Objective To investigate association of preoperative C‐reactive protein (CRP) and non‐cancer mortality (NCM) in a cohort of patients undergoing surgery for localised renal cell carcinoma (RCC). Patients and Methods Retrospective multicentre analysis of patients surgically treated for clinical Stage 1–2 RCC from 2006 to 2017, excluding all cases of cancer‐specific mortality. Descriptive analyses were obtained between the pre‐treatment normal‐CRP (≤5 mg/L) and elevated‐CRP (>5 mg/L) groups. The primary outcome was NCM. The secondary outcomes included progression to de novo chronic kidney disease Stages 3–4 (estimated glomerular filtration rate [eGFR] of <60, <45, and <30 mL/min/1.73 m2). Multivariable analyses (MVA) were performed to assess for risk factors associated with functional decline and NCM, and Kaplan–Meier analysis was used to obtain survival estimates for outcomes. Results A total of 1987 patients who underwent radical or partial nephrectomy were analysed (normal‐CRP group, n = 963; elevated‐CRP group, n = 1024). Groups were similar in age (59 vs 60 years, P = 0.079). An elevated CRP was more frequent in males (36.8% vs 27.8%, P < 0.001), African‐Americans (22.6% vs 2.9%, P < 0.001), and in those with a higher median body mass index (30 vs 25 kg/m2, P < 0.001) and larger median tumour size (4.5 vs 3.3 cm, P < 0.001). On MVA, an elevated CRP was independently associated with development of de novo eGFR of <60 mL/min/1.73 m2 (hazard ratio [HR] 1.32, P = 0.015), <45 mL/min/1.73 m2 (HR 1.41, P = 0.023) and <30 mL/min/1.73 m2 (odds ratio 2.23, P < 0.001). The MVA for factors associated with NCM demonstrated increasing age (HR 1.06, P < 0.001), preoperative elevated CRP (HR 2.18, P < 0.001) and an eGFR of <45 mL/min/1.73 m2 (HR 1.16; P = 0.021) as independent risk factors. Kaplan–Meier analysis revealed significantly higher 5‐year NCM in the elevated‐CRP group vs the normal‐CRP group (98% vs 80%, P < 0.001). Conclusions Pre‐treatment elevated CRP was independently associated with both progressive renal functional decline and NCM in patients undergoing surgery for Stage 1–2 RCC. Patients with elevated CRP and Stage 1 and 2 RCC may be considered as having indication for nephron‐sparing strategies, which may be prioritised if oncologically appropriate.
BackgroundSeveral markers of inflammation have been associated with oncologic outcomes. Prognostic markers are not well-defined for renal cell carcinoma (RCC). We sought to investigate the association of preoperative neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and De Ritis ratio with mortality in RCC.MethodsMulti-center retrospective analysis of patients undergoing surgery for RCC. Primary outcome of interest was all-cause mortality (ACM). Secondary outcomes were non-cancer mortality (NCM) and cancer-specific mortality (CSM). Elevated NLR was defined as ≥2.27, elevated PLR as ≥165, and elevated De Ritis ratio as ≥ 2.72. Multivariable cox regression analysis (MVA) was conducted to elucidate risk factors for primary and secondary outcomes, and Kaplan-Meier analysis (KMA) was used to evaluate survival outcomes comparing elevated and non-elevated NLR, PLR, and De Ritis ratio.Results2656 patients were analyzed (874 patients had elevated NLR; 480 patients had elevated PLR and 932 patients had elevated De Ritis). Elevated NLR was a significant predictor of ACM (HR 1.32, 95% CI: 1.07-1.64, p=0.003) and NCM (HR 1.79, 95% CI: 1.30-2.46, p<0.001) in MVA. Elevated De Ritis was a significant predictor of ACM (HR 2.04, 95% CI: 1.65-2.52), NCM (HR 1.84, 95% CI: 1.33-2.55, p<0.001), and CSM (HR 1.97, 95% CI:1.48-2.63, p<0.001). KMA revealed significant difference in 5-year overall survival (OS) (48% vs. 68%, p<0.001), non-cancer survival (NCS) (69% vs. 87%, p<0.001), and cancer-specific survival (CSS) (60% vs. 73%, p<0.001) for elevated versus non-elevated NLR. For PLR, there was a difference in 5-year OS (51% vs. 61%, p<0.001) and CSS (60% vs. 73%, p<0.001) with KMA.ConclusionsElevated NLR was independently associated with worse ACM and NCM, while elevated De Ritis was predictive for CSM in addition to ACM and NCM. These differences may be useful in refining risk stratification with respect to cancer-related and non-cancer mortality in RCC patients and deserve further investigation.
625 Background: Pathologically upstaged T3a renal cell carcinoma (RCC) carries higher oncologic risk than corresponding preoperative clinical stage and presents unique risks from a treatment planning standpoint due to reduced clinician awareness of locally aggressive disease. We sought to identify imaging criteria that predict risk of pathological upstaging of clinical T1 and T2 RCC to T3a and to assess accuracy of CT in detecting T3a RCC. Methods: Single institution retrospective analysis of patients who underwent surgery for RCC. A propensity-score matching process was used to match upstaged patients with non-upstaged (control) patients in a 1:2 fashion. Preoperative CT images were reviewed in a blinded fashion by 2 radiologists for presence of T3a stage imaging criteria. Multivariable analyses assessed risk conferred by imaging features and sensitivity analysis assessed accuracy in detecting T3a RCC. Results: After exclusions, 231 patients were analyzed (mean age 61 years, upstaged 83/control 148, mean tumor size 6.4 cm). In 71/83 (86%) of upstaged tumors, the presence of sinus fat invasion (SFI), perinephric fat invasion (PFI), or venous invasion (VI) was found. The presence of all three was not observed in any non-upstaged tumor. The following features were associated with upstaging: tumor necrosis (OR 2.1, p=0.017), irregular tumor edge (OR 2.9, p<0.001), thickened perirenal fascia (OR 2.6, p=0.001), perinephric stranding (OR 1.8, p=0.043), increased perinephric vascularity (OR 2.02, p=0.021), and perinephric nodules (OR 3.4, p=0.020). The SE/SP for tumor necrosis, irregular tumor edge, thickened perirenal fascia, perinephric stranding, increased perinephric vascularity, and perinephric nodules were 42%/74%, 74%/50%, 48%/74%, 70%/44%, 70%/46%, and 13%/96%, respectively. Conclusions: Upstaged T3a RCC contained several preoperative imaging attributes which were 2-3 times more likely to be present than in non-upstaged tumors. Of these, irregular tumor edge had highest sensitivity, and perinephric nodules had highest specificity. These features should elevate clinical suspicion for T3a disease and may be used to develop a novel risk scoring system. Further investigation is requisite.
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