|Year : 2009 | Volume
| Issue : 4 | Page : 563-565
Renal cell carcinoma: Preoperative prognostic nomogram
Abhishek Jain, Apul Goel
Department of Urology, King George Medical University, Lucknow - 226003, Uttar Pradesh, India
|Date of Web Publication||30-Nov-2009|
Department of Urology, King George Medical University, Lucknow - 226003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain A, Goel A. Renal cell carcinoma: Preoperative prognostic nomogram. Indian J Urol 2009;25:563-5
Kanao K, Mizuno R, Kikuchi E, Miyajima A, Nakagawa K, Ohigashi T, et al. J Urol 2009; 181:480-85. Preoperative Prognostic Nomogram (Probability Table) for Renal Cell Carcinoma Based on TNM Classification
| Summary|| |
Several nomograms have been developed to predict prognosis of malignant diseases, including renal cell carcinoma (RCC). These nomograms are used in clinical practice to determine treatment strategies and obtain informed consent. However, a preoperative prognostic nomogram that predicts survival in RCC patients is not available. In this retrospective study, the authors have developed a prognostic probability table to predict cause-specific survival in RCC patients.
From December 1985-2003, 545 patients (419 males and 126 females), who underwent either radical nephrectomy (n = 447) or partial nephrectomy (n = 98), were studied. Staging of the disease was done according to 2002 UICC TNM classification by using standard laboratory/radiological investigation. Cytoreductive surgery was done in metastatic or locally advanced disease, but not in patients with poor performance status, advanced age, or significant comorbidity. Disease was found advanced in 130 patients (46 with distant metastasis and 29 with nodal disease) and 60 died of RCC. Postoperative immunotherapy was given to 121 patients.
To calculate cause-specific survival rates, Kaplan-Meier method was used. The survival distribution was evaluated using T, N, and M factors, and log rank test was used to compare survival curves. Cox proportional hazard regression model was used to predict cause-specific survival using TNM factors. A nomogram predicting 1-, 3-, and 5-year cause-specific survival was developed by repeating analysis on 200 bootstrap samples to decrease overfit bias and determine 95% CIs.
The mean follow up was 65 months (range, 2-247). TNM classification showed statistically significant relationship with cause-specific survival in RCC. Overall, 1-, 3-, and 5-year patient survival was 95.2, 92.0, and 89.9%, respectively [Table 1]. Cause-specific survival was significantly related to the TNM classifications (each P < 0.001). T factor was significantly divided (T1a and T1b: P = 0.007; T1b and T3a: P = 0.008; T2 and T3b/c: P = 0.015; and T3b/c and T4: P = 0.002), except for T2 and T3a (P = 0.784). T, N and M factors were also significant prognostic factors on multivariate analysis. Study also revealed that there is reversal of risk of survival between T2 and T3a (i.e., perinephric fat involvement showed better prognosis then tumor size >7 cm but not in case of adrenal involvement). According to the proposed nomogram the 1-, 3-, and 5-year cause-specific survival for T1aN0M0 disease was 99.3, 98.6, and 97.9%, and for T3aN1M1 disease it was 55.0, 23.2, and 16.5%, respectively [Table 1]. On internal validation these probability tables revealed good correlation (Concordance index = 0.81) and had an excellent ability to discriminate.
| Discussion|| |
A recent study concluded that in patients with metastatic RCC, nephrectomy also improved survival if patients presented with good performance status.  Therefore, a preoperative prediction of patient survival may be helpful for discussing treatment and obtaining informed consent. Various nomograms have been proposed in RCC to predict prognosis or metastasis but these nomograms are mainly based on postoperative findings and are therefore useful for postoperative counseling. [2,3] Karakiewicz et al. developed a postoperative nomogram to predict survival in patients with RCC using six variables.  By using six variables the predictive accuracy of their nomogram may be better than the preoperative nomogram proposed by the authors.
Because of the recent introduction of newer drugs like sorafenib, sunitinib, etc. in patients with advanced disease the probabilities of survival may improve further. The authors noticed better prognosis for T3a tumors as compared to T2 disease. Some groups have reported that survival in patients with T3a fat disease is significantly better than in those with T3a adrenal disease.  It was shown that the survival of patients with adrenal gland involvement was similar to that of those with tumors involving adjacent organs, currently staged as pT4. Additional revision of T3a in the 2002 TNM system, for example, incorporating T3a fat disease into T1 or T2 and T3a adrenal disease into T4, may be required to optimize staging and improve prognostic information.
On internal validation, this nomogram showed a high concordance index but a better external validation of this nomogram in other institutes with different demographic conditions is required.
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