.77%, and 80%, respectively), the specificity of the former was higher (81.25%) than the latter (68.75%). A separate analysis revealed that the Ki-67 index at a cut-off of 18% had a sensitivity of 80% and a specificity of 81.25% for predicting an unfavorable outcome.

Use of a Novel Thyroid-Stimulating Hormone Model for Predicting the Progression of Hepatocellular Carcinoma.

BackgroundIndividuals with hepatocellular carcinoma (HCC) are at risk of tumor recurrence after surgical resection, which affects their survival. The aim of the present study was to establish a model for predicting tumor progression in patients with HCC.MethodsTo develop and validate the efficacy of a novel prognostic model, a retrospective cohort with HCC (n = 1005) at Beijing Ditan Hospital was enrolled from January 2008 and June 2017. Furthermore, a prospective cohort (n = 77) was recruited to validate the association between thyroid-stimulating hormone (TSH) levels and tumor progression in patients with HCC.ResultsThe model used in predicting the progression of HCC included four variables (namely, Barcelona Clinic Liver Cancer [BCLC] stage, presence of portal vein tumor thrombus, alpha-fetoprotein level, and TSH level). The AUROC of the 1-year progression-free survival (PFS) model was 0.755 and 0.753 in the deriving cohort and validation cohort, respectively, and these values were significantly higher than those of the Child–Pugh score, Model for End-stage Liver Disease (MELD), tumor–lymph node–metastasis (TNM) staging system, Okuda classification, and CLIP score. A simple assessment using a nomogram showed the 1-year PFS rate of patients with HCC. In the prospective cohort, the KM curve showed that the high TSH level group had a shorter PFS than the low TSH level (p = 0.001).ConclusionThe prognostic model of HCC progression was superior to other well-known classical tumor scoring systems. A high TSH level was correlated to poor outcome, particularly those with advanced HCC.

Contact surface area and its association with outcomes in robotic-assisted partial nephrectomy.

Renal tumor scoring systems, such as the contact surface area value, aim to assist in predicting outcomes following robotic-assisted partial nephrectomy. The aim of this study is to identify associations between specific postoperative outcomes and the contact surface area of renal masses. We analyzed 332 consecutive robotic-assisted partial nephrectomies and calculated contact surface area for renal tumors with the contact surface area formula (CSA = 2πrd), where π ≈ 3.14, r = greatest tumor radius (cm), and d = greatest tumor depth (cm). Higher contact surface area was associated with longer warm ischemia time (P < .001), higher estimated blood loss (P < .001), and longer length of hospital stay (LOS) (P < .001). Higher contact surface area was significantly associated with decreased renal function at 1 day, 1 month, and 6 months following robotic-assisted partial nephrectomy. Contact surface area is associated with certain outcomes following robotic-assisted partial nephrectomy and may be a useful predictive tool.

Tumor re-growth, case outcome, and tumor scoring systems in rehabilitated green turtles with fibropapillomatosis.

Fibropapillomatosis (FP) is an infectious, neoplastic disease of major concern in sea turtle rehabilitation facilities. Rehabilitating sea turtles that undergo tumor removal surgery often have tumor regrowth and may experience mortality. We evaluated tumor score, removal, and regrowth in rehabilitating green sea turtles with FP in 4 rehabilitation facilities in the southeastern USA during 2009-2017. Of 756 cases, 312 (41%) underwent tumor removal surgery, 155 (50%) of those had tumor regrowth within an average of 46 ± 45 d, and 85 (27%) had multiple (>1) regrowth events. Of 756 turtles with FP, 563 (75%) did not survive after admission into a rehabilitation facility, including 283 (37%) that were euthanized and 280 that died without euthanasia (37%), and 193 survived, including 186 (25%) released and 7 (1%) placed in permanent captive care. Tumor removal surgery increased the odds of tumor regrowth but also enhanced survivorship, whereas tumor regrowth was not a significant predictor of case outcome. Three FP tumor scoring systems were used to assign tumor scores to 449 cases, and differing results emphasize that tumor scoring systems should be applied to the situations and/or location(s) for which they were intended. FP tumor score was not a significant predictor for the event or extent of FP tumor regrowth after surgical excision. Under current rehabilitation regimes, outcomes of rehabilitation for tumored turtles have a low probability of success. The results of this study may be used to help guide clinical decision-making and determine prognoses for rehabilitating sea turtles with FP.

Selecting the Best Elements from Previous Kidney Tumor Scoring Systems to Restructure Efficient Predictive Models for Surgery Type

Objective: The aim of this work was to select the best elements from previous scoring systems to restructure efficient predictive models for surgery type. Methods: Sixteen elements were selected from 7 systems (RENAL, PADUA, DAP, ZS, NephRO, ABC, and CI). They were divided into 6 categories (tumor max. size, exophytic/endophytic, correlation with collecting system or sinus, tumor location, contact situation with the parenchyma, invasion depth). Three elements, selected from 3 different categories, were integrated to establish a total of 320 new models. According to AUC rank, optimized models were developed, and these models were divided into 3 sections. An analysis of the distribution of the 6 categories was made to explore the predictive capacities of the models. Results: A total of 166 consecutive patients were included. Seventy-five patients underwent radical nephrectomy operations. The AUC of the 7 systems ranged from 0.81 to 0.844. Three optimized models (AUC 0.88) were developed to predict surgery type. These optimized models were composed of DAP (D), PADUA, (sinus), and ABC; DAP (D), RENAL (N), and ABC; NePhRO (O), PADUA (UCS), and ABC. Two categories (“exophytic/endophytic,” p < 0.001; “correlation with collecting system or sinus,” p = 0.001) were nonuniformly distributed. Conclusions: Seven systems held good predictive power for surgery type. Three optimized models were developed. “Correlation with collecting system or sinus” is a critical factor for predicting surgery type.

Editorial Comment

Increasingly, leaders in minimally invasive and renal surgery are realizing the limitations of body mass index and nephrometric renal morphologic systems (RENAL, PADUA, C-index) to comprehensively account for increasing perioperative risk and worsened outcomes. 1 Okhunov Z. Rais-Bahrami S. George A.K. et al. The comparison of three renal tumor scoring systems: C-Index, P.A.D.U.A., and R.E.N.A.L. nephrometry scores. J Endourol. 2011; 25: 1921-1924 Crossref PubMed Scopus (117) Google Scholar , 2 Simhan J. Smaldone M.C. Tsai K.J. et al. Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy. Eur Urol. 2011; 60: 724-730 Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar , 3 Stroup S.P. Palazzi K. Kopp R.P. et al. RENAL nephrometry score is associated with operative approach for partial nephrectomy and urine leak. Urology. 2012; 80: 151-156 Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar , 4 Gorin M.A. Mullins J.K. Pierorazio P.M. et al. Increased intra-abdominal fat predicts perioperative complications following minimally invasive partial nephrectomy. Urology. 2013; 81: 1225-1230 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar , 5 Bylund J.R. Qiong H. Crispen P.L. et al. Association of clinical and radiographic features with perinephric “sticky” fat. J Endourol. 2013; 27: 370-373 Crossref PubMed Scopus (50) Google Scholar The authors started out with an interesting premise (to more precisely analyze the effect of differential fat distribution on safety and feasibility of minimally invasive nephron sparing surgery) and ended up concluding that increasing subcutaneous, visceral, and perinephric fat did not significantly affect performance of minimally invasive partial nephrectomy in individuals with mild-moderate obesity (body mass index, 30-35 kg/m2). Effect of Visceral Obesity on Minimally Invasive Partial NephrectomyUrologyVol. 82Issue 3PreviewTo assess the relationship between visceral obesity and perioperative parameters in patients undergoing laparoscopic or robotic-assisted partial nephrectomy. Full-Text PDF ReplyUrologyVol. 82Issue 3PreviewWe appreciate the comments of the reviewers regarding our manuscript. Surgical difficulty in minimally invasive partial nephrectomy is multifactorial. Each independently contributes to the index of difficulty. We do not believe that relying solely on body mass index is an adequate measure of the patient's true obesity that may affect minimally invasive partial nephrectomy and patient outcomes. We postulated that the distribution of the fat might be more important and has to be taken into account. Full-Text PDF

Editorial Comment to Clinical analysis of the PADUA and the RENAL scoring systems for renal neoplasms: A retrospective study of 245 patients undergoing laparoscopic partial nephrectomy

Nephron-sparing surgery has consistently become the main treatment option for renal tumors over the past decade.1 As a consequence of this major paradigm shift, the debate of the urological community has been centered on the best indication for partial nephrectomy (PN), which is technically complex, especially when being carried out in a minimally-invasive fashion. Besides patients' characteristics, the surgical indication is related to the complexity of the renal mass undergoing treatment. The introduction of scoring systems for renal tumors has changed the way investigators present their PN outcomes.2 The main attractive feature of these systems is the possibility of providing a single number (score) incorporating the main anatomical characteristics of the tumor. Intuitively, this has greatly facilitated the comparisons among different institutions, ultimately providing a shared language to use when presenting and discussing data. The fact of the scoring systems being attractive is demonstrated by the fact they have been extensively adopted in the field of nephron-sparing surgery, for open3 and minimally-invasive PN,4 including ablative therapies.5 In this issue of International Journal of Urology, Zhang et al. report a study investigating the “clinical significance” of both the PADUA and RENAL scoring systems in patients undergoing laparoscopic PN.6 The found both tools to be predictive of change in renal function at multivariate analysis. In contrast, there were no significant associations between these scoring systems and the occurrence of complications or tumor stage. They also found the two systems to be significantly correlated, and to be reproducible. The findings of the study partially mirror those from previous reports, confirming the validity of these scoring systems in the contemporary management of renal masses. One should keep in mind that tumor characteristics do not represent the only factors to consider in the equation. Patients' characteristics need to be considered, including previous surgical history, comorbidities, baseline renal function and body habitus. Furthermore, surgical expertise, and availability of instruments and technology represent other de facto determining factors. Overall, the challenges of a nephron-sparing procedure are related to multiple elements. In other words, renal tumor scoring systems unquestionably facilitate comparison between reported series, which was, until recently, a very complicated exercise. However, as clinicians, we do consider much more than just the tumor we are asked to treat. As previously done for radical prostatectomy, the concept of composite outcomes has also recently been introduced for PN.7-9 This might represent another way of comparing outcomes from different series, and tumor scoring systems can be tested in this way not for a single parameter (i.e. renal function, complication, etc.), but rather for a comprehensive outcome, as a measure of the quality of the procedure. Time will tell. Finally, an important consideration is that laparoscopic PN remains a challenging procedure to carry out and learn, especially in low-volume centers. Thus, robotic PN is being promoted as the new standard for minimally-invasive PN, whenever the necessary technology is available.10 Overall, the landscape of nephron-sparing surgery is rapidly evolving, and this evolution will ultimately benefit our patients. None declared.

R.E.N.A.L. Nephrometry Score Accurately Predicts Complications Following Laparoscopic Renal Cryoablation

The R.E.N.A.L. nephrometry is a standardized scoring system that quantifies the complexity of kidney tumors. We evaluated our experience with laparoscopic cryoablation and determined the ability of nephrometry to predict complications. We reviewed the records of all patients who underwent laparoscopic cryoablation from July 2005 to February 2010 at 3 institutions. The composite R.E.N.A.L. score was determined using preoperative imaging, and tumors were categorized as low (4-6), moderate (7-9) or high complexity (10-12). Perioperative data were analyzed to determine the presence of complications. The distribution of surgical complications and tumor categories was compared using the chi-square and Student's t test. Logistic regression was used to analyze the association between nephrometry score and postoperative complications. A total of 210 patients underwent laparoscopic cryoablation, 77 of whom had available preoperative imaging. Mean patient age was 64.5 years and mean tumor size was 2.6 cm (range 1 to 4.5). Mean nephrometry score was 6.1 (range 4 to 12). Of the tumors 47 (61%) were categorized as low, 23 (30%) as moderate and 7 (9%) as high complexity lesions. Overall there were 15 (19.5%) complications, including 7 (9.5%) major and 8 (10%) minor complications. There was a significant difference in complication rates among the low (47 patients, 0%), moderate (23 patients, 35%) and high complexity (7 patients, 100%) groups, respectively (p <0.001). On multivariate analysis nephrometry score was independently associated with a higher risk of postoperative complications (OR 2.23, 95% CI 1.05-2.11, p = 0.008). In a multi-institutional cohort of patients undergoing laparoscopic cryoablation, the R.E.N.A.L. nephrometry score is independently associated with the occurrence of complications. Therefore, nephrometry can be used to successfully stratify patients in terms of anticipated risk of complications which, in turn, may help with surgical decision making.

703 THE ASSOCIATION BETWEEN RENAL TUMOR SCORING SYSTEMS AND PARTIAL NEPHRECTOMY COMPLICATIONS

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging II1 Apr 2012703 THE ASSOCIATION BETWEEN RENAL TUMOR SCORING SYSTEMS AND PARTIAL NEPHRECTOMY COMPLICATIONS Darren J. Desantis, Luke T. Lavallée, Rodney Breau, Fadi Kamal, Brian Blew, James Watterson, Ranjeeta Mallick, Dean Ferguson, Chris Morash, and Ilias Cagiannos Darren J. DesantisDarren J. Desantis Ottawa, Canada More articles by this author , Luke T. LavalléeLuke T. Lavallée Ottawa, Canada More articles by this author , Rodney BreauRodney Breau Ottawa, Canada More articles by this author , Fadi KamalFadi Kamal Ottawa, Canada More articles by this author , Brian BlewBrian Blew Ottawa, Canada More articles by this author , James WattersonJames Watterson Ottawa, Canada More articles by this author , Ranjeeta MallickRanjeeta Mallick Ottawa, Canada More articles by this author , Dean FergusonDean Ferguson Ottawa, Canada More articles by this author , Chris MorashChris Morash Ottawa, Canada More articles by this author , and Ilias CagiannosIlias Cagiannos Ottawa, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.787AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Three renal mass scoring systems have been proposed to quantify difficulty of partial nephrectomy and risk of surgical complications. The objective of this study was to evaluate the associations between each renal tumor scoring system and post-operative complications. METHODS A consecutive cohort of partial nephrectomy patients between 2002-2009 was analyzed. Patient characteristics were abstracted from the medical record and R.E.N.A.L Nephrometry Score, PADUA score and C Index were determined from pre-operative axial images by two independent reviewers. Consensus was achieved for all reviewer discrepancies. Patients were evaluated for post-operative complications up to 30 days following surgery. Pre-specified complication definitions were used for 33 potential complications and severity of each complication was described using the Clavien classification system. Results were analyzed for significance using a Student t-test. RESULTS A total of 118 patients were included in the study. Median R.E.N.A.L. score was 7 (IQR 5-8), median PADUA score was 8 (IQR 7-9.8) and mean C index was 3.9 (SD 2.10). A total of 76 complications were recorded. There were no deaths. There were 18 Grade I, 40 Grade II, 5 Grade IIIa, 4 Grade IIIb and 9 Grade IVa complications. There were no Grade IVb or V complications. Nephrometery score was associated with overall complications (mean score 7.0 vs 6.4, p=0.04) and genitourinary specific complications (mean score 7.7 vs 6.5, p=0.003) respectively. PADUA score was also highly associated with overall (mean 8.8 vs 8.1 p=0.01) and genitourinary specific complications (mean 9.7 vs 8.2, p=0.0002). Mean C index score was not significantly associated with overall or genitourinary specific complications. CONCLUSIONS Renal tumor scoring systems are useful tools to predict risk of complications after partial nephrectomy. Tumor scores should be taken into consideration in the decision making process of partial vs. radical nephrectomy. Prospective studies are required to further evaluate if one scoring system is a superior predictor for surgical complexity. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e288 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Darren J. Desantis Ottawa, Canada More articles by this author Luke T. Lavallée Ottawa, Canada More articles by this author Rodney Breau Ottawa, Canada More articles by this author Fadi Kamal Ottawa, Canada More articles by this author Brian Blew Ottawa, Canada More articles by this author James Watterson Ottawa, Canada More articles by this author Ranjeeta Mallick Ottawa, Canada More articles by this author Dean Ferguson Ottawa, Canada More articles by this author Chris Morash Ottawa, Canada More articles by this author Ilias Cagiannos Ottawa, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Comparison of Three Renal Tumor Scoring Systems: C-Index, P.A.D.U.A., and R.E.N.A.L. Nephrometry Scores

The centrality-index (C-Index), preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification, and radius.exophyic/endophytic.nearness.anterior/posterior.location (R.E.N.A.L.) nephrometry schemes were developed as standardized scoring systems (SS) to quantify anatomic characteristics of kidney tumors. The objective of this study was to establish reliability and assess relationships between these three SS and perioperative and postoperative variables. A retrospective chart review was performed in 101 patients who underwent laparoscopic partial nephrectomy. The nephrometry schemes were correlated with intraoperative and postoperative parameters using Spearman correlations. In addition, interobserver reliability was assessed on 50 of the patients by interclass correlations comparing the scores assigned by two residents and one fellow who reviewed preoperative CT studies of these patients. The interobserver correlation was 0.84 for the C-Index, 0.81 for the P.A.D.U.A., and 0.92 for the R.E.N.A.L. scoring systems, demonstrating excellent interobserver reliability. All three SS were significantly associated with warm ischemia time (WIT) (C-Index, P=-0.44; P.A.D.U.A., P=0.25; R.E.N.A.L., P=0.32) and percent change in creatinine level (C-Index, P=- 0.33; P.A.D.U.A., P=0.37; R.E.N.A.L., P=0.37). There were no significant associations between any of the three SS assessed and the occurrence of complications, operative time, or estimated blood loss. No significant correlation was found between the P.A.D.U.A. and R.E.N.A.L. SS and length of stay; however, C-Index did show a significant relationship for patients with lower scores having longer hospital stays (P=-0.21). All three scoring systems demonstrated reliability among observers and represent novel methods of quantitatively describing renal tumors. They were all associated with WIT, percent change in creatinine level, and tumor size. They did not, however, correlate with any other perioperative parameters investigated. At this time, these SS provide a common language for describing renal tumors.

Treatment of relapsed aggressive lymphomas: regimens with and without high-dose therapy and stem cell rescue

Treatment of relapsed aggressive lymphomas: regimens with and without high-dose therapy and stem cell rescue

Bulky disease is an adverse prognostic factor in patients treated with chemotherapy comprised of cyclophosphamide, doxorubicin, vincristine, and prednisone with or without radiotherapy for aggressive lymphoma

BACKGROUND In the current study, the authors analyzed prognostic factors in patients with aggressive lymphoma treated with a chemotherapy regimen comprised of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with or without radiotherapy. METHODS Between September 1988 and December 1996, 294 patients with newly diagnosed, clinical Ann Arbor Stage I-IV, aggressive lymphoma were enrolled on 2 protocols at The University of Texas M. D. Anderson Cancer Center. Patients on these studies had a relatively favorable prognosis; 100% had M. D. Anderson tumor scores ≤ 2 and 95%% had International Prognostic Indices (IPIs) ≤ 2. Treatment was comprised of 5 ± 1 (mean ± the standard deviation) cycles of CHOP chemotherapy with or without involved-field radiotherapy to a total dose of 40.1 ± 3.3 grays (mean ± the standard deviation). RESULTS The median length of follow-up was 61 months. Three factors were found to retain independent prognostic significance on multivariate analysis in terms of progression-free survival: > 1 extranodal site of disease (P < 0.001), bulky disease (≥ 7 cm) (P = 0.005), and an at least 10% elevation in the serum lactate dehydrogenase (LDH) level (P = 0.007). Patient age > 60 years (P = 0.001), bulky disease (P = 0.016), and an at least 10% elevation in the serum LDH level (P = 0.040) also were found to be independent prognostic factors for overall survival. CONCLUSIONS The independent prognostic factors in the current study suggest that either the M. D. Anderson tumor score system or the IPI can be used to select which aggressive lymphoma patients are at high risk for disease recurrence based on their having more than two adverse factors and who consequently are candidates for more intensive frontline therapy. Involved-field radiotherapy should be considered in those patients with bulky lymphomas. Cancer 2001;91:2440–60. © 2001 American Cancer Society.

Bulky disease is an adverse prognostic factor in patients treated with chemotherapy comprised of cyclophosphamide, doxorubicin, vincristine, and prednisone with or without radiotherapy for aggressive lymphoma

In the current study, the authors analyzed prognostic factors in patients with aggressive lymphoma treated with a chemotherapy regimen comprised of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with or without radiotherapy. Between September 1988 and December 1996, 294 patients with newly diagnosed, clinical Ann Arbor Stage I-IV, aggressive lymphoma were enrolled on 2 protocols at The University of Texas M. D. Anderson Cancer Center. Patients on these studies had a relatively favorable prognosis; 100% had M. D. Anderson tumor scores <or= 2 and 95%% had International Prognostic Indices (IPIs) <or= 2. Treatment was comprised of 5 +/- 1 (mean +/- the standard deviation) cycles of CHOP chemotherapy with or without involved-field radiotherapy to a total dose of 40.1 +/- 3.3 grays (mean +/- the standard deviation). The median length of follow-up was 61 months. Three factors were found to retain independent prognostic significance on multivariate analysis in terms of progression-free survival: > 1 extranodal site of disease (P < 0.001), bulky disease (>or= 7 cm) (P = 0.005), and an at least 10% elevation in the serum lactate dehydrogenase (LDH) level (P = 0.007). Patient age > 60 years (P = 0.001), bulky disease (P = 0.016), and an at least 10% elevation in the serum LDH level (P = 0.040) also were found to be independent prognostic factors for overall survival. The independent prognostic factors in the current study suggest that either the M. D. Anderson tumor score system or the IPI can be used to select which aggressive lymphoma patients are at high risk for disease recurrence based on their having more than two adverse factors and who consequently are candidates for more intensive frontline therapy. Involved-field radiotherapy should be considered in those patients with bulky lymphomas.

Follicular Large Cell Lymphoma: An Aggressive Lymphoma That Often Presents With Favorable Prognostic Features

It is debated whether follicular large cell lymphoma (FLCL) has a clinical behavior that is distinct from indolent follicular lymphomas, and whether there is a subset of patients who can be potentially cured. We report here our experience with 100 FLCL patients treated at our institution since 1984 with three successive programs. We evaluated the predictive value of pretreatment clinical features, including two risk models, the Tumor Score System and the International Prognostic Index (IPI). With a median follow-up of 67 months, the 5-year survival is 72% and the failure-free survival (FFS) is 67%, with a possible plateau in the FFS curve, particularly for patients with stage I-III disease. Features associated with shorter survival included age ≥60, elevated lactic dehydrogenase (LDH) or beta-2-microglobulin (β2M), advanced stage, and bone marrow involvement. Stage III patients had significantly better survival than stage IV patients (P &lt; .05). By the IPI and Tumor Score System, 80% of the patients were in the lower risk groups; both systems stratified patients into prognostic groups. Patients with FLCL have clinical features and response to treatment similar to that reported for diffuse large cell lymphoma. Prognostic risk systems for aggressive lymphomas are useful for FLCL. A meaningful fraction of patients may possibly be cured when treated as aggressive lymphomas.

Follicular Large Cell Lymphoma: An Aggressive Lymphoma That Often Presents With Favorable Prognostic Features

AbstractIt is debated whether follicular large cell lymphoma (FLCL) has a clinical behavior that is distinct from indolent follicular lymphomas, and whether there is a subset of patients who can be potentially cured. We report here our experience with 100 FLCL patients treated at our institution since 1984 with three successive programs. We evaluated the predictive value of pretreatment clinical features, including two risk models, the Tumor Score System and the International Prognostic Index (IPI). With a median follow-up of 67 months, the 5-year survival is 72% and the failure-free survival (FFS) is 67%, with a possible plateau in the FFS curve, particularly for patients with stage I-III disease. Features associated with shorter survival included age ≥60, elevated lactic dehydrogenase (LDH) or beta-2-microglobulin (β2M), advanced stage, and bone marrow involvement. Stage III patients had significantly better survival than stage IV patients (P < .05). By the IPI and Tumor Score System, 80% of the patients were in the lower risk groups; both systems stratified patients into prognostic groups. Patients with FLCL have clinical features and response to treatment similar to that reported for diffuse large cell lymphoma. Prognostic risk systems for aggressive lymphomas are useful for FLCL. A meaningful fraction of patients may possibly be cured when treated as aggressive lymphomas.

Alternating triple therapy for the treatment of intermediate grade and immunoblastic lymphoma

CHOP is currently considered the gold standard of treatment for intermediate grade lymphomas. We designed a new regimen known as 'ATT' (alternating triple therapy) which uses three non-cross resistant combinations in alternating sequence for nine cycles. This is a phase II clinical trial with comparison to CHOP/CMED historical controls using prognostic factors. The tumor score system was used to evaluate the results of this trial. Two hundred sixty-eight eligible patients who had one or more of the following adverse features: bulky disease, elevated LDH or > 1 extranodal site were analyzed. Outcome measures consist of survival and failure free survival. At a median follow-up of 32 months, there was no statistically significant difference in survival for those with favorable prognostic factors (tumor score < or = 2). However, there was a statistically significant difference in favor of ATT for those with unfavorable tumor scores. When we examined the failure-free survival of those with unfavorable tumor scores, we again observed a superiority for the ATT regimen over CHOP/CMED but the opposite was true for those with favorable tumor scores. We also found a statistically significant difference in favor of the ATT regimen when compared with CHOP/CMED for patients < or = 60 years old with a tumor score > or = 3, while no advantage was found for those > 60 years. ATT appears more effective but only for patients < 60 years old with unfavorable tumor scores. In those older than 60 years with favorable tumor score, CHOP/CMED appears superior. ATT might be an adequate regimen for young patients with poor prognostic features while CHOP/CMED might be a better choice for those with good prognosis irrespective of age. For those > 60 years with unfavorable tumor scores neither ATT or CHOP/CMED were adequate treatment. Because of the phase II nature of this study, these conclusions should be considered as hypotheses which require prospective testing.

A proposal for a simple staging system for intermediate grade lymphoma and immunoblastic lymphoma based on the 'tumor score'.

A new staging system for intermediate grade lymphomas and immunoblastic lymphomas is described. This system is based on the tumor score which consists of assigning a point to each one of five variables that have been previously shown to have a high prognostic value. Ann Arbor stages III-IV, presence of bulky mass, elevation of B-2 microglobulin and LDH as well as presence of 'B' symptoms are the variables utilized in this system. When we applied this tumor score system to a population of 144 patients uniformly treated with CHOP/Bleo/CMED protocol, we observed that this system can accurately divide the population into two prognostic groups without an intermediate category. The first group is made up of those patients with a score of 0-2 points while the second group consists of patients with a score of > or = 3 points. The first group has a time-to-treatment failure (TTF) of 83% at three years in contrast to the second group whose TTF was 24%. If we compare this system with other commonly used systems in our institution, such as Ann Arbor, M.D. Anderson clinical staging system, and M.D. Anderson serological staging system, we observed that the tumor score system is not only more specific and sensitive than the others but also was capable of eliminating an intermediate risk group, thus facilitating therapeutic choices. This tumor score system is easy to apply and potentially reproducible in any institution.