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DOI: 10.1148/radiol.2362050263
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(Radiology 2005;236:739.)
© RSNA, 2005

Letters to the Editor

Molecular Markers, Paraneoplastic Syndrome, and Inferior Vena Cava Involvement as Risk Factors for Renal Tumor Recurrence

Nicola Mumoli, MD and Marco Cei, MD

1 Division of Emergency Medicine, Department of Internal Medicine, Livorno Hospital
viale Alfieri 36, Livorno LI-57100, Italy
e-mail: nimumoli{at}tiscali.it

Editor:

We read with much interest the article by Dr Chae and colleagues (1) in the January 2005 issue of Radiology. The authors describe retrospectively the recurrence patterns of renal cell carcinoma (RCC) and the factors affecting tumor recurrence. Actually, the major obstacle to cure is the lack of effective treatment for patients at high risk for relapse or those with metastatic disease. In their article, Dr Chae and colleagues specifically stated that physical examination and laboratory studies are not sufficiently sensitive for surveying tumor recurrence.

On the contrary, we believe that, in selected groups of patients at high risk for metastatic disease or early recurrence after nephrectomy, molecular markers for RCC could help early detection strategies for recurrences of localized disease (2). Furthermore, Dr Chae and colleagues did not report that RCC tends to invade the renal vein and to extend into the inferior vena cava, occasionally reaching the right side of the heart (3). This involvement could appear in association with primary disease at the time of first diagnosis or as a recurrence. In the absence of detectable metastases, about one-half of patients whose RCC recurs in the inferior vena cava can have prolonged survival after surgical resection in a specialized center, with surgical mortality ranging from 5% to 10% (4).

Last, a broad range of paraneoplastic syndromes have been reported in association with RCC, including erythrocytosis, hypercalcemia, hepatic dysfunction, and amyloidosis (5); we therefore suggest that the presence of these paraneoplastic syndromes may be used as a risk factor for tumor recurrence.

References

  1. Chae EJ, Kim KJ, Kim HS, Bae SJ, Cho KS. Renal cell carcinoma: analysis of postoperative recurrence patterns. Radiology 2005; 234:189–196.[Abstract/Free Full Text]
  2. Skates S, Iliopoulos O. Molecular markers for early detection of renal carcinoma: investigative approach. Clin Cancer Res 2004; 10(suppl 2):6296S–6301S.[Abstract/Free Full Text]
  3. Finkelstein MP, Drinis S, Tortorelis DG, Lafaro RJ, Konno S, Choudhury MS. Recurrence of renal cell carcinoma with extensive vena caval thrombus 3 years after radical nephrectomy. Urol Int 2002; 68:199–201.[CrossRef][Medline]
  4. Cherrie RJ, Goldman DG, Lindner A, deKernion JB. Prognostic implications of vena caval extension of renal cell carcinoma. J Urol 1982; 128:910–912.[Medline]
  5. Ritchie AW, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983; 10:390–400.[Medline]

Drs Kim and Cho respond:

Jeong Kon Kim, MD and Kyoung-Sik Cho, MD

Department of Radiology, Asan Medical Center, University of Ulsan
388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, South Korea
e-mail: rialto{at}amc.seoul.kr

We read with interest the comments from Drs Mumoli and Cei regarding (a) prediction of tumor recurrence by using molecular markers, (b) possible prolongation of patients' survival by means of surgical resection of recurred tumor confined to the inferior vena cava, and (c) prediction of tumor recurrence on the basis of presence of paraneoplastic syndrome (1–3).

First, to our knowledge, molecular markers have not been commonly used or commercially released yet. We basically agree that molecular markers may contribute to early detection of tumor recurrence. However, it is still uncertain that molecular markers will replace the role of imaging studies for surveillance of tumor recurrence. In most other malignant tumors with sensitive and specific tumor markers, patient evaluation is generally performed by using both tumor markers and imaging studies. Therefore, scheduled imaging follow-up should be performed for surveillance of recurred RCC.

Second, it is generally accepted that tumor invasion to the renal vein or inferior vena cava leads to poor prognosis. Our results also showed that 43% of patients (six of 14) with T3b tumors had recurrence (4). Although some authors have demonstrated prolonged patient survival by means of complete resection of recurred tumors confined to the inferior vena cava, we believe that the overall prognosis is worse in T3b tumors than in T1–T3a tumors.

Last, we agree that the paraneoplastic syndrome may suggest tumor recurrence in some cases. However, in fact, the clinical manifestations of paraneoplastic syndrome are diverse, and its incidence has not been constant among previous reports. Therefore, these limitations make us hesitate to accept paraneoplastic syndrome as a useful clinical reflection for tumor recurrence.

We thank Drs Mumoli and Cei for their interest in our study and their valuable comments.

References

  1. Skates S, Iliopoulos O. Molecular markers for early detection of renal carcinoma: investigative approach. Clin Cancer Res 2004; 10(suppl 2):6296S–6301S.
  2. Finkelstein MP, Drinis S, Tortorelis DG, Lafaro RJ, Konno S, Choudhury MS. Recurrence of renal cell carcinoma with extensive vena caval thrombus 3 years after radical nephrectomy. Urol Int 2002; 68:199–201.
  3. Ritchie AW, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983; 10:390–400.
  4. Chae EJ, Kim KJ, Kim HS, Bae SJ, Cho KS. Renal cell carcinoma: analysis of postoperative recurrence patterns. Radiology 2005; 234:189–196.




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