Stewart‐Merrill, Suzanne B.

Objectives 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. Patients and Methods 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. Results 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 ( pT 2: hazard ratio [ HR ] 4.36, P = 0.004; pT 3/4: 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). Conclusions 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.

Purpose The appropriate duration of surveillance for renal cell carcinoma (RCC) after radical or partial nephrectomy remains unknown, and evidence to support current guidelines are lacking. Herein, we provide an approach to surveillance that balances the risk of recurrence versus the risk of non-RCC death. Patients and Methods We identified 2,511 patients who underwent surgery for M0 RCC between 1990 and 2008. Patients were stratified for analysis by pathologic stage (pT1Nx-0, pT2Nx-0, pT3/4Nx-0, and pTanyN1), relapse location (abdomen, chest, bone, and other), age (< 50, 50 to 59, 60 to 69, 70-79 and ≥ 80 years), and Charlson comorbidity index (CCI; ≤ 1 and ≥ 2). Risks of disease recurrence and non-RCC death were estimated by using parametric models for time-to-failure with Weibull distributions. Surveillance duration was estimated at the point when the risk of non-RCC death exceeded the risk of recurrence. Results At a median follow-up of 9.0 years (interquartile range, 6.4 to 12.7 years), a total of 676 patients developed recurrence. By using a competing-risk model, vastly different surveillance durations were appreciated. Specifically, among patients with pT1Nx-0 disease and a CCI ≤ 1, risk of non-RCC death exceeded that of abdominal recurrence risk at 6 months in patients age 80 years and older but failed to do so for greater than 20 years in patients younger than age 50 years. For patients with pT1Nx-0 disease but a CCI ≥ 2, the risk of non-RCC death exceeded that of abdominal recurrence risk already at 30 days after surgery, regardless of patient age. Conclusion We present an individualized approach to RCC surveillance that bases the duration of follow-up on the interplay between competing risk factors of recurrence and non-RCC death. This strategy may improve the balance between the derived benefit from surveillance and medical resource allocation.