BACKGROUND Mortality rates from kidney cancer have continued to rise despite increases in the detection of smaller renal tumors and rates of renal operations. To explore factors associated with this treatment-outcome discrepancy, we evaluated how changes in tumor size have affected disease progression in patients following nephrectomy for localized kidney cancer. Furthermore, we sought to identify factors that are associated with disease progression and overall patient survival following resection for localized kidney cancer. METHODS We identified 1,618 patients with localized kidney cancer treated by nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) from 1989 to 2004. Patients were categorized by year of operation: 1989–1992, 1993–1996, 1997–2000, and 2001–2004. Tumor size was classified according to the following strata: <2 cm, 2 to 4 cm, 4 to 7 cm, and >7 cm. Progression was defined as the development of local recurrence or distant metastases. Five-year progression-free survival (PFS) was calculated for patients in each tumor size strata, according to year of operation, using the Kaplan-Meier method. Patient, tumor, and surgery related characteristics associated with PFS and overall survival (OS) were explored using univariable analysis and all significant variables were retained in a multivariable Cox regression analysis. RESULTS Overall, the number of nephrectomies increased for all tumor size categories from 1989 to 2004. A tumor size migration was evident during this period, as the proportion of patients with tumors <2 cm and 2 to 4 cm increased while those with tumors >7 cm decreased. 179 patients (11%) developed disease progression after nephrectomy. Local recurrence occurred in 16 (1%) and distant metastases in 163 (10%). When 5-year PFS was calculated for each tumor size strata according to 4-year cohorts, trends in PFS did not improve nor differ significantly over time. Compared to historical cohorts, patients in more contemporary cohorts were more likely to undergo partial, as opposed to radical, nephrectomy and less likely to have a concomitant lymph node dissection and adrenalectomy. Multivariable analysis showed that pathologic stage and tumor grade were associated with disease progression while patient age and tumor stage were associated with overall patient survival. CONCLUSIONS Despite an increasing number of nephrectomies and a size migration towards smaller tumors, trends in 5-year PFS and OS did not improve nor differ significantly over time. These findings require further research to identify causative mechanisms and argue for a re-evaluation of the current treatment paradigm of surgically removing solid renal masses upon initial detection and consideration of active surveillance for patients with select renal tumors.

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Purpose To analyze the Memorial Sloan Kettering Cancer Center 23-year experience with surgical resection and utilization of concurrent adrenalectomy and lymphadenectomy for locally advanced non-metastatic renal cell carcinoma. Material and Methods Retrospective review of 802 patients who underwent nephrectomy, with or without concurrent adrenalectomy or lymphadenectomy, for locally advanced renal cell carcinoma defined as stage ≥T3 and M0. Patients who had undergone adjuvant treatment within 3 months of surgery, had <3 months of follow-up, or had bilateral renal masses at presentation were excluded. Five- and 10-year progression-free and overall survivals were estimated using the Kaplan-Meier method. Differences between groups were analyzed by the log-rank test. Results A total of 596 (74%) and 206 (26%) patients underwent radical and partial nephrectomy, respectively. Renal cell carcinoma progressed in 189 patients and 104 died from it. Median follow-up for patients who did not progress was 4.6 years. Symptoms at presentation, American Society of Anesthesiologists classification, tumor stage, histologic subtype, grade, and lymph node status were significantly associated with progression-free and overall survival. On multivariate analysis, adrenalectomy utilization decreased over time with odds ratio .82/year, whereas lymphadenectomy increased with odds ratio 1.16/year. Larger tumors were associated with a higher likelihood of concurrent adrenalectomy and lymphadenectomy. Conclusions In our series of patients with locally advanced non-metastatic renal cell carcinoma, those who are in good health, asymptomatic upon presentation, have T3 tumors, and negative lymph nodes had favorable survival. Further, there has been a trend toward more selective use of adrenalectomy and increased use of lymphadenectomy.

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