The prognostic factors of renal cell carcinoma
PhD Thesis
Dr. Attila Szendrői
Semmelweis University School of Doctoral Studies
Program Leader:
Prof. Dr. Imre Romics, DSc, Chair of the Urological Department, Semmelweis University
Opponents:
Dr. Ferenc Mády, senior assistant professor, Ph.D.
Dr. Zoltán Bajory, associate professor, Ph.D.
Chairman of the Examination Board:
Prof. Dr. Anna Kádár, Professor emeritus, DSc
Members of the Examination Board:
Dr. Miklós Merksz, chief medical physician, Ph.D.
Dr. Szabolcs Várbíró, associate professor, Ph.D.
Budapest
2009.
Introduction
The most common malignant tumor which originates from the renal parenchyma is the renal clear cell carcinoma stemming from the renal proximal tubules. In addition, this disease takes 3% of all malignant tumors and it is the third most common urogenital carcinoma.
50,000 new patients and 12,000 deaths due to this disease are detected yearly in the U.S. As for Hungary, the incidence has the third-highest rate from all the countries of the world and unlike in the other developed countries, the frequency of the disease does not decrease, namely, 2000 new cases and 700 deaths are observed yearly. With the technical development and the wide spread of the imaging techniques, the symptom-free renal carcinomas can be detected in an earlier stage; moreover, they are often discovered incidentally. Therefore, the classical triad – haematuria, palpable abdominal mass and flank pain - are being experienced in fewer cases. However, this is not the only case reasoning the increase of the incidence: the number of the advanced cases and the mortality with specificity to the disease do not decrease significantly.
Due to some of public health and economical importance, the clinical factors affecting the life expectancy of the patients with renal tumors and the outcomes of their disease are currently on the focus of the international research. If the prognoses can more accurately be determined when the disease has just been diagnosed, many expensive investigations and treatments with possible side effects and complications could hereby be avoidable, furthermore, that group of patients could be determined in which patients might benefit from this diagnostic and therapeutic methods. Some authors proposed that the symptom caused by renal tumors is an independent prognostic factor beside the other clinical factors (stage, Fuhrman grade, general condition of the patient etc.) which have influence on the prognosis and influences the disease specific survival in a negative way. The clinical importance of the symptoms caused by the tumor is concerned in the first half of our thesis.
As the renal carcinoma is first diagnosed, one-third of the patients have distant metastases, and further one-third also developed metastases after nephrectomy. Regarding the metastases, they are usually formed in the lungs (55%), liver, bones (30-30%) and rarely do they occur in the other kidney, suprarenal glands, brain or in the retroperitoneal lymphatic glands.
The occurrence of the bone metastases could be regarded as a bad prognostic sign since the average life expectances of the patients is only 12 months in this case; however, surprisingly long survival is experienced in certain cases. The first successful surgical treatment of the renal clear cell carcinoma with solitary pulmonary metastases is reported by
Barney in 1939, following the surgery, a 23-year disease-free survival was noticed.
Afterwards, the surgical treatment of the bone metastasis of the renal carcinoma was brought into practice owning to the lack of any other efficient treatments (chemotherapy or radiotherapy). However, several discrepancies exist relating to the surgical indication and techniques. Some authors prefer the palliative surgeries because the illness often becomes disseminated and because of the probable bad life expectances, while others would prefer the radical surgeries with narrow indications based on the long survival of some patients . In the other half of our thesis, we attempted to investigate the factors influencing the survival of the patients of renal carcinoma with bone metastases and to determine the patients in who radical surgery must be performed due to their longer life expectances.
Aims
The investigations of our workgroup dealing with renal clear cell carcinoma are based on two different research on two different groups of patients. During the first research, the symptoms caused by primary renal carcinoma and other factors influencing the outcomes of the patients are investigated. While the other research consisted of the examination on the prognostic factors in the case of patients with bone metastases. According to the different experimental groups and experimental structure, the research results will separately be presented concerning the aims, the methods and results parts of the thesis.
A: We aimed at preparing our examination on the symptoms caused by the primary renal carcinoma and on the other clinical factors influencing the outcomes of the patients. During these, the followings were to be answered:
1. Do the symptoms caused by the renal carcinoma influence the survival apart from other prognostic factors?
2. With what kind of symptoms did the patients consult a doctor? What kinds of symptoms were neglected?
3. Do the characteristics of the symptoms or their local or systemic being show any correlation with the survival of the patients?
4. Is the presence of the symptoms in correlation with the intraoperative surgical complications?
With the above mentioned queries we aimed at getting answers to the correlation with more importance between the symptoms caused by the disease which is available in everyday practice and the disease-process. The main significance of this could be the fact that no study has been carried out yet in Hungary concerning the symptoms of the patients. Moreover, even the international data have a lack of information referring to those symptoms with which the patient neglected and to the relationship between the symptoms and the surgical complications.
B: Furthermore, we determined the prognostic factors characterizing the patients, the primary renal tumor as well as the bone metastases. The following questions were to be answered:
1. Do the age and gender of the patients with bone metastases influence the survival?
The renal carcinoma occurs twice frequently in the case of men. The reasons for that could be the environmental effects which might be derived from the different lifestyles and smoking habits; moreover, the different genetic store can also be a motif. Does the gender have a real influence on the outcome of the disease?
2. How do the well-known prognostic factors of the primary renal carcinomas (stage, grade) influence the survival of the patients in the case of detectable bone metastases? The stage and grade are considered as the most influential renal carcinoma prognostic factors. Are the survivals of the patients with bone metastases really influenced by the factors of the primary tumor, or at this time the outcome of the disease is primarily affected by the features of the metastasis?
3. What kind of correlation exists between the Fuhrman grades of the renal carcinoma and the Fuhrman grades of the bone metastases?
4. How is the survival affected by the following clinical and histopathological features of the bone metastases?
• The onset time of the metastasis compared to the nephrectomy,
• the presence or absence of the symptoms caused by the metastasis,
• the way of the metastasis detection,
• the localization of the metastasis in the bone system,
• the largest diameter of the metastasis,
• the spread of metastasis to the soft tissue,
• the Fuhrman grade of the metastasis,
• the solitary or multiplex being of the metastasis,
• the existence or lack of pathologic fracture,
• the presence or absence of extraskeletal metastases in the case of multiplex metastases 5. Do the radicalism of the surgery determine the survival of the patients?
The main significance of the above mentioned points cannot only be characterized by the fact that the prognostic roles of the listed factors are found to be inconsistent (e.g. the spread to the soft tissue, pathological fracture) but by the possibilities we had with the usage of multivariate analysis, namely the factors influencing the survival as an independent variable could be selected among the many closely correlative factors.
Methods
To perform our aims, we have carried out two clinical examinations. The surgeries of primary renal cancers were performed mostly at Urological Department of Semmelweis University, whereas the surgeries of bone metastases were carried out at Orthopedical Department of Semmelweis University. The postoperative oncological treatment of the participating patients took place at the Urooncological Center of Semmelweis University As for the histology investigations, they were carried out at the 2nd Pathological Institute of Semmelweis University.
The methods of the comparison of the symptoms caused by the primary renal carcinoma and the clinical factors which influence the outcomes of the patients
Between 1997 and 2002 363 patients were admitted to the Urological Department of Semmelweis University with the purposes of surgically treatment of the renal clear cell carcinoma. 226 of the patients were men and 137 of them were women, moreover, the average age was 61 (27-87 years). During the investigations the followings were abstracted based on the medical documentation: the medical history and admission symptoms which may be in relation with the disease, operative descriptions, and medical reports from the laboratories and from the medical check up.
The patients were categorized into three groups based on their complaints. Group X contained the symptom-free patients (200 patients, 55.3%), group Y included those whose disease were diagnosed incidentally during a check up of other medical examinations, however, their symptoms, which were detected at the admission, were in correlation with the renal carcinoma (59 patients, 16.1%). Furthermore, the patients who consulted a doctor because of their complaints concerning their tumors were categorized into the Z group (104 patients, 28.6%)
The symptoms characterizing the renal carcinoma were also divided into three groups:
• local symptoms (hematuria, palpable abdominal mass, abdominal and flank pain, varicocele on the same side, swelling in the lower limbs) (31.8%),
• systemic symptoms (fever, losing weight, paraneoplastic skin symptoms, anemia, polyglobulia, hypocalcaemia, thrombocytosis, neuromyopathia, elevated values of the liver enzymes) (7.7%)
• symptoms caused by the metastases (hemoptysis, pain in the bones, pathologic fractures, epilepsy) (6%).
The histological results of the removed tumors were evaluated according to the WHO system issued in 2004 while the TNM grading was applied to determine the stage. Regarding the size of the tumor, it was considered as the diameter specified by the pathologist; the grade of the cells was characterized in accordance with Fuhrman.
On one hand, the bleeding exceeded 200 ml, the injury of the surrounding organs (e.g.
liver, spleen) and any other events unexpected during the surgeries were classified as intraoperative complications. On the other hand, every deviation which occurred min. 1 month following the surgery (e.g. bleeding exceeded 200 ml, fever, inconvenience in the wound healing, azotaemia) were regarded as postoperative complications.
If it was technically implementable, the palliative removal of the tumorous kidney was also carried out in the presence of metastases. Moreover, if the metastasis was solitary and resectable, they were also removed with the cooperation of other surgical fields.
The monitoring and the oncological treatment of the patients were performed by the Urooncological Center of the Urological Department of Semmelweis University in accordance with the European guidelines. In order to ensure the entirety of the monitoring, during the calculation of survival data not only our outdoor patient recordings were utilized but also the data gotten from the Central Data Processing System of the Home Office were also applied.
For the descriptive statistics, the continuous variables were given in the form of average ± standard deviation (SD) while the categorical variables were quoted as percents.
Firstly, group Y and Z were compared with the utilization of two-sample t-test and khi2 test, namely, it was assumed that the behavior of the two groups are the same. Subsequently, these two groups were collapsed since no significant difference was detected. Therefore, the data of the groups with symptoms (group Y and Z together) were further compared with univariant tests (t-test and khi2 test). To determine the parameters showing correlations and independency of the symptoms caused by the tumors, multiple logistic regression was utilized in our former analysis with the usage of the variables which showed P<0.1 correlations (outcome index – the presence of the symptoms). Provided it was necessary, one part of the continuous variables was log-transformed. The correlation between the survival and the symptoms were analyzed with the usage of the survival curve according to Kaplan-Meier (log-rank test). The results are introduced as probabilities and as 95% confidence interval.
P<0.05 were generally considered as significant. The statistical evaluation was carried out with the usage of SPSS 13.0 for Windows.
The methods of prognostic investigations of the patients with bone metastases
In the course of our retrospective investigations, between 1990 and 2008 the data of 65 patients who were treated for their bone metastasis of renal clear cell carcinoma at the Orthopedic Department of Semmelweis University were analyzed. As for the majority of the patients’ renal surgeries, they were carried out at the Urological Department of Semmelweis University and their oncological treatment and follow-up were performed by the Urooncological Center which operates in the frameworks of the Urological Department. The patients with vertebral metastases were excluded from the survey. The average age of the patients referring to the date of the surgery was 61.1 years (34-79), and the distribution between the genders was: 50 men and 15 women.
Following the nephrectomy, in the case of 33 patients (50.8%, group A) the radical removal of the solitary metastases was carried out. Concerning those 7 cases when the metastases were not locally and entirely removable, intralesional resection or excochleation were made with the utilization of bone cement (10.8%, group B). In the further 10 cases the metastasis, however, was locally and radically removed, there had also been detectable metastasis somewhere else at the time of the surgery (15.4%, group C). Furthermore, in 15 cases the bone metastases were not removed owing to the poor general condition of the patients or to the short life expectancies, only histological sampling and to ease the mobility, the fixation of tumorous bone (transfocal fixation) were done (23.0%, group D).
A qualified pathologist has retrospectively controlled the histological diagnosis, the Fuhrman grades and stages of the primary tumors as well as metastases. The clinical data were collected according to the categorizations of medical documentation and the results of the imaging examinations. Had the survival data not been available in the outpatient documentation, the patients or their relatives were asked on phone, via mail or the Central Data Processing System of the Home Office was also applied. The survival data were analyzed in comparison with both the renal and the bone surgery. Our examinations were approved by the Scientific and Experiment Ethics Committee of Semmelweis University (TUKEB No.: 185/2007).
In the case of the continuous variables, in the descriptive statistical part the results were characterized with the usage of the number of elements, the average and the standard deviation; moreover, the results were controlled by Levene’s test. In the frameworks of the statistical investigations, ANOVA test was applied to the one variable variance check and Kuskal-Wallis ANOVA test was utilized with an amendment of Tukey test to the non- parametric variables. When the average values showed significant differences, their multiple
variable comparative check had also been done. In the case of categorical variables, contingence test and ML khi2 test were performed and in the case of small number of elements Fisher test was used to investigate the interactions. The survival intervals were analyzed with the help of Life table. The cumulative survival curves were examined with Kaplan-Meier method and their statistical analysis (paired comparison and trend analysis) required log-rank test. Moreover, Cox analysis was used to determine the independent prognostic factors. The differences were considered as significant in the case of P<0.05. The statistical evaluation required SAS (SAS/STAT, Software Release 9.1.3., SAS Institute Inc., and Cary, North Carolina 27513, USA) software.
Results
The prognostic importance of symptoms caused by the primary renal carcinoma
The comparative examination of the Y group (whose tumors were detected during imaging examinations performed for other reasons, but symptoms which are characteristic of the renal carcinoma were mentioned at the admission) verified that losing weight occurred significantly more often (p<0.0001); moreover the flank pain appeared almost significantly (p=0.063) often in group Y, and the symptoms caused by the metastases appeared in group Z significantly (p=0.001) more often. Regarding the other examined parameters, we observed no differences between this two groups of patients, therefore they had been collapsed. Thus, subsequently they are cited as the group with symptoms (Y+Z) and the symptom-free group (X).
As an examined parameter, the symptom did not show any relation with the gender as well as the age of the patients, with the fact whether the tumor originated from the right or the left kidney, in which area of the kidney the tumor located, what kind of surgical intervention was applied and in which histological group the removed tumor belonged to. Although, in the group with symptoms the nephron sparing surgery was rarely applied, complications during the operations were more frequently taken place, the stage and grade values were higher, the diameter of the tumors were also bigger, there were more patients with metastases and the postoperative survival of the patients were unfavorable as well.
According to our logistic regression results, the symptoms caused by the carcinoma showed independent correlation with the presence of the metastasis (p=0.002), with the stage of the tumor (p=0.001) and with the intraoperative complications (p=0.046).
The risk of the mortality was the less in the symptom-free group (24.7%), the higher in the case of the local symptoms (30.6%) even higher in the occurrence of the systemic symptoms (36.0%) and the highest in the case of the complaints caused by the metastases (70.0%; trend p<0.0001).
The factors which influence the survival of the patients of renal carcinoma with bone metastases
Based on he results of the Kaplan-Meier investigations we got the following relations as results:
• Neither the age nor the gender of the patients as factors characterizing the patients influenced the cumulative survival after the renal surgery (p=0.9430; p=0.3592) and after the bone surgery (p=0.6162; p=0.6913)
• The stage and the Fuhrman grade of the primary renal tumors affected the survival neither after the bone nor following the renal surgery. (In the case of the examination of the survival after the renal surgery the stage of primary tumor was 1/2:
p=0.2110, 1/3: p=0.7468, 2/3: p=0.1988; in the case of the investigation of the survival after the bone surgery the stage of primary tumor 1/2: p=0.0988, 1/3:
p=0.6964, 2/3: p=0.1422; Fuhrman grade 1+2/3+4 after the renal surgery: p= 0.8984 and following the bone surgery: p= 0.5634).
• From the examined factors of the bone metastasis the correlation between the time passed from the nephrectomy to the detection of the bone metastasis and the survival: the bone metastasis was detected at the same time with the renal tumor in two–third of the cases (43 cases, 66.1%), in the case of 22 patients (33.9%) average of 2.1±4.5 years (0.5-19 years) after the renal tumor surgery. Comparing the survival of the patients with the onset time of metastasis after renal surgery, we found that significantly longer survival can be detected in the case of the patients with late metachrone metastasis (occurrence more than 4 years after renal surgery) than in the synchronic cases (occurrence at the same time or in half year after the renal operation) (p=0.0001) and in the patients with early metachrone metastasis (more than half year but in 4 years after renal surgery) (p=0.0213). There were no detectable difference between the synchron and early metachron groups (p=0.2453). Should we consider the survival from the operation time of the bone metastasis, no significant difference could be detected between the three investigated groups (p=0.5001; p=0.0949;
p=0.2161). When the more homogenous group of patients with radical surgeries of their solitary bone metastases were examined in order to exclude the other factors which essentially influence the survival such as the multiplicity and the surgical radicalism. Concerning this case, we had got the above presented correlation.
• The symptoms caused by the metastasis were local in 85.7% of the cases and systemic in 14.3%. However, in the case of the systemic symptoms shorter survival could be
detected, nothing could be concluded in all details because of the small number of the patients with systemic symptoms.
• Pathological fracture occurred in 40 cases (61.5%) while the bone metastasis spread into the soft tissue in 7 cases (10.7%). Neither the pathological fracture nor the tumors invading the soft tissue influenced the survival in accordance with the orthopedic surgery (p=0.6518; p=0.2282) or with the nephrectomy (p=0.5170;
p=0.9981). In the case of the above mentioned relation is carried out regarding only the patients who had their solitary bone metastases radically removed, we got the same results.
• The average diameter of the bone metastases was 9.3±7.4 cm (3-20cm) according to the pathological description. The survival after neither the bone nor the renal surgery showed any correlations with the size of the metastases. (p=0.8777; p=0.7967) When the comparison above was only carried out in patients undergoing radical surgery with solitary metastasis, we got the same correlations (p=0.6583; p=0.8620).
• At the time of the orthopedic surgery 40 patients (61.6%) has solitary and 25 had (38.4%) multiplex metastases. Comparing the solitary metastases to multiplex metastases, we experienced longer survival after the bone surgeries (solitary/multiplex bone: p=0.0462; solitary/multiplex extraossealis: p=0.0028;
multiplex bone/multiplex extraossealis: p=0.4429), and after the renal surgery (solitary/ multiplex bone: p=0.0452; solitary/ multiplex extraossealis: p=0.0191;
multiplex bone/ multiplex extraossealis: p=0.1125). Concerning either of the cases, the survival was not influenced by the extraossealis (multiorganic) or skeletal only location of the multiplex metastasis.
• Regarding their locations, the metastases were occurred axially (on the bones of the shoulder girdle and the pelvis, vertebra and sacrum are excluded) in 10 cases (15.4%), in 55 other cases (84.6%) they formed on the limbs, primarily on the long tubular bones; moreover in only few cases they were tangential to the metacarpus of the hand and to the ankle. The location inside the osseous system showed correlation with the survival neither after renal (p=0.1787) nor after the bone surgeries (p=0.4786). When the more homogenous group of patients with radical surgeries of their solitary bone metastases were examined no correlation was detected between the localization and the survival, either (p=0.5294; p=0.4836).
• According to their radicalism, the orthopedic surgeries were categorized into the following groups: group A: radical resection of the solitary metastasis, group B:
intralesional removal of the solitary metastasis, group C: locally radical resection in
the cases of multiplex metastases, group D: transfocal fixation or biopsy in the case of multiplex metastases. Based on the above presented distribution, significantly longer survival was detected in the case of the patients who had radical surgeries of their solitary metastases (group A) while regarding the other surgeries (B, C and D groups of patients) the survivals does not significantly differ. (D/A: p: 0.0017; B/A:
p=0.0479; C/A: p=0.0459; D/B: p=0.3288; D/C: p=0.0251; B/C: p=0.0395). For the investigations of the survival after the renal surgery, in the case of distant metastasis the survival of the patients who had local radical surgery (group C) increases and the significant difference compared to group A disappears. (D/A: p:0.0010; B/A:
p=0.0275; C/A: p=0.4712; D/B: p=0.3134; D/C: p=0.0107; B/C: p=0.4003)
• Both after the renal (p=0.0475) and the bone surgeries (p=0.0336) the survival of the patients showed close relation with the Fuhrman grade of the metastasis in contrast with those which were experienced in the case of the primary tumors.
• When the Fuhrman grades of the primary tumor and the bone metastasis were compared, concerning the bone metastases in 29.5% lower grades, in 44.0% higher grades and in 26.5% the same grades were found.
• By applying Cox regression we concluded that from the examined variables (gender, age, symptoms, localization of the metastasis in the skeletal system, size, multiplicity, date of the recognition, presence of pathological fracture or spreading into the soft tissue, the type of the applied surgery, the stage , the Fuhrman grade of the primary tumor and the Fuhrman grade of the bone metastasis) the multiplicity as well as the Fuhrman grade of the metastasis and the type of the applied surgery is considered as factors which significantly affect the survival after the bone surgery. As for the survival after the renal surgery, the multiplicities as well as the Fuhrman grade of the bone metastases and the onset time after renal surgery were the influential factors independently of the other variables.
• In the case of the radical removal of the solitary metastasis 35.5% of the patients survived the fifth postoperative year. Nobody survive the fifth postoperative year when the metastasis was multiple or the surgery was not radical.
Consequences
• The symptoms caused by the primary renal cell carcinoma, primarily the losing weight, the flank and abdominal pain are often neglected as the sign of a malignant disease.
• The symptoms caused by the renal cell carcinoma; however, show correlation with the size, the stage and the grade of the tumor, influence negatively the survival of the patients independently of the above mentioned prognostic factors.
• The characteristic of the symptom essentially correlates the survival (local, systemic or metastases related symptoms)
• The frequency of the surgical complications was influenced by the symptoms caused by the renal clear cell carcinoma independently of the size, the stage the grade and the other investigated prognostic parameters of the tumor. As far as we know, this correlation has never been examined previously.
• The outcome of the disease in the case of renal clear cell carcinoma with bone metastasis is independent of the examined typical factors of the patients, the age and the gender.
• The outcome of the disease in the case of renal clear cell carcinoma with bone metastasis is independent of the examined features of the primary tumor, its stage and Fuhrman grade.
• In the case of renal clear cell carcinoma with bone metastasis the prognosis is not influenced by the following clinical factors which are characteristic of the metastases:
the symptoms caused by the metastases, the size of the metastasis, its location in the skeletal system (patients with vertebral and sacrum metastases were not examined), its spread into soft tissue and its causing pathological fracture. The presence of extraskeletal metastasis does not depreciate the survival, in the case of multiple metastases.
• In the case of renal cell carcinoma with bone metastasis the prognosis is primarily dependent on the multiplicity of metastases as clinical factor, and on the Fuhrman grade of the bone metastasis as a histopathological factor. As far as we know, we have published first the latter correlation.
• The surgical radicalism was also regarded as a factor which influences the prognosis (which is independent of the stage and of the other examined factors of the tumor) However, the above mentioned factors (multiplicity, radicalism and the Fuhrman grade of the metastasis) have an influence on each other; they can be considered as independent prognostic factors.
• The Fuhrman grade of the primary tumor and the Fuhrman grade of the bone metastasis showed a deviation of 73.5%.
• Should the general condition and comorbidities of the patient allow and his metastasis is surgically removable entirely, it is suggested to choose the radical surgery based on the better expectations of life quality and possible longer survival.
• In the case of surgically not removable or multiplex bone metastasis minimal invasive surgery, transfocal stabilization and biopsy for histological confirmation is suggested since the life expectancy is short, and there is no use having the risk and complications of the radical surgery.
Bibliography of the author
Articles published in the topic of the thesis
1. Szendrői A, Rusz A, Riesz P, Székely E, Kelemen Zs. (2003) Renal tumor causing haematuria and sepsis. Pathol Oncol Res, 9(4):246-248.
2. Szendrői A, Székely E, Riesz P, Romics I. (2003) Vesedaganat kezelése klinikánkon.
M Urol, 15(4):224-232
3. Szendrői A, Rusz A, Riesz P, Székely E, Kelemen Zs. (2004) Terhesség alatti vérvizelést, gyermekágyban szeptikus állapotot okozó vesetumor esete. Uroonkológia, 1(2):46-48.
4. Szendrői A, Antal I, Riesz P, Szendrői M, Romics I. (2004) Vesedaganat csontáttétjének műtéti kezelése. Magy Urol, 16(1):9-17.
5. Szendrői A, Nagy Z, Pánovics J, Harsányi L, Szűcs M, Hamvas A, Romics I. (2007) Vesetumor miatt végzett radikális nephrectomia és cava inferior thrombectomia. Magy Urol, 19(1):19-25.
6. Szendrői A, Tabák A, Riesz P, Szűcs M, Nyirády P, Majoros A, Haas G, Romics I (2009) Clinical symptoms related to renal cell carcinoma are independent prognostic factors for intraoperative complications and overall survival.
Int Urol Nephrol. Ahead of print, DOI: 10.1007/s11255-009-9539-8 IF: 0,912
7. Szendrői A., Dinya E., Kardos M., Szász AM., Németh Z., Ats K., Kiss J., Antal I., Romics I., Szendrői M. (2009) Prognostic Factors and Survival of Renal Clear Cell Carcinoma Patients with Bone Metastases.
Pathol Oncol Res, Ahead of print, DOI: 10.1007/s12253-009-9184-7 IF: 1,260
Abstract cited in the topic of the thesis
1. Szendrői A, Riesz P, Romics I. (2000) Veserákos betegek klinikánk anyagában. Uro- onkológiai Továbbképző Szeminárium, Tihany, 2000 jún. 1-3.
2. Szendrői A. (2003) Terhesség alatti vérvizelés differenciáldiagnosztikája. Magyar Urológusok Társaságának XII. Kongresszusa, Szeged, 2003 szept. 11-13.
3. Szendrői A, Szűcs M, Székely E, Kelemen Zs, Romics I. (2004) Renal tumor causing haematuria during pregnancy and sepsis in puerperium.
EAU: 4th Central European Meeting 2004 október 21-22 Bukarest: (Poster session 4:
Renal cancer, abstract number 54)
4. Szendrői A, Szendrői M, Szűcs M, Székely E, Romics I. (2005) Csont, vese és mellékvese áttétet adó vesesejtes rákos beteg 20 éves túlélése. Füvészkerti Urológus Napok 2005 február 18-19: (Poster session: poster Nr. 22)
5. SzendrőA, Nagy Z, Pánovics J, Harsányi L, Szűcs M, Romics I. (2005) Radical nephrectomy and inferior vena cava thrombectomy in our renal cell cancer cases.
(poszter session abstract nr.:118) EAU: 5th Central European Meeting 2005 October 7-8.
6. Szendrői A, Nagy Z, Pánovics J, Romics I, Harsányi L, Szűcs M. (2005) Vesetumor miatt végzett radikális nephrectomia és véna cava inferior thrombectomia. Budapest Magyar Onkológus Társaság XXVI. Kongresszusa, Budapest, Kongresszusi Központ 2005 November 10-13.
7. Szendrői A, Hamvas A, Szűcs M, Romics I. (2006) Nephron sparing surgery for renal cell cancer 65 consecutive cases. Eur Urol Meetings, 1(1):113 (poster session abstract Nr.:118)
8. Szendrői A, Hamvas A, Szűcs M, Romics I. (2006) Vesedaganatok szervmegtartó sebészi kezelése. Magy Urol, 18(3):162. Magyar Urológus Társaság XIII.
Kongresszusa, Siófok, 2006. november 02-04
9. Szendrői A, Tabák Á. (2007) A vesesejtes rák által okozott tünet, mint prognosztikai tényező. Magy Onk, 51(4):400. Magyar Onkológus Társaság XXVII. Kongresszusa, Budapest, Kongresszusi Központ 2007 november 8-10.
10. Szendrői A, Tabák Á, Riesz P, Romics I: A vesesejtes rák által okozott tünet, mint független prognosztikai tényező. Füvészkerti Urológus Napok 2009 február 20-21, Budapest: (Uroonkológia VI. évf./1 2009 18.old.)
11. Szendrői A, Kardos M, Szász M: Role of HIF1a in renal cell carcinoma and consequtive bone metastases. 22nd European Congress of Pathology 2009 szeptember 4-9, Firenze (Florence) Poster number: (Poster Category: Nephropathology P4-139) Virchows Archiv 2009; 455 (1): P4.139 S410 DOI: 10.1007/s00428-009-0805-z IF=2,029
12. Szendrői A.,. Kardos M, Tőkés AM, Idan R, Tímár J, Szendrői M, Kulka J, Szász AM, Riesz P, Romics I: A HIF 1 alfa gén szerepe csontáttétet adó vesesejtes daganatokban. Magyar Urológus Társaság XIV. Kongresszusa, Keszthely, 2009 október 1-3 (idézhető: M.Urol., XXI. Évf/3 2009, 146-147.old; award of best poster presentation)
13. Szendrői A., Dinya E, Szász AM, Németh Zs, Kardos M, Kiss J, Antal I, Riesz P, Romics I, Szendrői M.: Csontáttétet adó világossejtes veserákos betegek túlélését befolyásoló tényezők Magyar Urológus Társaság XIV. Kongresszusa, Keszthely, 2009 október 1-3: (M.Urol., XXI. Évf/3, 121.old)
14. Szendrői A, Dinya E, Kardos M, Szász AM, Németh Z, Ats K, Kiss J, Antal I, Romics I, Szendrői M: Prognostic Factors and Survival of Renal Clear Cell Carcinoma Patients with Bone Metastases. EAU: 9th Central European Meeting 2009 október 23-24 Ljubjana: (poster session 4, abstract Nr:C52) Idézhető: European Urology Meetings 2009;
Articles published not in the topic of the thesis
1. Szendrői A, Riesz P. (2002) A preputium bőrének epidermális cystája. Magy Urol, 14(4):340-342.
2. Szendrői A, Hamvas A, Székely E, Szűcs M, Romics I. (2005) Jóindulatú daganat-e az angiomyolipoma? Uroonkológia, 2(3):76-80.
3. Szendrői A, Hakan S, , Romics I, Nagy B. (2008) Gene network and canonical pathway analysis in prostate cancer: a microarray study. Exp Mol Med, 40(2):176- 185.
IF: 2,376 (the first two authors are contributed equally to this work)
4. Szendrői A, Székely E, Romics I. (2008) Húgyhólyagból kiinduló pecsétgyűrűsejtes rák. LAM, 18(5):379-383.
5. Szendrői A, Majoros A, Székely E, Szűcs M, Romics I. (2009) Mucoepidermoid lung tumor appearing as scrotal abscess. Urol Int, 82:122-124. IF: 0,891
6. Szendrői A., Speer G ., Tabák Á., Kósa P. J., Horváth H., Szűcs M., Riesz P., Romics I ., Lakatos P.: A D vitamin, ösztrogén és calcium sensing receptor genotípusainak valamint a szérum kalciumnak a prosztatarák kialakulásában betöltött szerepe.
Uroonkológia. 6(2):40-47. 2009.
7. Szendrői A: Húgyúti kövesség. Magyar Családorvosok Lapja 2009/6, 3-7.
Abstract cited in not the topic of the thesis
1. Szendrői A, Hamvas A, Székely E, Romics I. (2004) Életet veszélyeztető vérzés képében jelentkező angiomyolipoma.
Füvészkerti Urológus Napok 2004 február 13-14
2. Szendrői A, Szűcs M, Székely E, Romics I. (2004) Hólyagdaganat pénisz metasztázisa. Füvészkerti Urológus Napok 2004 február 13-14
3. Szendrői A, Majoros A, Székely E, Süttő Z, Szűcs M. (2007) Scrotalis bőrmetasztázis formájában manifesztálódó tüdődaganat ritka esete. Uroonkológia, 4(1):28.
Poszter szekció 8.poszter, idézhető Uroonkológia IV. évf./1 2007 28.old.) Füvészkerti Urológus Napok 2007 február 23-24, Budapest
4. Szendrői A, Majoros A, Székely E, Kiss A, Szűcs M. (2007) Herezacskó tályog képében jelentkező mucoepidermoid tüdődaganat. Magyar Onkológia, 51(4):400.
Magyar Onkológus Társaság XXVII. Kongresszusa, Budapest, Kongresszusi Központ 2007 november 8-10
5. Szendrői A, Székely E, Romics I. (2008) Húgyhólyagból kiinduló pecsétgyűrűsejtes rák. Uroonkológia, 5(1):16.
Füvészkerti Urológus Napok 2008 február 22-23, Budapest
6. Szendrői A, Bata P, Lovasz S, Tóth G, Berczi V, Romics I. (2008) A new diagnostic method int he detection of renal pelvis tumors: early results with virtual pyeloscopy Eur Urol Meetings 3(10):115 (poster session 7, abstract Nr:115) 8th Central European Meeting 2008 október 24-25 Varsó
Book articles
1. Szendrői A. A prosztatarák patogenezise, incidenciája és epidemiológiája. In: Romics I. (szerk), A prosztata betegségei. White Golden Book, Budapest, 2005: 18-26.
2. Szendrői A. Milyen gyakori betegség a prosztatarák? In: Romics I. (szerk), 66 kérdés a prosztata betegségeiről. White Golden Book, Budapest, 2005: 17-19.
3. Szendrői A. Mitől lesz valakinek prosztatarákja?. In: Romics I. (szerk), 66 kérdés a prosztata betegségeiről. White Golden Book, Budapest, 2005: 19-25.
4. Szendrői A. Renal tumours. In: Nyírády P és Romics I (szerk) Textbook of Urology.
Semmelweis Publisher, Budapest, 2009: 65-71.
5. Szendrői A: Enoszkópos vesekősebészet. In: Urológia (szerk: Romics Imre, 2009, Semmelweis Kiadó, Budapest) ahead of print
