Renal fossa recurrence after nephrectomy for renal cell carcinoma: prognostic features and oncological outcomes

Abstract

ObjectivesTo describe the clinicopathological features associated with increased risk of renal fossa recurrence (RFR) after radical nephrectomy (RN) and to describe the prognostic features associated with cancer-specific survival (CSS) among patients with RFR treated with primary locally directed therapy, systemically directed therapy or expectant management. Patients and MethodsThe records of 2 502 patients treated with RN for unilateral, sporadic, localized renal cell carcinoma (RCC) between 1970 and 2006 were reviewed. CSS after RFR was estimated using the Kaplan-Meier method. Associations with the development of RFR and CSS after RFR were evaluated using Cox proportional hazards regression models. ResultsA total of 33 (1.3%) patients developed isolated RFR (iRFR) and 30 (1.2%) patients developed RFR in the setting of synchronous metastases after RN (study cohort, N = 63). The median follow-up for the series was 9.0 years after RN and 6.0 years after RFR diagnosis. On multivariable analysis, advanced pathological stage (pT2: hazard ratio [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 after RN among the 33 patients with iRFR, and 1.4 years among all patients. Overall, the median CSS was 2.5 years after diagnosis of iRFR, 1.3 years after RFR in the setting of synchronous metastases, and 2.2 years overall. After 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 with observation, locally directed therapies were associated with a significantly decreased risk of death from RCC (HR 0.26, P < 0.001). ConclusionsRenal fossa recurrence is a rare event after RN for RCC and portends a poor prognosis, even in the absence of synchronous metastases. Development of iRFR is associated with advanced stage and aggressive tumour biology. Patients who underwent primary locally directed therapy had superior CSS compared with those treated with expectant management, supporting the use of aggressive local treatment in carefully selected patients with RFR. Future research is needed to determine the optimum role and sequencing of combined therapy in patients with this rare entity.

Role of metastasis‐directed treatment in kidney cancer

“…32 Technical feasibility also is contingent upon a patient's burden of comorbidity and functional status, which may determine the safety of submitting the patient to general anesthesia and a potentially complex operation. In addition to the urologist, depending on the location, a surgical team comprised of members with expertise in cardiothoracic, hepatobiliary, colorectal, and endocrine surgery; surgical oncology; orthopedics; and neurosurgery may need to be involved in addition to an experienced anesthesia team.…”

“…54 Indeed, radiotherapy has demonstrated utility in the management of mRCC both as monotherapy and as adjuvant therapy to surgical resection [55][56][57] and in the management of osseous, 58-61 pulmonary, 62 brain, 63 and pancreatic metastases. 54 Indeed, radiotherapy has demonstrated utility in the management of mRCC both as monotherapy and as adjuvant therapy to surgical resection [55][56][57] and in the management of osseous, 58-61 pulmonary, 62 brain, 63 and pancreatic metastases.…”

Canadian Urological Association guideline for followup of patients after treatment of non-metastatic renal cell carcinoma

“…Patients undergoing surgery for symptomatic recurrences have a higher rate of incomplete resection of recurrence, positive surgical margins and worse survival compared to surgery without symptoms. [41][42][43] Extensive tumour recurrence reduces the possibility of complete surgical resection, which is standard therapy for patients with local recurrence or resectable solitary metastasis. Furthermore, an early diagnosis of metastatic disease relapse may enhance efficacy of systemic therapy or allow for metastasectomy if the tumour burden is low.…”

“…44,45 Tumour grade, local extent of the primary tumour, presence of nodal metastasis, and histological subtype are predictors of the disease relapse (Level of Evidence 3). 41,[46][47][48] As such, these variables should be noted because they contribute to important prognostic information.…”

“…41,[54][55][56][57] Molecular markers including carbonic anhydrase IX, hypoxia inducible factor, Ki67, p53, phosphatase and tensin homolog (PTEN), regulator of apoptosis Bcl-2, Ecadherins, C-reactive protein (CRP), microRNAs (miR-21 and miR-126) and others have demonstrated potential utility as prognostic markers, and vascular endothelial growth factor (VEGF) as predictive biomarker. 58 Higher level of PD-L1 expression has been linked with a negative prognostic factor in RCC.…”