|Year : 2016 | Volume
| Issue : 1 | Page : 114-117
Clinical characteristics of renal cell carcinoma: Five years review from a tertiary hospital in Eastern India
RP Ray, RS Mahapatra, S Khullar, DK Pal, AK Kundu
Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
|Date of Web Publication||28-Apr-2016|
R P Ray
Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Renal cell carcinoma (RCC) is the one of the dreadful urological carcinoma. In comparison to the West, it is very rarely seen in Asia as well in India. Very small number of studies is available in this geographical area. Aims: We studied the demographic pattern, presentation, risk factors and survival of RCC in an Eastern Indian institution. We characterized and compared these data with available literature Settings and Design: Retrospective study. Materials and Methods: A total of 81 patients of RCC from January 2008 to December 2012 were enrolled. Their pre-operative data were reviewed. They were followed as per institutional follow-up protocol. Statistical Analysis Used: Kaplan-Meier plot was constructed for survival analysis. Comparison of survival curves was performed by Logrank test. P < 0.05 was considered to be significant. Results: A total of 75 patients were analyzed with a mean follow-up of 26.3 ± 17.7 months. The mean age of presentation in our study was 52.79 years with a peak at 5th decade. Nearly 73.33% patients having one or more risk factors. 9 out of 10 had presented with some symptoms. The survival for localized RCC was 100% and significantly greater than advanced RCC (P < 0.0001). Similarly in the stage III, significant greater survival (P < 0.0001) was noted compare to stage IV. Conclusions: The age of presentation of RCC in India has been found in 5th decade, which is a decade earlier than the western countries. Symptomatic RCC is still majority in India. Organ confined tumors have good prognosis. When it metastasizes to lymph node or distant organ, the outcome is poor. Our results may form the basis for further studies and it may be used as future reference.
Keywords: Epidemiology, India, presentations, renal cell carcinoma, risk factors, survival
|How to cite this article:|
Ray R P, Mahapatra R S, Khullar S, Pal D K, Kundu A K. Clinical characteristics of renal cell carcinoma: Five years review from a tertiary hospital in Eastern India. Indian J Cancer 2016;53:114-7
|How to cite this URL:|
Ray R P, Mahapatra R S, Khullar S, Pal D K, Kundu A K. Clinical characteristics of renal cell carcinoma: Five years review from a tertiary hospital in Eastern India. Indian J Cancer [serial online] 2016 [cited 2019 Aug 22];53:114-7. Available from: http://www.indianjcancer.com/text.asp?2016/53/1/114/180851
| » Introduction|| |
Incidence of renal cell carcinoma (RCC) is 2-3% of all malignancy. It is the most common renal malignancy. Country to country the incidence varies and mostly common in the western part of the world. Incidence of RCC is less in Asian country, particularly in India. The data regarding RCC in India is scarce. The objective of this study was to assess the profile of the patients of RCC in respect to age distribution, sex distribution, presentation, site of occurrence, risk factors, staging, treatment received and death, and the comparisons of the result with available literature. It will help to understand characteristics of RCC in this geographical area and can be used as sources for future reference.
| » Materials and Methods|| |
This retrospective study was conducted in Department of Urology of our institution, a tertiary center of West Bengal, India. A total of 81 patients diagnosed as renal tumor from January 2008 to December 2012 were included. Data were collected from departmental register in a pre-defined proforma. Patient's data were entered into follow-up schedule 3 months after the operation and they were examined bi-annually until December 2012. Locally advanced and metastatic RCC were referred to Radiotherapy Department of our institution for adjuvant therapy.
Statistical analysis was performed using MedCalc® statistical software, version 11.6 (MedCalc Software bvba, Mariakerke, Belgium). Kappa coefficient was used to measure the magnitude of agreement between clinical tumor node metastasis (cTNM) and pathological tumor node metastasis (pTNM) staging. Kaplan-Meier plot was constructed to analyze the survival. Logrank test was used for comparison of survival curves. P < 0.05 was considered to be significant.
| » Result|| |
A total of 81 patients diagnosed as renal tumor from January 2008 to December 2012 were included in this study. Six patients did not attend for follow-up, so they were excluded from this study. Out of remaining 75 patients 51 (68%) were male and 24 (32%) were female with a male to female ratio was 2.1:1. [Table 1] summarizes the clinical parameters of the patients. The mean age was 52.79 ± 13.47 with a range 24-91. The peak age of incidence was in 5th decade (n = 21) and almost 3/4th (73.33%, n = 55) in between 4th and 6th decades [Figure 1]. Right sided RCC was 49.33% (n = 37) and left sided was 50.67% (n = 38). The most common presenting symptom is hematuria (53.33%, n = 40) followed by pain (50.67%, n = 38). Incidentally diagnosed cases are very less (n = 7) and only accounts 9.33% in our series. Five risk factors were assessed. 45 patients (60%) had a history of taking one form of tobacco and out of this 80% were male (n = 40). Nearly 41.33% patients (n = 31) were hypertensive who were on anti-hypertensive medication and 8 patients were obese. Only 4 patients had a history of occupational exposure for more than 15-20 years. Out of which two were working in the printing industry, one in the rubber industry and the other one in the dye industry. None had a family history of RCC. Hence, overall 55 patients (73.33%) had at least one or more risk factors for RCC. All patients were underwent surgery except one whose tumor was unresectable. Hence biopsy was done. Standard radical nephrectomy was attempted in all cases. Inferior vena cava thrombus was found in 2 cases; both were level 2 needing cavotomy and removal of thrombus enblock. Enblock resection with colon was needed in 4 cases where colon was adhered with the tumor. In one case, there was isolated jejunal metastasis. Segmental resection of jejunum and end to end anastomosis were performed in addition to the standard radical nephrectomy.
Histopathology report in our series showed most common type was clear cell carcinoma (n = 67). Non clear cell carcinoma (6) was found in 9.33% including papillary (4), chromophobe (1), poorly differentiated carcinoma (1). Only 2 cases of sarcoma were found in this series. Stage I and stage II RCC, found in 36 cases (48%). Stage III disease found in 42.67% (n = 32). Stage IV disease was only in 7 cases (9.33%), out of which 2 cases had metastasis. In one there was isolated jejunal metastasis and in the other liver metastasis was found.
Overall lymph node involvement was found in 21.33% (n = 16). Five cases (6.67%) were T4 disease, out of which one was unresectable and in 4 enblock colon resection were performed.
The cTNM and pTNM staging were analyzed for all cases. In some cases, it was seen that there was upstaging of tumor following histopathology. The reasons are lymph node involvement, visceral metastasis, vascular infiltration that is not picked up by imaging pre-operatively. However, a good agreement was seen between this two group [Table 2] using kappa coefficient(κ 0.738; standard error 0.0555: 95% CI 0.629-0.847).
Mean follow-up was 26.3 ± 17.7 months with a range from 0.7 to 58.9 months. Total 11 patients (14.67%) died, almost all are either locally advanced or metastatic RCC. Overall survival (OS) in this series was 68.7% (at 52.9 months) [Table 3] and [Figure 2]. The median survival for stage III was 52.9 months and for stage IV was 18.7 months. 5 year survival for stages I and II were 100%, for stage III 43.4% and for stage IV 0% [Table 4] and [Figure 3]. The survival for localized RCC was significantly greater than advanced RCC (P < 0.0001). Similarly the stage III had a significantly greater survival (P < 0.0001) when compared with stage IV [Table 5]. However, no statistical comparison was possible between stage I and stage II.
| » Discussion|| |
RCC is a potentially lethal urological malignancy. Incidence varies considerably among different geographical area. Incidence rates are highest in western and eastern Europe, Australia and Scandinavia followed by Southern Europe and Japan. In south East Asia the incidence rates are significantly lower. The lowest incidences have been reported from African countries. Most epidemiological studies of RCC were done in western countries. So whatever literatures available on RCC are based on western data. Studies in Asian countries are very few, may be because of low incidence of RCC. Indian data in this regard is lacking. RCC ranks 13th most common malignancy world-wide. The incidence in Asian population is in between 1.1 and 6.0/100,000. It is more common in male than female. Male:Female ratio ranges from 1.5:1 to 2.5:1. In our series it is 2.1:1, comparable to the available literatures. However, a higher male to female ratio was found in another study on Indian population. It may be because of the male are greater exposed to the risk factors than female. We found 80% all tobacco consumer and the entire 4 patient who exposed to occupational risk factors were male. Similar results were seen in Malaysian population also., RCC is primarily seen in 6th and 7th decade of life. Mean age at presentation in our study was 52.79 years, with the highest occurrence in 5th decade. Our patient population group was a decade younger in comparison to western data. A study conducted in South Korean population supported our findings. They found mean age was 53 years in their cohort. A study by Singam et al. also found younger mean age at presentation (57.1 years) in their study population in Malaysia. Similarly, Sivaramakrishna et al., had shown mean age at presentation was 53 years in their series. Although Asian population has a low incidence of RCC but it may present at a younger age than western country. Such differences can be due to environmental factors, dietary factors or genetic susceptibility, need conclusively addressed by further studies.
RCC are now frequently diagnosed incidentally and it is in part due to widespread use of radiologic imaging. Compared with symptomatic tumors, these incidental tumors often are smaller in size, are of lower nuclear grade and present at an earlier stage. However, in our series most of the presents were symptomatic (80.67%). Asymptomatic patients were only 7 (9.33%) diagnosed by ultrasonography done for other reasons. High proportion of symptomatic cohort in our study is due to lack of the screening program, lack of widespread use and availability of imaging studies, low socioeconomic conditions and lack of awareness. However, we found most common presenting symptom is hematuria (53.33%) followed by pain (50.67%) and mass (9.33%). Patients are usually frightened by the sudden onset of blood in the urine and frequently seek medical attention. Similar finding has shown in other series also., It is seen that Incidental tumor detection is still low in India as compared to western country.
Several risk factors have been studied. Smoking, hypertension and obesity are established risk factors. Others like diet, environmental factors and occupational exposures are putative. In western countries, due to declining trends of smoking the incidence and mortality rates are stabilizing or start to decline. The association between body mass index and RCC has been documented in many studies, but the exact mechanism is still not understood. The possible mechanism may be an increased exposure to the sex steroids estrogen and androgen. Hypertension or its treatment has been linked to occurrence of RCC and it said that better control of blood pressure may reduce the risk. We found most common occurrence of risk factor is smoking (60%) followed by hypertension (41.33%) and obesity. No patients had history of RCC in family. Overall, 3 out of 4 (73.33%) had at least one or more risk factors for RCC. RCC also has been linked to occupational exposure. In our series, only 4 patients had positive occupational exposure. However, the association between this two is often confusing because of inconsistent result in different studies. Although the protection against the exposure and rehabilitation of the worker may reduce the risk but the role may be very limited.
In modern era, with widespread use of cross sectional imaging more than half is incidentally detected tumor. In our study, majority is in stage III (42.67%). Combined stage I and stage II disease shared 48%. Limited health care facility, together with low socio-economic conditions of the population may be the reason patients present with advanced stage. Though Very limited data available in this regard, Sivaramakrishna et al. studied 343 patients in north India and found a third of the patients presented with stage III. However, in their series majority was stage I and in comparison to our series they also had higher metastatic group.
In country like India, it is seen in different series that incidental renal tumors are still not common and stage migration secondary to imaging studies are slow because heterogeneity in health care facilities.
RCC arises from renal tubular epithelial cells. Clear cell carcinoma is most common variant and accounts for 70-80%. A higher proportion of clear cell carcinoma found in our series. Although studies conducted in Asian population does not differ from western data. Another Indian study also showed similar result. This difference may be explained by the small number of cases in our study.
Though RCC is a potentially lethal urological malignancy, 5 year survival for stage I is excellent, ranging from 80 to as high as 100%., However when the cancer spreads to the lymph node the survival significantly dropped to 30%, and with systemic metastasis survival rate is <10%., 10, ,,,,,,, Stage is still best prognostic factor and lymph node metastasis is considered as dire prognostic sign.
The OS in our series was 68.7%. It is comparable to available literatures., In Europe between 1990 and 94 the OS was 34-68%. Similar OS found in united states and it was 63% in between 1992 and 99. However, we found excellent survival rate for stage I and stage II RCC and it is slightly better than other series.,,, Supporting our findings, Stafford et al., in 2008 had shown Asian/Pacific Islanders have higher survival rate. As there are several other prognostic factors have been described and heterogeneity in different literature, it is not possible to predict out come by only stage. Furthermore environmental factors may play role in this regards also. Although survival for locally advanced disease varies widely, without nodal involvement a 5-year survival between 60% and 70% had been documented in different studies., We found survival in stage III is only modest (43.4%). However, 46.88% of locally advanced cases of this study had lymph node metastasis. Lymph node metastasis is a poor prognostic sign and it negatively affects survival. Our findings in this regard are similar to the survival data of western countries.,, Stage IV RCC has dismissal survival and we observed median survival was 18.7 months with 0% 5 year survival rate. Sivaramakrishna et al. shown higher survival in Indian population for stage III and stage IV RCC. In our study, metastatic patients did not receive immunotherapy because of economic consideration. Some patients even could not afford palliative care. This may be the reason of dismissal survival in advanced stage patient group.
| » Conclusion|| |
RCC in Asian population is very rare with a similar male to female ratio world-wide. Though stage migration has shifted symptomatic to asymptomatic population in west, symptomatic tumor with advance stage is still more common here. Though advanced and metastatic RCC have a similar outcome in all part of the world; over all, the prognosis of the RCC in Asian population is much better than Western County. Further research is needed to validate our findings.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]