Psutka Sarah P, Heidenreich Mark, Boorjian Stephen A, Bailey George C, Cheville John C, Stewart-Merrill Suzanne B, Lohse Christine M, Atwell Thomas D, Costello Brian A, Leibovich Bradley C, Thompson R Houston
Department of Urology, Mayo Clinic, Rochester, MN, USA.
Division of Urology, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA.
BJU Int. 2017 Jan;119(1):116-127. doi: 10.1111/bju.13620. Epub 2016 Aug 31.
To 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.
The 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.
A 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).
Renal 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.
描述根治性肾切除术后肾窝复发（RFR）风险增加相关的临床病理特征，并描述接受原发性局部定向治疗、全身定向治疗或观察等待治疗的RFR患者中与癌症特异性生存（CSS）相关的预后特征。
回顾了1970年至2006年间接受根治性肾切除术治疗单侧、散发性、局限性肾细胞癌（RCC）的2502例患者的记录。采用Kaplan-Meier法估计RFR后的CSS。使用Cox比例风险回归模型评估与RFR发生及RFR后CSS的相关性。
共有33例（1.3%）患者发生孤立性RFR（iRFR），30例（1.2%）患者在根治性肾切除术后发生同步转移情况下出现RFR（研究队列，N = 63）。该系列患者根治性肾切除术后的中位随访时间为9.0年，RFR诊断后的中位随访时间为6.0年。多变量分析显示，高级别病理分期（pT2：风险比[HR] 4.36，P = 0.004；pT3/4：HR 4.39，P = 0.003）和凝固性坏死（HR 2.71，P = 0.006）与iRFR风险增加独立相关。33例iRFR患者根治性肾切除术后复发的中位时间为1.5年，所有患者的中位复发时间为1.4年。总体而言，iRFR诊断后的中位CSS为2.5年，同步转移情况下RFR后的中位CSS为1.3年，总体中位CSS为2.2年。在接受原发性局部定向治疗（手术、消融或放疗）、全身治疗或观察等待治疗后，iRFR患者的3年CSS率分别为63%、50%和13%（P = 0.001），所有患者的3年CSS率分别为64%、50%和28%（P = 0.006）。多变量分析显示，与观察等待相比，局部定向治疗与RCC死亡风险显著降低相关（HR 0.26，P < 0.001）。
根治性肾切除术后肾窝复发是RCC患者中的罕见事件，即使在没有同步转移的情况下预后也较差。iRFR的发生与晚期和侵袭性肿瘤生物学相关。与接受观察等待治疗的患者相比，接受原发性局部定向治疗的患者CSS更好，这支持在精心选择的RFR患者中采用积极的局部治疗。未来需要开展研究以确定联合治疗在这种罕见疾病患者中的最佳作用和顺序。
