World J Urol DOI 10.1007/s00345-016-1773-y

TOPIC PAPER

Renal cell carcinoma recurrences and metastases in primary non‑metastatic patients: a population‑based study Saeed Dabestani1 · Andreas Thorstenson2 · Per Lindblad3 · Ulrika Harmenberg4 · Börje Ljungberg5 · Sven Lundstam6 

Received: 2 December 2015 / Accepted: 21 January 2016 © Springer-Verlag Berlin Heidelberg 2016

Abstract  Purpose  To present the occurrence of metastases and local recurrences in primary non-metastatic patients with renal cell carcinoma (RCC) in a contemporary Swedish population-based cohort. Methods  Between 2005 and 2009, a total of 4527 patients were included in the prospective National Swedish Kidney Cancer Register accounting for nearly all RCC patients in Sweden. Among M0 patients, 472 (13 %) had no followup data registered within 5-year follow-up time and were excluded from the analysis. Results  In total, 939 (21 %) had distant metastases at presentation with a decrease from 23 to 18 % during the inclusion period. Of 3107 patients with follow-up data and with M0 disease, 623 (20 %) were diagnosed with a tumor recurrence during 5-year follow-up. Mean time to recurrence was 24 months (SD ± 20 months). Among these, 570

patients (92 %) were at primary diagnosis treated with radical nephrectomy, 23 patients (3.7 %) with partial nephrectomy and 12 patients (1.9 %) with minimally invasive treatments. The most frequent sites of metastases were lung (54 %), lymph nodes (22 %) and bone (20 %). The treatment of recurrence was in 50 % systemic treatments, while metastasectomy was performed in 17 % of the patients, out of which 68 % were with a curative intention. Conclusions  In this population-based study, 21 % of the patients had metastatic disease at presentation, with a decreasing trend over the study period. During 5-year follow-up, 20 % of the primary non-metastatic patients had recurrent disease. Of the patients with recurrence, half were given systemic oncological treatment and 17 % underwent metastasectomy.

For the National Swedish Kidney Cancer Register Group.

Keywords  Renal cell carcinoma · Metastases · Recurrent disease · Local recurrence · Surgery · Nephrectomy · Partial nephrectomy · Minimal invasive therapy

* Börje Ljungberg [email protected]

Introduction

1



Department of Urology, Skåne University Hospital, 205 02 Malmö, Sweden

2

Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, 171 64 Solna, Stockholm, Sweden

3

Department of Urology, Faculty of Medicine and Health, Örebro University, 701 85 Örebro, Sweden

4

Department of Oncology, Karolinska University Hospital, 171 64 Solna, Stockholm, Sweden

5

Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, 901 85 Umeå, Sweden

6

Department of Urology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden





Renal cell carcinoma (RCC) accounts globally for 2–3 % of all malignancies and has a 2:1 male-to-female occurrence ratio. The disease is estimated to 338,000 new cases per year worldwide with the highest incidence in North America, Australia/New Zealand and Northern Europe with a decreasing occurrence trend in the latter [1–4]. Approximately 20–30 % of the patients present with synchronous metastases at diagnosis, while 20–30 % of the patients get asynchronous metastatic disease or local recurrence after treatment of which about 90 % develop within 5 years [5– 7]. Local recurrence is relatively rare, while sites for distant metastases (M1) most frequently include lung and bone [6,

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8]. In patients with metastatic disease (mRCC) at diagnosis, cytoreductive nephrectomy (CN) has some evidence of prolonging the overall survival [9], while in regard to local treatment for metastases there are multiple modalities of which metastasectomy remains the sole potentially curative option [10]. A number of oncological medical options with several lines of systemic targeting therapies are available, all of which prolong the survival but remain palliative [6]. The aim of this study is to present contemporary population-based data on RCC demographics in Sweden between 2005 and 2009 from the National Swedish Kidney Cancer Register (NSKCR), with focus on local recurrence and metastases within 5 years of follow-up, subsequent treatments and in relation to performed primary surgery.

World J Urol

Patients During 2005–2009, a total of 4527 patients diagnosed with RCC were registered in the NSKCR, out of which 939 (21 %) patients had distant metastases (M1) and 3579 (79 %) were without metastases (M0). Data were missing in nine patients (0.2 %) concerning metastatic status at diagnosis; hence, they were excluded. Among the 3579 patients with no metastases at diagnosis, 472 (13 %) patients had no follow-up data registered at 5 years. A total of 4046 (939 M1 and 3107 M0) patients remained with available 5-year follow-up data. Median age was 67 years (range 9–10.5 years), 2451 (61 %) men and 1595 (39 %) women. The study was performed after approval of the regional Ethical Review Board of northern Sweden (Dnr 2012-418-31M).

Materials and methods Statistical analysis Study cohort Since January 2005, all healthcare regions in Sweden participate in the registration of newly diagnosed patients with RCC to the NSKCR. The coverage of the NSKCR is 99 % of all patients with RCC compared to the Swedish Cancer Register to which reporting of all new cancer patients is mandated by law [11]. Identification of patients was efficient because Swedish citizens have a personal identity number (PIN) which was used to record and follow up the NSKCR cohort [12]. The NSKCR cohort is a nation-based material including the whole Swedish population and has been described in earlier publications [13–15]. In summary, the register 2005– 2009 contained information on tumor characteristics, histological RCC type, nuclear grade, tumor size, tumor, node and metastasis (TNM) classification according to the Union for International Cancer Control 2002 [16]. Further, information on preoperative work-up, surgical treatment and overall survival was available in the register. Histopathologic classification of RCC subtype was performed according to the WHO classification, and for tumor grade the Fuhrman nuclear grading is used [17, 18]. In patients with more than one tumor, the largest tumor defined the tumor stage. Tumor size was measured by computed tomography (CT) or magnetic resonance imaging (MRI) and in rare cases from histopathological reports. Lymph node stage was based on CT and/or MRI examinations of the abdomen or findings at surgery. The classification N0 was dependent of a negative CT of the abdomen and the finding of no pathologically enlarged lymph nodes at surgery. Chest CT was recommended in all patients to rule out pulmonary metastases. The NSKCR contained no information on patient performance status. Patients without distant metastases at primary diagnosis (M0) 2005–2009 were followed up after 5 years regarding occurrence and treatment of local recurrence or metastases.

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Two-tailed t tests and Chi-square tests were performed for statistical calculations. Two-tailed p value of

Renal cell carcinoma recurrences and metastases in primary non-metastatic patients: a population-based study.

To present the occurrence of metastases and local recurrences in primary non-metastatic patients with renal cell carcinoma (RCC) in a contemporary Swe...
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