The presentation, treatment and outcome of renal cell carcinoma in old age

Age and Ageing,  July, 1999  by John G. Doherty,  Axel Rufer,  Peter Bartholomew,  David M. Beaumont

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Introduction

Renal cell carcinoma is a tumour derived from renal tubular epithelium [1] and accounts for 3% of all malignancies [2, 3], with a peak incidence in the seventh decade [4]. As a retroperitoneal tumour, it can become large before clinical detection [5], and many present in a non-specific manner which may lead to diagnosis by physicians and geriatricians [6, 7]. In elderly patients, many carcinomas present insidiously often against a background of co-existing disease and are often not diagnosed until the disease is advanced [8]. The aims of the present study were to identify whether renal cell carcinoma presents in a more non-specific manner in elderly subjects, to establish the clinical features in this age group, to determine whether elderly patients receive more conservative treatment than younger patients and to look for evidence of age on survival.

Subjects and methods

All new cases presenting with renal cell carcinoma to Gateshead hospitals between 1987 and 1995 were identified from hospital activity data and histopathology records. The case notes of 39 patients were reviewed retrospectively to identify presenting clinical features, laboratory data, details of cell morphology, clinico-pathological staging, patient management and survival.

Assessment of staging was carried out using the criteria described by Robson et al. [9]. To identify differences in symptomatology, laboratory features, stage and survival with advancing age, the study group was divided in to two groups of `young' subjects (defined as aged 69 years or under) and `elderly' subjects (aged 70 years or over). Statistical analysis was performed using the Mann-Whitney U test for comparisons of clinical data and a [chi square] analysis for comparisons of staging data.

Results

Thirty-nine patients presenting with a histologically-proven diagnosis of renal cell carcinoma were identified. Inadequate clinical information was available for two subjects, leaving 37 patients to be included in the study.

Characteristics of the study subjects

The mean age of the study group was 64.5 years (range 39-92); 25 were male. Seventeen tumours involved the right kidney, 17 the left kidney; the remaining three patients had bilateral tumours. Sixty percent of patients presented to surgical or urology departments and almost 40% of diagnoses were made in medical or geriatric departments, usually in outpatients. Seven tumours (19%) were diagnosed incidentally while imaging for other indications.

Presenting clinical and laboratory features of the study groups

Table 1 demonstrates the presenting symptoms in young and elderly subjects. Anorexia, weight loss and abdominal pain were common in both groups. Although haematuria was reported by half of the elderly subjects, there were no statistically significant differences in the prevalence of reported symptoms between the young and the elderly group. Mean symptom duration was 9.9 weeks (95% confidence interval 5.2-14.6) and did not differ significantly between groups. Hypertension was common in both study groups, being present overall in 46%, and identified for the first time in 16% of subjects. Anaemia occurred in 46% of all patients and was more common in elderly subjects, although this difference did not achieve statistical significance. In six of the 17 anaemic patients, the anaemia was of hypochromic, microcytic type; none of these patients had frank or microscopic haematuria. The mean value of the erythrocyte sedimentation rate (ESR), measured in 11 of the young group, was 63 mm/h (range 8-130); the mean value in the four elderly patients in whom it was measured was 78mm/h (7-142). Only two of the young group had an ESR of [is less than] 30 mm/h and seven values were higher than 60 mm/h. Two of the elderly group had ESR values [is greater than] 100 mm/h. An abdominal mass was palpable in half the elderly subjects, but there were no statistically significant differences in examination findings and laboratory features between the two groups.

Table 1. Presenting symptoms of renal cell carcinoma in young and elderly subjects

                        No. (and %) by group

                         Young     Elderly
                        (n = 27)   (n = 10)

Abdominal symptoms(a)   11 (41%)   3 (30%)
Haematuria               6 (22%)   5 (S0%)
Loin pain                6 (22%)   2 (20%)
Bone pain                3 (11%)   1 (10%)
Night sweats             1 (4%)    1 (10%)
Respiratory symptoms     2 (7%)    0

(a) Weight loss, abdominal pain, anorexia.

Clinicopathological staging

About half the patients in each group presented with early stage I disease, and although a higher proportion of elderly patients presented with advanced stage IV disease, this did not achieve statistical significance.

Management

Table 2 shows the treatment offered to young and elderly subjects presenting with renal cell carcinoma. Over 75% of patients were offered nephrectomy and five patients in the young group were given radiotherapy. Three patients of the 37 cases identified were diagnosed at post mortem examination so were not offered surgical treatment. There was no evidence that elderly patients were managed more conservatively than younger patients, although two elderly patients presenting with advanced disease did not receive surgery but were offered chemotherapy, with additional radiotherapy given to one of them.