Urological Oncology

Bohle, Andreas

doi:10.1590/S1677-55382008000400023

UROLOGICAL SURVEY

Urological Oncology

Renal cell carcinoma in adults 40 years old or less: young age is an independent prognostic factor for cancer-specific survival

Taccoen X, Valeri A, Descotes JL, Morin V, Stindel E, Doucet L, Joulin V, Bocqueraz F, Coulange C, Rambeaud JJ, Fournier G, Mejean A; Oncology Committee of the Association Française d'Urologie

Service d'Urologie, Centre Hospitalier et Universitaire, 29609 Brest Cedex, France

Eur Urol. 2007; 51: 980-7

OBJECTIVES: Renal cell carcinoma (RCC) is uncommon in young adults. Based on the few studies published to date, it is difficult to determine whether this tumour has a particular progression pattern. This retrospective, multicentre study analysed RCC in young patients, defined as </= 40 yr old, compared to RCC in older patients.

METHODS: Between 1988 and 2000, 1233 patients, 93 under 40 yr old and 1140 older (mean ages, 34.2 and 61.9 years, respectively) underwent surgery for RCC in four teaching hospitals. Clinical and biologic parameters at diagnosis were compared and subjected to univariate and multivariate analyses to study survival. Mean follow-up was 4.5 yr for young and 4.1 yr for older patients.

RESULTS: When comparing younger to older patients, respectively, they had a lower male-to-female ratio (1.2 vs. 2.5), lower stage (84.9% vs. 67.4% pT1-pT2N0M0; p = 0.001), and fewer clear-cell carcinomas (73.1% vs. 82%), but more papillary carcinomas (20.4% vs. 11.4%; p = 0.01) and better 5-yr cancer-specific survival rates (90.8% vs. 78.3%; p = 0.005). Independent prognostic factors for survival, in the order of decreasing impact, were tumor stage (p < 0.0001), Fuhrman nuclear grade (p < 0.0001), and age </= 40 yr at diagnosis (risk ratio 0.4, p < 0.047). Young patients tended to have a better 5-yr progression-free survival (80.5% vs. 70.7%; p = 0.05).

CONCLUSIONS: RCC in young adults was more often localised at diagnosis and had a better prognosis than the disease in older subjects. Age under 40 yr old was an independent prognostic factor for survival.

Editorial Comment

This report focuses on a large database of roughly 1300 patients with renal cell carcinoma from several hospitals in France. 10% of these patients were less than 40 years old and were analyzed in comparison to the older ones. Interestingly, young patients had a better 5 year progression-free prognosis.

One of the factors that differed between these groups was that younger patients had more symptomatic tumors (60,2% vs. 50,4%), which , however, was not due to a different tumor size (5.8 cm vs. 6 cm). Aggressive growth showed differences, as favourable pT1 and pT2 tumors were more often among younger patients (84.9% vs. 67.4%). The differences between the age groups is interesting and, to my opinion, might be due to a shift in immunologic control with age. This should be focused in further scientific approaches on renal cell cancer.

Dr. Andreas Bohle

Professor of Urology

HELIOS Agnes Karll Hospital

Bad Schwartau, Germany

E-mail: boehle@urologie-bad-schwartau.de

Should we replace the Gleason score with the amount of high-grade prostate cancer?

Vis AN, Roemeling S, Kranse R, Schröder FH, van der Kwast TH

Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands

Eur Urol. 2007; 51: 931-9

OBJECTIVES: The stage and grade shift of currently diagnosed prostate cancer has led to a diminished prognostic power of the Gleason score system. We investigated the predictive value of the amount of high-grade cancer (Gleason growth patterns 4/5) in the biopsy for prostate-specific antigen (PSA) and clinical relapse after radical prostatectomy.

METHODS: PSA-tested participants (N = 281) of the European Randomized Study of Screening for Prostate Cancer (ERSPC) who underwent radical prostatectomy were analyzed. Besides clinical features, and serum-PSA, histopathologic features as determined in the diagnostic biopsy and matching radical prostatectomy specimen were related to patient outcome.

RESULTS: At a median follow-up of 7 yr, 39 (13.9%), 24 (8.5%), and 12 (4.3%) patients had PSA >/= 0.1 ng/ml, PSA >/= 1.0 ng/ml, and clinical relapse after radical prostatectomy, respectively. Using Cox proportional hazards, PSA level (p = 0.002), length of tumour (p = 0.040), and length of high-grade cancer (p = 0.006) in the biopsy, but not Gleason score, were independent prognostic factors for biochemical relapse (PSA >/= 0.1 ng/ml) when assessed as continuous variables. In radical prostatectomies, the proportion of high-grade cancer (p < 0.001) was most predictive of relapse (PSA >/= 0.1 ng/ml). For PSA >/= 1.0 ng/ml and clinical relapse, the amount of high-grade cancer, both in the biopsy specimen (p = 0.016 and p = 0.004, respectively) and radical prostatectomy specimen (p = 0.002 and p = 0.005, respectively), but not Gleason score, was an independent predictor.

CONCLUSIONS: In biopsy and radical prostatectomy specimens of surgically treated prostate cancer, the amount of high-grade cancer is superior to the Gleason grading system in predicting patient outcome. We propose that, in addition to the Gleason score, the amount of Gleason growth patterns 4/5 in the biopsy (whether absolute length or proportion) should be mentioned in the pathology report.

Editorial Comment

Gleason sum score is widely used for tayloring treatment to patients with prostate carcinoma. In this report, the authors compare the usual Gleason sum score to the amount of Gleason 4/5 (aggressive growth pattern) in the biopsy in predicting outcome after radical prostatcetomy. They found that the proportion of aggressive tumor correlates very well with PSA relapse after radical prostatectomy and suggest to indicate this proportion in the pathological report.

Indeed, from these data and other reports this approach can only be emphasized and every pathologist should be asked for this additional service. The only caveat may be the difficulty to define the proportion of aggressive tumor growth (Gleason 4/5) in biopsies with small amount of tumors. Still, this approach may be very helpful in clinical practice.