To describe clinicopathologic features associated with increased risk of renal fossa recurrences (RFR) following radical nephrectomy (RN) and to describe prognostic features associated with cancer-specific survival (CSS) among patients with RFR treated with primarily locally-directed therapy, systemically directed therapy, or expectant management.
Records of 2502 patients treated with RN for unilateral, sporadic, localized RCC between 1970 and 2006 were reviewed. CSS following RFR was estimated using the Kaplan-Meier method. Associations with the development of RFR and CSS following RFR were evaluated using Cox proportional hazards regression models.
A total of 33 (1.3%) patients developed isolated RFR (iRFR) and 30 (1.2%) patients developed RFR in the setting of synchronous metastases following RN (study cohort, N=63). Median follow-up for the series was 9.0 years after RN and 6.0 years following RFR diagnosis. On multivariable analysis, advanced pathologic stage (pT2: HR 4.36, p=0.004; pT3/4: HR 4.39, p=0.003) and coagulative necrosis (HR 2.71, p=0.006) were independently associated with increased risk of iRFR. The median time to recurrence was 1.5 years post-nephrectomy among the 33 patients with iRFR, and 1.4 years among all patients. Overall, median CSS was 2.5 years after iRFR diagnosis, 1.3 years after RFR in the setting of synchronous metastases, and 2.2 years overall. Following primary locally directed therapy (surgery, ablation, or radiation), systemic therapy, or expectant management, the 3-year CSS rates among patients with iRFR were 63%, 50%, and 13% (p=0.001) and were 64%, 50%, and 28% (p=0.006) among all patients,respectively. On multivariable analysis, when compared to observation, locally directed therapies were associated with a significantly decreased risk of death from RCC (HR 0.26, p<0.001).
RFR is a rare event following radical nephrectomy for RCC and portends a poor prognosis, even in the absence of synchronous metastases. Development of iRFR is associated with advanced stage and aggressive tumor biology. Patients who underwent primarily locally directed therapy had superior CSS compared to those treated with expectant management, supporting the use of aggressive local treatment in carefully selected RFR patients. Future research is needed to determine the optimal role and sequencing of multimodal therapy in patients with this rare entity. This article is protected by copyright. All rights reserved.
BJU international. 2016 Aug 04 [Epub ahead of print]
Sarah P Psutka, Mark Heidenreich, Stephen A Boorjian, George C Bailey, John C Cheville, Suzanne B Stewart-Merrill, Christine M Lohse, Thomas D Atwell, Brian A Costello, Bradley C Leibovich, R Houston Thompson
Department of Urology, Mayo Clinic, Rochester, Minnesota., Mayo Medical School, Rochester, Minnesota., Department of Urology, Mayo Clinic, Rochester, Minnesota., Department of Urology, Mayo Clinic, Rochester, Minnesota., Department of Pathology, Mayo Clinic, Rochester, Minnesota., Division of Urology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania., Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota., Department of Radiology, Mayo Clinic, Rochester, Minnesota., Division of Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, Minnesota., Department of Urology, Mayo Clinic, Rochester, Minnesota., Department of Urology, Mayo Clinic, Rochester, Minnesota.