243 THE NUMBER OF POSITIVE LYMPH NODES AFFECTS CANCER-SPECIFIC SURVIVAL IN PATIENTS WITH NODE-POSITIVE RENAL CELL CARCINOMA

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Metastasectomy significantly prolongs survival in patients with metastatic renal cell cancer Staehler M.D.1, Kruse J.1, Haseke N.1, Stadler T.C.1, Bruns C.2, Graeb C.2, Hatz R.2, Jauch K.W.2, Stief C.G.2 University of Munich, Dept. of Urology, Munich, Germany, 2University of Munich, Dept. of Surgery, Munich, Germany

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Introduction & Objectives: The aim of this study was to evaluate the efficacy of metastasectomy in metastatic renal cell carcinoma (mRCC) in a controlled population. Material & Methods: We included n=240 patients (pts.) with potentially resectable mRCC between 1995 and 2006 at the University Hospital Munich Großhadern. All patients underwent nephrectomy. In n=183 patients metastasectomy was performed. The control group consisted of n=57 patients who denied surgery. Sites of metastases were liver, lungs, lymph nodes and other. Surgery was performed in n=68 pts. with liver metastases, n=121 pts. with lung metastases, n=87 pts. with lymph node metastases, and in n=141 pts. with other metastatic lesions. The control group consisted of n=20 pts. with liver metastases, n=41 pts. with lung metastases, n=29 pts. with lymph node metastases and n=36 pts. with other metastatic lesions. Patients were evaluated according, to MSKCC prognostic score, grading, histological subtype, and administration of systemic therapy. Results: The 5-years overall survival rate in all patients was 52.6 % (± 6.9). Median follow up was 26 months (range 1-187). In the group of patients that underwent metastasectomy it was significantly higher than in the control group, 57.8% (± 5.9) vs. 35.3 %(±9.2) respectively (p < 0.001). This significant survival benefit was found to be independent from the metastatic site (see table 2). No benefit for metastasectomy was found in patients with G3/G4 RCC in their initial nephrectomy specimen and in patients with an ECOG performance status greater than 0. All other parameters, such as histological subtypes and prognostic score were related to a significant survival benefit for metastasectomy patients. Conclusions: The 5-years overall survival rate was significantly higher in patients who underwent metastasectomy. Negative prognostic factors for surgery were grading with G3/G4 RCC in the initial nephrectomy specimen and an ECOG performance status greater than 0 not showing a survival benefit after metastasectomy. Thus, in patients with G1 and G2 RCC metastasectomy should be standard of care if technically feasible.



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The number of positive lymph nodes affects cancerspecific survival in patients with node-positive renal cell carcinoma Roscigno M.1, Bertini R.1, Strada E.1, Petralia G.1, Volpe A.2, Scattoni V.1, Angiolilli D.1, Matloob R.1, Sozzi F.1, Gallina A.1, Terrone C.2, Montorsi F.1, Rigatti P.1 Vita-Salute University, Dept. of Urology, Milan, Italy, 2Piemonte Orientale University, Dept. of Urology, Novara, Italy

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Introduction & Objectives: To evaluate the impact of the number of positive lymph nodes (LNs) on cancer-specific survival (CSS) in patients with node-positive renal cell carcinoma (RCC). Material & Methods: The study included 153 consecutive patients with RCC who underwent RN and LND between 1987 and 2006 in three urologic centers. The extent of lymphadenectomy was at the surgeon’s discretion. The Kaplan-Meier method and univariable and multivariable Cox regression analyses were used to determine the effect of predictors on cancer-specific survival (CSS). Finally, the most informative cut-off for the number of positive LNs was investigated. Results: Median follow-up was 12 months (range:1-234). Median follow-up for patients alive was 53 months (range:2-234). Median patient age was 60 years (range: 21-83). Patient characteristics: pT1/pT2/pT3a/pT3b/pT3c-4: 15/31/26/61/20, respectively; pN1/pN2: 50/103, respectively; G2/G3/G4: 53/85/16, respectively; M0/M+: 73/80, respectively. No significant difference in the actuarial 5-year CSS was found between pN1 and pN2 patients (22.9% vs. 22.2%; p=0.41). Median number of LNs removed was 10 (range: 1-35); Median number of positive LNs was 3 (range: 1-20). A higher number of positive LNs was significantly associated with worse CSS (p=0.002; HR 1.07). The cut-off of 4 positive LNs was the most informative discriminator for CSS. Patients with <4 positive LNs had significantly better 5-year CSS than patients with 4 or more positive LNs (27% vs. 14%; p=0.003). In multivariable analysis, the number of positive LNs was independently associated with CSS both when analyzed as a continuous variable (HR 1.07; p=0.005) or when defined dichotomously (<4 vs. ³4), after adjusting for the effects of age, pathologic stage and grade and distant synchronous metastases (HR 1.69; p=0.01). Current pN classification did not reach the independent predictor status after adjusting for age, pathologic stage and grade and distant synchronous metastases. Conclusions: A higher number of positive LNs was significantly associated with worse CSS. Patients with <4 positive LNs had significantly better 5-year CSS estimates than patients with 4 or more positive LNs. In our population, the current pN stratification of positive LNs is not significantly correlated with patients outcome, while classification as <4 or ³4 positive LNs seems to better reflect the impact of nodal disease on CSS.



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Resection of renal cell carcinoma (RCC) with extended vena cava involvement with cardiopulmonary by pass, hypothermia and cardiac arrest using either standard technique or Heartport® Port-Access™ Systems Giusti G., Maugeri O., Piccinelli A., Graziotti P. Istituto Clinico Humanitas, Dept. of Urology, Rozzano (Milan), Italy Introduction & Objectives: Herein we present our experience of surgical resection of RCC with level IV vena cava involvement with cardiopulmonary by pass, hypothermia and cardiac arrest by using either standard technique (abdominal incision +sternotomy) or a novel technique with Heartport® Port-Access™ Systems (solely abdominal incision). Material & Methods: Since 1997, 15 patients (pts) affected with RCC with level IV vena cava involvement were treated at our department. All pts underwent complete preoperative staging to exclude gross nodal involvement or distant metastases. In 9 pts, since MRI and/or Doppler caval sonography showed a floating thrombus into the caval and/or atrial lumen, suitable for shape and dimensions to retrograde extraction from an inferior vena cava incision, Heartport® System was employed. This technique allows for both nephrectomy and thrombus removal from a solely abdominal access. One of these procedures was converted in median sternotomy with atriotomy in order to remove a thrombus fragment that continuous transoesophageal ultrasound immediately showed to be left behind into the atrium. In 6 pts standard technique through median sternotomy and Chevron incision was carried out. Mean age was 62.6 years (54-71) in standard tech group and 69,6 (37-79) in Hearport group respectively. Technique with Heartport: first of all, blood is drained and sent to the hearth-lung machine through 2 cannulas inserted in the jugular and femoral vein, respectively. Then the Heartport balloon catheter, once inserted into the femoral artery onto a guidewire, is advanced cephalad to reach ascending aorta. The oxigenated blood is then drawn from the machine and retrograde infusion is performed via this cannula till endoclamping, cardioplegia and circulatory arrest at 20-22°C. Then entire procedure is performed through an abdominal access and a caval incision. Results: Standard Operation OR time (min) Blood units Intensive care unit stay (days) Hospital stay (days) Postoperative death Temporary acute renal failure Pulmonary embolism Pneumothorax

Operation with Heartport® Port-Access™ Systems 270 (200-385) 285 (190-435) 6.4(3-10) 7.2 (4-10) 3.7 (2-13) 2.6 (1-6) 8.5 (7-15) 7.7 (7-10) 2/7 (28.5%) 1/8 (12.5%) 3 1 1 1 1 0

Postoperative death in all cases was due to intestinal infarctions happened only in pts over 70 years. Four pts with progressive disease are alive after a mean follow-up of 44 mos (36-52) and 4 are alive free of disease after a mean of 17 mos (8-31). 4 patients died for metastatic disease after a mean time of 14.2 mos (6-18). Conclusions: Surgery of RCC with extended caval involvement is a demanding procedure that should be performed only at referral centers. In highly selected pts the use of Heartport® System makes sternotomy be unnecessary reducing significantly the huge invasiveness of this operation.



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Prospective assessment of health-related quality of life after surgery for renal cell carcinoma Novara G. 1, Secco S.2, Galfano A.2, Botteri M.2, De Marco V.2, Artibani W.2, Ficarra V.2 University of Padua, Dept. of Urology, Padua, Italy, 2Urology Clinic, Dept. of Oncological and Surgical Sciences, Padua, Italy 1

Introduction & Objectives: To evaluate the general state of health-related quality of life (HRQoL) in a group of patients undergoing radical nephrectomy (RN) or nephron sparing surgery (NSS) for renal tumors. Material & Methods: From February 2006 to September 2007 168 patients underwent surgical treatment for renal tumors at our institution and were invited to participate in this study. We used the Italian validated version of the RAND 36-Item Health Survey 1.0 (SF-36) to evaluate generic aspects of HRQoL. Patients received the questionnaire before, 6- and 12-month after surgery. A patient was considered to have returned to the baseline value when the follow-up score returned to within 10 points of that before treatment on a particular scale. Results: 151 (90%) of the invited patients decided to participate but 22 of them were excluded from the present analysis because of their delay in returning the questionnaires. The responses of the remaining 129 patients (85%) were finally evaluated. The mean (± SD) age of patients was 61.3 ± 12.4 years. 81 (63%) patients were male. ECOG performance status was 0 in 117 (91%) cases, the median Charlson comorbidity index was 0. RN was performed in 64 (50%) patients, while elective and imperative NSS was done in 57 (44%) and 8 (6%) cases, respectively. Twenty patients (15%) had benign tumors, 91 (83%) had pathologically localized renal cell carcinoma cancers. Comparing the baseline median values of each SF-36 single-scale score to those at 6 and 12 months, there were statistically significant differences in role limitations due to physical health problems (p=0.007), bodily pain (p<0.001), emotional well-being (p<0.001), role limitations due to emotional problems (p<0.001), energy/fatigue (p=0.038), and social function (p<0.001) domains. Six and 12-month after surgery, percentages of patients ranging from 49% to 81% had scores overlapping the baseline values. Mode of presentation, stage of the primary tumor, tumor size, and histological type were associated to the recover of the baseline quality of life scores 6- and 12-month after surgery in some domains of the SF-36 questionnaire. Conclusions: We showed significant modifications in the HRQoL during the first year after surgery for kidney tumors. Specifically, worsening of the patients’ HRQoL was observed in the physical function, role limitations due to physical problem and bodily pain domains, while significant improvement was found in emotional well being, role limitations due to emotional problem and social function domains. Six and 12-month after surgery, percentage of patients ranging from 49% to 81% recovered the baseline HRQoL scores. Some characteristics of patients (age, BMI, educational level, occupational status, NYHA class, and ASA) and tumors (mode of presentation, stage, size, and histological type) were significantly correlated to the recover of the baseline HRQoL scores.

Eur Urol Suppl 2009;8(4):181