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OBJECTIVE: To develop and compare various models for risk stratification in chromophobe renal cell carcinoma (chrRCC). Models have been developed to predict progression-free (PFS) and cancer-specific survival (CSS) following surgery for localized renal cell carcinoma (RCC). Notably, chromophobe RCC (chrRCC) is not included in American Urological Association (AUA) risk stratification, as nuclear grading is not recommended. METHODS: We queried our institutional registry to identify patients managed surgically for unilateral, sporadic, M0, chrRCC from 1970-2012. AUA risk groups were defined using reported criteria, excluding grade, and were compared to the Mayo system incorporating nodal involvement, perinephric/renal sinus fat invasion, and sarcomatoid differentiation. PFS and CSS were estimated using the Kaplan-Meier method. Predictive ability was summarized using c-indexes from Cox proportional hazard regression models. RESULTS: A total of 257 patients were identified. Thirty-nine patients experienced disease progression at a median 30 months (IQR 5.0-84) and 25 died from chrRCC at a median 34 months (IQR 15-79) following surgery. PFS and CSS rates at 10 years after surgery were 84% and 90%, respectively. C-indexes for modified AUA and Mayo risk groups were similar at 0.76 and 0.75, respectively, for PFS, and 0.77 and 0.76, respectively for CSS. CONCLUSION: The modified AUA and Mayo risk stratification systems have similarly robust c-indexes for PFS and CSS in chrRCC. These models can be used to counsel patients based on pathologic features, inform clinicians on appropriate follow-up pathways, and identify patients at risk of disease progression for enrollment in adjuvant systemic therapy trials.
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OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.
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Internato e Residência , Urologia , Humanos , Masculino , Feminino , Educação de Pós-Graduação em Medicina , Urologia/educação , Competência ClínicaRESUMO
OBJECTIVE: To update our experience and report on features predictive of high-quality urology residents at the time of the urology match, because data predicting which medical students will mature into excellent urology residents are sparse. METHODS: We reviewed our experience with 84 urology residents who graduated from 2006 to 2023. Residents were independently scored 1-10 based on overall quality by the current and former Program Director. Discrepant scoring by >2 was resolved by an independent review. Associations of features from the medical student application with an excellent score (defined as 8-10) were evaluated with logistic regression. RESULTS: Discrepant scoring >2 was noted in only 5 (6%) residents. Among the 84 residents, the median overall score was 7 (range 1-10) and 36 (43%) residents had an excellent score of 8-10. Univariably, higher USMLE step II score (Pâ¯=â¯.03), election to alpha omega alpha (Pâ¯=â¯.004), no negative interview comments (Pâ¯=â¯.002), honors in OB/Gyn (Pâ¯=â¯.048) and psychiatry clerkships (Pâ¯=â¯.04), and honors in all core clinical clerkships (Pâ¯<â¯.001) were significantly associated with an excellent score. In a multivariable model, no negative interview comments (Pâ¯=â¯.003) and honors in all core clinical clerkships (Pâ¯=â¯.001) were independently associated with an excellent score (c-index 0.76). There were several notable features (sex, letters of recommendation, USMLE step I, externship at our institution, surgery clerkship grade, and rank list) that were not significantly associated with excellent residents. CONCLUSION: We demonstrate features associated with excellent urology residents, most notably no negative interview comments and an honors grade in all core clinical clerkships.
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Estágio Clínico , Internato e Residência , Estudantes de Medicina , Urologia , Humanos , Urologia/educação , Avaliação EducacionalRESUMO
Context: Bladder recurrences have been reported in 22-47% of patients after surgery for upper urinary tract urothelial carcinoma (UTUC). This collaborative review focuses on risk factors for and treatment strategies to reduce bladder recurrences after upper tract surgery for UTUC. Objective: To review the current evidence on risk factors and treatment strategies for intravesical recurrence (IVR) after upper tract surgery for UTUC. Evidence acquisition: This collaborative review is based on a literature search of PubMed/Medline, Embase, Cochrane Library, and currently available guidelines on UTUC. Relevant papers on bladder recurrence (etiology, risk factors, and management) after upper tract surgery were selected. Special attention has been paid to (1) the genetic background of bladder recurrences, (2) bladder recurrences after ureterorenoscopy (URS) with or without a biopsy, and (3) postoperative or adjuvant intravesical instillations. The literature search was performed in September 2022. Evidence synthesis: Recent evidence supports the hypothesis that bladder recurrences after upper tract surgery for UTUC are often clonally related. Clinicopathologic risk factors (patient, tumor, and treatment related) have been identified for bladder recurrences after UTUC diagnosis. Specifically, the use of diagnostic ureteroscopy before radical nephroureterectomy (RNU) is associated with an increased risk of bladder recurrences. Further, a recent retrospective study suggests that performing a biopsy during ureteroscopy may further worsen IVR (no URS: 15.0%; URS without biopsy: 18.4%; URS with biopsy: 21.9%). Meanwhile, a single postoperative instillation of intravesical chemotherapy has been shown to be associated with a reduced bladder recurrence risk after RNU compared with no instillation (hazard ratio 0.51, 95% confidence interval 0.32-0.82). Currently, there are no data on the value of a single postoperative intravesical instillation after ureteroscopy. Conclusions: Although based on limited retrospective data, performing URS seems to be associated with a higher risk of bladder recurrences. Future studies are warranted to assess the influence of other surgical factors as well as the role of URS biopsy or immediate postoperative intravesical chemotherapy after URS for UTUC. Patient summary: In this paper, we review recent findings on bladder recurrences after upper tract surgery for upper urinary tract urothelial carcinoma.
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To determine the incidence of renal neoplasia among patients undergoing nephrectomy for polycystic kidney disease (PKD), we queried our institutional nephrectomy registry (years 2000-2020). Approximately 4% (231 of 5757) of patients who underwent nephrectomy had PKD, and 26 of these 231 patients (11.3%) had renal neoplasia. Tumors from an additional two patients with PKD were also evaluated. Patients with PKD who had tuberous sclerosis complex (TSC)-associated renal neoplasia were screened for PKD1/TSC2 contiguous gene deletion syndrome (CGS) using single nucleotide polymorphism arrays. The median age of patients with PKD and renal neoplasia at nephrectomy was 54 yr. The median tumor size was 2.0 cm and the tumors were predominantly of low grade and stage. The tumors consisted of 23 renal cell carcinomas (RCCs), one epithelioid angiomyolipoma, and four angiomyolipomas. The median follow-up was 59.5 mo (n = 26) and only one patient with clear cell RCC developed metastases. Two patients with angiomyolipomas had PKD1/TSC2 CGS. Our results support screening of patients with PKD and TSC-associated renal neoplasia as well as TSC patients with cystic renal disease for CGS, as identification of patients with CGS can better define the manifestation and prognosis of CGS and guide counseling regarding patterns of inheritance. PATIENT SUMMARY: We identified patients with abnormal kidney cell growth (called renal neoplasia) among those undergoing removal of kidney tissue for polycystic kidney disease (PKD) and patients with a syndrome involving deletions in two genes, called PKD1/TSC2 contiguous gene deletion syndrome (CGS) at our institution. Of 231 PKD patients with removal of kidney tissue, 11.3% had renal neoplasia, and two patients with angiomyolipoma tumors had PKD1/TSC2 CGS. Detection of renal neoplasia associated with a condition called tuberous sclerosis complex in PKD may increase the identification of patients with PKD1/TSC2 CGS and guide patient counseling regarding outcomes and patterns of inheritance.
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Angiomiolipoma , Neoplasias Renais , Doenças Renais Policísticas , Canais de Cátion TRPP/genética , Proteína 2 do Complexo Esclerose Tuberosa/genética , Esclerose Tuberosa , Angiomiolipoma/complicações , Angiomiolipoma/genética , Feminino , Deleção de Genes , Humanos , Neoplasias Renais/complicações , Neoplasias Renais/genética , Masculino , Doenças Renais Policísticas/complicações , Doenças Renais Policísticas/genética , Esclerose Tuberosa/complicações , Esclerose Tuberosa/diagnóstico , Esclerose Tuberosa/genéticaRESUMO
BACKGROUND: Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics. OBJECTIVE: To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS). DESIGN, SETTING, AND PARTICIPANTS: Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation. RESULTS AND LIMITATIONS: The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m2, estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume. CONCLUSIONS: We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs. PATIENT SUMMARY: We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.
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Carcinoma de Células Renais , Neoplasias Renais , Adulto , Carcinoma de Células Renais/cirurgia , Técnicas de Apoio para a Decisão , Humanos , Neoplasias Renais/cirurgia , Masculino , Nefrectomia/métodos , Medicina de Precisão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: The optimal management approach for synchronous bilateral renal masses is unknown, particularly regarding surgical sequencing of bilateral partial nephrectomy (PN). We evaluated the impact of simultaneous vs. staged bilateral PN on renal functional, perioperative, and oncologic outcomes. PATIENTS AND METHODS: We reviewed our institutional nephrectomy registry to identify patients who underwent simultaneous or staged (within 6 months) bilateral PN for nonmetastatic bilateral synchronous solid renal masses between 1980 and 2015. Short-term and long-term renal function changes were assessed at 3 and 12 months, respectively. Perioperative outcomes were pooled across staged surgeries by taking the sum of each outcome. Local recurrence-free, distant metastases-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier method. Outcomes were compared by surgical sequencing approach. A sensitivity analysis was performed that grouped approaches by preoperative intent. RESULTS: Among the 107 patients studied, 77 (72%) underwent simultaneous and 30 (28%) underwent staged PN. The majority of PN were performed by open approach. Clinicopathologic features were similar between groups. Patients who underwent simultaneous PN had lower mean short-term (-6% vs. -24%, Pâ¯=â¯0.015) and median long-term (-4% vs. -22%, P < 0.001) reduction in eGFR vs. staged PN, respectively. Furthermore, patients with simultaneous PN had lower pooled length of stay (median 6 vs. 8 days, P < 0.001), rate of urine leak (3% vs. 17%, Pâ¯=â¯0.018), and rate of high-grade complications (8% vs. 23%, Pâ¯=â¯0.044), relative to staged PN, respectively. However, on sensitivity analysis, only differences in long term reduction in estimated glomerular filtration rate and length of stay remained. There were no significant differences in oncologic outcomes between groups. CONCLUSIONS: Our results suggest that when technically feasible, simultaneous PN yields comparable outcomes vs. staged PN, offering a reasonable surgical sequencing approach for patients presenting with bilateral synchronous renal masses.
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Neoplasias Renais/cirurgia , Nefrectomia/métodos , Feminino , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: Previous studies noted discordance of programmed death-1 (PD-1) and one of its ligands (PD-L1) across patient-matched primary and metastatic clear cell renal cell carcinoma (ccRCC). There are inconsistencies if the primary or metastatic tumor has higher expression, and whether metastatic tumor expression is associated with patient outcome. Thus, we examined PD-1 and PD-L1 in patient-matched tumors using a large number of ccRCC patients with long follow-up. MATERIALS AND METHODS: We analyzed PD-1 and PD-L1 using immunohistochemistry in patient-matched primary and metastatic tumors from 110 ccRCC patients. Concordance was assessed among longitudinal metastatic tumors, as well as across patient-matched primary and metastatic tumors. Cox proportional hazards regression was used to evaluate the associations of metastatic tumor expression with cancer-specific survival. RESULTS: We observed inter-metastatic tumor heterogeneity of PD-1 in 25 (69%) of the 36 patients and of PD-L1 in seven (19%) patients. Concordance between patient-matched primary and metastatic tumors was 73% (Kappa = 0.16, 95% CI: -0.003-0.32). Similarly, concordance of PD-L1 between metastatic and patient-matched primary tumors was 78% (Kappa = 0.27, 95% CI: 0.09-0.46). Both markers demonstrated higher expression in primary vs metastatic tumors. Metastatic tumor expression of PD-1 was significantly associated with metastatic location (P < .0001) and ccRCC-specific survival (HR = 2.15, 95% CI: 1.06-4.36, P = .035). CONCLUSIONS: The expression of PD-1 and PD-L1 is discordant across patient-matched ccRCC tumors, with higher expression in primary tumors. Higher PD-1 expression was associated with metastatic location and lower cancer-specific survival. If validated, these results highlight the importance of evaluating these biomarkers in metastatic tissue specifically.
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Antígeno B7-H1/genética , Biomarcadores Tumorais/genética , Carcinoma de Células Renais/genética , Neoplasias Renais/genética , Receptor de Morte Celular Programada 1/genética , Adulto , Idoso , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Feminino , Regulação Neoplásica da Expressão Gênica , Heterogeneidade Genética , Humanos , Estimativa de Kaplan-Meier , Rim/patologia , Rim/cirurgia , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Metastasectomia , Pessoa de Meia-Idade , Nefrectomia , Análise de SobrevidaRESUMO
OBJECTIVES: Although statins have been found to induce apoptosis and demonstrate antimetastases activity both in vitro and in vivo for renal cell carcinoma (RCC), clinical evidence of a role for these medications is limited. We evaluated the association of statin therapy with outcomes among patients with surgically treated localized RCC. METHODS AND MATERIALS: We reviewed 2,357 patients who underwent nephrectomy between 1995 and 2009 for pNx/0, M0 RCC. Of these, 630 (27%) were taking statins within 3 months of surgery. Progression-free survival, cancer-specific survival, and overall survival were estimated using the Kaplan-Meier method. The associations of statin use with clinicopathologic outcomes were evaluated with multivariable logistic and proportional hazards regression models. RESULTS: Statin therapy at the time of nephrectomy was not significantly associated with the risks of locally advanced (pT3-4) pathologic tumor stage (odds ratio = 0.96; P = 0.80) or high (3-4) tumor grade (odds ratio = 1.11; P = 0.30). Median postoperative follow-up was 7.8 years. Compared with patients not on statin therapy, patients taking statins at surgery had similar 10-year progression-free survival (80% vs. 79%; P = 0.56), cancer-specific survival (85% vs. 84%; P = 0.71), and overall survival (59% vs. 64%; P = 0.11). On multivariable analysis, statin use was not significantly associated with the risks of disease progression (hazard ratio [HR] = 1.22; P = 0.10), death from RCC (HR = 1.02; P = 0.90), or all-cause mortality (HR = 0.84; P = 0.05). CONCLUSIONS: We found no independent association between preoperative statin therapy and oncologic outcomes among patients with surgically treated localized RCC. Our data thus do not support an anticancer role for statin therapy in this setting.
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Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/patologia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Neoplasias Renais/patologia , Idoso , Carcinoma de Células Renais/cirurgia , Feminino , Humanos , Hipercolesterolemia/tratamento farmacológico , Estimativa de Kaplan-Meier , Neoplasias Renais/mortalidade , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , NefrectomiaRESUMO
OBJECTIVES: Determining clinicopathologic features that stratify the risk of disease progression in patients with seminal vesicle invasion at radical prostatectomy remains critical for patient counseling, clinical trial enrollment, and the judicious application of secondary therapies. Then, we evaluated the prognostic significance of concomitant extracapsular extension (ECE) in patients with seminal vesicle invasion and negative lymph nodes at radical prostatectomy. METHODS: We identified 1,132 patients who underwent prostatectomy between 1987 and 2009 and were found to have pT3bN0 disease. Median postoperative follow-up was 10.6 years (interquartile range, 5.9-15.3). Survival was estimated using the Kaplan-Meier method and compared for patients with and without ECE with the log-rank test. The association of ECE with outcome was evaluated using Cox proportional hazards regression models. RESULTS: A total of 693 (61%) patients were noted to have ECE. Compared with pT3bN0 patients without ECE, patients with pT3bN0 tumors and ECE had a significantly worse 15-year biochemical recurrence-free survival (29% vs. 39%; P<0.001), systemic progression-free survival (71% vs. 81%; P<0.001), cancer-specific survival (80% vs. 89%; P<0.001), and overall survival (50% vs. 63%; P<0.001). On multivariate analysis, the presence of ECE was associated with significantly increased risks of systemic progression (hazard ratio [HR], 1.56; P=0.006), death from prostate cancer (HR, 1.71; P=0.01), and all-cause mortality (HR, 1.35; P=0.007). Meanwhile, adjuvant hormonal therapy, which was received by 334 patients (29.5%), was associated with significantly decreased risks of systemic progression (HR, 0.50; P=0.0004) and cancer death (HR, 0.57; P=0.03), but not all-cause mortality (HR, 0.81; P=0.09). Limitations included retrospective design and nonstandardized application of secondary treatments. CONCLUSIONS: The presence of ECE in patients with pT3bN0 prostate cancer is associated with increased risks of systemic progression and cancer death. Pending validation, ECE may be incorporated into risk stratification or staging classification or both. Meanwhile, these patients continue to represent ideal candidates for adjuvant therapy trials.
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Linfonodos/patologia , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Glândulas Seminais/patologia , Idoso , Progressão da Doença , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática/patologia , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Prognóstico , Modelos de Riscos Proporcionais , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Micropapillary urothelial carcinoma exhibits amplification of the human epidermal growth factor receptor, ERBB2(HER2), and overexpression of the ERBB2 protein product. The clinical significance of this has yet to be established. The objective of this study was to examine ERBB2 amplification and protein expression in micropapillary urothelial carcinoma and stage-matched typical urothelial carcinoma treated by radical cystectomy to assess the frequency of amplification and protein expression, and to determine the association with cancer-specific survival. Pathologic material and data from patients undergoing cystectomy at Mayo Clinic between 1980 and 2008 were reviewed. ERBB2 amplification by fluorescence in situ hybridization (FISH) and protein expression by immunohistochemistry were assessed. Univariate and multivariate Cox proportional hazards regression models were used to evaluate for associations of ERBB2 amplification and protein expression with survival. ERBB2 amplification was identified in 9 (15%) of 61 micropapillary carcinomas compared with 9 (9%) of 100 urothelial carcinomas. In patients with micropapillary carcinoma, ERBB2 amplification was associated with a nearly threefold increased risk of cancer death. ERBB2 amplification (hazard ratio 4.3; P=0.0008) remained associated with an increased risk of death from bladder cancer among patients with micropapillary urothelial carcinoma on multivariate analysis. The association of cancer-specific survival and ERBB2 amplification was not seen in patients with urothelial carcinoma. ERBB2 immunohistochemistry correlated with ERBB2 amplification but there was no association of ERBB2 protein expression and survival. ERBB2 amplification is more frequent in micropapillary urothelial carcinoma than typical urothelial carcinoma, and patients with micropapillary carcinoma who have ERBB2 amplification have worse cancer-specific survival than those who do not. Identification of ERBB2 amplification in micropapillary carcinoma could provide important prognostic information and possibly provide a role for ERBB2 targeted therapy.
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Carcinoma Papilar/cirurgia , Carcinoma de Células de Transição/cirurgia , Amplificação de Genes , Receptor ErbB-2/genética , Neoplasias da Bexiga Urinária/cirurgia , Urotélio/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Papilar/genética , Carcinoma Papilar/patologia , Carcinoma de Células de Transição/genética , Carcinoma de Células de Transição/patologia , Cistectomia , Feminino , Humanos , Hibridização in Situ Fluorescente , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento , Neoplasias da Bexiga Urinária/genética , Neoplasias da Bexiga Urinária/patologiaRESUMO
BACKGROUND: In a previous study of gene array data, the authors identified survivin as a candidate marker of aggressiveness in clear cell renal cell carcinoma (ccRCC). What remained in question was whether survivin expression at the protein level is an independent predictor of disease progression and cancer-specific survival. METHODS: Between 1990 and 1994, 312 patients underwent nephrectomy for ccRCC at Mayo Clinic Rochester and had paraffin tissue available. The authors performed immunohistochemistry with antisurvivin antibody, quantitated the expression by using an image-analysis system, and analyzed the association of survivin expression with disease progression and cancer-specific survival. RESULTS: Within the cohort, 97 patients (31.1%) had high levels of survivin expression. Patients who had high survivin expression levels were at significantly increased risk of death from RCC compared with patients who had low expression levels (risk ratio [RR], 5.3; 95% confidence interval [95% CI], 3.5-7.9). The 5-year cancer-specific survival rate was 43.0% for patients with high survivin expression and 87.2% for patients with low survivin expression. In multivariate analysis, survivin expression remained associated with death from RCC even after adjusting for the Eastern Cooperative Oncology Group performance status; 2002 Tumor, Lymph Node, Metastases (TNM) stage groupings and nuclear grade (RR, 2.4; 95%CI, 1.5-3.8); and the Mayo Clinic composite TNM stage groupings, tumor size, nuclear grade, and tumor necrosis (SSIGN) score (RR, 1.8; 95%CI, 1.1-2.9). Among 273 patients who had localized ccRCC, survivin expression was associated significantly with cancer progression (RR, 3.9; 95%CI, 2.4-6.2). CONCLUSIONS: Survivin expression is an independent predictor of ccRCC progression and death from RCC. Thus, survivin has the potential to offer additional prognostic information and to provide a novel target for the development of new adjuvant therapies.