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Letters to the Editor

Was capsule penetration of locally advanced renal cell carcinoma associated with recurrence in patients undergoing curative surgery?

Chou, Fang-Weia; Chang, Wen-Hsuna,b,c; Wang, Peng-Huia,c,d,e,*

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Journal of the Chinese Medical Association: June 2021 - Volume 84 - Issue 6 - p 664
doi: 10.1097/JCMA.0000000000000543
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We read the recently published article in the April issue of the Journal of the Chinese Medical Association entitled “Predictive factors for disease recurrence in patients with locally advanced renal cell carcinoma treated with curative surgery” with much interest.1 The authors attempted to identify the factors associated with recurrence in 159 patients with locally advanced renal cell carcinoma treated with curative surgery and finally they found that Fuhrman grade of 3 or 4 was a critical and independent factor associated with recurrence in these patients (hazard ratio 5.70, 95% CI 2.2–14.6).1 We congratulate the success of their publication. However, we have a question about the authors’ discussion to claim that locally advanced renal cell carcinoma with capsule penetration was significantly associated with recurrence after curative surgery, while a positive surgical margin, a pathological T stage higher than T3a, and administration of adjuvant targeted therapy were not significantly related to disease recurrence.1 Could the authors kindly explain the above-mentioned sentence?

Furthermore, we would be interested to know whether the independent predictor would be still similar or not if the study subjects were limited to T3a cases (n = 134). We found that adjuvant targeted therapy was applied in 22 patients, although the detailed information of these subjects was not shown by authors. We believed that the majority of these patients had a higher pathology T stage (>T3a), since co-existence of many risk factors may be directly associated with a higher pathology T stage. Therefore, if the authors could provide the results obtained from these 134 T3a patients, the audience may learn much more when we deal with the patients with similar clinical state in future clinical practice. In fact, locally advanced cancers,2–5 regardless whether these tumors are located, cervical cancer as an example, are still a biggest challenge for physicians and patients, since both surgery and radiation therapies may be applied, although some tumors favor the definite surgical approach, as shown in the current article, and some tumor may favor the definite concurrent chemoradiation. Therefore, our comments are not against the value of Dr. Chang’s finding. We are looking forward to see the positive response of authors. Thanks.


1. Chang TW, Cheng WM, Fan YH, Lin CC, Lin TP, Eric Huang YH, et al. Predictive factors for disease recurrence in patients with locally advanced renal cell carcinoma treated with curative surgery. J Chin Med Assoc. 2021; 84:405–9.
2. Liu CH, Lee YC, Lin JC, Chan IS, Lee NR, Chang WH, et al. Radical hysterectomy after neoadjuvant chemotherapy for locally bulky-size cervical cancer: a retrospective comparative analysis between the robotic and abdominal approaches. Int J Environ Res Public Health. 2019; 16:3833.
3. Lu HW, Chen CC, Chen HH, Yeh HL. The clinical outcomes of elderly esophageal cancer patients who received definitive chemoradiotherapy. J Chin Med Assoc. 2020; 83:906–10.
4. Lin JW, Hsu CP, Yeh HL, Chuang CY, Lin CH. The impact of pathological complete response after neoadjuvant chemoradiotherapy in locally advanced squamous cell carcinoma of esophagus. J Chin Med Assoc. 2018; 81:18–24.
5. Cheng HY, Liang JA, Hung YC, Yeh LS, Chang WC, Lin WC, et al. Stereotactic body radiotherapy for pelvic boost in gynecological cancer patients with local recurrence or unsuitable for intracavitary brachytherapy. Taiwan J Obstet Gynecol. 2021; 60:111–8.
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