Vol. 114, l'\ovember

THE JO\"R'1AL OF lJROLOCi\

Copyright© 1975 by The Williams & Wilkins Co.

Printed in U.S.A,

AN ANALYSIS OF FACTORS AFFECTING SURVIVAL IN 150 PATIENTS WITH RENAL CARCI>JOMA IAN M, THOMPSON, H, SHAT\NOT\, G, ROSS, .JR.

A"-D

J. MONTIE

From the Section of Urology, University of Missouri School of Medicine, Columbia, Missouri

ABSTRACT

A review of 150 patients with renal carcinoma revealed that 45 per cent were hospitalized with distant metastases or tumors that were unresectable, Although the behavior of the neoplasm in the ,S,S per cent who were theoretically curable was generally unpredictable, longevity and survival were markedly increased in patients with tumors less than 8 cm, in size and concomitantly with other acknowledged features of low stages of the disease. Since patients can survive with tumor for long periods and metastases may occur many years after the operation prognosis must be guarded and long followup is needed to assess the results of therapy at any stage of the disease. During a 17-year period, through July 1974, lfiO patients with renal cell carcinoma in whom followup was sufficient to determine their status at the time of this report were admitted to our medical center. The records of these patients were reviewed to determine what relationship clinical, radiographic, surgical and pathological findings might have had on the length of survival. As in many retrospective studies all data sought for evaluation were not available in every patient but information secured in any of the predetermined categories has been included. Longevity data are current to early 1975. The patients were divided into 4 groups relative to the time of hospitalization during the 17-year period to permit comparison of survival in consecutive 5-year intervals (table 1). The current status of patients in each group is depicted as alive without evidence of tumor, alive with tumor, dead of tumor or dead of other causes (table 2). The periods of survival for patients in each group are listed in table :i. This raw survival data for the 150 patients. if those dying of other causes are excluded, depicts 27 patients ( 18 per cent) alive and free of tumor for 1 to 17 years after diagnosis. If the most recent patients (group A) are excluded the ;3 to 17-year survival is less than 10 per cent. The paucity of long-term survivors may be explained by the number of patients admitted to the hospital with metastases (table 4). The majority of patients hospitalized with metastases died in less than 1 year but survival ranged from 1 month to 4 years (table 5). In addition to those hospitalized with metastases 5 individuals had tumors that were deemed unresectable. often after tedious operative endeavor. Their survival ranged from 2 Accepted for publication ,June :211. 197:i. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-lR. Hl7;i.

to 6 years. If these patients were included the presumably unsalvageable patients would be in excess of 45 per cent of the entire group. Nephrectomy was performed in 6 patients with distant metastases (2 with solitary pulmonary lesions) and all died within 4 years-2 in less than 1 year, :3 between 2 and :i years and 1 between 3 and 4 years, Survival did not appear to be prolonged by this intervention. Other reports on renal carcinoma have depicted more satisfactory survival statistics but in our group of patients, if those with metastases or who had unresectable tumors are excluded, we are left with 80 of 150 patients not at obvious risk of death when first seen. The raw 1 to 17-year survival data for these 80 patients (27 alive without tumor) would approximate 33 per cent but if the 1 to :3-year followup group were excluded, survival ( 14 patients) is then only 17 per cent. If the Fi to 17-year followup groups (C and D) are considered separately (11 patients) survival falls to 11 per cent. The 10-year survival rate in this group (6 patients) is less than 8 per cent. The addition of patients presumably dying of other causes (7 during the 17-year period) would not appreciably alter the rather poor over-all long-term survival. particularly since at least half of them could be considered still at risk owing to relatively short survival intervals. This is particularly pertinent when patients alive with tumor surviving up to nearly 12 years and those known dead of tumor surviving up to lfi years are considered, If significant numbers of patients in each group die of tumor :3, :'i, 8. 10 and lfi years following diagnosis and treatment, prognosis in any patient with renal carcinoma must be guarded. Data relative to age, sex, interval between symp-

694

SURVIVAL IN

toms and signs and the time of diagnosis, physical findings, urographic and angiograph ic characteristics, therapeutic modalities, a nd surgical-pa thological findings were reviewed referable to surviva l. There were 106 men and 44 women in our series, again emphasizing t he known sex preponderance. The youngest patient was 15 years old a nd the oldest was 84 (table 6) . A greater number of patients died of tumor in the younger and older age groups but this appeared to be related more to the preponderance of adm ission to the hospital with metastases than any other facto r. Intervals between onset of symptoms and signs, and the time of diagnosis bore no apparent relat ionship to survival or longevity. Although this information is notoriously inaccurate the time intervals were nearly identical in t hose dying of tumor in less than 3 years and those of the longer term survivors with or without tumor. By combin ing patients a live without tumor and patients who survived for 5 years or more we did find certain correlations referable to radiographic, surgical and pathologica l data that appeared to influence longevity and survival. TABLE

1.

3 to 5 5 to 10

A B C

:\2 18 57

10 to 17

D

4:J

~o.

(~roup..,;

A

J:l

B

10 26 16 65

C

D Total

No Tumor

~o. Pts.

1- :l 3-,1 5- 10 10-17 Totals

1:1 8 5 6

27

1- 2 2 :l

14

:l- 4

4

(i

TABLE

No

Tumor

Tumor

4

:sin. Pts.

15

:lll- '.\9 40- 49 50- 59 60- li9 70 - 79 80-1'9

17

1 0 2

6. A!!e incidence

Age (vrs. I

Tumor

14 48

2 :l

;\:l

7

iiT

(421

,1. Admitted 1rith metastases

T AHLE

Sun·in,d

Dead

( I"( )

Pts.

2

Alive

Diagnosis (yrs.)

Admitted u·ith metastases

t ~·r:--.)

TABLE

A B C D

TABLE~-

:--:o. Pts.

Group

I to ;J

Group

Tumor size by arteriographic and pathological determination, renal vein and cava l involvement, capsu lar invasion, and perinephric or reg iona l lymphatic involvement were the significant determinant s of longevity or su rviva l. Selective angiographic size of tumor correlated we ll with its magnitude at operation an d pathological exa mination, as did venographic delineation of renal vein and ca va l involvement . Of 24 patients surviving with or without tumor for 5 years or more 22 had tumo rs less than 8 cm. in greatest diameter. The 2 patients with larger tumors were not amo ng the group free of tumor. In contrast of 103 patients d ying of tumor within 5 years 96 had neoplasms larger than 8 cm. in size.

Numbers relative to vear of diaunosis

Diagnosis (vrs. I

695

150 PATIENTS W ITH RENAL CARC INOMA

21

42 ;;;1 20 9

TABLE;)

Groups

Alive without tumor

A No.

B (yrs.I

1:1 ( 1- 2.8 1

No.

:1

D

C (yrs.)

1:l.91 (4 1 I

(5.01

No.

(yrs.I

;, 18.7) (JO.OJ I IO.Ill (1(10)

(l{l.111

Alive with tumor

1 ( 1.2)

Dead without tumor

:\io.

(,-rs. I

6(I0.2) ( 11.0) ( 12 0) ( 12.0) (J:lll)

2 ( 7.1)

( 17.11)

(9.01 2 (4.01

I (11.!il :\ (4.:il

(8.0)

(G,0)

(7.01

Dead with tumor

17 (1 mo. - :lyrs.l*

14

((J.:l - 4 5) +

48 ( I mo. - 7.H ,-rs. l:j:

:n11mo. 1'1,-rs.ls

* 7-1 year or more. 2-2 to :3 vears. t 3- 2.0. 3.7 and 4.5 years. re~ainder dead between :land 11 months.

t 22-1 month to 1 year. 11-1 to 2 years. fl-2 to 1 years.:\-:) to -1 years. ~--l to S years. 1-5 to 6 .\1ears. ~-6 to 7 years. '2-7 to 8 years. 18-0to 1 year. 3-1 to2years. 5-2 10:lyea rs. 2- 3 to4 years. l -4 to 5,·ears. 2-,'>to6,·ears. l -llltt1 11 years. 1-1.',vears.

*

t

696

THOMPSON AND ASSOCIATES

In all 24 patients surviving 5 years or more there was no evidence of renal vein or caval involvement at diagnosis or exploration. One of these patients is still alive with tumor involving all of a solitary kidney. In the 103 patients dead of tumor within 5 years, 53 had at least suggestive evidence of renal vein or caval involvement and in many instances of contiguous or dis tant spread. Pericapsular extension of tumor was documented , although not grossly visible, in only 2 of the 24 patients surviving 5 years or more, whereas it was not present in only 9 of the 103 patients dying of tumor within 5 years. Radical nephrectom y was contemplated in all patient s in whom it seemed feasible but in our hands was not always practicable owing to the s ize and extent of the tumor. Of the 24 patients surviving 5 years or more 23 had radical nephrectomy and at least an assessment of regional lymph nodes. Two patient s with microscop ic pericapsul a r invasion had postoperative radiation. Only 56 of the 103 patients dying of tumor in less than 5 years had radical nephrectomy. Postoperative radiation was given in 21 of these patients. Nineteen patients had either biopsy or no operation and in the remaining 28 as extensive an ablative procedure as possible was done. Of these patients 23 had postoperative radiation. DISCUSSION

Quantification of these data must necessarily be imprecise but certain general features of renal carcinoma can be examined. This tumor and its clinical vagaries are c_a pricious. Patients with inoperable tumors live for long periods while some with apparently low stage neoplasms survive only briefly. Metastases may appear and death from tumor can occur many years after the operation. Our patients differ from those in other report ed series in that 65 presented with metastases (Robson classification 4B) and another 5 (Robson stage

4A) were unresectable totaling 46 per cent of the entire group. 1 This is an unusually large number of potentially incurable patients leaving a disheartening residuum in whom more benign stages of the disease were found . Only 1.5 to 20 per cent of our patients could be retrospectively classified as being in Robson stages 1 and 2. The fact that our long-term survivors, whether free of tumor or not , fall into this group again emphasizes the more salubrious aspects of discovering and treating the disease in these stages. We were not able to acc umulate sufficient data on tumor grading to provide meaningful information but the finding that tumor size did appear to correlate with other characteristics of low tumor stage and prolonged survival is perhaps an important contribution to the behavioral pattern of these neoplasms . The paucity of trul y long-term , tumor-free survivors in :l5 to 40 per cent of the patients classified in stage 3 A, Band C as well as 15 to 20 per cent of the patients in stages 1 and 2 emphasizes the need for at least a 10-year followup evaluation to permit assessment of the results of any form of therapy at any stage of the disease. The meticulous clinical-pathological categorization of tumor stage and grade described by Robson and associates combined with current angiographic staging expertise should permit more precise estimation of prognosis but until more patients can be discovered in potentially curable stages of the disease, long-term survival. if all categories of patients with rena l carcinoma are included , will continue to be poor. REFERENCE

I. Robso n, C. ,J .. Churchill, B. M. and Anderson, W.: The resu lts of radical nephrectomy for renal cell carcinoma.,). Urol., 101: :297, 1969.