- Email: [email protected]
Malignant Neoplasms of the Kidney: An Analysis of 353 Patients Followed Five Years or More
THE JOURNAL OF UROLOGY
Vol. 79, No. 2, February 1958
Printed in U.S.A.
MALIGNANT NEOPLASMS OF THE KIDNEY: AN ANALYSIS OF 353 PATIENTS FOLLOWED FIVE YEARS OR MORE R. H. FLOCKS
AND
M. C. KADESKY
From the Department of Urology, University Hospitals, Iowa City, Iowa
It is the purpose of this report to present an analysis of 353 patients with malignant neoplasms of the kidney confirmed by microscopic tissue study and followed for five years or more by the Tumor Clinic at the University Hospitals in Iowa City, Iowa. These patients were seen during the period 1926-1950, inclusive. These tumors were classified as follows: Renal cell carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Embryoma (Wilms' tumor)...................................................... 31 Tumors arising from renal pelvis (epidermoid and transitional cell carcinomas)... 17
They were staged on the basis of the extent of the primary lesion as follows: Stage I-Limited to the renal capsule Stage 2-Invasion of the renal pedicle and/or renal fat Stage 3-Regional lymph node involvement Stage 4-Distant metastasis demonstrable Two hundred and forty-three of these patients were seen prior to 1946 and thus enabled us to obtain the results of a 10-year or more followup study. These were classified as 220 renal carcinomas, 22 embryomas, and 11 tumors of the renal pelvis. RENAL CARCINOMA
Three hundred and five cases of renal carcinoma were analyzed. One hundred and sixteen of these were in stage 4 and 21 cases were not staged. Fifty-two received only palliative treatment due to advanced age or general debility and these were not considered as treated cases. Of the 137 treated cases, four were of unknown stages but were included in all the studies except those related to stage of the disease. Tables 1 to 5 summarize the results of these analyses. Treatment, when used alone in these tables, means an attempt to destroy the tumor by nephrectomy, irradiation, or a combination of nephrectomy and irradiation. Table 1 gives the five- and 10-year survival according to the stage at the time of the diagnosis and compares the treated cases with the over-all group in the various stages. Twenty-one cases were not staged and therefore are not included in this table. It is to be noted that the five- and 10-year survival is very definitely improved by the institution of therapy in all stages studied. In stage 1, 16 patients received no therapy. Of these only two survived, making a five-year survival of 12½ per cent as contrasted to 55 per cent in the treated cases. Similarly, of the 10year cases one of 14 survived, making a 7 per cent 10-year survival as contrasted Read at annual meeting of the American Association of Genito-Urinary Surgeons, Hot Springs, Va., May 1-3, 1957. 196
197
l\IALIG1'ANT NEOPLASMS OF KIDXEY
TABLE l,
followup
i
Renal carcinoma
) :'\umber of Cases
i
5-Year Survival
I
10-Year Sur,·inil
-----------'---------------------------1------ --
Stage
, over-all
Treated cu;;es Stage 2. over-all Treated case,
St age 3, over-all Trnated rn.ses SL1ge 4
Totn.l ctk,e~
Treated ca,scs'' nephrecTreated tomy* Treated bv x-ray plus neph.* Treated by x-ray onl:v* 1\,o treatment* Treated by x-rny pre-op-~lfm
5-:vear 10-year .5-ye,u 10-year .5-vear 10-year 5-)'8l1r 10- 0-ear 5-year 10-:rnar 5-year 10-year 5-year J0-;1-car
I
'
76 ,58 60
35 (46%) 23 (40%) :n (55%) 22 (.50%) 22 (37%) 18 (38%) 21 (40.5%) 17 (40.5%) 3 (9%) 2 (9.5%) 3 (14%) 2 (16.6%) 1± (:3. 5%) 3 (3.8%)
I
-----------
'
H 59 47 52 42 33 21 21 12 116 7\l
TABLE
2. Renal carcinoma
___Fo-ll_o,_,u_p_
/_N_'u-mb_er_of_C_'ase~
5-year lO-year .5-year 10-year 5-year 10-year 5-:veur 10year 5-year lO-ycar 5-year 10-year 5-year
305 220 137 101 56 39 40 27 41 35 50 40 25
neph_:__ _______ __io-vea_r______~ - -
I
-
ll (19%)
' lO (23%) 12 (28%) ll (25 . .5%)
2 (9.5%) 2 (16.6%) (l 3%)
s-_Y_e,_'.,,r_s_u_n_+._;a_J_I_ JO Year SuniYal __
71 (23%) 48 (22%) 41.1% 40. 6% 48. 2% 46% 52.5% .55% 24.4% 23% 10% ' 12.5% I (13) 52o/c
) __(8)
~%
27 (]2.3%) 22 8%
23% 33 3%
14.5% 5% (7) 50%
* Cttse,,; in stages 1, 2 and :3.
,1-ith a 23 per cent survi,,al in the treated cases. For stage 2 cases a similar sis shows a H per cent fiye-year surviyal for the untreated as contrasted to a 40 per cent suryiyal for the treated; and, similarly, a 20 per cent 10-year survi1,-al as contrasted to a 25 per cent survival in the treated case:c:. In stage 3 the contrast iB even more marked. There is a zero per cent survival in the untreated cases as contrasted to a 14 per cent fiye-year, and 16 per cent 10-year surviYal. These figures 1nmld seem to indicate that in those patients where was utilized the prognosis was better either because of the intrinsic nature of the situation or because of the therapy itself. :'.V[oreoYer, it ,rnuld seem that there is little difference bet.Yeen stages l and 2 as far as prognm,is is concerned; but the results in stages ;3 and 4 ,Yere definitely ,rnrne. Table 2 illustrates the effects of the nuions types of therapy upon smTivat
198
R. H. FLOCKS AND M. C. KADESKY
A.Attrition curve age 56, 1940 census. B.14 coses treated by x-roy followed by nephrectomy. C. 27 cases treated by combination x-roy and nephrectomy as initial therapy. D. 39 coses treated by nephrectomy alone. All cases followed 10 or more years.
5
10
Fm. 1
It demonstrates again the marked improvement in survival in the treated cases as contrasted to the untreated cases. It is of interest also to note that the combination of nephrectomy and irradiation produces what seems to be significantly hetter results than nephrectomy alone. The total number of cases is small but the difference particularly in the IO-year survival group is so marked that it may be of real significance. Figure I illustrates the difference between nephrectomy alone and the combined treatment cases as far as IO-year survival is concerned. It shows that those of the combined treatment group who have passed the five-year mark have a mortality which is no greater than that of the general population. It is also of interest to point out that the only two patients in stage 3 who survived 10 years and the one case in stage 4 that did so received irradiation as part of their therapy. Table 3 shmvs an analysis of survival related to staging in the 25 patients ,vho received preoperative irradiation follmrnd by nephrectomy. We want to emphasize the IO-year smvival figures in this group. These patients all received approximately 7000 roentgens through several ports over a period of three weeks. Six ,rneks later nephrectomy was carried out. Irradiation therapy seemed to have shrunk some of the dilated veins and made the nephrectomy in no way more difficult. Aside from shrinkage of collateral TABLE
Trea te
Followup
3. Renal carcinoma 5-Y ear Survival
Number of Cases
10-Year Survival -·~
Stage 1 Stage 2 Stage 3 Unknown stage
5-year IO-year 5-year IO-year 5-year IO-year 5-year IO-year
6 2 7 6 0 0 0
9
5 12 8 3 1 1 0
i
(66.6%) (40%) (58%) (75%) (00%) (00%) (00%)
2 (40%)
5 (62.5%) 0 (00%)
199
MALIGNANT NEOPL.c1_SMS OF KID:'fEY
4. Renal carcinoma
TABLE I
Author 1 Date
Bergendal, lfl36
I
I~-~ I
Beer, 19:37 Priestley, 193!) lVlelicoK, 1!)43 Bixler, ct al., 1!)4+ Fool, ct al., 1949
!
Follmvup
-
Number of Treated Cases -----
5-Year Survival
57 40
40.4%
5-year 10-year 5-year 5-year 10-year 5-year 5-year 5-year
Dick and Flint, 1!)51 Throckmori,on, 1!)55 Goldstein, 1%6 This ;;eries, 1957
30% Apparent :34% 38.4%
357 253 20 64 37 17 36 22 14 77 137 101
10-year 5-year 5-year 10-year 5-year 5-year 10-year
10-Year Survival
27 3% 50% 35.5% 41% 23% 46% 36.3% 14.5% 31% 41.1% 40.6%
22.8%
------TABLE
5. Renal carcinoma
----------------·--- - - - - - - - ~ -·-----5-Year Survival -------------·-------···-~ Over-all Treated ca sec;
Duration of Symptoms
--~----------
------
Less than 1 month. 1-6 months 7-12 months 1-2 years. 2-3 years 3-5 year,. -5-10 yeius . Over 10 years.
31%
I I
•
·1
16% 12%
11% I
- - - - - - - - - - ---·--·-----·
35% 31% 56% 20%
60% 24% 16% 27% 43% 50% 64% 20%
----
circulation no other unusual gross or microscopic changes in the tumor were 11oted in the8e patients at the time of operation. It is of interest moreover to compare tables 1, 2, and 3 with table 4. Table 4 is a summary and comparison of five- and 10-year survivals of patients with renal carcinoma as reported in the literature by various investigators of the 20 years. It would 8eem that the over-all results with the exception of the small group receiving combined therapy have been essentially the same at various times and in variom, hands. Table 5 gives the percentage survival according to the duration of symptoms prior to institution of symptoms. These figures were analyzed to obtain further information ,Yith regard to the life history of this tumor. Their significance is not clear. They are simply presented for the record. EMBRYO:NL\ (wILMS' TeMOR)
There were 31 embryomas of the kidney in this series. All but three received treatment. Table G summarizes the results in our series and compares these with
200
R. H. FLOCKS AND M. C. KADESKY TABLE
Author, Date
Followup Period
6. Wilms' tumor
Numher of Cases
5-Year Survival
2-Y ear Survival
10-Year Survival
--
Priestley,* 1939
Ladd, 1941 Weisel, 1943 Nesbit, 1946 Foot et al., 1949 Gross and Neuhauser, 1950 Haines, 1954 This series Treated by x-ray only Treated by x-ray prep. plus nephrectomy Over-all
3-year 5-year IO-year
5-year
17 15 11 60 44 16 11 38
4(23.5%)
3 (23.5%) 1 (9.1%)
14 (23%) 7 (16%) 8 (50%) 3 (27%) 47.3%
18
7 (38.8%)
5-year IO-year 5-year IO-year
14 10 14 9
4 2 7 5
5-year IO-year
31 22
2 2 5 4
(28.6%) (20%) (50%) (55.5%)
11 (35.5%) 7 (32.5%)
(14.3%) (20%) (35.7%) (44.4%)
7 (22.6%) 6 (27.3%)
0 (00%) 2 (22.2%)
2 (9.1%)
* Treated cases. but 2 treated with surgery plus post op. irradiation.
t All
TABLE
Author, Date
Priestley, 1939 Foot, et al., 1949 Dick and Flint, 1951 This series Over-all Treated cases
7. Tumors of the renal pelvis
Followup
5-year IO-year 5-year 5-year 5-year IO-year 5-year IO-year
Number of Treated Cases
40 19 12 8
17 11 11 6
5-Year Survival
10-Year Survival
14 (35%) 2 (10.5%) 3 2 7 3 5 2
(25%) (25%) (41%) (27.2%) (45%) (33%)
1 (9.1%) 1 (16.5%)
others reported in the literature. It is to be noted that our two-year survival in the 14 cases treated by preoperative irradiation followed by nephrectomy is similar to the two-year survival in a larger group of patients reported by Gross and Neuhauser. It is also to be noted that 2-year survival is by no means indicative of a cure. There is every indication from the study of this group of cases and from the reports in the literature such as that of Gross and Neuhauser that irradiation is an important part of the therapy of these cases. Preoperative x-ray treatment proved useful in this group of patients. TUMORS OF THE RENAL PELVIS
There were 17 tumors of the renal pelvis and the results of an analysis of these cases are compared with some similar groups reported in the literature in
NL\LIGX.\N"T '.\:EOPLASMS CW KIDXEY
:201
table 7. Note that one patient lived and is fo·ing 10 years after the institution of therapy which eom;isted of nephro-ureterectomy. No combined therapy ,ms instituted in thiR group of patients. Whether it would alter the poor prog110:sis is not knowu and deserv<'s study. SUMMARY
An analysis of 35;3 eases ot malignant renal neoplmm1s 8tudied at the University Hospitals from I 92(i to Hli:iO, indm,ive, i8 pre8ented. vVith regard to renal carcinoma, combined surgical and radiation therapy seems to have given better resultR than simple surgery alone. Further studies are needed in this regard. A small group of Wilms' tumors is analyzed. From this study it would seem that 2-year survival does not necessarily mean a cure of this dread disease. :Moreover, combined therapy iR superior to either irradiatioH alone or surgery alone. REFERENCES HEARE, J.B. AND MciloNALD, .J. R. Involvement of the renal capSLtle in surgically rnmov<,d hypernephroma· gross and histopathologic study. J. Urol., 61: 857, 1949. BEER, EDWIN: Some aspects of malignant tumors of the kidney. Surg., Gynec. & Obst., 65: 433, 1937. BERGENDAL, S.: The diuienJ study and prognosis of tumors of the kidney. Acta chir. Scandinav., 77: 563, 1935-36. BIXLER, L. C., STENSTROM, K. W. AND CREEVY, C. D. · 1\Ialignant tumors of the kidnry: Review of 117 cases. Radiology, 42: 329, 1944. Bo·rrrn, A. E.: The effect of rom1tgen therapy upon tumors of the kidney. Arn ..J. Roen I.. , 33: 529, 1935. DICK, U.S. AND FLTN1', L. n. · The prognosis of renal tumors. Surg. Clin. North Amer., 31: 633, 1951. FoLEY, F. E. B., l'vh:LYANEY, W. P., R1cHARDSON, E. J. AND VrcTOR, T.: Radical nephrec· tomy for neoplasm . .J. 68: :39, 1952. FooT, N. C., HmvrPHREYS, A. AND WHITMORE, W. F.: Renal tumors: Pathology and prog-· nosis in 295 cases. ,J Urol., 66: 190, 1951. GoLDS'l'EIN, A. E.: Longevity following nephrectomy . .J. Urol., 76: 31, 1956. GRoss, R. E. AND NEUHAl!SER, KB. D.: Treatment of mixed h1mors of the kidney in childhood. Pediatrics, 6: 843, 1950. HAINES, V. E.: Wilms' tumor. Arn. Smg., 20: 885, HJ54. HARVEY, R. M.: Wilms' tumor: Evaluation of treatment methods. Hadiologr, 54: G8P. 1050. KERR, H. D. AND FLYKK, R. E.: The role of irradiation in 1.he treatment of Wilnrn' tumor in children. Am. J. Roent., 75: 971, HJ56. LADD, W. E. A'.\TD WmTE, R.H.: Embryoma of the kidne.v (Wilms' tumor). J.A.l\l.A., 117: 1858. 1941. MELrcm-i·, M. M.: Classification of renal neophLsms: A clinicrd and r.rnthnlogil'al study based on 199 cases. J. 51: 333, 1944. NESBIT, R. M. AND ADAMS, F. : Wilms' tumor: review of l(i cases. J. Pedia1., 29: 295, 194G. O'CoNOR, V . .J.: Treatment. and prognosis of papilbry tumors of the renal pelvis . .J. Urol., 61: 485, 1949. PRIESTLEY, J. T.: Survival following the removal of malignant renal noeplaw1s. J.A.J\LA., 113: 902, 1939. ScoTT, L. S.: Wilms' Lnmor: hs treatment and prognosis. Brit. l\Ied . .J., 1: 200, 1956. SHAHEEN, A. L., CASSANO, C. AKD LtsA, .J. R.: Primary tumors of the kidney. J. Urol., 51: 597, 1944. THROCK1WRTON, 1\1. A. Prognosis in hypernephronrn: A review of the literature and report of 42 cases . .J. Urol., 73: 773, 1955. WALKER, K.: Prognosis of renal growths. Lancet, 1: 565, 1935. WATERS, C. A. Preoperative irradiation of cortical renal tumors. Am ..J. Roent., 33: 14!), 1935. WF;rsEL, W., DocKER'rY, M. B. AND PRIESTLEY, J. T.: Wilms' tumor of the kidnA)': A clinicopathologic study of 44 proved cases. J. Urol., 50: 3P9, 194:l.
Vol. 79, No. 2, February 1958
Printed in U.S.A.
MALIGNANT NEOPLASMS OF THE KIDNEY: AN ANALYSIS OF 353 PATIENTS FOLLOWED FIVE YEARS OR MORE R. H. FLOCKS
AND
M. C. KADESKY
From the Department of Urology, University Hospitals, Iowa City, Iowa
It is the purpose of this report to present an analysis of 353 patients with malignant neoplasms of the kidney confirmed by microscopic tissue study and followed for five years or more by the Tumor Clinic at the University Hospitals in Iowa City, Iowa. These patients were seen during the period 1926-1950, inclusive. These tumors were classified as follows: Renal cell carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Embryoma (Wilms' tumor)...................................................... 31 Tumors arising from renal pelvis (epidermoid and transitional cell carcinomas)... 17
They were staged on the basis of the extent of the primary lesion as follows: Stage I-Limited to the renal capsule Stage 2-Invasion of the renal pedicle and/or renal fat Stage 3-Regional lymph node involvement Stage 4-Distant metastasis demonstrable Two hundred and forty-three of these patients were seen prior to 1946 and thus enabled us to obtain the results of a 10-year or more followup study. These were classified as 220 renal carcinomas, 22 embryomas, and 11 tumors of the renal pelvis. RENAL CARCINOMA
Three hundred and five cases of renal carcinoma were analyzed. One hundred and sixteen of these were in stage 4 and 21 cases were not staged. Fifty-two received only palliative treatment due to advanced age or general debility and these were not considered as treated cases. Of the 137 treated cases, four were of unknown stages but were included in all the studies except those related to stage of the disease. Tables 1 to 5 summarize the results of these analyses. Treatment, when used alone in these tables, means an attempt to destroy the tumor by nephrectomy, irradiation, or a combination of nephrectomy and irradiation. Table 1 gives the five- and 10-year survival according to the stage at the time of the diagnosis and compares the treated cases with the over-all group in the various stages. Twenty-one cases were not staged and therefore are not included in this table. It is to be noted that the five- and 10-year survival is very definitely improved by the institution of therapy in all stages studied. In stage 1, 16 patients received no therapy. Of these only two survived, making a five-year survival of 12½ per cent as contrasted to 55 per cent in the treated cases. Similarly, of the 10year cases one of 14 survived, making a 7 per cent 10-year survival as contrasted Read at annual meeting of the American Association of Genito-Urinary Surgeons, Hot Springs, Va., May 1-3, 1957. 196
197
l\IALIG1'ANT NEOPLASMS OF KIDXEY
TABLE l,
followup
i
Renal carcinoma
) :'\umber of Cases
i
5-Year Survival
I
10-Year Sur,·inil
-----------'---------------------------1------ --
Stage
, over-all
Treated cu;;es Stage 2. over-all Treated case,
St age 3, over-all Trnated rn.ses SL1ge 4
Totn.l ctk,e~
Treated ca,scs'' nephrecTreated tomy* Treated bv x-ray plus neph.* Treated by x-ray onl:v* 1\,o treatment* Treated by x-rny pre-op-~lfm
5-:vear 10-year .5-ye,u 10-year .5-vear 10-year 5-)'8l1r 10- 0-ear 5-year 10-:rnar 5-year 10-year 5-year J0-;1-car
I
'
76 ,58 60
35 (46%) 23 (40%) :n (55%) 22 (.50%) 22 (37%) 18 (38%) 21 (40.5%) 17 (40.5%) 3 (9%) 2 (9.5%) 3 (14%) 2 (16.6%) 1± (:3. 5%) 3 (3.8%)
I
-----------
'
H 59 47 52 42 33 21 21 12 116 7\l
TABLE
2. Renal carcinoma
___Fo-ll_o,_,u_p_
/_N_'u-mb_er_of_C_'ase~
5-year lO-year .5-year 10-year 5-year 10-year 5-:veur 10year 5-year lO-ycar 5-year 10-year 5-year
305 220 137 101 56 39 40 27 41 35 50 40 25
neph_:__ _______ __io-vea_r______~ - -
I
-
ll (19%)
' lO (23%) 12 (28%) ll (25 . .5%)
2 (9.5%) 2 (16.6%) (l 3%)
s-_Y_e,_'.,,r_s_u_n_+._;a_J_I_ JO Year SuniYal __
71 (23%) 48 (22%) 41.1% 40. 6% 48. 2% 46% 52.5% .55% 24.4% 23% 10% ' 12.5% I (13) 52o/c
) __(8)
~%
27 (]2.3%) 22 8%
23% 33 3%
14.5% 5% (7) 50%
* Cttse,,; in stages 1, 2 and :3.
,1-ith a 23 per cent survi,,al in the treated cases. For stage 2 cases a similar sis shows a H per cent fiye-year surviyal for the untreated as contrasted to a 40 per cent suryiyal for the treated; and, similarly, a 20 per cent 10-year survi1,-al as contrasted to a 25 per cent survival in the treated case:c:. In stage 3 the contrast iB even more marked. There is a zero per cent survival in the untreated cases as contrasted to a 14 per cent fiye-year, and 16 per cent 10-year surviYal. These figures 1nmld seem to indicate that in those patients where was utilized the prognosis was better either because of the intrinsic nature of the situation or because of the therapy itself. :'.V[oreoYer, it ,rnuld seem that there is little difference bet.Yeen stages l and 2 as far as prognm,is is concerned; but the results in stages ;3 and 4 ,Yere definitely ,rnrne. Table 2 illustrates the effects of the nuions types of therapy upon smTivat
198
R. H. FLOCKS AND M. C. KADESKY
A.Attrition curve age 56, 1940 census. B.14 coses treated by x-roy followed by nephrectomy. C. 27 cases treated by combination x-roy and nephrectomy as initial therapy. D. 39 coses treated by nephrectomy alone. All cases followed 10 or more years.
5
10
Fm. 1
It demonstrates again the marked improvement in survival in the treated cases as contrasted to the untreated cases. It is of interest also to note that the combination of nephrectomy and irradiation produces what seems to be significantly hetter results than nephrectomy alone. The total number of cases is small but the difference particularly in the IO-year survival group is so marked that it may be of real significance. Figure I illustrates the difference between nephrectomy alone and the combined treatment cases as far as IO-year survival is concerned. It shows that those of the combined treatment group who have passed the five-year mark have a mortality which is no greater than that of the general population. It is also of interest to point out that the only two patients in stage 3 who survived 10 years and the one case in stage 4 that did so received irradiation as part of their therapy. Table 3 shmvs an analysis of survival related to staging in the 25 patients ,vho received preoperative irradiation follmrnd by nephrectomy. We want to emphasize the IO-year smvival figures in this group. These patients all received approximately 7000 roentgens through several ports over a period of three weeks. Six ,rneks later nephrectomy was carried out. Irradiation therapy seemed to have shrunk some of the dilated veins and made the nephrectomy in no way more difficult. Aside from shrinkage of collateral TABLE
Trea te
Followup
3. Renal carcinoma 5-Y ear Survival
Number of Cases
10-Year Survival -·~
Stage 1 Stage 2 Stage 3 Unknown stage
5-year IO-year 5-year IO-year 5-year IO-year 5-year IO-year
6 2 7 6 0 0 0
9
5 12 8 3 1 1 0
i
(66.6%) (40%) (58%) (75%) (00%) (00%) (00%)
2 (40%)
5 (62.5%) 0 (00%)
199
MALIGNANT NEOPL.c1_SMS OF KID:'fEY
4. Renal carcinoma
TABLE I
Author 1 Date
Bergendal, lfl36
I
I~-~ I
Beer, 19:37 Priestley, 193!) lVlelicoK, 1!)43 Bixler, ct al., 1!)4+ Fool, ct al., 1949
!
Follmvup
-
Number of Treated Cases -----
5-Year Survival
57 40
40.4%
5-year 10-year 5-year 5-year 10-year 5-year 5-year 5-year
Dick and Flint, 1!)51 Throckmori,on, 1!)55 Goldstein, 1%6 This ;;eries, 1957
30% Apparent :34% 38.4%
357 253 20 64 37 17 36 22 14 77 137 101
10-year 5-year 5-year 10-year 5-year 5-year 10-year
10-Year Survival
27 3% 50% 35.5% 41% 23% 46% 36.3% 14.5% 31% 41.1% 40.6%
22.8%
------TABLE
5. Renal carcinoma
----------------·--- - - - - - - - ~ -·-----5-Year Survival -------------·-------···-~ Over-all Treated ca sec;
Duration of Symptoms
--~----------
------
Less than 1 month. 1-6 months 7-12 months 1-2 years. 2-3 years 3-5 year,. -5-10 yeius . Over 10 years.
31%
I I
•
·1
16% 12%
11% I
- - - - - - - - - - ---·--·-----·
35% 31% 56% 20%
60% 24% 16% 27% 43% 50% 64% 20%
----
circulation no other unusual gross or microscopic changes in the tumor were 11oted in the8e patients at the time of operation. It is of interest moreover to compare tables 1, 2, and 3 with table 4. Table 4 is a summary and comparison of five- and 10-year survivals of patients with renal carcinoma as reported in the literature by various investigators of the 20 years. It would 8eem that the over-all results with the exception of the small group receiving combined therapy have been essentially the same at various times and in variom, hands. Table 5 gives the percentage survival according to the duration of symptoms prior to institution of symptoms. These figures were analyzed to obtain further information ,Yith regard to the life history of this tumor. Their significance is not clear. They are simply presented for the record. EMBRYO:NL\ (wILMS' TeMOR)
There were 31 embryomas of the kidney in this series. All but three received treatment. Table G summarizes the results in our series and compares these with
200
R. H. FLOCKS AND M. C. KADESKY TABLE
Author, Date
Followup Period
6. Wilms' tumor
Numher of Cases
5-Year Survival
2-Y ear Survival
10-Year Survival
--
Priestley,* 1939
Ladd, 1941 Weisel, 1943 Nesbit, 1946 Foot et al., 1949 Gross and Neuhauser, 1950 Haines, 1954 This series Treated by x-ray only Treated by x-ray prep. plus nephrectomy Over-all
3-year 5-year IO-year
5-year
17 15 11 60 44 16 11 38
4(23.5%)
3 (23.5%) 1 (9.1%)
14 (23%) 7 (16%) 8 (50%) 3 (27%) 47.3%
18
7 (38.8%)
5-year IO-year 5-year IO-year
14 10 14 9
4 2 7 5
5-year IO-year
31 22
2 2 5 4
(28.6%) (20%) (50%) (55.5%)
11 (35.5%) 7 (32.5%)
(14.3%) (20%) (35.7%) (44.4%)
7 (22.6%) 6 (27.3%)
0 (00%) 2 (22.2%)
2 (9.1%)
* Treated cases. but 2 treated with surgery plus post op. irradiation.
t All
TABLE
Author, Date
Priestley, 1939 Foot, et al., 1949 Dick and Flint, 1951 This series Over-all Treated cases
7. Tumors of the renal pelvis
Followup
5-year IO-year 5-year 5-year 5-year IO-year 5-year IO-year
Number of Treated Cases
40 19 12 8
17 11 11 6
5-Year Survival
10-Year Survival
14 (35%) 2 (10.5%) 3 2 7 3 5 2
(25%) (25%) (41%) (27.2%) (45%) (33%)
1 (9.1%) 1 (16.5%)
others reported in the literature. It is to be noted that our two-year survival in the 14 cases treated by preoperative irradiation followed by nephrectomy is similar to the two-year survival in a larger group of patients reported by Gross and Neuhauser. It is also to be noted that 2-year survival is by no means indicative of a cure. There is every indication from the study of this group of cases and from the reports in the literature such as that of Gross and Neuhauser that irradiation is an important part of the therapy of these cases. Preoperative x-ray treatment proved useful in this group of patients. TUMORS OF THE RENAL PELVIS
There were 17 tumors of the renal pelvis and the results of an analysis of these cases are compared with some similar groups reported in the literature in
NL\LIGX.\N"T '.\:EOPLASMS CW KIDXEY
:201
table 7. Note that one patient lived and is fo·ing 10 years after the institution of therapy which eom;isted of nephro-ureterectomy. No combined therapy ,ms instituted in thiR group of patients. Whether it would alter the poor prog110:sis is not knowu and deserv<'s study. SUMMARY
An analysis of 35;3 eases ot malignant renal neoplmm1s 8tudied at the University Hospitals from I 92(i to Hli:iO, indm,ive, i8 pre8ented. vVith regard to renal carcinoma, combined surgical and radiation therapy seems to have given better resultR than simple surgery alone. Further studies are needed in this regard. A small group of Wilms' tumors is analyzed. From this study it would seem that 2-year survival does not necessarily mean a cure of this dread disease. :Moreover, combined therapy iR superior to either irradiatioH alone or surgery alone. REFERENCES HEARE, J.B. AND MciloNALD, .J. R. Involvement of the renal capSLtle in surgically rnmov<,d hypernephroma· gross and histopathologic study. J. Urol., 61: 857, 1949. BEER, EDWIN: Some aspects of malignant tumors of the kidney. Surg., Gynec. & Obst., 65: 433, 1937. BERGENDAL, S.: The diuienJ study and prognosis of tumors of the kidney. Acta chir. Scandinav., 77: 563, 1935-36. BIXLER, L. C., STENSTROM, K. W. AND CREEVY, C. D. · 1\Ialignant tumors of the kidnry: Review of 117 cases. Radiology, 42: 329, 1944. Bo·rrrn, A. E.: The effect of rom1tgen therapy upon tumors of the kidney. Arn ..J. Roen I.. , 33: 529, 1935. DICK, U.S. AND FLTN1', L. n. · The prognosis of renal tumors. Surg. Clin. North Amer., 31: 633, 1951. FoLEY, F. E. B., l'vh:LYANEY, W. P., R1cHARDSON, E. J. AND VrcTOR, T.: Radical nephrec· tomy for neoplasm . .J. 68: :39, 1952. FooT, N. C., HmvrPHREYS, A. AND WHITMORE, W. F.: Renal tumors: Pathology and prog-· nosis in 295 cases. ,J Urol., 66: 190, 1951. GoLDS'l'EIN, A. E.: Longevity following nephrectomy . .J. Urol., 76: 31, 1956. GRoss, R. E. AND NEUHAl!SER, KB. D.: Treatment of mixed h1mors of the kidney in childhood. Pediatrics, 6: 843, 1950. HAINES, V. E.: Wilms' tumor. Arn. Smg., 20: 885, HJ54. HARVEY, R. M.: Wilms' tumor: Evaluation of treatment methods. Hadiologr, 54: G8P. 1050. KERR, H. D. AND FLYKK, R. E.: The role of irradiation in 1.he treatment of Wilnrn' tumor in children. Am. J. Roent., 75: 971, HJ56. LADD, W. E. A'.\TD WmTE, R.H.: Embryoma of the kidne.v (Wilms' tumor). J.A.l\l.A., 117: 1858. 1941. MELrcm-i·, M. M.: Classification of renal neophLsms: A clinicrd and r.rnthnlogil'al study based on 199 cases. J. 51: 333, 1944. NESBIT, R. M. AND ADAMS, F. : Wilms' tumor: review of l(i cases. J. Pedia1., 29: 295, 194G. O'CoNOR, V . .J.: Treatment. and prognosis of papilbry tumors of the renal pelvis . .J. Urol., 61: 485, 1949. PRIESTLEY, J. T.: Survival following the removal of malignant renal noeplaw1s. J.A.J\LA., 113: 902, 1939. ScoTT, L. S.: Wilms' Lnmor: hs treatment and prognosis. Brit. l\Ied . .J., 1: 200, 1956. SHAHEEN, A. L., CASSANO, C. AKD LtsA, .J. R.: Primary tumors of the kidney. J. Urol., 51: 597, 1944. THROCK1WRTON, 1\1. A. Prognosis in hypernephronrn: A review of the literature and report of 42 cases . .J. Urol., 73: 773, 1955. WALKER, K.: Prognosis of renal growths. Lancet, 1: 565, 1935. WATERS, C. A. Preoperative irradiation of cortical renal tumors. Am ..J. Roent., 33: 14!), 1935. WF;rsEL, W., DocKER'rY, M. B. AND PRIESTLEY, J. T.: Wilms' tumor of the kidnA)': A clinicopathologic study of 44 proved cases. J. Urol., 50: 3P9, 194:l.