title: Renal cell carcinoma clinically involving adjacent organs: experience with aggressive surgical management.
abstract: BACKGROUND
  Historically, patients with nonmetastatic renal cell carcinoma (RCC) involving adjacent organs have been considered inoperable and incurable. The oncologic efficacy of an aggressive surgical approach was evaluated in a selected subpopulation of RCC patients. Further, an attempt was made to define the clinical and pathologic characteristics predictive of surgical failure.
  
  
  METHODS
  With Institutional Review Board approval, the institutional nephrectomy database of 3470 patients treated at MD Anderson Cancer Center from 1990 to 2006 was searched for RCC patients treated with radical nephrectomy and resection of at least 1 adjacent organ thought to be directly involved by RCC. Patients with nonmetastatic RCC and a minimum follow-up of 6 months were included in the analysis.
  
  
  RESULTS
  In all, 30 patients with clinical T4NxM0 RCC and median follow-up of 32.3 months (range, 8.5-140.1) met the study inclusion criteria and comprise the dataset for the analysis. On pathologic evaluation 60% of patients were clinically overstaged, as only 12 (40%) of 30 patients demonstrated direct invasion into adjacent organs resected. None of the clinical tumor characteristics predicted a finding of pathologic T4 RCC. Nodal involvement and pathologic T stage were significant independent predictors of disease recurrence (hazard ratio [HR] 3.726, P = .043, and HR 2.414, P = .045, respectively) and cancer-specific survival (HR 17.145, P = .002, and HR 3.791, P = .024, respectively). Disease recurred in 11 of 18 (61.1%) of <pT4 patients and in 10 of 12 (83.3%) of pT4 patients at a median 13.3 and 2.3 months, respectively; 13 (73.3%) <pT4 patients and 5 (41.7%) pT4 patients were alive at the time of analysis.
  
  
  CONCLUSIONS
  True pathologic involvement of adjacent organs by RCC cannot be predicted from pre- or intraoperative parameters. A significant proportion of patients clinically suspected of having T4 RCC are downstaged, and benefit from aggressive surgical resection with en bloc removal of involved organs.
authors.affiliation: Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.forename: Ricardo F
authors.initials: RF
authors.lastname: Sánchez-Ortiz
authors.forename: Pheroze
authors.initials: P
authors.lastname: Tamboli
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Cohen
authors.forename: David A
authors.initials: DA
authors.lastname: Swanson
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
mesh_terms: D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009392:Nephrectomy; D015996:Survival Rate