1991 Volume 82 Issue 1 Pages 122-129
A study was made on treatment-related factors, notably prognosis, in 148 patients treated by surgical resection of the primary lesion among 170 consecutive patients who were admitted to the Department of Urology, Gunma University for the treatment of renal cell carcinoma during the period from September 1961 through August 1989.
Operative procedures used in this series were radical nephrectomy in 100 patients, simple nephrectomy in 46, partial nephrectomy in 1 and tumor enucleation in 1, lymph node dissection being performed in 53 of the 100 patients treated by radical nephrectomy.
The patients receiving surgical resection of the primary lesion were stratified according to sex, PS, disease stage, surgical procedure, lymph node dissection and weight of renal substance resected and comparisons were made on survival rate and recurrence rate among patients in different strata in an effort to observe if these factors are determinant of postoperative prognosis.
No significant difference in survival rate was observed between sexes. Patients displaying a PS value of 0 had a significantly higher survival rate than those having a PS value of 1 or above. Whereas a significant difference in survival rare was noted between stage IIIA+IIIB+C disease patients, no significant difference was observed among stage I, II and III patients, thus stages up to IIIA being considered low stage.
Radical nephrectomy was associated with a significantly higher survival rate than simple nephrectomy in low stage (stage I-II) disease patients. However, there was no significant difference in survival rate between stage I-II disease patients with vs. without lymph node dissection.
A significantly higher survival rate was obtained in patients having less than 500g of renal substance removed than those having 500g or more of renal substance removed. No significant difference was noted between the two groups of patients so far as those with stage I-IIIA disease were concerned, however.
When the recurrence of malignancy was studied in relation to operative procedure and disease stage, it became obvious that the recurrence rate was lower in patients with stage I or II disease treated by radical nephrectomy than in those who underwent simple nephrectomy. Among patients treated by radical nephrectomy, those with stage II disease had recurrence rate (about 30%) which was almost equal to that for those with stage IIIA disease.
Among stage III or more advanced disease patients, the extrapleural lumbar approach was employed for noncurative resection in all patients undergoing simple nephrectomy, while the transabdominal or thoracicoabdominal approach was used in patients treated by radical nephrectomy, allowing for an extensive operation involving retroperitoneal lymph node dissection, vena caval tumor thrombectomy or conjoined resection of contiguous organs.
Particularly in stage IIIA patients, since they had a survival rate not significantly different from that for stage I and II patients and a recurrence rate comparable to stage II patients, it was considered of utmost importance to perform a perfect tumor thrombectomy.
These results led us to conclude that a PS value of 0 is a primary prerequisite for a favorable outcome of surgery for renal cell carcinoma; that a radical nephrectomy is the treatment of choice for stage I-II disease, and that, for stage III or more advanced disease, an extended operation including radical nephrectomy by the thoracicoabdominal approach is highly recommendable, because it will certainly provide an improvement of prognosis.
