Advertisement

Risk Factors for Upstaging, Recurrence, and Mortality in Clinical T1-2 Renal Cell Carcinoma Patients Upstaged to pT3a Disease: An International Analysis Utilizing the 8th Edition of the Tumor-Node-Metastasis Staging Criteria

Published:December 10, 2019DOI:https://doi.org/10.1016/j.urology.2019.11.036

      ABSTRACT

      Objective

      To investigate risk factors for and outcomes in pathological T3a-upstaging in Renal Cell Carcinoma (RCC), as Tumor-Node-Metastasis staging for T3a RCC was recently revised.

      Methods

      Multicenter retrospective analysis of patients with clinical T1-T2 RCC, stratified by occurrence of pathologic T3a-upstaging. Primary outcome was recurrence-free survival (RFS). Multivariable analyses (MVA) were conducted for upstaging and recurrence. Kaplan-Meier analysis (KMA) was utilized for RFS and overall survival (OS).

      Results

      We analyzed 2573 patients (1223 RN/1350 PN). Upstaging occurred in 360 (14.0%). On MVA, higher clinical stage was associated with increasing risk of upstaging [cT1a (referent), odds ratio for cT1b, cT2a, and cT2b was 2.6, 6.5, and 14.1, P < .001]. Higher clinical stage at presentation correlated with increasing risk of recurrence in pT3a-upstaged RCC (cT1a upstaged-pT3a [referent], hazard ratio [HR] for cT1b, cT2a, and cT2b upstaged pT3a was 1.16 [P = .729], 3.02 [P = .013], and 4.5 [P = .003]). Perirenal fat (HR 1.6, P = .038) and renal vein (HR 2.2, P = .006) invasion were associated with increased risk of recurrence; type of surgery was not (P = .157). KMA for RFS and OS in pT3a-upstaged patients demonstrated differences based on initial clinical stage (5-year PFS for cT1a/b, and cT2 upstaged was 84.5%/72.8%, and 44.7%, P < .001; 5-year OS for cT1 and cT2 upstaged was 83.8% and 63.2%, P < .001).

      Conclusion

      Risk of pT3a-upstaging and recurrence in pT3a-upstaged RCC correlates with clinical stage at presentation. Renal vein and perinephric fat invasion were associated with increased risk of recurrence. PN did not increase risk of recurrence and potential of pT3a-upstaging should not deter consideration of PN.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • AJCC
        Cancer Staging Manual.
        8th ed. Springer-Verlag, New York2017
        • Novick AC
        • Derweesh I
        Open partial nephrectomy for renal tumours: current status.
        BJU Int. 2005; 95: 35-40
        • Ljungberg B.
        • Albiges L.
        • Abu-Ghanem Y.
        • et al.
        European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update.
        Eur Urol. 2019; 75: 799-810
        • Campbell S
        • Uzzo RG
        • Allaf ME
        • et al.
        Renal mass and localized renal cancer: AUA guideline.
        J Urol. 2017; 198: 520-529
        • Derweesh IH
        • Ryan ST
        • Hamilton ZA
        Partial nephrectomy for T1b and T2 renal masses: a subtle paradigm shift and a new synthesis.
        Cancer. 2018; 124: 3798-3801
        • Mir MC
        • Derweesh I
        • Porpiglia F
        • et al.
        Partial nephrectomy versus radical nephrectomy for clinical T1b and T2 renal tumors: a systematic review and meta-analysis of comparative studies.
        Eur Urol. 2017; 71: 606-617
        • Pierorazio PM
        • Johnson MH
        • Patel HD
        • et al.
        Management of renal masses and localized renal cancer: systematic review and meta-analysis.
        J Urol. 2016; 196: 989-999
        • Ristau BT
        • Handorf EA
        • Cahn DB
        • et al.
        Partial nephrectomy is not associated with an overall survival advantage over radical nephrectomy in elderly patients with stage Ib-II renal masses: an analysis of the national cancer data base.
        Cancer. 2018; 124: 3839-3848
        • Shum CF
        • Bahler CD
        • Sundaram CP
        Matched comparison between partial nephrectomy and radical nephrectomy for T2 N0 M0 tumors, a study based on the National Cancer Database.
        J Endourol. 2017; 31: 800-805
        • Kopp RP
        • Liss MA
        • Mehrazin R
        • et al.
        Analysis of renal functional outcomes after radical or partial nephrectomy for renal masses ≥7 cm using the RENAL score.
        Urology. 2015; 86: 312-320
        • Ramaswamy K
        • Kheterpal E
        • Pham H
        • et al.
        Significance of pathologic T3a upstaging in clinical T1 renal masses undergoing nephrectomy.
        Clin Genitourin Cancer. 2015; 13: 344-349
        • Nayak JG
        • Patel P
        • Saarela O
        • et al.
        Pathological upstaging of clinical T1 to pathological T3a renal cell carcinoma: a multi-institutional analysis of short-term outcomes.
        Urology. 2016; 94: 154-160
        • Mouracade P
        • Kara O
        • Dagenais J
        • et al.
        Perioperative morbidity, oncological outcomes and predictors of pT3a upstaging for patients undergoing partial nephrectomy for cT1 tumors.
        World J Urol. 2017; 35: 1425-1433
        • Maurice MJ
        • Zhu H
        • Kim SP
        • Abouassaly R
        Increased use of partial nephrectomy to treat high-risk disease.
        BJU Int. 2016; 117: E75-E86
        • Larcher A
        • Capitanio U
        • Terrone C
        • et al.
        Elective nephron sparing surgery decreases other cause mortality relative to radical nephrectomy only in specific subgroups of patients with renal cell carcinoma.
        J Urol. 2016; 196: 1008-1013
        • Kopp RP
        • Mehrazin R
        • Palazzi KL
        • et al.
        Survival outcomes after radical and partial nephrectomy for clinical T2 renal tumours categorised by R.E.N.A.L. nephrometry score.
        BJU Int. 2014; 114: 708-718
        • Donat SM
        • Diaz M
        • Bishoff JT
        • et al.
        Follow-up for clinically localized renal neoplasms: AUA guideline.
        J Urol. 2013; 190: 407-416
        • Dindo D
        • Demartines N
        • Clavien P-A
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Ficarra V
        • Galfano A
        • Guillé F
        • et al.
        A new staging system for locally advanced (pT3-4) renal cell carcinoma: a multicenter European study including 2,000 patients.
        J Urol. 2007; 178: 418-424
        • Chevinsky M
        • Imnadze M
        • Sankin A
        • et al.
        Pathological stage T3a significantly increases disease recurrence across all tumor sizes in renal cell carcinoma.
        J Urol. 2015; 194: 310-315
        • Thompson RH
        • Leibovich BC
        • Cheville JC
        • et al.
        Is renal sinus fat invasion the same as perinephric fat invasion for pT3a renal cell carcinoma?.
        J Urol. 2005; 174: 1218-1221
        • Tay MHW
        • Thamboo TP
        • Wu FMW
        • et al.
        High R.E.N.A.L. nephrometry scores are associated with pathologic upstaging of clinical T1 renal-cell carcinomas in radical nephrectomy specimens: implications for nephron-sparing surgery.
        J Endourol. 2014; 28: 1138-1142
        • Kutikov A
        • Uzzo RG
        The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.
        J Urol. 2009; 182: 844-853
        • Ficarra V
        • Novara G
        • Secco S
        • et al.
        Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery.
        Eur Urol. 2009; 56: 786-793
        • Weight CJ
        • Lythgoe C
        • Unnikrishnan R
        • et al.
        Partial nephrectomy does not compromise survival in patients with pathologic upstaging to pT2/pT3 or high-grade renal tumors compared with radical nephrectomy.
        Urology. 2011; 77: 1142-1146
        • Shah PH
        • Moreira DM
        • Patel VR
        • et al.
        Partial nephrectomy is associated with higher risk of relapse compared with radical nephrectomy for clinical stage T1 renal cell carcinoma pathologically up staged to T3a.
        J Urol. 2017; 198: 289-296
        • Kim SP
        • Campbell SC
        • Gill I
        • et al.
        Collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses.
        Eur Urol. 2017; 72: 64-75
        • Weight CJ
        • Miller DC
        • Campbell SC
        • et al.
        The management of a clinical T1b renal tumor in the presence of a normal contralateral kidney.
        J Urol. 2013; 189: 1198-1202
        • Kutikov A
        • Smaldone MC
        • Egleston BL
        • et al.
        Anatomic features of enhancing renal masses predict malignant and high-grade pathology: a preoperative nomogram using the RENAL nephrometry score.
        Eur Urol. 2011; 60: 241-248
        • Lebentrau S
        • Rauter S
        • Baumunk D
        • et al.
        Nephron sparing surgery for renal cell carcinoma up to 7 cm in the context of guideline development: a contribution of healthcare research.
        World J Urol. 2017; 35: 753-759