- Email: [email protected]
47 Prognostic significance of microvascular invasion in renal clear cell carcinoma
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46
CHROMOPHOBE RENAL CELL CARCINOMA: A COMPREHENSIVE ANALYSIS OF 104 CASES FROM A MULTICENTRIC EUROPEAN DATABASE
A NEW AND IMPROVED L O O K AT RENAL MASSES; CONTRAST ENHANCED ULTRASOUND USING CONTRAST PULSE SEQUENCE IMAGING
Cindolo L / , Gallo A. a, De La Taille A. 3, Ficarra 7, 4, Schips L. s, Tostain J/', Abbou C.C. 3, Lobel B. 7, Zigeuner R.E. s, Artibani W.4, Autorino R. s, Salzano L. t, Patard j.j.7 1G. Rummo Hospital, Urology, Benevento, Italy, 2National Cancer Institute, Urology, Naples, Italy, 3CHU "H Mondor", Urology, Creteil, France, 4University of Verone, Urology, Verone, Italy, SUniversity of Graz, Urology, Graz, Austria, SCHU Saint Etienne, Urology, Saint Etienne, France, 7CHU "Pontchaillou", Urology, Rennes, France, SSecond University, Urology, Naples, Italy I N T R O D U C T I O N & OBJECTIVES: In 1985, chromophobe renal cell carcinoma (CRCC) was identified as a new renal cell carcinoma (RCC) histological subtype. Because of its low frequency, only few large CRCC series are available. In order to analyze its clinical behaviour, we retrospectively evaluated data from six European centres. MATERIAL & METHODS: We created a renal cancer database including 3228 patients operated between 1986 and 2002 in 6 European centres. Relevant clinical and pathological data were extracted from clinical charts at each institution and collected into a unique database. End point was cancer specific survival. RESULTS: One hundred and four patients affected by CRCC were identified (3.2%). Mean age at diagnosis was 57.6 years (range: 22-83 years). 51 patients (49%) were males and 53 (51%) were females. Mean tumour size was 6.4±3.6 cm. Incidental diagnosis accounted for 61.5% of the cases. Radical nephrectomy was performed in 88 patients (85%). After a median follow-up of 38 months (mean: 44; range 1-153) no local recurrence was observed. Five year OS for CRCC was 81%. Five (4.8%) and nine (8.6%) patients died of unrelated causes and renal cancer, respectively. CONCLUSIONS: Our series confirmed a favourable outcome for CRCC subtype with little local aggressiveness as well as low propensity for progression and death of cancer.
Wink M., Wijkstra H., Laguna P., Lagerveld B., De la Rosette J. Academic Medical Center, Urology,Amsterdam, The Netherlands INTRODUCTION & OBJECTIVES: The decision whether or not to surgically remove a renal mass is based on imaging, with contrastenhanced computertomography(CE-CT) as the gold standard. In case CE-CT is not possible because of allergy to iodine containing contrast media or renal insufficiency, usually a MRI is performed. Ultrasound (US) contrastmedia enhance reflectivity of blond flow snd enable visualization of flow even in the smallest vessels, using different techniques. One of these methods, Contrast Pulse Sequencing (CPS), allows exclusive detection of the signal reflected by the contrast agent. This enables simultaneous selective viewing of tissue-only and contrast-only images. Purpose of this pilot study is to determine accuracy and additional value of contrast enhanced ultrasound (CE-US) with CPS in the diagnosis of renal masses. MATERIAL & METHODS: 18 patients with a total of 20 renal masses, detected either on US or CT, were evaluated in a period of one month by the same urologist using CE-US. A Siemens Sequoia system with CPS was used and a maximum of 2 boluses of 2.4 millilitre Sonovae (Bracco) was injected intravenously. Each kidney was investigated using greyscale and CE-US and images were stored digitally. 2 independent urologists,blinded to CT results, evaluated the images off line. Conclusionswere compared to CT and, in those patients who underwent surgery,pathology reports. RESULTS: On CT 15 renal cell carcinomas (RCC), 1 complicated cyst, 1 angiomyolipoma and 2 simple cysts were diagnosed. In 1 patient the characterization of the mass was unclear. Subjectively, CPS imagingwas considered to be of very high quality and contrastonly images proved to be of additional clinical value. Using CPS, one urologist accurately characterized 14/15 RCC, 2/2 simple cysts and the angiomyolipoma. The other urologist correctly diagnosed 6/15 malignant and 2/3 benign lesions. On both CT and CE-US the complicated cyst was diagnosed as a bleeding, because no enhancement occurred inside or in the capsule. The diagnosis of the undetermined mass remained unclear until surgery,with the differential diagnosis of an abscess or RCC. 11 patients underwentsurgeryup to date; 2 had cryosurgery,in which no histologyis obtained, 2 a partial and 7 a radical nefrectomy.The undeterminedmass was diagnosed as an infiltrative necrotic transitional cell carcinoma. All other specimens showed RCC, thus diagnosis based on imaging was confirmed. CONCLUSIONS: CPS is a promisingtechnique in CE-US and the possibilityto see contrastonly and greyscale images simultaneouslycertainly seems to have clinical value. Specific indications for rite use of CE-US still have to be determined but clinical value is probably present in case CE-CT is not possible. CE-US used in first instance can possibly decrease the number of CT scans needed to characterize renal masses in the future.
47 PROGNOSTIC SIGNIFICANCE OF MICROVASCULAR INVASION IN RENAL CLEAR CELL CARCINOMA Seller D., Leppert J.T., Lam J.S., Li N., Li G., Pantuck A.J., Figlin R.A., Belldegrun A.S.
48 PROGNOSIS OF RENAL CELL CARCINOMA IN YOUNG ADULTS Wunderlich H~, Reichelt O., Schlichter A., Schubert J. Friedrich-Schiller-University,
Dept. of Urology, Jena, Germany
University of California Los Angeles, Urology, Santa Monica, United States INTRODUCTION & OBJECTIVES: Microvascular invasion (MVI) may represent an early event in hematogenous tumour dissemination. Recent reports have shown the expression of angiogenic factors to be associated with presence of tumour metastases. We sought to determine the prognostic significance of MVI in patients with clear cell renal cell carcinoma (RCC). MATERIAL & METHODS: 1,466 patients with RCC treated with nephrectomy were retrospectively reviewed to identify patients with clear cell RCC and microvascular invasion. Clinical variables analyzed from these cases included the presence of symptoms at presentation, turnout size, TNM staging, Fuhrman grade, the presence of necrosis, estimated blood loss, positive surgical margin rates, perioperative complications and disease free survival.
INTRODUCTION & OBJECTIVES: Renal cell carcinoma is a rare tumour in the first three decades of life, Because of its sporadic occurrence in this age group little is known about the characteristics, biological activity and outcome of these tumours. The purpose of this study is to describe our experience with diagnosis, treatment and prognosis of these tumours. MATERIAL & METHODS: We retrospectively reviewed the records of 17 patients age 15-29 who presented with solid renal masses between 1994-2002. Patients demographics, clinical presentation, laboratory, histologic, radiographic and follow-up data were reviewed. For tumour classification the 1987 TNMsystem was used.
RESULTS: 121 (12%) tulnour specimens were found to have MVI. These patients were more likely to present with symptoms related to their disease (78% vs. 67%, p=.03), high grade mmours (52% vs. 29%, p<.0001) and larger tumour size (8.8 cm vs. 5.9 cm, p<.0001). No difference was seen in performance status (p-.1), the number of medical co-morbidities (p-.26) or the presence of necrosis within the tumour (p=. 15). MVI was associated with higher T stage with T1, T2, T3 and T4 rates of 20%, 21%, 54% and 5% compared with 54%, 16%, 23% and 2%, respectively (p<.0001). MVI was also associated with lymph node involvement (28% vs. 8%, p=0.0002), distant metastasis (63% vs. 25%, p<.0001), and positive surgical margins (8% vs. 3.9%, p=.008). Patients with MVI were less likely to undergo partial nephrectomy (7% vs. 28%, p<.0001) and more likely to receive lymph node dissection (71% vs. 46%, p=.0001) as part of their surgical treatment. 5 year disease free survival rates were poorer in patients with MVI (27% vs. 61%, p<.0001).
RESULTS: There were 17 patients that underwent 1l radical and 8 partial nephrectomies. Two patients had a bilateral renal cell carcinoma. The mean age was 22,8 years and male patients comprised 13/17 of the population. Mode of presentation was classified as symptomatic in 7/17 (1 x increased creatinine, 2 x pain, 4 x hematuria), 1/17 familial and 9/17 incidental. Malignant tumour were seen in 15 out of these 17 patients (17 renal cell carcinoma). In 1 case we found an unilateral oncocytoma and 1 case an unilateral polycystic adenoma. Of the 17 renal cell carcinoma 9 were low grade and 8 intermediate grade tumours, 14/17 were organ confined. With an average follow-up of 63 months, the overall recurrence free survival is 88.2%.
CONCLUSIONS: Microvascular invasion in clear cell RCC is associated with a more aggressive tumour phenotype including high tumour grade, larger tumour size, increased incidence of lymphatic and distant metastases, and poorer survival. Patients with MVI should be considered high risk and warrant consideration for inclusion in adjuvant clinical trials.
CONCLUSIONS: Based on our experience, renal cell carcinoma in young adults is characterized by low grade and appears to have a favourable prognosis. Although rare, renal cell carcinoma should be considered in the differential diagnosis of young patients presenting with painless hematuria.
European Urology Supplements 4 (2005) No. 3, pp. 14
46
CHROMOPHOBE RENAL CELL CARCINOMA: A COMPREHENSIVE ANALYSIS OF 104 CASES FROM A MULTICENTRIC EUROPEAN DATABASE
A NEW AND IMPROVED L O O K AT RENAL MASSES; CONTRAST ENHANCED ULTRASOUND USING CONTRAST PULSE SEQUENCE IMAGING
Cindolo L / , Gallo A. a, De La Taille A. 3, Ficarra 7, 4, Schips L. s, Tostain J/', Abbou C.C. 3, Lobel B. 7, Zigeuner R.E. s, Artibani W.4, Autorino R. s, Salzano L. t, Patard j.j.7 1G. Rummo Hospital, Urology, Benevento, Italy, 2National Cancer Institute, Urology, Naples, Italy, 3CHU "H Mondor", Urology, Creteil, France, 4University of Verone, Urology, Verone, Italy, SUniversity of Graz, Urology, Graz, Austria, SCHU Saint Etienne, Urology, Saint Etienne, France, 7CHU "Pontchaillou", Urology, Rennes, France, SSecond University, Urology, Naples, Italy I N T R O D U C T I O N & OBJECTIVES: In 1985, chromophobe renal cell carcinoma (CRCC) was identified as a new renal cell carcinoma (RCC) histological subtype. Because of its low frequency, only few large CRCC series are available. In order to analyze its clinical behaviour, we retrospectively evaluated data from six European centres. MATERIAL & METHODS: We created a renal cancer database including 3228 patients operated between 1986 and 2002 in 6 European centres. Relevant clinical and pathological data were extracted from clinical charts at each institution and collected into a unique database. End point was cancer specific survival. RESULTS: One hundred and four patients affected by CRCC were identified (3.2%). Mean age at diagnosis was 57.6 years (range: 22-83 years). 51 patients (49%) were males and 53 (51%) were females. Mean tumour size was 6.4±3.6 cm. Incidental diagnosis accounted for 61.5% of the cases. Radical nephrectomy was performed in 88 patients (85%). After a median follow-up of 38 months (mean: 44; range 1-153) no local recurrence was observed. Five year OS for CRCC was 81%. Five (4.8%) and nine (8.6%) patients died of unrelated causes and renal cancer, respectively. CONCLUSIONS: Our series confirmed a favourable outcome for CRCC subtype with little local aggressiveness as well as low propensity for progression and death of cancer.
Wink M., Wijkstra H., Laguna P., Lagerveld B., De la Rosette J. Academic Medical Center, Urology,Amsterdam, The Netherlands INTRODUCTION & OBJECTIVES: The decision whether or not to surgically remove a renal mass is based on imaging, with contrastenhanced computertomography(CE-CT) as the gold standard. In case CE-CT is not possible because of allergy to iodine containing contrast media or renal insufficiency, usually a MRI is performed. Ultrasound (US) contrastmedia enhance reflectivity of blond flow snd enable visualization of flow even in the smallest vessels, using different techniques. One of these methods, Contrast Pulse Sequencing (CPS), allows exclusive detection of the signal reflected by the contrast agent. This enables simultaneous selective viewing of tissue-only and contrast-only images. Purpose of this pilot study is to determine accuracy and additional value of contrast enhanced ultrasound (CE-US) with CPS in the diagnosis of renal masses. MATERIAL & METHODS: 18 patients with a total of 20 renal masses, detected either on US or CT, were evaluated in a period of one month by the same urologist using CE-US. A Siemens Sequoia system with CPS was used and a maximum of 2 boluses of 2.4 millilitre Sonovae (Bracco) was injected intravenously. Each kidney was investigated using greyscale and CE-US and images were stored digitally. 2 independent urologists,blinded to CT results, evaluated the images off line. Conclusionswere compared to CT and, in those patients who underwent surgery,pathology reports. RESULTS: On CT 15 renal cell carcinomas (RCC), 1 complicated cyst, 1 angiomyolipoma and 2 simple cysts were diagnosed. In 1 patient the characterization of the mass was unclear. Subjectively, CPS imagingwas considered to be of very high quality and contrastonly images proved to be of additional clinical value. Using CPS, one urologist accurately characterized 14/15 RCC, 2/2 simple cysts and the angiomyolipoma. The other urologist correctly diagnosed 6/15 malignant and 2/3 benign lesions. On both CT and CE-US the complicated cyst was diagnosed as a bleeding, because no enhancement occurred inside or in the capsule. The diagnosis of the undetermined mass remained unclear until surgery,with the differential diagnosis of an abscess or RCC. 11 patients underwentsurgeryup to date; 2 had cryosurgery,in which no histologyis obtained, 2 a partial and 7 a radical nefrectomy.The undeterminedmass was diagnosed as an infiltrative necrotic transitional cell carcinoma. All other specimens showed RCC, thus diagnosis based on imaging was confirmed. CONCLUSIONS: CPS is a promisingtechnique in CE-US and the possibilityto see contrastonly and greyscale images simultaneouslycertainly seems to have clinical value. Specific indications for rite use of CE-US still have to be determined but clinical value is probably present in case CE-CT is not possible. CE-US used in first instance can possibly decrease the number of CT scans needed to characterize renal masses in the future.
47 PROGNOSTIC SIGNIFICANCE OF MICROVASCULAR INVASION IN RENAL CLEAR CELL CARCINOMA Seller D., Leppert J.T., Lam J.S., Li N., Li G., Pantuck A.J., Figlin R.A., Belldegrun A.S.
48 PROGNOSIS OF RENAL CELL CARCINOMA IN YOUNG ADULTS Wunderlich H~, Reichelt O., Schlichter A., Schubert J. Friedrich-Schiller-University,
Dept. of Urology, Jena, Germany
University of California Los Angeles, Urology, Santa Monica, United States INTRODUCTION & OBJECTIVES: Microvascular invasion (MVI) may represent an early event in hematogenous tumour dissemination. Recent reports have shown the expression of angiogenic factors to be associated with presence of tumour metastases. We sought to determine the prognostic significance of MVI in patients with clear cell renal cell carcinoma (RCC). MATERIAL & METHODS: 1,466 patients with RCC treated with nephrectomy were retrospectively reviewed to identify patients with clear cell RCC and microvascular invasion. Clinical variables analyzed from these cases included the presence of symptoms at presentation, turnout size, TNM staging, Fuhrman grade, the presence of necrosis, estimated blood loss, positive surgical margin rates, perioperative complications and disease free survival.
INTRODUCTION & OBJECTIVES: Renal cell carcinoma is a rare tumour in the first three decades of life, Because of its sporadic occurrence in this age group little is known about the characteristics, biological activity and outcome of these tumours. The purpose of this study is to describe our experience with diagnosis, treatment and prognosis of these tumours. MATERIAL & METHODS: We retrospectively reviewed the records of 17 patients age 15-29 who presented with solid renal masses between 1994-2002. Patients demographics, clinical presentation, laboratory, histologic, radiographic and follow-up data were reviewed. For tumour classification the 1987 TNMsystem was used.
RESULTS: 121 (12%) tulnour specimens were found to have MVI. These patients were more likely to present with symptoms related to their disease (78% vs. 67%, p=.03), high grade mmours (52% vs. 29%, p<.0001) and larger tumour size (8.8 cm vs. 5.9 cm, p<.0001). No difference was seen in performance status (p-.1), the number of medical co-morbidities (p-.26) or the presence of necrosis within the tumour (p=. 15). MVI was associated with higher T stage with T1, T2, T3 and T4 rates of 20%, 21%, 54% and 5% compared with 54%, 16%, 23% and 2%, respectively (p<.0001). MVI was also associated with lymph node involvement (28% vs. 8%, p=0.0002), distant metastasis (63% vs. 25%, p<.0001), and positive surgical margins (8% vs. 3.9%, p=.008). Patients with MVI were less likely to undergo partial nephrectomy (7% vs. 28%, p<.0001) and more likely to receive lymph node dissection (71% vs. 46%, p=.0001) as part of their surgical treatment. 5 year disease free survival rates were poorer in patients with MVI (27% vs. 61%, p<.0001).
RESULTS: There were 17 patients that underwent 1l radical and 8 partial nephrectomies. Two patients had a bilateral renal cell carcinoma. The mean age was 22,8 years and male patients comprised 13/17 of the population. Mode of presentation was classified as symptomatic in 7/17 (1 x increased creatinine, 2 x pain, 4 x hematuria), 1/17 familial and 9/17 incidental. Malignant tumour were seen in 15 out of these 17 patients (17 renal cell carcinoma). In 1 case we found an unilateral oncocytoma and 1 case an unilateral polycystic adenoma. Of the 17 renal cell carcinoma 9 were low grade and 8 intermediate grade tumours, 14/17 were organ confined. With an average follow-up of 63 months, the overall recurrence free survival is 88.2%.
CONCLUSIONS: Microvascular invasion in clear cell RCC is associated with a more aggressive tumour phenotype including high tumour grade, larger tumour size, increased incidence of lymphatic and distant metastases, and poorer survival. Patients with MVI should be considered high risk and warrant consideration for inclusion in adjuvant clinical trials.
CONCLUSIONS: Based on our experience, renal cell carcinoma in young adults is characterized by low grade and appears to have a favourable prognosis. Although rare, renal cell carcinoma should be considered in the differential diagnosis of young patients presenting with painless hematuria.
European Urology Supplements 4 (2005) No. 3, pp. 14