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539 VALIDATION OF PROGNOSTIC MODELS FOR NONMETASTATIC RENAL CELL CARCINOMA AFTER NEPHRECTOMY IN A MEDITERRANEAN CAUCASIAN POPULATION
Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011
THE JOURNAL OF UROLOGY姞
e219
539
540
VALIDATION OF PROGNOSTIC MODELS FOR NONMETASTATIC RENAL CELL CARCINOMA AFTER NEPHRECTOMY IN A MEDITERRANEAN CAUCASIAN POPULATION
PARTIAL NEPHRECTOMY VERSUS RADICAL NEPHRECTOMY FOR NON-METASTATIC RENAL CELL CARCINOMA: UTILIZATION TRENDS IN THE UNITED STATES
Maria C. Santiago*, Carlos Sanchez, Ana M. Palacin, Eva Golmayo, Alcala de Henares, Spain; Cristina Fernandez, Madrid, Spain; Antonio Garcia, Caceres, Spain; Manuel Sanchez-Chapado, Alcala de Henares, Spain
Maxine Sun*, Claudio Jeldres, Montreal, Canada; Firas Abdollah, Milan, Italy; Daniel Liberman, Montreal, Canada; Jan Schmitges, Hamburg, Germany; Orchid Djahangirian, Monica Morgan, Salima Ismail, Kevin Zorn, Montreal, Canada; Shahrokh F. Shariat, New York, NY; Paul Perrotte, Pierre I Karakiewicz, Montreal, Canada
INTRODUCTION AND OBJECTIVES: To determine the applicability of the current prognostic models to predict disease recurrencefree survival (RFS) and cancer-specific survival (CSS) after nephrectomy in nonmetastatic renal cell carcinoma (RCC) in a Mediterranean Caucasian population. METHODS: We retrospectively reviewed the clinical and pathological variables of 305 patients treated with nephrectomy (partial or radical) for RCC. Three models were used to predict RFS (Kattan nomogram, Sorbellini model and Leibovich model), and three ones to predict CSS: the University of California at Los Angeles Integrated Staging System (UISS) model, the Stage, Size, Grade and Necrosis (SSIGN) model and the Karakiewicz nomogram. Survival was estimated using the Kaplan-Meier method. The predictive ability of the different scores was evaluated using the Harrell concordance index. RESULTS: With a median follow-up of 50.7 months, 41 patients (15.1%) died of RCC and in 54 (19.9%) the disease progressed. The 5-years CSS and RFS rates were 84.9% and 77.5%, respectively. Among the features included in the models, the Eastern Cooperative Oncology Group Performance Score (ECOG PS), pathological T (pT) stage, tumor size in surgical specimen, nuclear grade and pathological necrosis were significantly associated with RFS and CSS on univariate analysis. The ECOG PS, pT stage and nuclear grade also influenced in the multivariate analysis (Table 1). The c-indexes for RFS at 5 years were 0.626 for the Kattan nomogram and 0.696 for the Sorbellini model. The Leibovich nomogram presented c-indexes for RFS at 1, 3 and 5 years of 0.807, 0.728 and 0.721 respectively. The c-indexes for CSS were 0.774, 0.773, 0.772, 0.760 and 0.760 at 1, 2, 3, 4 and 5 years respectively for the UISS model, 0.831, 0.819 and 0.795 at 1, 3 and 5 years respectively for the SSIGN nomogram, and 0.752, 0.753 and 0.767 at 1, 2 and 5 years respectively for the Karakiewicz model. CONCLUSIONS: The current prognostic models are therefore validated in the Mediterranean Caucasian population with nonmetastatic RCC treated by surgery. The Leibovich nomogram was found to be most accurate to predict RFS, and SSIGN model to predict CSS. The most influential features in our population, both in RFS and CSS, were nuclear grade, ECOG PS and pT stage.
541 IS HOSPITAL VOLUME A DETERMINANT OF TYPE OF SURGERY, COMPLICATIONS, LENGTH OF STAY, AND IN-HOSPITAL MORTALITY IN NON-METASTATIC RENAL CELL CARCINOMA?
Multivariate
Univariate
Multivariate
Cancer-specific survival (CSS)
Source of Funding: None
Univariate
VARIABLE
Disease recurrence-free survival (RFS)
Table 1. Univariate and multivariate Cox regression model for prediction of renal cell carcinoma (RCC).
INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) has several important advantages over radical nephrectomy (RN) in the management of renal cell carcinoma (RCC). The advantage hinges on the preservation of renal function and its long-term effects. Several previous investigators suggested that PN remains relatively underutilized in North America. We examined this hypothesis in a population-based analysis. METHODS: We examined the Nationwide Inpatient Sample and performed a retrospective cohort analysis of 48321 patients with non-metastatic RCC treated with PN or RN between years 1998 and 2007. We examined the utilization rates of PN and RN throughout the study period, as well as the patient characteristics, in-hospital mortality, and length of stay. Finally we assessed the determinants of PN use using logistic regression models. RESULTS: Overall, PN was performed in 8551 patients (18%). The rate of PN increased over time: from 7% in 1998 to 26% in 2007 (P⬍0.001). Patients treated with PN were on average younger relative to RN patients (mean: 60 vs. 63, P⬍0.001) and had lower baseline Charlson Comorbidity Index [CCI] (CCI 0: 64 vs. 62%, P⬍0.001). A higher proportion of PN patients were treated at academic (69 vs. 52%, P⬍0.001) and high-volume (46 vs. 31%, P⬍0.001) institutions. Laparoscopic procedure was performed less frequently in PN patients (6 vs. 9%, P⬍0.001). The rate of in-hospital mortality (0.4 vs. 0.8%, P⬍0.001) and the proportion of patients with a length of stay above the median (45 vs. 50%, P⬍0.001) was lower in PN patients. After adjusting to all variables, octogenarians (odds ratio [OR]: 0.5, P⬍0.001), female gender (OR: 0.9, P⫽0.008), Hispanic race (OR: 0.8, P⫽0.02), CCIⱖ4 (OR: 0.7, P⬍0.001), and non-academic institutions (OR: 0.6, P⬍0.001) were associated with a decreased use of PN. In contrast, intermediate- (OR: 1.2, P⬍0.001) and high-volume institutions (OR: 1.6, P⬍0.001), as well as more contemporary year of surgery (2005–2007 OR: 2.0, P⬍0.001) were associated with a higher odds of undergoing PN. CONCLUSIONS: The rate of PN increased nearly 4-fold over the study decade, which represents a favorable result. It is of concern that important variability in PN rates exists with respect to hospital and patient characteristics. Some of these characteristics (e.g. high hospital volume, female gender, Hispanic race) could undermine access to PN and warrant closer examination within institutions where nephrectomies are performed.
ECOG PS
HR p value HR p value HR p value HR p value 3,53 ⬍0,001 3,710 ⬍0,001 3,87 ⬍0,001 3,143 0,001
pT stage
3,67 ⬍0,001 1,839
Tumor size
2,84
Nuclear grade
4,82 ⬍0,001 4,083 ⬍0,001 9,14
Presence of necrosis
2,11
0,022
0,001
Source of Funding: None
0,058 4,52 ⬍0,001
1,950
0,065
4,70 0,012
2,84 ⬍0,001
8,333 ⬍0,001
Maxine Sun*, Claudio Jeldres, Montreal, Canada; Firas Abdollah, Milan, Italy; Monica Morgan, Montreal, Canada; Jan Schmitges, Hamburg, Germany; Daniel Liberman, Salima Ismail, Orchid Djahangirian, Daniel Pharand, Montreal, Canada; Shahrokh F. Shariat, New York, NY; Paul Perrotte, Pierre I Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: Hospital volume (HV) represents an established quality of care determinant. We examined the effect of HV in surgically managed patients treated for non-metastatic renal cell carcinoma (RCC) on the rate of post-operative outcomes and type of surgery.
THE JOURNAL OF UROLOGY姞
e219
539
540
VALIDATION OF PROGNOSTIC MODELS FOR NONMETASTATIC RENAL CELL CARCINOMA AFTER NEPHRECTOMY IN A MEDITERRANEAN CAUCASIAN POPULATION
PARTIAL NEPHRECTOMY VERSUS RADICAL NEPHRECTOMY FOR NON-METASTATIC RENAL CELL CARCINOMA: UTILIZATION TRENDS IN THE UNITED STATES
Maria C. Santiago*, Carlos Sanchez, Ana M. Palacin, Eva Golmayo, Alcala de Henares, Spain; Cristina Fernandez, Madrid, Spain; Antonio Garcia, Caceres, Spain; Manuel Sanchez-Chapado, Alcala de Henares, Spain
Maxine Sun*, Claudio Jeldres, Montreal, Canada; Firas Abdollah, Milan, Italy; Daniel Liberman, Montreal, Canada; Jan Schmitges, Hamburg, Germany; Orchid Djahangirian, Monica Morgan, Salima Ismail, Kevin Zorn, Montreal, Canada; Shahrokh F. Shariat, New York, NY; Paul Perrotte, Pierre I Karakiewicz, Montreal, Canada
INTRODUCTION AND OBJECTIVES: To determine the applicability of the current prognostic models to predict disease recurrencefree survival (RFS) and cancer-specific survival (CSS) after nephrectomy in nonmetastatic renal cell carcinoma (RCC) in a Mediterranean Caucasian population. METHODS: We retrospectively reviewed the clinical and pathological variables of 305 patients treated with nephrectomy (partial or radical) for RCC. Three models were used to predict RFS (Kattan nomogram, Sorbellini model and Leibovich model), and three ones to predict CSS: the University of California at Los Angeles Integrated Staging System (UISS) model, the Stage, Size, Grade and Necrosis (SSIGN) model and the Karakiewicz nomogram. Survival was estimated using the Kaplan-Meier method. The predictive ability of the different scores was evaluated using the Harrell concordance index. RESULTS: With a median follow-up of 50.7 months, 41 patients (15.1%) died of RCC and in 54 (19.9%) the disease progressed. The 5-years CSS and RFS rates were 84.9% and 77.5%, respectively. Among the features included in the models, the Eastern Cooperative Oncology Group Performance Score (ECOG PS), pathological T (pT) stage, tumor size in surgical specimen, nuclear grade and pathological necrosis were significantly associated with RFS and CSS on univariate analysis. The ECOG PS, pT stage and nuclear grade also influenced in the multivariate analysis (Table 1). The c-indexes for RFS at 5 years were 0.626 for the Kattan nomogram and 0.696 for the Sorbellini model. The Leibovich nomogram presented c-indexes for RFS at 1, 3 and 5 years of 0.807, 0.728 and 0.721 respectively. The c-indexes for CSS were 0.774, 0.773, 0.772, 0.760 and 0.760 at 1, 2, 3, 4 and 5 years respectively for the UISS model, 0.831, 0.819 and 0.795 at 1, 3 and 5 years respectively for the SSIGN nomogram, and 0.752, 0.753 and 0.767 at 1, 2 and 5 years respectively for the Karakiewicz model. CONCLUSIONS: The current prognostic models are therefore validated in the Mediterranean Caucasian population with nonmetastatic RCC treated by surgery. The Leibovich nomogram was found to be most accurate to predict RFS, and SSIGN model to predict CSS. The most influential features in our population, both in RFS and CSS, were nuclear grade, ECOG PS and pT stage.
541 IS HOSPITAL VOLUME A DETERMINANT OF TYPE OF SURGERY, COMPLICATIONS, LENGTH OF STAY, AND IN-HOSPITAL MORTALITY IN NON-METASTATIC RENAL CELL CARCINOMA?
Multivariate
Univariate
Multivariate
Cancer-specific survival (CSS)
Source of Funding: None
Univariate
VARIABLE
Disease recurrence-free survival (RFS)
Table 1. Univariate and multivariate Cox regression model for prediction of renal cell carcinoma (RCC).
INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) has several important advantages over radical nephrectomy (RN) in the management of renal cell carcinoma (RCC). The advantage hinges on the preservation of renal function and its long-term effects. Several previous investigators suggested that PN remains relatively underutilized in North America. We examined this hypothesis in a population-based analysis. METHODS: We examined the Nationwide Inpatient Sample and performed a retrospective cohort analysis of 48321 patients with non-metastatic RCC treated with PN or RN between years 1998 and 2007. We examined the utilization rates of PN and RN throughout the study period, as well as the patient characteristics, in-hospital mortality, and length of stay. Finally we assessed the determinants of PN use using logistic regression models. RESULTS: Overall, PN was performed in 8551 patients (18%). The rate of PN increased over time: from 7% in 1998 to 26% in 2007 (P⬍0.001). Patients treated with PN were on average younger relative to RN patients (mean: 60 vs. 63, P⬍0.001) and had lower baseline Charlson Comorbidity Index [CCI] (CCI 0: 64 vs. 62%, P⬍0.001). A higher proportion of PN patients were treated at academic (69 vs. 52%, P⬍0.001) and high-volume (46 vs. 31%, P⬍0.001) institutions. Laparoscopic procedure was performed less frequently in PN patients (6 vs. 9%, P⬍0.001). The rate of in-hospital mortality (0.4 vs. 0.8%, P⬍0.001) and the proportion of patients with a length of stay above the median (45 vs. 50%, P⬍0.001) was lower in PN patients. After adjusting to all variables, octogenarians (odds ratio [OR]: 0.5, P⬍0.001), female gender (OR: 0.9, P⫽0.008), Hispanic race (OR: 0.8, P⫽0.02), CCIⱖ4 (OR: 0.7, P⬍0.001), and non-academic institutions (OR: 0.6, P⬍0.001) were associated with a decreased use of PN. In contrast, intermediate- (OR: 1.2, P⬍0.001) and high-volume institutions (OR: 1.6, P⬍0.001), as well as more contemporary year of surgery (2005–2007 OR: 2.0, P⬍0.001) were associated with a higher odds of undergoing PN. CONCLUSIONS: The rate of PN increased nearly 4-fold over the study decade, which represents a favorable result. It is of concern that important variability in PN rates exists with respect to hospital and patient characteristics. Some of these characteristics (e.g. high hospital volume, female gender, Hispanic race) could undermine access to PN and warrant closer examination within institutions where nephrectomies are performed.
ECOG PS
HR p value HR p value HR p value HR p value 3,53 ⬍0,001 3,710 ⬍0,001 3,87 ⬍0,001 3,143 0,001
pT stage
3,67 ⬍0,001 1,839
Tumor size
2,84
Nuclear grade
4,82 ⬍0,001 4,083 ⬍0,001 9,14
Presence of necrosis
2,11
0,022
0,001
Source of Funding: None
0,058 4,52 ⬍0,001
1,950
0,065
4,70 0,012
2,84 ⬍0,001
8,333 ⬍0,001
Maxine Sun*, Claudio Jeldres, Montreal, Canada; Firas Abdollah, Milan, Italy; Monica Morgan, Montreal, Canada; Jan Schmitges, Hamburg, Germany; Daniel Liberman, Salima Ismail, Orchid Djahangirian, Daniel Pharand, Montreal, Canada; Shahrokh F. Shariat, New York, NY; Paul Perrotte, Pierre I Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: Hospital volume (HV) represents an established quality of care determinant. We examined the effect of HV in surgically managed patients treated for non-metastatic renal cell carcinoma (RCC) on the rate of post-operative outcomes and type of surgery.