To develop the PRIMAL (Prognostic Risk stratification for Integrating Manifestations of symptoms and Abnormal Labs) score to predict prognosis in renal cell carcinoma (RCC) by integrating clinical presentation, paraneoplastic syndromes (PNS), and abnormal laboratory values at diagnosis.
5256 T1-T4, N0/1, M0/1 RCC surgical patients from 4 institutions were analyzed retrospectively. Preoperative variables included hematuria, visceral pain, nausea/vomiting, thrombocytopenia (<100 × 109/L), hypoalbuminemia (<3.5 g/dL), anemia (<11.5 mg/dL for women, <12.5 mg/dL for men), elevated De Ritis Ratio (AST/ALT > 1.25), elevated neutrophil-to-lymphocyte-ratio (NLR > 2.27). Patients were stratified into 4 PRIMAL categories (Low = 0, Favorable-intermediate = 1-2, Unfavorable-intermediate = 1-2+anemia, High ≥ 3). Multivariable Cox regression and Kaplan-Meier analyses assessed association with overall survival (OS) and cancer-specific survival (CSS). C-indexes, Receiver operating characteristic curves and Area under curve assessed accuracy of the model towards OS and CSS individually and in combination with the Leibovich score.
2513 (48%) patients had low, 1532 (29%) favorable-intermediate, 909 (17%) unfavorable-intermediate, 302 (6%) high PRIMAL score. High score patients exhibited highest hazard ratios (HR) for all-cause mortality (ACM) (HR = 7.71, 95% CI = 5.98-9.93) and cancer-specific mortality (CSM) (HR = 8.54, 95% CI = 5.96-12.24). Five-year OS rates were 91%, 82%, 65% and 46%, while CSS rates were 95%, 90%, 76% and 60% for Low, Favorable-Intermediate, Unfavorable-Intermediate and High groups, respectively. PRIMAL achieved C-indexes of 0.70 for OS and 0.74 for CSS prediction. The combined CSS PRIMAL-Leibovich model yielded an AUC of 0.76 (P = 0.02), outperforming individual scores.
PRIMAL is a valuable tool for RCC prognostication, enabling assessment of disease aggressiveness at diagnosis. Including PRIMAL score during initial evaluations enhances stratification, identifying patients with a higher risk disease and aids clinical decision-making.
Urologic oncology. 2025 Apr 21 [Epub ahead of print]
Giacomo Musso, Margaret F Meagher, Kit L Yuen, Benjamin Baker, Omer Baker, Aaron Ahdoot, Dhruv Puri, Mai Dabbas, Natalie Birouty, Cesare Saitta, Melis Guer, Dattatraya Patil, Hajime Tanaka, Masaki Kobayashi, Shohei Fukuda, Francesco Montorsi, Alberto Briganti, Andrea Salonia, Umberto Capitanio, Alessandro Larcher, Yasuhisa Fujii, Viraj Master, Ithaar H Derweesh
Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Urology, UC San Diego School of Medicine, La Jolla, CA., Department of Urology, UC San Diego School of Medicine, La Jolla, CA., Department of Urology, Emory University School of Medicine, Atlanta, GA., Department of Urology, Institute of Science Tokyo, Bunkyo City, Tokyo, Japan., Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy., Department of Urology, UC San Diego School of Medicine, La Jolla, CA. Electronic address: .