The Surgical Management of Renal Cell Carcinoma

The Surgical Management of Renal Cell Carcinoma

Vol. 107, May Printed in U.S.A. THE JOURNAL OF UROLOGY Copyright © 1972 by The Williams & Wilkins Co. THE SURGICAL MANAGEMENT OF RENAL CELL CARCINO...

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Vol. 107, May Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1972 by The Williams & Wilkins Co.

THE SURGICAL MANAGEMENT OF RENAL CELL CARCINOMA DONALD G. SKINNER,* CLINTON D. VERMILLION

AND

ROBERT B. COLVIN

Frorn the Departments of Urology and Pathology, Massachusetts General Hospital, Boston, Massachusetts

The incidence of renal cell carcinoma is 3.5 per 100,000 population per year. This represents approximately 1.7 per cent of cancer occurring in male subjects and 1.0 per cent of cancer in female subjects.1 In 1883 Grawitz first described this tumor when he noted the striking gross resemblance of the yellow renal mass to the adrenal cortex and suggested that it might be derived from adrenal rests. 2 The term hypernephroma was introduced by Birch-Hirschfeld in 1892 as an appropriate name for the Grawitz tumors. Gradually urologists and pathologists realized that most renal parenchymal tumors arise from renal tubular epithelial cells-a fact supported by light and electron microscopy. 3· 4 Thus, the term renal cell carcinoma or renal cell adenocarcinoma seems most appropriate. These parenchymal tumors, the renal cell carcinomas, constitute approximately 85 per cent of all renal tumors. The remaining 15 per cent include tumors of the renal pelvis and tumors of the renal capsule. Herein we shall deal only with renal cell carcinomas.

approach for the removal of an extremely difficult left renal tumor7 and in 1949 Chute and associates reported on 39 cases in which a radical nephrectomy was performed via the thoracoabdominal approach. 8 Since it has been demonstrated that the direct extension of tumor into the perinephric fat occurs in 13 to 25 per cent of cases of renal cell carcinoma, the principles of cancer surgery dictate that nephrectomy be done in such a way as to include the complete removal of Gerota's fascia with its contents intact along with early ligation of the renal artery and vein. 9 • 10 This generally constitutes a radical nephrectomy. In 1963 and again in 1968 Robson indicated that extensive radical nephrectomy plus regional lymph node dissection would markedly improve survival.11 · 12 However, despite the trend toward more radical operation, the published 5-year survival results have remained in the 25 to 50 per cent range, although few investigators have reported either the method of treatment or the pathologic extent of the tumors treated. In the past 20 years several investigators have suggested that irradiation either preoperatively or postoperatively could favorably affect survival in patients with renal cell carcinoma. Flocks and Kadesky and subsequently Riches and associates have given support for the adjunctive use of irradiation.13-15 Their total number of patients treated with irradiation is small, however, and Peeling's recent data derived from a larger series indicate that the adjunctive use of irradiation actually de-

HISTORICAL DATA

In 1871 Walcott performed the first nephrectomy for renal cell carcinoma. 5 In 1932 Hand and Broders reported a 23 per cent 5-year survival for patients with renal parenchymal tumors treated by nephrectomy at the Mayo Clinic. Operative morhlity was 12 per cent. 6 Since Walcott's bold adventure there have been numerous reports on results of treatment of renal cell carcinoma by nephrectomy. Before 1950 the reported 5-year survivals ranged from 13 to 40 per cent. In 1948 Mortensen described a transthoracic Accepted for publication June 25, 1971. Read at annual meeting of American Urological Association, Chicago, Illinois, May 16-20, 1971. * Current address: Department of Surgery /Urology, U.C.L.A. School of Medicine, Los Angeles, California 90024. 1 MacDonald, E. J.: Present incidence and survival picture in cancer and promise of improved prognosis. Bull. Amer. Coll. Surgeons, 33: 75, 1948. 2 Melicow, M. M.: Classification of renal neoplasms: a clinical and pathological study based on 199 cases. J. Urol., 51: 333, 1944. 3 Carter, R. L.: The pathology of renal cancer. J.A.M.A., 204: 221, 1968. 4 Pinals, R. S. and Krane, S. M.: Medical aspects of renal carcinoma. Postgrad. Med. J., 38: 507, 1962. •Mintz, E. R. and Gaul, E. A.: Kidney tumors; some causes of poor end results. New York State J. Med., 39: 1405, 1939. 6 Hand, J. R. and Broders, A. C.: Carcinoma of the kidney: the degree of malignancy in relation to factors bearing on prognosis. J. Urol., 28: 199, 1932.

7 Mortensen, H.: Transthoracic nephrectomy. J. Urol., 60: 855, 1948. 8 Chute, R., Soutter, L. and Kerr, W. S., Jr.: Value of thoraco-abdominal incision in removal of kidney tumors. New Engl. J. Med., 241: 951, 1949. 9 Foley, F. E. B., Mulvaney, W. P., Richardson, E. J. and Victor, I.: Radical nephrectomy for neoplasm. J. Urol., 68: 39, 1952. 10 Beare, J. B. and McDonald, J. R.: Involvement of the renal capsule in surgically removed hypernephroma: a gross and histopathologic study. J. Urol., 61: 857, 1949. 11 Robson, C. J.: Radical nephrectomy for renal cell carcinoma. J. Urol., 89: 37, 1963. 12 Robson, C. J., Churchill, B. M. and Anderson, W.: The results of radical nephrectomy for renal cell carcinoma. J. Urol., 101: 297, 1969. . 13 Flocks, R. H. and Kadesky, J\'.C· C.: _Mahg_nant neoplasms of the kidney: an analysis of 3:.i3 patieI:ts followed five years or more. J. Urol., 79: 196, 19:.i8. 14 Riches, E. w., Griffiths, I. H. and Thackray, A. C.: New growths of the kidney and ureter. Bnt. J. Urol., 23 : 297 , 195 1. . h . h 15 Riches, E.: The place of radwt erapy m t e management of parenchymal carcinoma of the kidney. J. Urol., 95: 313, 1966.

705

706

SKINNER, VERMILLION AND COLVIN

1. 8urnrnary of published results of treatrnent of renal cell carcinorna, comparing nephrectorny alone to nephrectorny plus i rracliation therapy. Pathologic stage I to III tumors includes all patients surgically treated except those with metastases present on admission

TABLE

5-Year Survival Series

Flocks and Kadesky 1 3 Iowa, 1926-1950 Riches and associates 14 British Isles, 1935-1950 Peeling and associates 1 6 London, 1940-1965 Hand and Broders 6 Mayo Clinic, 1901-1923 Foot and associates 17 New York, 1926-11)49 :Myers and associates 18 Mayo Clinic, 1940-1955 }Iiddletonl' Ne\v York Hospital, 1932-1905 Kaufman and Mims2o UCLA, 1966 Robson and associates 12 Toronto, 1949-1964 Skinner and associates Boston, 1\)35-1965

No. Cases

N ephrectomy

10-Year Survival Over-All No.(%)

N ephrectomy Alone No.(%)

N ephrectomy Plus Irradiation No.(%)

Over-All No.(%)

21/40 (52)

48/96 (50)

9/39 (23)

9/27 (33)

18/66 (27)

105/3-15 (30)

26/53 (49)

131/398 (33)

30/177 (17)

4/15 (27)

34/192 (17)

164

50/96 (52)

17 /68 (25)

67;15-1 (-lo)

193

+4/193

44/193 (23)

104

33/81 (40)

33/81 (40)

9/±0 (22)

9/40 (22)

479

259/479 (54)

0

259 / 4i9 (54)

183/479 (38)

183/479 (38)

25% received irradiation

112/320 (35)

Alone No.(%)

Nephrectomy Plus Irradiation No.(%)

96

27 /56 (-18)

398

334

25% received irradiation

19/108 (18)

79

37/79

cm

0

37 /79 (47)

27/79 (34)

0

27/79 (34)

70

40/70 (57)

0

40/70 (57)

18/34 (53)

0

18/34 (53)

232

109/190 (57)

9/18 (50)

118/208 (57)

61/139 (44)

0

61/139 (44)

creased survival in those patients as compared to patients treated by nephrectomy alone. 16 Recently a nationwide cooperative study involving the random assignment of preoperative irradiation to patients with renal call carcinoma has been established to specifically answer the question of whether preoperative irradiation does in fact alter survival. It will be some time before the longterm results of that study are known. Table 1 is an attempt to summarize the published results of the surgical management of renal cell carcinoma with and without preoperative or postoperative irradiation. This is a comparison of results in all patients surgically treated except those with metastases present at hospitalization or those whose primary tumor histological!y involved contiguous visceral organs. 6 , 12 - 14 , 16-20 It is our purpose herein to report the results of a 30-year experience in the surgical management of renal cell carcinoma, according to pathologic stage and hist8logic grade as relating to 5 and 10-year survival and type of treatment employed. 16 Peeling, W. B., Mantell, B. S. and Shepheard, B. G. F.: Post-operative irradiation in the treatment of renal cell carcinoma. Brit. J. Urol., 41: 23, 1969. 17 Foot, N'. C., Humphreys, G. A. and Whitmore, W. F.: Renal tumors: pathology and prognosis in 295 cases. J. Urol., 66: 190, 1951. 18 Myers, G. H., Jr., Fehrenbaker, L. G. and Kelalis, P. P.: Prognostic significance of renal vein invasion by hypernephroma . •T. Urol., 100: 420, 1968. 19 Middleton, R. G.: Surgery for metastatic renal cell carcinoma. J. Urn!., 97: 973, 1067. 2°Kaufman, J. J. and Mims, M. M.: Tumors of the kidney. In: Current Problems in Surgery. Chicago: Year Book Medical Publishers, Inc., pp. 1-44, 1966.

MATERIALS AND METHODS

Between 1935 and 1965, 329 patients with renal cell carcinoma were surgically treated at this hospital. All patients underwent renal exploration and all except 10 underwent nephrectomy. Between 1935 and 1948 simple nephrectomy via the lumbar or the transperitoneal approach was the usual form of therapy. Since 1948 radical nephrectomy, usually via the thoracoabdominal approach, has become the standard operation. This approach has been designed to include the removal of Gerota's fascia and its contents intact with early ligation of the renal artery and vein. Regional lymph node dissection has been done in most of these cases. The term radical nephrectomy will refer to this operation with or without lymph node dissection. Of these 329 patients, 20 could not be traced and their hospital records were not sufficiently complete to permit evaluation. These 20 patients were excluded, leaving 309 patients for evaluation. In calculating survival we have included those patients who died at operation or during the immediate postoperative period (operative mortality). Patients who died within 5 years of unrelated causes (24) but had autopsy or good clinical evidence of freedom from metastatic -renal cell carcinoma were excluded from the 5-year survival calculations. Tenyear survival calculations were based on those patients who were at risk at least 10 years from the date of their operation. The operative mortality was included in this calculation but patients who died within 10 years of unrelated causes were excluded. As others have found also, male subjects dominated this series by a 2 to 1 ratio. Only 9 per cent of these

707

RENAL CELL CARCIN0:\1A

patients presented with a combination of gross hematuria, pain and an abdominal mass, the socalled classic triad. A combination of any 2 of these 3, however, occurred in 36 per cent and hematuria was noted in 60 per cent. Ten patients had secondary polycythemia (hematocrit greater than 50 per cent or hemoglobin greater than 15.5) at hospitalization which returned to normal following nephrectomy. On the other hand, anemia (hematocrit less than 33 per cent or hemoglobin less than 10) was a common finding and was noted in 64 patients (21 per cent). Secondary hyper11arathyroidism with hypercalcemia (serum calcium greater than 10.5) was found at hospitalization in 11 patients. Seven male patients were referred because of the sudden onset of a varicocele, 6 of these 7 occurring on the left side. One patient with tumor involving the vena cava presented with an acute right varicocele. One other patient presented with a large hematoma in the right flank following spontaneous rupturn of a carcinoma. \Vhile 10 per cent of patients presented because of clinical symptoms secondary to metastases, 77 of 309, or nearly 25 per cent, had x-ray or clinical evidence of metastases when first seen for therapy. In 7 per cent of our patients renal cell carcinoma was an incidental finding, usually di,;covered during the course of another operative procedure. With the exception of those patients who presented with metastases and those in whom renal cell carcinoma was an incidental finding, no significant prognostic relation could be found between various presenting symptoms or laboratory abnormalities and the over-all survival. In these 309 patients, 93 simple nephrectomies STAGE I

-

were performed and 203 patients underwent radical nephrectomy. Three heminephrectomies were performed in patients with either a solitary kidney or hypoplastic contralateral kidney. Ten patients with extensive metastases underwent exploration and were regarded as inoperable. Fifteen of the 309 patients died at operation or in the immediate postoperative period. This is an over-all operative mortality of 5 per cent. Irradiation was used as adjunctive therapy in only 19 of the 232 patients who were without metastases when first seen for therapy. Operations for removal of an apparent solitary metastasis were performed on 34 patients and 7 others underwent 2 operations for removal of 2 metastatic foci. RESULTS

To analyze the outcome of therapy, surgical staging according to the plan of Robson and associates was employed. 11 , 12 Briefly, this divides the over-all group of tumors into 4 stages dependent upon specific pathologic involvement. Stage I. Tumor is confined to the kidney-perinephric fat, renal vein and regional nodes are negative. There were 102 patients with this stage tumor treated, resulting in a 65 per cent 5-year survival and a 56 per cent 10-year survival (see figure). Radical nephrectomy produces slightly but not statistically better results at 5 and 10 years. Adjunctive irradiation was given to 6 of 102 patients; 2 of these 6 patients survived beyond 5 years. Stage II. Tumor involves the perinephric fat but is confined within Gerota's fascia-renal vein and regional nodes are negative. There were 22 patients STAGE 1I - 22

02

5yr = 65 %

5yr=47%

iOyr = 56%

10yr =(20%)

STAGE III - 108

STAGE

:nz:: -

77

5 yr= 51 %

5 yr= 8%

10yr = 37%

lOyr= 7%

PLUS: distant melostases or extension to contiguous visceral structures.

Five and 10-year survival of 30!) surgically treated patients according to specific pathologic stage. Parentheses indicate too few patients to be significant.

708

SKINNER, VERMILLION AND COLVIN TABLE

2. Summary of survival according to extent of pathologic involvement by tumor 5-Y ear Survival

10-Year Survival

No.(%)

No.(%)

Histologic Extent of Tumor

59/91 (65)

34/61 (56)

Renal Yein involvement

Renal vein only Renal vein plus perinephric fat Renal vein plus regional nodes Renal vein plus perinephric fat plus regional nodes Total

34/48 (66) 16/33 (50) 0/6 (0) 0/4 (0)

17/35 (49) 7/21 (33) 0/3 (O) 0/2 (0)

48/81 (59)

24/61 (40)

Perinephric fat involvement

Perinephric fat only Perinephric fat plus renal vein Perinephric fat plus regional nodes Perinephric fat plus renal vein plus regional nodes Total

8/17 (47) 16/33 (50) 1/3 (33) 0/4 (0)

2/10 (20) 7/21 (33) 0/1 (OJ 0/2 (O)

25/57 (44)

9/34 (26)

Regional node involvement

Regional nodes only Regional nodes plus renal vein Regional nodes plus perinephric fat Regional nodes plus renal vein plus perinephric fat Total

Confined to kidney (stage I)

Direct extension of tumor to contiguous visceral structures

TABLE

Pathologic Stage

Stage Stage Stage Total Stage Total

I

II III (stages I-III) IV (stages I-IV)

2/6 0/6 1/3 0/4

(33) (0) (33) (0)

1/6 0/3 0/1 0/2

(17) (0) (0) (O)

3/19 (16)

1/12 (8)

0/15 (O)

0/12 (0)

3. Over-all summary of results of surgical treatment according to pathologic stage

No. Cases

Dead Within 5 Years Free of TumorExcluded From Study

102 22 108 232 77 309

11 5 8 24 0 24

Op. Mortality No.(%)

4/102 (4) 0 3/108 (3) 7/232 (3) 8/77 (10) 15/309 (5)

with this stage tumor treated, resulting in a 5-year survival of 47 per cent and a 10-year survival of 20 per cent (see figure). This group is small but a 10 per cent improvement in the 5-year survival was noted with radical nephrectomy. Three patients were treated with adjunctive irradiation therapy, all of whom survived more than 5 years. Stage III. Tumor involves renal vein and/or regional nodes, with or without involvement of the vena cava or perinephric fat. There were 108 patients with this stage tumor treated, with a 5-year survival of 51 per cent and a 10-year survival of 37 per cent (see figure). Table 2 further shows 5 and 10-year survival according to various specific combinations of histologic involvement. While a statistically significant improvement in over-all survival between radical nephrectomy and simple nephrectomy cannot be demonstrated, 2 of 6 patients with positive regional nodes survived 5 years following radical nephrectomy as the only form of therapy, and one of. these is well more than 10 years following surgical treatment. Irradiation was used as adjunctive therapy in 10 patients, 4 of whom survived more than 5 years. Vascular involvement, by itself, does not statis-

5-Year Survival No.(%)

59/91 (65) 8/17 (47) 51/100 (51) 118/208 (57) 6/77 (8) 124/285 (44)

10-Year Survival No.(%)

34/61 (56) 2/10 (20) 25/68 (37) 61/139 (44) 4/56 (7) 65/195 (33)

Dead Beyond 10 Years Due to Renal Cell Carcinoma

1 1 5 7 1 8

tically alter the prognosis at either 5 or 10 years compared to stage I tumors (table 2). Five of these 48 patients with vascular involvement only had extension of tumor into the vena cava. All 5 of these survived 5 years and 3 of 4 survived more than 10 years. Stages I through II I. Patients in these stages are those who are potentially curable by a surgical procedure. Table 3 summarizes the results of therapy in these 232 patients. As noted by Peeling16 the adjunctive use of irradiation did not improve survival at 5 years compared to nephrectomy alone. Stage IV. There are distant metastases secondary to renal cell carcinoma present at hospitalization or histologic involvement by tumor of contiguous visceral structures. There were 77 patients who presented with a stage IV tumor. The 5-year survival was 8 per cent and 10-year survival was 7 per cent with an operative mortality of 10 per cent (see figure). All but one of the long-term survivors in this group had excision of an apparently solitary metastasis. One other patient had multiple pulmonary nodules on chest x-ray that were considered to represent metastatic renal cell carcinoma. Following nephrectomy these lesions disappeared and this

709

RENAL CELL CARCINOMA

patient is currently well. The nature of these pulmonary lesions was never proved histologically. There were 15 patients in whom carcinoma directly invaded contiguous visceral structures. None of these 15 survived 5 years (table 2). Table 3 shows the over-all results of the surgical treatment of renal cell carcinoma for the entire 309 patients, regardless of pathologic involvement. Excision of metastatic renal cell carcinoma. Since 1935 there have been 48 operations for the removal of metastatic lesions of renal cell carcinoma in 41 patients. Of these 41 patients 5 are alive and 4 died free of disease more than 10 years following excision of the metastasis. Of the 32 deaths from renal cell carcinoma in this group, 23 patients died within 2 years, 6 patients died between 2 and 5 years and 3 patients survived more than 5 years but subsequently died with widespread metastases. Of the 5 patients who are alive and of the 7 who survived more than 5 years following removal of an apparent solitary metastasis, 9 underwent operation for the removal of metastasis more than 4 years after nephrectomy. Seven patients had 2 separate metastases excised; 3 of these 7 patients are alive although one has recurrent disease. One other patient who died of metastases lived more than 6 years following the excision of the second metastasis. HISTOLOGIC GRADING

All available microscopic sections were independently reviewed by a pathologist (R. C.). Numerous microscopic features were recorded and the means of grading was chosen for its ease of aplication. Ours is somewhat similar to Hand and Broders' approach. 6 Two important differences are that our classification is concerned only with nuclear morphology and not with cytoplasmic products or histological organization, and that the worst area of the tumor, rather than an over-all impression, defines the grade. Grade 1 tumors consisted of cells with small nuclei indistinguishable from those seen in normal tubular epithelial cells. Grade 2 tumors had slightly irregular and frequently pyknotic nuclei but were without abnormal nucleoli. Grade 3 tumors consisted of enlarged irregular and pleomorphic nuclei often with prominent nucleoli. Grade 4 tumors included those with extremely bizarre giant nuclei. Table 4 is a brief summary of survival according to histologic grade and its relation to pathologic stage. Grade significantly affects survival but to a -lesser degree than does pathologic stage. Because these tumors may include a great variety of cell types, grades and histologic patterns, microscopic examination can define only the minimum malignant potential, since more malignant areas may not be sampled. This may be one reason why staging generally correlates better with survival, since it is based upon the most malignantly behaving portion of the tumor. The influence of the cytoplasmic appearance of

4. Summary of survival according to histologic grade of tumor and its relation to pathologic stage

TABLE

."

"

.i')H

bOH .i')H

u:,

u:,

,~"

~H

-- -

Grade 1

Grade 2

Grade 3

Grade 4

No. cases 1-year survival 5-year survival 10-year survival No. cases !-year survival 5 year survival 10-year survival No. cases !-year survival 5-year survival 10-year survival No. cases 1-year survival 5-year survival 10-year survival

(%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%)

8 88 (75) (75) 40 95.

81 73 36 78 58

53 9 78 67 67

1 (100) (100)

8 88 38 9 100 62 42 2 (100) (33)

-

"

'"> .i'JH

u:,

'

.i'l

~~~

0

-- --

0 0 0 0 31 96 70

55 39 77 40

36 23 61

27 -

-19

0 0 0 0 9 89 22 (11)

32 31 3 (-) 17 20 (5) 0

9 77 (75) 88 65 55 118 56 48 57 26 22

* Underlined survivals are significantly different within each stage (p < 0.05). Parentheses indicate groups with less than 5 at risk. TABLE

5. Influence of cytoplasmic appearances and cell type on survival (%)* Cell Type

Pure clear Clear and/or granular Spindle

No. Cases

!-Year 5-Year 10-Year Survival Survival Survival

67 169 36

(%)

(%)

(%)

87

58 46 23

54 38 16

73 47

• p < 0.01 forall types except 5- year and 10-yearsurvivals of pure clear and clear/granular con1binations which have p < 0.03 and p < 0.10, respectively.

these tumors on survival also was analysed (table 5). While pure spindle cell tumors significantly decreased survival, the prognosis of pure clear cell tumors compared to pure granular or mixtures of granular and clear cell was only slightly better at 5 and 10 years. In most cases with biopsies of metastases, the metastases appeared at least equal to the grade of the worst portion of the primary tumor, and no grade 1 tumors were noted in metastases or in the renal vein. A more detailed study of the histologic grade and its relation to stage and survival is presented elsewhere.21 DISCUSSION

In 1939 Mintz and Gaul reported the results of simple nephrectomy on survival in 127 patients treated at this hospital between 1900 and 1935. Of these 127 patients only 17 (13 per cent) survived 5 years. 5 While our report shows a marked improvement in the results of surgical management over the succeeding 30 years, surgical technique, advancement in postoperative management and pa21 Skinner, D. G., Colvin, R. B., Vermillion, C. D., Pfister, R. C. and Leadbetter, W. F.: The diagnosis and management of renal cell carcinoma: a clinical and pathologic study of 309 cases. Cancer, 28: 1165, 1971.

710

SKINNER, VERMILLION AND COLVIN

tient selection have changed w markedly that further comparison is not warranted. In a retrospective study such as this, it is difficult to draw significant conclusions regarding the best form of surgical treatment. Over-all results suggest that radical nephrectomy does not improve the survival compared to simple nephrectomy. Such a conclusion does not seem justified because of patient selection. Early in this series the operative findings and surgical ability of the operator would often dictate the form of treatment-that is the more extensive tumor was often treated by a more extensive operation and vice versa. Fifty-two per cent of the simple nephrectomies were performed for stage I tumors whereas only 24 per cent of radical nephrectomies were done for tumors of this low stage. The perinephric fat or regional nodes were involved in nearly 30 per cent of potentially curable patients in this series. Survival in this group of patients was improved by radical nephrectomy. The principles of cancer surgery would dictate that because of extension of renal cell carcinoma to the perinephric fat and regional nodes in a significant percentage of cases, the best operation should include the removal of Gerota's fascia with its contents intact together with the early ligation of the renal artery and vein, followed by regional lymph node dissection. We prefer to do this through the thoracoabdominal approach. Contrary to other reports, tumor invasion of the renal vein, by itself, did not significantly alter prognosis compared to stage I tumors. 18 • 20 The operative mortality cannot be considered independent of stage and grade. The operative mortality of stage IV tumors was 10 per cent and that of grade 4 was 10.5 per cent as opposed to 5 per cent over-all in this series. We have elected to include the operative mortality in calculating the survival figures. If operative mortality were excluded the 5 and 10-year survival calculations for potentially curable patients would be 59 per cent and 46 per cent, respectively. Our study tends to confirm the previous observations by Petkovic, Arner and recently Biittiger that division by pathologic stage correlates better with survival than does division by grade. 22 - 24 Grading according to nuclear morphology was more meaningful than division according to cytoplasmic "differentiation''. Several investigators have alluded to the possibility that irradiation therapy, either preoperatively or 22 Petkovic, S. D.: An anatomical classification of renal tumors in the adult as a basis for prognosis. J. Urol., 81: 618, 1959. 23 Arner, 0., Blanck, C. and Schreek, T., von: Renal adenocarcinoma: morphology-grading of malignancy-prognosis. A study of 197 cases. Acta Chir. Scand., suppl. 346, p. 1, 1965. 24 Biittiger, L. E.: Prognosis in renal carcinoma. Cancer, 26: 780, 1970.

postoperatively, can improve survival.1 3- 15 • 25 This report, as well as those by Robson, Peeling and Biittiger, has demonstrated that to date the results of the surgical management of renal cell carcinoma are as good or better than any results in which irradiation has been used as adjunctive therapy.11· 12 • 16, 24

In carefully selected cases an aggressive approach to apparently solitary metastases seems justified. 19 In our study it was apparent that patients operated on for an apparent solitary metastasis did better if a significant period of time elapsed between nephrectomy and removal of the metastasis. Previous 5-year survival figures reported in the literature vary between 30 and 60 per cent for patients without obvious metastatic disease. This variation in survival has undoubtedly occurred because the majority of authors fail to correlate prognosis with pathologic stage and many have not even reported method of treatment. It has been our purpose to attempt to correlate survival with pathologic staging in a large series, so that it might be possible to form a rational opinion as to the prognosis of individual cases. SUMMARY

The results of a 30-year experience in the surgical management of renal cell carcinoma have been reported according to pathologic stage as relating to 5 and 10-year survival and the type of treatment used. Between 1935 and 1965, 329 patients with renal cell carcinoma underwent renal exploration at this hospital. Of these 309 patients were followed and analyzed. There were 93 simple nephrectomies and 203 patients underwent radical nephrectomy. Three heminephrectomies were performed and the remaining 10 patients had only biopsies of the primary tumor. Operative mortality was 5 per cent and over-all survival was 44 per cent at 5 years and 33 per cent at 10 years. Excluding those patients with metastases present when first seen for treatment, the 5-year survival was 57 per cent and the 10-year survival was 44 per cent. Division by pathologic stage was noted to correlate better with survival than did division by grade, and no significant prognostic relations could be found between various presenting symptoms or laboratory abnormalities and the over-all survival of these patients. It is noteworthy that vascular involvement, by itself, did not statistically alter the prognosis at either 5 or 10 years compared to stage I tumors. In selected cases an aggressive approach to apparently solitary metastases seems justified. 25 Cox, C. E., Lacy, S. S., Montgomery, W. G. and Boyce, W. H.: Renal adenocarcinoma: 28-year reviAw, with emphasis on rationale and feasibility of preoperative radiotherauv. ,T. Hrnl.. 104: 53. 1970.