|Year : 2010 | Volume
| Issue : 3 | Page : 287-291
Renal tumors presentation: Changing trends over two decades
NP Gupta, R Ishwar, A Kumar, PN Dogra, A Seth
Department of Urology, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||28-Jun-2010|
N P Gupta
Department of Urology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Purpose: We have analyzed the changing trends in surgical treatment of renal tumors over the last 2 decades with regard to age incidence, presentation, incidental detection, and histopathology. Materials and Methods: Records of renal tumors were analyzed from January 1, 1988 to December 31, 2007. Data were split into 4 parts based on a 5-year time period, 1 for each cohort of patients: cohort 1 (1988-1992)-103 patients, cohort 2 (1993-1997)-161 patients, cohort 3 (1998-2002)-243 patients, and cohort 4 (2003-2007)-304 patients. A comparative study was performed with regard to age incidence, presentation, incidentallomas, histopathology, and management with statistical analysis. Results: Out of 811 renal tumors, 17.63% cases were benign and 82.37% were malignant. In the first cohort, 34.95% cases were detected in the seventh decade as compared with cohort 4 in which these were detected in the sixth (34.86%) and fifth decades (21.38%). Incidentallomas increased from 11 (10.67%) in cohort 1 to 84 (27.63%) in cohort 4 (P = 0.001). The cases of surgically treated tumors increased in number from 103 to 304 in cohort 4. Among the presenting features, incidence of weight loss, flank pain, and lump decreased while other clinical syndromes were constant. Only open radical nephrectomy was performed in the first 2 consecutive timeperiods. Laparoscopic radical nephrectomy was increasingly used in cohort 4 as compared with cohort 3 (121 vs 32, respectively). Similarly, open nephron sparing surgery (NSS) was increasingly used in cohort 4 as compared with cohort 3. Among the histopathologies, clear cell carcinoma was most common (73.35 %), but Fuhrman grading showed a trend toward more cases detected with grade 1 and 2 in cohort 4; 23.73% and 61.86%, respectively, as compared with 15.85% and 45.12% in cohort 1 (P = 0.001); more T1 tumors were detected (63.42% in cohort 4 as compared with 41.46% in cohort 1). Conclusions: A majority of renal tumors presented as symptomatic tumors. Recently, tumors are being detected at an early stage and grade; in the younger patients, with an increasing trend of laparoscopic and open NSS.
Keywords: Laparoscopy, nephron sparing, renal tumor
|How to cite this article:|
Gupta N P, Ishwar R, Kumar A, Dogra P N, Seth A. Renal tumors presentation: Changing trends over two decades. Indian J Cancer 2010;47:287-91
| » Introduction|| |
Renal cell carcinoma (RCC), which accounts for 2% to 3% of all adult malignant neoplasms, is the most lethal of all the urologic cancers.  More than 40% of patients with RCC have died of their cancer, in contrast with the 20% of mortality rates associated with prostate and bladder carcinomas.  Introduction and extensive application of modern imaging techniques, including ultrasonography, computed tomography, and magnetic resonance imaging, has led to an increase in the number of incidentally discovered renal tumors, many of which are small.  Incidentally discovered tumors have a higher likelihood of being low-stage RCCs or benign lesions. , The management of renal masses has undergone a rapid evolution during the past decade. Laparoscopic approaches to renal malignancies are gradually replacing open procedures for the treatment of low-stage renal tumors. Appropriate tumors continue to be treated with open nephron sparing surgery (NSS); however, laparoscopic NSS is increasing in frequency. Interestingly, mortality associated with RCC has not decreased accordingly. As incidentallomas are increasingly diagnosed, we tried to find out, at our centre, whether these are of lower stage and grade.
| » Materials and Methods|| |
Renal tumors surgically treated at our centre between January 1, 1988 and December 31, 2007 were included in this study. Data were split into 4 timeperiods with each timeperiod consisting of 5 years: timeperiod 1 (1988-1992)-103 patients, timeperiod 2 (1993-1997)-161 patients, timeperiod 3 (1998-2002)-243 patients, and timeperiod 4 (2003-2007)-304 patients. Five variables-age incidence, clinical presentation, incidental tumors, histopathologic findings, and management modality-were studied.
Data of the 4 cohorts were compared statistically using the Chi-square test for the categorical variables and Fisher's exact test. In this intergroup analysis, P value < 0.05 was considered significant. Treatment modalities were compared between the last 2 cohorts only.
| » Results|| |
A total of 811 renal tumors surgically treated at our centre from January 1, 1988 to December 31, 2007 were included in this study. The cases of surgically treated renal tumors increased in number progressively from 103 to 161, 243 in cohorts 2 and 3 and finally 304 in the last cohort.
In cohort 1 (1988-1992), out of 103 renal tumors 36 (34.95%) were encountered in the 7th decade, whereas in cohort 4 (2003-2007), out of 304 renal tumors 106 (34.86%) were detected in the 6th decade. More importantly, only 12 (11.65%) renal tumors were found in the 5th decade in cohort 1 which increased to 65 (21.38%) in the same decade in cohort 4. Additionally, there was a decrease in the incidence of renal tumors at extremes of age, that is, 5 (4.85%) renal tumors in cohort 1 in first 2 decades compared with 5 (1.64%) in cohort 4 and 9 (8.73%) renal tumors in cohort 1 in patients aged 70 years and above as compared with 19 (6.25%) in the same population in the last cohort [Figure 1]. In our study, a total of 184 (21.94%) renal tumors were incidentally detected (IRT-incidental renal tumors). In cohort 1, a total of 11 (10.67%) renal tumors were incidentally detected, which increased to 84 (27.63%) in cohort 4 (P = 0.001)-still quite lower to most of the published series [Figure 2]. In our study, hematuria was present in 30 (29.12%) patients in cohort 1 which increased to 113 (46.50%) patients in cohort 3, which again decreased to 119 (39.14%) patients in cohort 4. Similarly, patients presenting with renal lump and flank pain were 51 (49.51%) and 29 (28.15%) in cohort 1, which decreased to 69 (22.69%) and 41 (13.48%), respectively, in cohort 4 [Table 1]. These findings can be explained by increasing incidental detection of renal masses by widespread use of cross-sectional imaging studies.
In cohort 1 (1988-1992), 103 solid renal masses suspected of malignancy on imaging were all treated with open radical nephrectomy (ORN), which increased to 161 in the next 5 years. The number of ORNs, laparoscopic radical nephrectomies (LRNs), and open NSSs in cohort 3 were 202, 32, and 9, respectively; and the corresponding figures were 143, 121, and 40, respectively, in cohort 4 [Figure 3].
A total of 21 (20.38%) benign renal tumors were detected in cohort 1 and this tally was 47 (15.46%) in cohort 4. For malignant histopathologic types, clear cell carcinoma was obviously the most common, that is 57 (69.51%) in cohort 1, which slightly increased to 190 (73.92%) in cohort 4; other histopathologic types also showed similar trends.
In our study, Fuhrman grading trends among all the 4 groups were worth mentioning. As expected, grade 2 was most common in all the groups; more and more patients are now presenting with either grade 2 or grade 1. A total of 37 (45.12%) patients were found as grade 2 in cohort 1, which increased to 159 (61.86%) in cohort 4; similarly, 13 (15.85%) grade 1 tumors were found in cohort 1, which increased to 61 (23.73%) in cohort 4 (P = 0.001) [Figure 4].
Regarding stage comparison among the 4 cohorts, 34 patients had T1 disease in the first cohort, which increased to 163 patients in the last cohort (P = 0.001), similarly, 5 patients with T4 disease were surgically treated in cohort 1 and 19 patients were found with T4 disease in cohort 4 [Figure 5].
| » Discussion|| |
We have presented a large series of surgically treated solid renal masses spanning over the last 2 decades taking 5 parameters into account-age incidence of renal tumors, incidence of incidentallomas, clinical presentation of these renal tumors, histopathologic findings, and management.
The evolution and improvements in diagnosis, staging, and therapeutics make RCC an exemplary study of cancer treatment. Moreover, in the general population, about 30% of patients with RCC have evidence of metastatic disease at diagnosis.
Patients with RCC typically present in the sixth and seventh decades of life.  Since the 1970s, the incidence of RCC has increased by an average of 3% per year for whites and 4% per year for blacks. 
Our study showed that the number of cases of surgically treated solid renal tumors increased from 103 in first cohort (1988-1992) to 304 in the last cohort (2003-2007); moreover, 34.95% tumors were encountered in the seventh decade of life in cohort 1 as compared with 34.86% tumors in the sixth decade in the last cohort, highlighting progressively early-age incidence of RCC.
This suggests that a deleterious change in tumor biology may have occurred during the past several decades, perhaps related to environmental factors, such as diet, tobacco use, and exposure to other carcinogens. The mortality rates from RCC would presumably be even higher, if not for the trend toward incidental detection. , RCC in childhood is uncommon, representing only 2.3% to 6.6% of all renal tumors in children.  Mean age at presentation in children is 8-9 years, and the incidence is similar in boys as well as girls. Interestingly, there was a decrease in the incidence of renal tumors in the first 2 decades of life, that is, 4.85% renal tumors in the first cohort compared with 1.64% in the last cohort. Because of the sequestered location of the kidney within the retroperitoneum, many renal masses remain asymptomatic and nonpalpable until they are advanced. With the more pervasive use of noninvasive imaging for the evaluation of a variety of nonspecific symptom complexes, more than 50% of RCCs are now detected incidentally.  Incidental detection in our study was 21.9% overall, but more importantly 10.6% tumors were incidentally detected in the first cohort, which increased to 27.6 % in the last cohort (P = 0.001) suggesting increased use of imaging studies for vague abdominal complaints.
Symptoms associated with RCC can be due to local tumor growth, hemorrhage, paraneoplastic syndromes, or metastatic disease. Flank pain is usually due to hemorrhage and clot obstruction, although it can also occur with locally advanced or invasive disease. The classic triad of flank pain, gross hematuria, and palpable abdominal mass is now rarely found.  Paraneoplastic syndromes are found in 20% of patients with RCC, and few tumors are associated with the diversity of such syndromes.  It is still important to evaluate for paraneoplastic phenomena because they can be a source of major morbidity and can affect clinical decision-making.
The incidence of weight loss, flank pain, and lump is decreasing, whereas other clinical syndromes are constant in their occurrence as evidenced by our study. The percentages of patients presenting with lump, flank pain, weight loss in the first cohort were 49.5, 28.1, 25.2, which decreased to 22.6, 13.4, 16.1, respectively, in the last cohort. Hypercalcemia has been reported in up to 13% of patients with RCC and could be due to either paraneoplastic phenomena or osteolytic metastatic involvement of the bone. 
Hypercalcemia was reported in 4.1% of patients with RCC in our study but included only surgically treated renal tumors.
Trends in surgical management over the last 2 decades were noteworthy. The number of ORNs increased in the first 3 cohorts, that is, from 103 to 202, but only 143 ORNs were performed in the last cohort highlighting the increased use of laparoscopy and NSS. Interestingly, the number of LRNs increased from 32 in cohort 3 to 121 in cohort 4 (P = 0.005). Similarly, 13 NSSs were performed in cohorts 2 and 3, which increased to 40 in cohort 4 (P = 0.007). It has been well established that LRN with intact specimen removal for localized RCC provides satisfactory short- and long-term oncologic efficacy.  In patients with solitary, small localized, unilateral renal tumors with normal contralateral kidney, elective open NSS is an appropriate, safe, and feasible surgical option, which provides excellent long-term oncologic results with functional benefits. 
Conventional RCC accounts for approximately 70% to 80% of all RCCs, representing the garden variety of RCC.  For malignant histopathologic types, clear cell carcinoma was obviously the most common-57 (69.51%) in cohort 1, which slightly increased to 190 (73.92%) in cohort 4; other histopathologic types also showed similar trends.
Nuclear features can be highly variable, and a number of grading systems have been based on such features as nuclear size and shape and the presence or absence of prominent nucleoli. Fuhrman's system has been most generally adopted and is now recognized as an important independent prognostic factor for RCC.  Fuhrman grading showed a trend toward more cases detected with grade 1 and 2-a total of 37 (45.12%) patients were found as grade 2 in the first cohort, which increased to 159 (61.86%) in cohort 4; similarly, 13 (15.85%) grade 1 tumors were found in the first cohort, which increased to 61 (23.73%) in cohort 4 (P = 0.001).
The tumor, nodes, and metastasis system proposed by the International Union Against Cancer represented a major improvement because it separated tumors with venous involvement from those with lymphatic invasion, quantified each, and defined the anatomic extent of disease more explicitly.  More T1 tumors are being detected-63.42% in cohort 4 as compared with 41.46% in cohort 1 (P < 0.001); similarly, 5 patients with T4 disease were surgically treated in cohort 1 and 19 patients were found with T4 disease in cohort 4.
| » Conclusions|| |
This study tracked the changing trends in RCC in the academic urologic practice in a developing country like ours. Even today, a majority of renal tumors are diagnosed symptomatically, however, only in relatively young patients. Over the last 2 decades, due to extensive use of imaging, more and more renal tumors with lower stage and grade are diagnosed leading to a surge in laparoscopic and open NSS.
| » References|| |
|1.||Pantuck AJ, Zisman A, Rauch MK,Belldegrun A. Incidental renal tumours. Urology 2000;56:190-6. [PUBMED] [FULLTEXT] |
|2.||Landis SH, Murray T, Bolden S, Wingo PA. Cancer stastitics, 1999. CA Cancer J Clin 1999;49:8-31. [PUBMED] [FULLTEXT] |
|3.||Silver DA, Morash C, Brenner P, Campbell S, Russo P. Pathologic findings at the time of nephrectomy for renal mass. Ann Surg Oncol 1997;4:570-4. [PUBMED] |
|4.||Kessler O, Mukamel E, Hadar H, Gillon G, Konechezky M, Servadio C. Effect of improved diagnosis of renal cell carcinoma on the course of the disease. J Surg Oncol 1994;57:201-4. [PUBMED] |
|5.||Katz DL, Zheng T, Holford TR, Flannery J. Time trends in the incidence of renal carcinoma: Analysis of Connecticut Tumor Registry data, 1935-1989. Int J Cancer 1994;58:57-63. [PUBMED] |
|6.||Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr. Rising incidence of renal cell cancer in the United States. JAMA 1999;281:1628-31. [PUBMED] [FULLTEXT] |
|7.||Broecker B. Non-Wilms' renal tumors in children. Urol Clin North Am 2000;27:463-9. [PUBMED] |
|8.||Jayson M, Sanders H. Increased incidence of serendipitously discovered renal cell carcinoma. Urology 1998;51:203-5. [PUBMED] [FULLTEXT] |
|9.||Kamra D, Boselli J, Sloane BB, Gladstone DE. Renal cell carcinoma induced Coombs negative autoimmune hemolytic anemia and severe thrombocytopenia responsive to nephrectomy. J Urol 2002;167:1395. [PUBMED] [FULLTEXT] |
|10.||Magera JS Jr, Leibovich BC, Lohse CM, Sengupta S, Cheville JC, Kwon ED, et al. Association of abnormal preoperative laboratory values with survival after radical nephrectomy for clinically confined clear cell renal cell carcinoma. Urology 2008;71:278-82. [PUBMED] [FULLTEXT] |
|11.||Hemal AK, Kumar A, Gupta NP, Kumar R. Oncologic outcome of 132 cases of laparoscopic radical nephrectomy with intact specimen removal for T1-2N0M0 renal cell carcinoma. World J Urol 2007;25:619-26. [PUBMED] [FULLTEXT] |
|12.||Gupta NP, Kumar A, Hemal AK, Dogra PN, Seth A, Kumar R. Open nephron-sparing surgery in renal tumors with contralateral kidney: A single centre experience of 8 years. Indian J Urology 2007;23:18-22. |
|13.||StOrkel S, Ebie JN, Adlakha K, Amin M, Blute ML, Bostwick DG, et al. Classification of renal cell carcinoma: Workgroup no. 1 Union Internationale Contre le Cancer (UICC) and the American Joint Committee on Cancer (AJCC). Cancer 1997;80:987-9. |
|14.||Fuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 1982;6:655-63. [PUBMED] |
|15.||Beahrs OH, Henson DE, Hutter RV, Myers MH. American Joint Committee on Cancer Manual for Staging of Cancer. 3 rd ed. Philadelphia: JB Lippincott; 1988. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
|This article has been cited by|
||Evolution of the clinical presentation of renal cancer. Fifteen years experience
| || Perez Gonzalez, S., Aguilera Bazan, A., Polo Lopez, C.A., (...), Diaz, J., De La Peña Barthel, J. |
| ||Archivos Espanoles de Urologia. 2013; |