title: Subcentimeter pulmonary nodules are not associated with disease progression in patients with renal cell carcinoma.
abstract: OBJECTIVE
  Renal cell carcinoma most commonly metastasizes to the lung. Indeterminate pulmonary nodules develop preoperatively in half of the patients with localized renal cell carcinoma but clinical significance remains poorly defined. We determined whether the presence of indeterminate pulmonary nodules, or nodule size or number is associated with renal cell carcinoma outcomes.
  
  
  METHODS
  We reviewed data on 1,102 patients with renal cell carcinoma in whom chest computerized tomography was done within 6 months before nephrectomy from 2002 to 2012. Patients with metastatic disease at presentation, benign tumors, pulmonary nodules greater than 2 cm or concurrent pulmonary disease were excluded, leaving 748 available for analysis. Study outcomes included lung metastasis, any distant metastasis or death from renal cell carcinoma. Cox proportional hazards models were used to assess whether the presence of indeterminate pulmonary nodules, or nodule size or number was associated with outcomes. Models were evaluated by comparing discrimination using the Harrell c-index.
  
  
  RESULTS
  Indeterminate pulmonary nodules were present in 382 of 748 patients (51%). Median followup was 4.1 years (IQR 2.2-6.1). The presence of indeterminate pulmonary nodules was not associated with distant metastasis or death from kidney cancer. However, compared to subcm indeterminate pulmonary nodules the nodules greater than 1 cm were associated with metastatic disease after adjusting for tumor histology, stage and size (HR 2.48, 95% CI 1.08-5.68, p = 0.031). The outcome c-index increased slightly after adding nodule size to a predictive model adjusted for tumor characteristics.
  
  
  CONCLUSIONS
  No evidence in the current study suggested that indeterminate pulmonary nodules less than 1 cm are associated with renal cell carcinoma progression, although large nodules significantly predicted metastatic disease. Patients with subcm indeterminate pulmonary nodules would be unlikely to benefit from extensive postoperative chest imaging surveillance, which should be reserved for patients with nodules greater than 1 cm.
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Roy
authors.initials: R
authors.lastname: Mano
authors.affiliation: Departments of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Emily
authors.initials: E
authors.lastname: Vertosick
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Alexander I
authors.initials: AI
authors.lastname: Sankin
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Chevinsky
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Yaniv
authors.initials: Y
authors.lastname: Larish
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Jakubowski
authors.affiliation: Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Andreas M
authors.initials: AM
authors.lastname: Hötker
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: A Ari
authors.initials: AA
authors.lastname: Hakimi
authors.affiliation: Departments of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Sjoberg
authors.affiliation: Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Oguz
authors.initials: O
authors.lastname: Akin
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York. Electronic address: russop@mskcc.org.
authors.forename: Paul
authors.initials: P
authors.lastname: Russo
mesh_terms: D002292:Carcinoma, Renal Cell / Q000556:secondary*; D003937:Diagnosis, Differential; D018450:Disease Progression; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology*; D008175:Lung Neoplasms / Q000473:pathology* / Q000556:secondary*; D055613:Multiple Pulmonary Nodules / Q000473:pathology*; D011446:Prospective Studies
keywords: carcinoma; emission-computed; kidney; lung; neoplasm metastasis; renal cell; tomography