Editorial: Renal Cell Carcinoma—Prognostic Factors

Many different prognostic factors have been evaluated for renal cell carcinoma including symptoms, tumor size, cell type, Fuhrman grade, pathological stage, performance status and nodal disease. In this issue of The Journal Frank et al (page 2217) analyzed tumor size and renal cell carcinoma subtype. Small tumors, particularly less than 1 cm, are more frequently benign (46%) than tumors larger than 7 cm (6%). High grade renal cell carcinoma increased from 2% for tumors less than 1.0 cm to 58% for tumors larger than 7 cm. Only 9% of the tumors less than 2 cm were high grade malignancies. These findings support the general guidelines for overall management of renal tumors in von HippelLindau cases and partial nephrectomy or local ablative techniques for smaller renal tumors. Interestingly, for each increase of 1 cm in size there was a 17% increase in the odds of carcinoma. Overall, this review of 2,770 patients reflects a significant experience and supports many observations made by others in the past. Han et al (page 2221) made outcome predictions for patients with renal cell carcinoma based on a combination of factors. A previous clinical outcome algorithm based on T stage, Fuhrman grade and performance score was validated with data from 3 separate institutions. The groups were divided into low, intermediate and high risks. The concordance indices were quite good for each of the databases. Having this information may be useful for patient counseling, postoperative followup and identification of those who might profit by adjuvant chemotherapy or immunotherapy. Several other groups, including Memorial Sloan-Kettering Cancer Center and Mayo Clinic, have also devised grading systems for outcome predictions. Although grade and stage have been prognostic for many groups, relative risk has been determined on the basis of clinical parameters for tumor vaccines as a form of adjuvant therapy. In addition, other parameters such as nuclear morphometry can also be prognostic and identify at risk groups.1 It is possible to determine low risk patient populations with results being a need for fewer followups. Less followup with fewer examinations will result in less cost. On the other hand, higher risk groups may profit by early adjuvant therapy either in the form of chemotherapy or immunotherapy. Although concordance was demonstrated reasonably among the 3 institutions compared in this article, there were variations in treatment with fewer nephrectomies performed in Nijmegen compared to UCLA. This is also a retrospective study with potential variations in pathological analysis but overall this information may be helpful to the treating urologist with a simple clinical grading system. In the other article by Frank et al (page 2225) a postoperative surveillance algorithm was based on significant predictors of site specific disease recurrence. As expected, recurrences in the thoracic region were the most common (16%) followed by the abdomen (10%), bone (7%) and brain (4%). A total of 1,864 patients underwent partial or radical nephrectomy for nonmetastatic clear cell renal cell carcinoma from 1970 to 2000. Positive surgical margins, TNM stage, size, grade and necrosis were associated with abdominal recurrence. Similar findings were associated with thoracic recurrence. Stage, grade and necrosis on multivariate analysis were predictive of recurrence in bone. The average length of followup was 8.1 years, which is longer than many studies. Several important features were noted. Low accumulative scores were associated with later recurrence and higher scores were associated with recurrence in the first 2 years. Importantly brain and bone metastases were frequently symptomatic whereas chest metastases were not symptomatic. A site specific pattern of disease recurrence can be used with a multifactorial scoring system to direct postoperative surveillance in patients with surgically treated renal cell carcinoma. As a result, routine screening for brain and bone metastasis would include only routine physical examination and laboratory tests. Routine imaging was not indicated unless symptoms were present. Many of these factors may be intuitively apparent to some urologists but this study of 1,864 patients accurately determines the sites of recurrence and their presentation. The varying scores give a percentage of disease-free survival. However, histological tumor necrosis appears to be unique to this group and its scoring system. The scoring system can be used to tailor postoperative surveillance and determine the need for adjuvant therapy. Effective adjuvant therapy has not been effective but as new forms of treatment become available these scoring algorithms may assume increased importance.