Prognosis

Five-year relative survival is 78.6% in the US (2015-2021 data).[20] Five-year relative survival by stage at diagnosis (kidney and renal pelvis cancer, 2015-2021 data):[20]

  • Localised 93.3%

  • Regional 76.4%

  • Distant 19.1%

Patients who experience symptoms on presentation have poorer prognosis.[16] Prognosis is particularly poor in those who develop paraneoplastic syndromes.[19]

Tumour histology subtypes can indicate varying prognoses, but when adjusted for stage and tumour grade, this may become less relevant. Clear cell histology may, in general, be associated with poorer prognosis; in addition, sarcomatoid differentiation in any histology tends to dictate a more aggressive tumour.[34] Pathological and clinical staging, as well as certain patient characteristics, are included in prognostic models.

Prognostic models

RCC is diagnosed by a combination of imaging and pathology to confirm malignancy, and to stage patients both clinically and pathologically.[7][8] Prognostic models have been developed to integrate these diagnostic findings into a schema that includes other patient factors, and that may better predict for survival or prognosis than classic staging.[75][76][78] The effort to integrate molecular profiling and biomarkers into prognostic models continues.

The UCLA Integrated Staging System and SSIGN (Mayo) algorithms can be applied to patients with early localised disease, post-nephrectomy.[75][76]

The Memorial Sloan Kettering Cancer Center (MSKCC) model is one of the more widely used prognostic models in metastatic disease, and has been well validated.[62] Further prognostic criteria for patients with metastatic RCC treated with sunitinib, sorafenib, and bevacizumab have been elucidated, in addition to validation of some of the MSKCC criteria.[77] This study found that haemoglobin less than the lower limit of normal, corrected calcium greater than the upper limit of normal (ULN), Karnofsky performance status less than 80%, time from original diagnosis to treatment of less than 1 year, 2 or more organ sites of metastatic disease, neutrophils greater than the ULN, and platelets greater than the ULN were independent adverse prognostic factors.[77] Patients were segregated into three risk categories: favourable-risk group (no prognostic factors), in which median overall survival (mOS) was not reached and 2-year OS (2y OS) was 75%; intermediate-risk group (1 or 2 prognostic factors), in which mOS was 27 months and 2y OS was 53%; and the poor-risk group (3 to 6 prognostic factors), in which mOS was 8.8 months and 2y OS was 7%.[77]

The International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria, which includes neutrophilia and thrombocytosis, is most commonly used in current practice. IMDC criteria have been used for trials of immune checkpoint inhibitor combination therapies. Predictors of poor survival are:[78]

  • Karnofsky performance status of less than 80%

  • Less than 1 year from diagnosis to treatment

  • Anaemia (haemoglobin concentration less than the lower limit of normal)

  • Hypercalcaemia (corrected calcium concentration greater than the ULN)

  • Neutrophilia (neutrophil count greater than the ULN)

  • Thrombocytosis (platelet count greater than the ULN).

Early-stage RCC prognosis

Early-stage disease in general has excellent prognosis, with greater than 95% cancer-specific survival among all management strategies (median follow-up 22 to 120 months).[4] Increasing age, larger tumour size, and higher tumour grade were the most common predictors of worse cancer-specific survival.[90]

Risk of local relapse after adequate curative surgery for small renal tumours is rare (about 2%) and is unlikely after 5 years. However, between 20% to 30% of patients with localised disease who undergo curative surgery will develop recurrent or metastatic disease within 5 years.[176]

Advanced stage/metastatic RCC prognosis

In one study in patients diagnosed with locally advanced disease, the 10-year progression-free survival for those with T3 clear cell tumours was 72%.[177]

The median overall survival of untreated metastatic disease is 5 months; this improved to 10.2 months in the cytokine era, and to 17.7 months when treated with targeted molecular therapy.[178] A near-doubling of overall survival was observed with the general availability of sunitinib for metastatic RCC.[179] The advent of immune checkpoint inhibitors and combinations of therapies has led to prolonged disease control in some patients.[81][180]​ The CheckMate 214 trial reported a median overall survival of 52.7 months with nivolumab plus ipilimumab combination therapy at median 8-year follow-up.[138]

Metachronous metastases (recurrent metastatic disease diagnosed at a later time) fare better than synchronous metastases (metastases diagnosed in separate sites at the same time), and there is evidence to support repeat metastasectomy.[181] Patients with the best prognoses are those with a long disease-free interval since original diagnosis (>12 months), R0 resections (no residual microscopic tumour cells remaining in tumour bed; surgical resection margins on pathology are completely negative [i.e., clear of tumour]), and no more than 6 metastases.[181][182] Survival at 5 years has been found to range from 30% to 50% in patients with resection of metastases for pulmonary lesions, and up to 33% at 10 years with pulmonary resections.[181][182][183]

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