What is the prognosis following a radical nephrectomy?

Updated: Feb 05, 2019
  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Historically, 4-10% of patients with RCC have tumor thrombus extending into the inferior vena cava, and 1% have tumor involving the right atrium. Surprisingly, the prognosis for patients with resectable inferior vena caval extension without unresected vena caval wall invasion or lymph node involvement approaches that of stage I cancer. In the absence of metastases, an aggressive surgical approach provides the only hope for a potential cure.

Lymph node involvement and metastases are adverse predictors of survival. [12] People with stage IV disease and with distant metastasis have a 5-year survival rate of less than 10%. If metastasis is discovered preoperatively, surgery is considered only for palliation, for entry into adjuvant treatment protocols, or, possibly, for a solitary metastasis. Metastases, particularly hepatic metastases, recognized at the time of surgery are associated with poor outcomes, and further surgery should probably be abandoned in these patients. Unfortunately, metastases after complete surgical resection is not uncommon. In these patients, postsurgical metastatic RCC is the most common cause of death.

Survival rates in relationship with surgical stage, type of therapy, and pathologic characterization of the primary tumor were studied in 326 patients treated at New York University from 1970-1982. At the time of diagnosis, 25.5% of tumors were stage I, 15% were stage II, 28.5% were stage III, and 31% were stage IV. [13]

The retrospective study showed that patients with tumor confined within the capsule achieved the highest 5-year and 10-year survival rates (88% and 66%, respectively). Survival rates decreased as tumor invaded perirenal fat (67% and 35%, respectively) or regional lymph nodes (17% and 5%, respectively). [13] Tumor invasion into the renal vein alone did not significantly change 5-year survival rates (84%), but it did lower 10-year survival rates to 45%. Outcomes were poor in patients with metastases at the time of nephrectomy, regardless of the site of metastases or type of adjuvant therapy, except for those treated with surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis. These included a size smaller than 5 cm in diameter; lack of invasion of the collecting system, perirenal fat, or regional lymph nodes; and a predominance of clear or granular cells growing into a recognizable histologic pattern. [13]

A study by Morgan et al that included 565 patients who underwent a radical nephrectomy for RCC reported that cell cycle proliferation score was an independent predictor of recurrence and death. [14]


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