|Year : 2017 | Volume
| Issue : 4 | Page : 601-604
Kidney cancer demographics and outcome data from 2013 at a tertiary cancer hospital in India
Amit Joshi1, Amitesh Anand2, Kumar Prabhash1, Vanita Noronha1, Sameer Shrirangwar1, Ganesh Bakshi2, Mahendra Pal2, Vedang Murthy3, Rahul Krishnatry3, Sangeeta Desai4, Santosh Menon4, Deepali Patil5, Sheetal Kulkarni6, Nilesh Sable7, Palak Popat7, Archi Agrawal8, Venkatesh Rangarajan8, Gagan Prakash2
1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
5 Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Homi Bhabha National Institute, Mumbai, Maharashtra, India
6 Department of Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
7 Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
8 Department of Nuclear Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||30-Jul-2018|
Dr. Gagan Prakash
Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
INTRODUCTION: The stage at diagnosis of renal cell cancer (RCC) in developed countries is lower due to increased utilization of routine health checkups by patients compared to developed countries. This study aims to determine the sociodemographic and clinical distribution of RCC in patients presenting to Tata Memorial Hospital (TMH). SUBJECTS AND METHODS: We performed a retrospective audit of all patients presenting to TMH with a diagnosis of RCC. Data were retrieved from our electronic medical record system from January 1, 2013 to December 31, 2013. The survival analysis was done by Kaplan–Meir analysis method of estimating survival. Log-rank test of comparison was applied to estimate the difference in the survival among the different stages of renal cancer. RESULTS: Of the 35,197 new registered patients at TMH, 338 were diagnosed with RCC. Most patients were in the 50–60 years age group, with 56.6 years being the median age at presentation. Among patients treated at TMH, 84 underwent surgery and tyrosine kinase inhibitor was given in 55 (16%) patients. The patients' characteristics, clinical characteristics of RCC, treatment modalities offered, and survival of patients treated for RCC are presented in this paper. CONCLUSION: In the absence of robust Indian data on RCC, this audit provides baseline information on epidemiology, stage at presentation, and outcomes of RCC at our center compared with the West.
Keywords: Indian data, kidney cancer, renal cell carcinoma, Tata Memorial Hospital
|How to cite this article:|
Joshi A, Anand A, Prabhash K, Noronha V, Shrirangwar S, Bakshi G, Pal M, Murthy V, Krishnatry R, Desai S, Menon S, Patil D, Kulkarni S, Sable N, Popat P, Agrawal A, Rangarajan V, Prakash G. Kidney cancer demographics and outcome data from 2013 at a tertiary cancer hospital in India. Indian J Cancer 2017;54:601-4
|How to cite this URL:|
Joshi A, Anand A, Prabhash K, Noronha V, Shrirangwar S, Bakshi G, Pal M, Murthy V, Krishnatry R, Desai S, Menon S, Patil D, Kulkarni S, Sable N, Popat P, Agrawal A, Rangarajan V, Prakash G. Kidney cancer demographics and outcome data from 2013 at a tertiary cancer hospital in India. Indian J Cancer [serial online] 2017 [cited 2019 Dec 15];54:601-4. Available from: http://www.indianjcancer.com/text.asp?2017/54/4/601/237908
| » Introduction|| |
Renal cell carcinoma (RCC) is an aggressive malignancy constituting 2–3% of all adult cancers. Incidence rates are highest in Europe, North America, and Australia and lowest in India, Japan, Africa, and China., While developed nations see more small renal masses (<4 cm), developing nations still see a greater proportion of large masses that are often metastatic at presentation. The data on RCC from India are scarce. This study aims to determine the demographic and stage distribution, utilization of various treatment modalities, and oncological outcome in patients with RCC presenting to Tata Memorial Hospital (TMH).
| » Subjects and Methods|| |
We performed a retrospective audit of all patients diagnosed as renal cancer in TMH from January 1, 2013 to December 31, 2013. Electronic medical records of these patients were checked for most of the information gathered. Patients whose follow-up was not on records were contacted telephonically. The survival analysis was done by Kaplan–Meir analysis method of estimating survival. Log-rank test of comparison was applied to estimate the difference in the survival among the different stages of renal cancer. Statistical Package for the Social Sciences version 24 was used.
| » Results|| |
The annual patient registration in 2013 at our hospital was 35,197. We registered 1817 new patients under the service of Uro-oncology Disease Management Group. The newly registered renal cancer patients were 338. Out of this, 263 were males and 75 females. Most patients were in the 50–60 years age group, with 56.6 years being the median age at presentation [Figure 1]. Youngest patient presenting with RCC was 22 years and oldest was 86 years old. [Table 1] shows the state of domicile of our patients. Common presenting symptoms were abdominal pain in 85 (25%) cases and hematuria in 82 (24%) cases [Table 2]. Majority (52%) of our patients had multiple comorbidities such as hypertension, diabetes, coronary artery disease, or chronic obstructive pulmonary disease. At presentation, 213 (63%) were treatment naïve, 83 (25%) had undergone radical nephrectomy, 14 (4%) underwent biopsy, and 6 (2%) had received tyrosine kinase inhibitor (TKI) from outside before coming to TMH. Median time from date of registration to joint clinic or treatment planning was 8 days and median time from date of registration to starting treatment was 27 days. Forty-four patients visited the hospital only once and 186 patients never followed up after planning the treatment; 150 patients were lost to follow-up before planning treatment. Among patients treated at TMH, 84 patients underwent surgery. Radical nephrectomy was done in 59 patients, nephron sparing surgery (NSS) in 16, cytoreductive nephrectomy in 7, and simultaneous metastasectomy in 2 patients. TKI was given in 55 (16%) patients, best supportive care in 16 (5%) patients, and observation in 11 (3%). Metastatic disease was the commonest presentation with 56 patients (40%) having single or multiple metastases at presentation. [Figure 2] depicts the T stage at presentation on final histopathology of patients undergoing surgery.
As per our policy, all T1 and some T2 tumors are assessed and considered for NSS. Feasibility of performing an NSS was assessed using the RENAL score. [Figure 3] depicts a flowchart of our protocol for managing patients presenting with renal cancer.
|Figure 3: TMH protocol for managing patients with renal cancer (Original)|
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Radical nephrectomies were performed in 59 patients, 45 open and 14 laparoscopically. Seven patients had renal vein thrombus, most commonly of grade I. In 45 patients lymph node dissection was performed because of suspicious nodes either on preoperative imaging or intraoperatively. Average blood loss was 520 cc in open surgeries and 130 cc in laparoscopic. A few resections with renal vein thromboses increased the average blood loss, in most cases, it was in the range of 500–600 cc. Average length of stay in hospital was 7.6 days for those undergoing open surgery and 5.1 days for those undergoing minimally invasive. Average serum creatinine of these patients was 0.9 presurgery and 1.1 postsurgery, as seen on last follow-up. We categorized 30-day perioperative complications according to Clavian Dindo classification. 54% patients had grade I complications, 3% had grade II, 2% had grade III, and none had grade IV. In 46 patients we had follow-up data available with a median follow-up of 3.1 years, and 13 patients were lost to follow-up.
16 patients underwent NSS, all by open approach. Average size of tumor as assessed radiologically preoperatively was 4.4 and 3.7 cm as per histopathology of resected specimen. Average cold ischemia time was 31.6 min. Fuhrman II was the commonest grade. Four patients underwent lymph node dissection on intraoperative suspicion but none of them were involved on histopathology. Intraoperative ultrasonography was required in 6 patients and 7 patients underwent DJ stenting because of pelvicalyceal system repair. There were prolonged urinary leaks in 2 patients, which were refractory to conservative measures and eventually required conversion to radical nephrectomy after 2 months. Average length of stay in hospital was 10 days.
Nine patients underwent cytoreductive nephrectomy. Average blood loss for this surgery was 430 cc. Length of stay was 7.2 days.
Among operated patients, overall survival of patients undergoing radical nephrectomy at 3 years was 56.09% with a median disease-free interval of 12.8 months. In patients undergoing NSS, 3-year overall survival was 96%. 31.6% patients who underwent surgery with curative intent developed recurrence or metastases on a follow-up of 3.1 years. Overall survival at 3 years for patients undergoing cytoreductive nephrectomy was 33%.
Among metastatic disease, a total of 55 patients received TKI/mTOR-based therapy in palliative setting. The most common prescribed TKI was sorafinib in 38 patients (70%), followed by pazopinib in 8 (14%) patients, sunitinib in 7 (12%), and everolimus in 2 (4%) cases.
Grade 3 hand foot syndrome (HFS) was seen in 17 (31%) patients, grade 3 diarrhea in 4 (8%), grade 3 mucositis in 3 (6%), grade 3 cardiotoxicity in 2 (4%), and grade 3/4 dyselectrolytemia in 4 (8%) cases. Dose reduction of drugs due to toxicities was required in 26 (48%) of patients. Best radiological response was stable disease (SD) in 21 (39%) cases followed by partial response (PR) in 12 (23%) cases and progressive disease in 9 (17%) cases. Response was not evaluable in 11 (20%) cases. After 3.5 years follow-up, 16 (29%) cases are alive, 28 (51%) are dead, and 11 (20%) are lost to follow-up.
| » Discussion|| |
As per the SEER database, almost 50% patients with RCC present in the age group between 55 and 75 and median age at presentation is 64. In our series, median age at presentation was 56.6 years, which is a decade earlier than in the West. Similar finding of younger age at presentation was also reported in another Indian series. Our male/female ratio is far different from Western data. As per existing literature from developed world, the male to female ratio is 2:1; however, we found this to be 3.5:1 for all patients presenting with renal cancer. The ratio of patients undergoing surgery for renal cancer was even more skewed toward males by 6:1. Other studies on Indian population have found a similar higher male predominance of this cancer., We found the proportion of clear cell histology to be around 90%, which was similar to that in Western literature. This is contrary to some other Indian data, where Agnihotri et al. found lower percentage of clear RCC in Indian patients as compared to Western literature.
Stage at presentation in our patients is also different from those in West. 40% of our patients presented with metastatic disease and only 22% in stage I. This is similar to another Indian data by Ray et al., in which only 20% of patients presented at stage I and 42.6% of patients presented at stage III.[ 3] Most common stage in operated patients was T3 (25%). SEER data suggest that 60–70% of their patients present at stage I. In fact, the increase in incidence of renal cancer seen in the last decade in developed nations is predominantly contributed by tumors <2 and 2–4 cm size. This difference in stage at presentation also explains lesser number of NSS being performed by us compared to the West. Among patients undergoing radical nephrectomy, blood loss was clearly much more in open than in laparoscopic surgery. We performed lymph node dissection in almost two-thirds of our patients based on intraoperative suspicion of nodes; however, majority (>80%) of these nodes turned out to be uninvolved.
Most common TKI prescribed was sorafinib in 38 patients (70%) followed by pazopinib in 8 (14%) patients, sunitinib in 7 (12%), and everolimus in 2 (4%). Cost constraints and lack of health insurance for most patients in our country made sorafinib the more utilized TKI in government hospitals; however, this trend seems to be changing with every passing year.
Radiological response in this series is very similar to the results from our institution published earlier, where best response of complete response, PR, and SD was achieved in 6 (2.9%), 40 (19.6%), and 78 patients (38.2%), respectively, for a response rate of 22.5% and CBR of 60.7%.
Toxicity profile due to TKI in this study were grade 3 HFS in 31% patients, grade 3 diarrhea in 8%, grade 3 mucositis in 6%, grade 3 cardiotoxicity in 4%, and grade 3/4 dyselectrolytemia in 8% cases. Dose reduction of drugs due to toxicities was required in 26 (48%) patients. In the previous series from our institution, Ramaswamy et al. found to have similar incidence to HFS but lower incidence of mucositis, with 24.5% patient requiring a dose reduction because of various adverse events.
This audit had various limitations. It had a short follow-up and many patients were lost to follow-up. Getting lost to follow-up during various stages of treatment is also a problem more common in our country. Financial constraints, ignorance, lack of education, and lack of logistics at a new city are the likely factors responsible for this.
| » Conclusion|| |
In the absence of robust Indian data on renal cancer, this audit provides a baseline information on epidemiology, stage at presentation, and outcomes of renal cancer in our center and highlights what aspects of this disease are different from that of the West.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Ljungberg B, Campbell SC, Choi HY, Jacqmin D, Lee JE, Weikert S, et al
. The epidemiology of renal cell carcinoma. Eur Urol 2011;60:615-21.
Chow WH, Devesa SS. Contemporary epidemiology of renal cell cancer. Cancer J 2008;14:288-301.
Ray RP, Mahapatra RS, Khullar S, Pal DK, Kundu AK. Clinical characteristics of renal cell carcinoma: Five years review from a tertiary hospital in Eastern India. Indian J Cancer 2016;53:114-7.
] [Full text]
Agnihotri S, Kumar J, Jain M, Kapoor R, Mandhani A. Renal cell carcinoma in India demonstrates early age of onset & a late stage of presentation. Indian J Med Res 2014;140:624-9.
] [Full text]
Abraham GP, Cherian T, Mahadevan P, Avinash TS, George D, Manuel E. Detailed study of survival of patients with renal cell carcinoma in India. Indian J Cancer 2016;53:572-4.
] [Full text]
Sun M, Abdollah F, Bianchi M, Trinh Q, Jeldres C, Tian Z, et al
. A stage-for-stage and grade-for grade analysis of cancer specific mortality rates in renal cell carcinoma according to age: A competing-risks regression analysis. Eur Urol 2011;60:1152-9.
Ramaswamy A, Joshi A, Noronha V, Patil V, Kothari R, Sahu A, et al
. Patterns of care and clinical outcomes in patients with metastatic renal cell carcinoma—results from a tertiary cancer center in India. Clin Genitourin Cancer 2017;15:e345-55.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]