Predicting Occult Multifocality of Renal Cell Carcinoma

Background

Multifocal renal cell carcinoma (RCC) has been reported in up to 25% of all radical nephrectomy specimens. Modern imaging tends to underestimate the rate of multifocality. Recognition of multifocality before treatment may guide physicians and patients to the type of intervention and tailor long-term follow-up.

Objective

Our aim was to develop and assess preoperative nomograms to predict occult multifocal RCC.

Design, setting, and participants

We evaluated 560 consecutive patients undergoing radical nephrectomy for clinically localized suspected sporadic RCC between 2000 and 2008 in a tertiary center. Clinically manifest multifocal lesions were excluded. Logistic regression models were used to assess the potential risk factors of occult multifocality with and without pathologic variables that may be available with preoperative biopsy. Nomograms were developed and assessed for diagnostic properties.

Interventions

All patients underwent radical nephrectomy.

Measurements

Assessments of risk factors for occult multifocal RCC were obtained using regression models and nomograms.

Results and limitations

The incidence of occult multifocality was 7.9%. Significantly associated predictors of multifocality were male gender, family history of malignancy other than RCC, radiographic size of the lesion, histologic subtype other than clear cell, and Fuhrman grade IV. The two designed nomograms had 0.75 and 0.82 concordance indices, respectively.

Conclusions

Our data suggest that occult multifocal RCC is more frequently associated with small (2–4 cm) renal lesions. Male gender, family history of kidney cancer, histologic subtype, and grade are strongly associated with an increased risk of occult multifocal RCC. The developed nomograms had good predictive accuracy that was enhanced when combined with pathologic variables.     

Assessing the Impact of Ischaemia Time During Partial Nephrectomy

Context

The impact of applying renal ischaemia during nephron-sparing surgery to avoid renal damage in the treated kidney has gained importance in different surgical techniques.

Objective

The main objective of the present study is to point out the limit of renal ischaemia times for warm and cold ischaemia approaches. Important results of research on renal ischaemia and different surgical techniques as well as results of clinical studies concerning renal function after renal ischaemia in partial nephrectomy are highlighted.

Evidence acquisition

A Medline literature research was performed, combining queries on the keywords nephron-sparing surgery, partial nephrectomy, and ischemia. Links to related articles and cross-reading of citations in related articles were surveyed, as were reviews, letters to editors, and information collected from urologic textbooks. The references formed the basis of this review article, with selection and deletion based on the relevance and importance of the content. In a final step, interactive peer review by the expert panel of coauthors completed the review.

Evidence synthesis

Renal ischaemia research showed an increasing renal damage proportional to ischemic time. Current clinical data support safe ischaemia times, within 20 min of warm ischaemia and up to 2 h of cold ischaemia, to minimise renal ischemic damage. To date, no ischaemia dose-response curve or algorithm is available to predict the risk of acute kidney injury and chronic kidney disease in patients undergoing intraoperative ischaemia. In general, there seems to be a higher risk for comorbidity caused by renal damage in patients suffering from kidney tumour.

Conclusions

If ischaemia is required, the tumour should be removed within 20 min of warm ischaemia, regardless of surgical approach. Efforts should be made to start immediately with cold ischaemia, if the feasibility within this span of time seems to be jeopardised. Thus, cold ischaemia times up to 2 h can be tolerated by the kidney, depending on the individual method. Nevertheless, cold ischaemia with ice slush should be kept as short as possible—at best within 35 min. In ischemic nephron-sparing surgery, one of the surgeon's main aims should be to avoid loss of renal function. Only after optimal preoperative appraisal and planning can the best postoperative outcomes for renal function be achieved.     

The Expanding Role of Partial Nephrectomy: A Critical Analysis of Indications,Results, and Complications

Context

The gained expertise in the surgical technique of partial nephrectomy (PN) with excellent oncologic outcome and reduced morbidity has contributed to more frequent use of PN in many centres of reference, and the recent evidence favouring PN over radical nephrectomy (RN) in the prevention of chronic kidney disease and possibly linking it to a better overall survival (OS) will constitute a strong argument for wider use of PN.

Objective

To objectively analyse the advantages of PN over RN and to evaluate the risk–benefit ratio of expanding the indications of PN T1b renal cortical tumours.

Evidence acquisition

Literature searches on English-language publications were performed using the National Library of Medicine database. The queries included the keywords partial nephrectomy and nephron sparing surgery. Eight hundred four references were scrutinised, and 175 publications were identified and reviewed. Sixty-nine articles were selected for this review. These references formed the basis for this analysis and were selected based on their relevance and the importance of their content.

Evidence synthesis

The use of PN has been steadily increasing, particularly in tertiary care centres. This trend is now strengthened by evidence supporting the role of PN in reducing the risk of chronic kidney disease in patients with renal masses ≤4 cm. A wider use of PN for larger tumours, granted technical feasibility, is supported by the preliminary evidence, suggesting an OS advantage favouring PN over RN. However, the potential for selection bias and residual confounding factors may contribute to the observed difference. In the carefully selected patients with tumours >4 cm, PN obtained equivalent oncologic outcome to that achieved after RN. Although higher morbidity rates were seen after PN, the complication type and severity were not prohibitive.

Conclusions

The available evidence supports elective PN as the standard surgical treatment for renal cortical tumours ≤4 cm. For larger tumours, PN has demonstrated feasibility and oncologic safety in the carefully selected patient population studied.     

Partial Nephrectomy Is Associated with Improved Overall Survival Compared to Radical Nephrectomy in Patients with Unanticipated Benign Renal Tumours

Background

Partial nephrectomy (PN) has been associated with improved overall survival (OS) in select cohorts with localised renal masses when compared to radical nephrectomy (RN). The driving forces behind these differences have been difficult to elucidate given the heterogeneity of previously compared cohorts.

Objective

Compare OS in a subset of patients with unanticipated benign renal masses to minimise the confounding effect of cancer.

Design, setting, and participants

We retrospectively evaluated 2608 consecutive clinical T1 enhancing renal masses that were treated with extirpative surgery at our institution between 1999 and 2006. Of these, 499 tumours (19%) were found to be benign on final pathology. Preoperative data and renal functional data were used to generate a propensity model that was then plugged into a multivariate model of survival. Median follow-up for the entire cohort was 50 mo (interquartile range [IQR]: 32–73).

Intervention

All patients underwent PN or RN.

Measurements

We measured OS and cardiac-specific survival.

Results and limitations

Five-year OS estimates for the PN (n = 388) and RN (n = 111) cohorts were 95% (95% confidence interval [CI], 93–98) versus 83% (95% CI, 74–90), respectively (P < 0.0001). On multivariate analysis, controlling for both comorbidity and age, RN was associated with a 2.5-fold increased risk of death compared to PN (hazard ratio [HR]: 2.5; 95% CI, 1.3–5.1). Postoperative estimated glomerular filtration rate (eGFR) was also an independent predictor of OS and cardiac-specific survival (HR: 0.97; 95% CI, 0.95–0.99 and HR: 0.96; 95% CI, 0.93–0.99, respectively). The retrospective nature of this analysis limits the strength of the conclusions.

Conclusions

PN was associated with better OS when compared to RN in patients with unanticipated benign tumours. This observed survival advantage appears partly to be the result of better preservation of eGFR, but other kidney functions or unmeasured factors may also play a role. These data indicate that PN should be aggressively pursued in any patient where PN is technically feasible.     

Successful Sorafenib Treatment for Metastatic Renal Cell Carcinoma in a Case with Chronic Renal Failure

Treatment options for patients with end-stage renal disease (ESRD) and metastatic renal cell carcinoma (mRCC) are limited. We report the case of a 69-yr-old male who was treated with sorafenib after failure of immunotherapy. The treatment has resulted in remission with stable disease for 13 mo so far. Sorafenib seems to be a safe treatment option for patients with ESRD and mRCC, but further studies are required.     

Laparoscopic versus Open Partial Nephrectomy: Analysis of the Current Literature

Objectives

To critically review the current scientific evidence about open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) to define the current role of these techniques in the treatment of renal tumours.

Methods

PubMed and Medline were searched for reports about OPN and LPN that were published from 1990 to 2007 and the most relevant papers were reviewed.

Results

OPN is an established curative approach for the treatment of small renal tumours. LPN is challenging and the technique is still under development. The intermediate-term oncologic and functional outcomes of LPN are similar to those of OPN in experienced centres. However, the ischaemia time is longer in laparoscopy and a long learning curve is needed to decrease the risk of complications. In the first phase of a surgeon's experience with LPN, a careful case selection based on the tumour growth pattern is required.

Conclusion

OPN is today the first treatment option for small renal tumours. LPN is technically challenging, but has been shown to achieve similar intermediate-term cancer cure and renal function results in centres with advanced laparoscopic expertise. Larger series with longer follow-up and prospective randomised studies are needed to confirm the safety and efficacy of LPN.     

Renal Tumor Contact Surface Area: A Novel Parameter for Predicting Complexity and Outcomes of Partial Nephrectomy

Background

The contact surface area (CSA) of a tumor with adjacent renal parenchyma may determine the complexity and thus the perioperative outcomes of partial nephrectomy (PN).

Objective

We devised a novel imaging parameter, renal tumor CSA, and correlate it with perioperative outcomes in patients undergoing PN.

Design, setting, and participants

Of 200 patients undergoing PN for a tumor (January 2010 to August 2011), 162 had renal protocol computed tomography scanning data available. CSA was calculated using image-rendering software (Synapse 3D, Fujifilm), and interobserver variability was determined between three independent observers.

Outcome measurements and statistical analysis

CSA was correlated to baseline demographics and perioperative outcomes as a continuous and categorical variable using multivariable logistic regression analysis. The ability of CSA to predict adverse perioperative events was compared with demographic factors and nephrometry scoring systems.

Results and limitations

The mean tumor size was 3.1 cm; CSA was 18.3 cm². CSA ≥20 cm² correlated with adverse tumor characteristics (greater tumor size, volume, and complexity) and perioperative outcomes (more parenchymal volume loss, blood loss, and complications) compared with CSA <20 cm². On multivariable logistic regression, CSA independently predicted operative time, complications, hospital stay, and renal functional outcomes. This predictive ability of CSA was superior to the other parameters evaluated.

Conclusions

CSA is a novel imaging parameter that quantifies the CSA of renal tumor with adjacent parenchyma. Our preliminary data indicate that CSA correlates with PN outcomes. If validated externally in a larger cohort, CSA could be incorporated into future versions of nephrometry scoring systems.

Patient summary

In this study we outline the method of calculating the contact surface area (CSA) of renal tumors with the surrounding normal kidney using image-rendering software. We found that CSA correlates with a number of important surgical outcomes including operative time, loss of renal function, and complications.     

ClearCode34: A Prognostic Risk Predictor for Localized Clear Cell Renal Cell Carcinoma

Background

Gene expression signatures have proven to be useful tools in many cancers to identify distinct subtypes of disease based on molecular features that drive pathogenesis, and to aid in predicting clinical outcomes. However, there are no current signatures for kidney cancer that are applicable in a clinical setting.

Objective

To generate a signature biomarker for the clear cell renal cell carcinoma (ccRCC) good risk (ccA) and poor risk (ccB) subtype classification that could be readily applied to clinical samples to develop an integrated model for biologically defined risk stratification.

Design, setting, and participants

A set of 72 ccRCC sample standards was used to develop a 34-gene classifier (ClearCode34) for assigning ccRCC tumors to subtypes. The classifier was applied to RNA-sequencing data from 380 nonmetastatic ccRCC samples from the Cancer Genome Atlas (TCGA), and to 157 formalin-fixed clinical samples collected at the University of North Carolina.

Outcome measurements and statistical analysis

Kaplan-Meier analyses were performed on the individual cohorts to calculate recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Training and test sets were randomly selected from the combined cohorts to assemble a risk prediction model for disease recurrence.

Results and limitations

The subtypes were significantly associated with RFS (p < 0.01), CSS (p < 0.01), and OS (p < 0.01). Hazard ratios for subtype classification were similar to those of stage and grade in association with recurrence risk, and remained significant in multivariate analyses. An integrated molecular/clinical model for RFS to assign patients to risk groups was able to accurately predict CSS above established, clinical risk-prediction algorithms.

Conclusions

The ClearCode34-based model provides prognostic stratification that improves upon established algorithms to assess risk for recurrence and death for nonmetastatic ccRCC patients.

Patient summary

We developed a 34-gene subtype predictor to classify clear cell renal cell carcinoma tumors according to ccA or ccB subtypes and built a subtype-inclusive model to analyze patient survival outcomes.     

Simple Enucleation for the Treatment of PT1a Renal Cell Carcinoma: Our 20-Year Experience

Objectives

To evaluate the safety and efficacy of simple enucleation as a conservative treatment for pT1a RCC, and to report on the incidence of major complications, local recurrence, and progression-free and disease-specific survival rates.

Methods

We retrospectively reviewed the data of 232 patients who had nephron-sparing surgery (NSS) by simple enucleation between 1986 and 2004 for sporadic, unilateral, pathologically confirmed pT1a RCC. The patients’ status was evaluated last in September 2005. The mean (median, range) follow-up was 76 (61, 12–225) months.

Results

The mean (SD, median, range) tumor greatest dimension was 2.8 (0.78, 2.85, 0.6–4) cm. The histopathologic review according to the International Union Against Cancer and American Joint Commission for Cancer (1997) classification revealed 198 clear cell (85.3%), 18 papillary (7.8%), 15 chromophobe (6.5%) and one (0.4%) collecting duct RCCs. There were no major complications, such as prolonged acute tubular necrosis/chronic renal insufficiency and bleeding requiring open reoperation. One patient developed postoperative late retroperitoneal fluid collection consistent with urinoma, which required aspiration, drainage position and JJ stenting for 3 weeks. The 5- and 10-year cancer-specific survival were 96.7% and 94.7%, respectively. The 5- and 10-year progression-free survival were 96% and 94%, respectively. Overall, 13 (6.4%) patients had disease progression, three of whom had local recurrences alone (1.5%) elsewhere in the kidney; none had local recurrence at the level of the enucleation bed.

Conclusions

Simple tumor enucleation is a safe and acceptable nephron-sparing treatment that provides excellent long-term local control and cancer-specific survival rates.     

Assessment of Risk Factors for Complications of Laparoscopic Partial Nephrectomy

Objective

Laparoscopic partial nephrectomy (LPN) is a technique that is emerging as an attractive option for the treatment of renal tumors ≤4 cm. We retrospectively analyzed our experience with LPN to identify patient and tumor features that correlate with a higher risk of complications.

Material and methods

From January 2001 to May 2007, 90 patients underwent LPN at our institution for a clinically localized renal tumor. A retrospective chart review was carried out. Clinical and pathological information were collected for each patient, including patient age and body mass index, tumor size, location and pattern of growth (cortical vs. corticomedullar), surgical approach (transperitoneal vs. retroperitoneal), warm ischemia time, technique that was used to achieve hemostasis, maximum thickness of the margin of resection, and histology. Statistical analysis (chi-square test, Fisher exact test, Mann-Whitney U test, linear regression model) was performed to test the correlation between the above-mentioned variables and the occurrence of complications.

Results

Twenty-two patients (24.4%) had surgical and/or medical complications in our series. The only variable that was found to significantly correlate with a higher number of complications was a corticomedullar tumor growth pattern as opposed to a cortical growth pattern (p = 0.02).

Conclusions

LPN is an attractive alternative to open partial nephrectomy for the treatment of small renal tumors. On the basis of our experience, the selection of patients with cortical renal lesions seems to be required to reduce the risk of complications and therefore maximize the advantages of this minimally invasive but challenging procedure.     

R-LESS Partial Nephrectomy Trifecta Outcome Is Inferior to Multiport Robotic Partial Nephrectomy: Comparative Analysis

Background

Trifecta achievement in partial nephrectomy (PN) is defined as the combination of warm ischemia time ≤20 min, negative surgical margins, and no surgical complications.

Objective

To compare trifecta achievement between robotic, laparoendoscopic, single-site (R-LESS) PN and multiport robotic PN (RPN).

Design, setting, and participants

Data from 167 patients who underwent RPN from 2006 to 2012 were retrospectively analyzed.

Outcome measurements and statistical analysis

Primary outcome measurement was trifecta achievement; secondary outcome was the perioperative and postoperative comparison between groups. The measurements were estimated and analyzed with SPSS v.18 using univariable, multivariable, and subgroup analyses.

Results and limitations

Eighty-nine patients were treated with RPN and 78 were treated with R-LESS PN. Baseline characteristics of both groups were similar. Trifecta was achieved in 38 patients (42.7%) in the multiport RPN group and 20 patients (25.6%) in the R-LESS PN group (p = 0.021). Patients in the R-LESS PN group had longer mean operative time, warm ischemia time, and increased estimated glomerular filtration rate (eGFR) percentage change. No significant differences were found between the two groups in days of hospitalization, blood loss, postoperative eGFR, positive surgical margins, and surgical complications. Patients with increased PADUA and RENAL scores, infiltration of the collecting system, and renal sinus involvement had an increased probability of not achieving the trifecta. In regression analysis, the type of procedure and the tumor size could predict trifecta accomplishment (p = 0.019 and 0.043, respectively). The retrospective study, the low number of series, and the controversial definition of trifecta were the main limitations.

Conclusions

The trifecta was achieved in significantly more patients who underwent multiport RPN than those who underwent R-LESS PN. R-LESS PN could be an alternative option for patients with decreased tumor size, low PADUA and RENAL scores, and without renal sinus or collecting system involvement.

Patient summary

In this study, we looked at the outcomes of patients who had undergone robotic partial nephrectomy. We found that conventional robotic partial nephrectomy is superior to R-LESS partial nephrectomy with regard to the accomplishment of negative margins, reduced warm ischemia time, and minimal surgical complications.     

Organ-Sparing Surgery for Adult Testicular Tumours: A Systematic Review of the Literature

Context

According to current guidelines, radical orchidectomy is the standard treatment for testis tumours of malignant and unknown origin. Testis-sparing surgery (TSS) has recently been proposed as an alternative option in selected cases.

Objective

Our aim was to analyse the cumulative evidence for TSS in the treatment of adult malignant tumours of different histology, including notes on operative technique, indications, complications, and oncologic and functional outcome.

Evidence acquisition

A systematic literature search of the Medline/PubMed database for full-length papers reporting on TSS for adult malignant tumours was performed up to September 2009. Bibliographies of retrieved articles and review articles were also examined. Only those articles with complete data on operative technique, complications, and oncologic or functional outcome were selected. Furthermore, published abstracts at major urologic meetings in the last decade (1999–2009) and guidelines on testis cancer from major oncologic and urologic medical associations were searched and evaluated.

Evidence synthesis

No randomised controlled trials have compared TSS and radical orchidectomy; only retrospective outcome studies and case reports on TSS are available. In patients with small malignant germ cell tumours arising in both or in solitary testes, TSS coupled with local adjuvant radiotherapy ensures good oncologic control and is associated with a preserved endocrine function in most cases. In patients with small Leydig cell tumours, TSS can also be performed with elective indications (healthy contralateral testes), provided that pathology fails to reveal aggressive features. Finally, TSS is an option for patients with small ultrasound-detected, nonpalpable tumours even with elective indications because the incidence of benign definitive histology is high at approximately 80%. The overall complication rate is low (<6%). Data on exocrine and endocrine gonadal function, male body image, and health-related quality of life after TSS are still immature.

Conclusions

TSS can be safely adopted for the treatment of carefully selected cases of tumours of different histology. Prospective multicentre studies are warranted to further qualify TSS as a treatment option to be recommended as an alternative to radical orchidectomy and to explore the perceived functional advantages of testis preservation.     

Survival Outcome and Treatment Response of Patients with Late Relapse from Renal Cell Carcinoma in the Era of Targeted Therapy

Background

A subset of primarily localized renal cell carcinoma (RCC) patients will experience disease recurrence ≥5 yr after initial nephrectomy.

Objective

To characterize the clinical outcome of patients with late recurrence beyond 5 yr.

Design, setting, and participants

Patients with metastatic RCC (mRCC) treated with targeted therapy were retrospectively characterized according to time to relapse. Relapse was defined as the diagnosis of recurrent metastatic disease >3 mo after initial curative-intent nephrectomy. Patients with synchronous metastatic disease at presentation were excluded. Patients were classified as early relapsers (ERs) if they recurred within 5 yr; late relapsers (LRs) recurred after 5 yr.

Outcome measurements and statistical analysis

Demographics were compared with the Student t test, the chi-square test, or the Fisher exact test. The survival time was estimated with the Kaplan-Meier method, and associations with survival outcome were assessed with univariable and multivariable Cox regression analyses.

Results and limitations

Among 1210 mRCC patients treated with targeted therapy after surgery for localized disease, 897 (74%) relapsed within the first 5 yr and 313 (26%) (range: 5–35 yr) after 5 yr. LRs presented with younger age (p < 0.0001), fewer with sarcomatoid features (p < 0.0001), more clear cell histology (p = 0.001), and lower Fuhrman grade (p < 0.0001). Overall objective response rates to targeted therapy were better in LRs versus ERs (31.8% vs 26.5%; p = 0.004). LRs had significantly longer progression-free survival (10.7 mo vs 8.5 mo; p = 0.005) and overall survival (OS; 34.0 mo vs 27.4 mo; p = 0.004). The study is limited by its retrospective design, noncentralized imaging and pathology review, missing information on metastatectomy, and nonstandardized follow-up protocols.

Conclusions

A quarter of patients who eventually developed metastatic disease and were treated with targeted therapy relapsed over 5 yr from initial nephrectomy. LRs have more favorable prognostic features and consequently better treatment response and OS.     

A Proposal for Reclassification of the Fuhrman Grading System in Patients with Clear Cell Renal Cell Carcinoma

Background

The conventional Fuhrman grading system, which categorizes renal cell carcinoma (RCC) with grades I, II, III, and IV, is the most widely used predictor assessment of RCC cancer-specific mortality (CSM).

Objectives

The aim of this study was to test the prognostic ability of simplified Fuhrman grading schemes (FGSs) that rely on two- or three-tiered classifications.

Design, setting, and participants

The current study addressed a population of 14 064 patients with clear cell RCC who were treated with partial or radical nephrectomy between 1988–2004, within nine Surveillance, Epidemiology, and End Results (SEER) cancer registries.

Measurements

Univariable and multivariable analyses as well as prognostic accuracy analyses were performed for various FGSs to test their ability to predict CSM rates. The conventional four-tiered FGS was compared to a modified two-tiered FGS in which grades I and II and grades III and IV were combined. A second simplified three-tiered FGS in which grades I and II were combined but grades III and IV were kept separate was also tested.

Results and limitations

The overall 5-yr CSM-free rate was 81.5%. All three FGSs achieved independent predictor status in multivariable analyses. Prognostic accuracy of multivariable models that relied on various FGSs was 83.6% for the modified two-tiered FGS and 83.8% for both the conventional four-tiered and the modified three-tiered FGS.

Conclusions

Our findings indicate that the simplified FGSs perform equally as well as the conventional four-tiered FGS. The use of simplified grading schemes may represent an advantage for pathologists as well as for clinicians caring for patients with RCC.     

Prognostic and Therapeutic Impact of the Histopathologic Definition of Parenchymal Epithelial Renal Tumors

Context

In the last few years, the treatment of renal cell carcinoma (RCC) has progressed significantly, and some histopathologic issues have become important for selection and follow-up after medical and surgical therapies.

Objective

The aim of this collaborative article is to review the most recent literature on the role of traditional histopathologic features obtained from renal core biopsy or nephrectomy specimens in the management of confined, locally advanced, and metastatic RCC.

Evidence acquisition

A nonsystematic review of the literature was performed in April 2010 using the Medline database. Multiple free-text searches were performed for the following items: renal cell carcinoma, clear cell, papillary, chromophobe, histologic* subtype*, histotype*, nuclear grade*, necrosis, sarcomatoid differentiation, biopsy, molecular marker*, and cytogenetic marker*. A total of 2369 records were retrieved from Medline, and 263 full-text studies were considered and partially included in the present review. A panel of experts reached consensus on the main subheadings of this paper.

Evidence synthesis

Core needle biopsies can provide important information that is useful to avoid the overtreatment of benign tumors and to help plan watchful waiting or minimally invasive treatments in selected patients. Tumor histotype is fundamental in the pathologic report. In the context of integrated prognostic systems, the combination of the most important clinical and pathologic factors (TNM stage, Fuhrman nuclear grade, presence of necrosis, microvascular invasion, and sarcomatoid dedifferentiation) allows us to reach a high prognostic accuracy. These models can be used to select patients suitable for adjuvant protocols, to design an appropriate follow-up schedule, and to provide careful patient counseling. Molecular and cytogenetic markers should be further evaluated.

Conclusions

The histopathologic definition of parenchymal epithelial renal tumors is fundamental to plan the management and follow-up of patients with locally confined, locally advanced, and metastatic RCC.     

Observation Should be Considered as an Alternative in Management of Renal Masses in Older and Comorbid Patients

Background

Renal masses diagnosed in older and comorbid patients represent a challenge with regard to treatment.

Objective

To evaluate clinical outcome and tumor progression in patients with renal masses managed by observation due to age and comorbidity.

Design, setting, and participants

The medical records of 63 consecutive patients with renal masses primarily managed by observation during 2002–2007 were reviewed retrospectively and analyzed. The mean age for all patients at diagnosis was 76.6 yr, and 59% were male. Mean tumor size was 4.3 cm in diameter at diagnosis. Of these, 30% had Eastern Cooperative Oncology Group performance status (PS) of 2 or 3, 78% were American Society of Anesthesiologists (ASA) class 3, and the patients had a mean of 2.8 other medical conditions.

Measurements

Registration of age, ASA class, PS, comorbid conditions, computed tomography scans, primary tumor size, tumor growth rate, pathology parameters, observation time, survival time.

Results and limitations

Five-year overall survival (OS) and cancer-specific survival (CSS) rates were 42.8% and 93.3%, respectively. For tumors ≤4.0 cm in size, 5-yr CSS was 100%. Nine patients received delayed radical treatment, none of whom had later progression of the disease. In 18 patients histopathologic diagnosis of the renal masses were available, and in 15 patients (83%) renal cell carcinoma (RCC) was verified. The annual growth rate was <1 cm/yr in 85.4% of the cases. In tumors ≤4.0 cm, only 1 of 27 tumors (3.7%) grew faster than 1 cm/yr.

Conclusions

Management of renal masses by observation among older and comorbid patients seems to give acceptable results with regard to OS and CSS rates after 5 yr. The risk of disease progression is significantly higher in patients with larger sized renal masses (>4 cm). Thus, selection for observation in this group has to be stricter than in a group of patients with smaller sized renal masses (≤4.0 cm).     

Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Nephrectomy

Natural orifice translumenal endoscopic surgery (NOTES) within urology has largely been limited to experimental animal studies and diagnostic procedures in humans. Attempts to complete a pure NOTES transvaginal nephrectomy have thus far been unsuccessful. We report the first clinical experience with pure NOTES transvaginal nephrectomy.     

Survival and Impact of Clinical Prognostic Factors in Surgically Treated Metastatic Renal Cell Carcinoma

Background

The survival impact of metastasectomy for metastatic renal cell carcinoma (mRCC) is still an active research field, particularly in the multimodal/targeted therapy era.

Objective

To determine the survival impact of clinical prognostic factors and their application to stratification of patients according to their prognosis so clinicians may be aided in their management of mRCC.

Design, setting, and participants

Retrospective, bi-institutional cohort study of 109 consecutive patients (71 male and 38 female; median age: 62 yr (range: 25–82 yr) with renal cell carcinoma (RCC) who underwent partial or radical nephrectomy and at least one metastasectomy for mRCC.

Intervention

Metastasis resection from various anatomic sites with the aim of completely removing detected lesions.

Outcome measurements and statistical analysis

Univariable and multivariable Cox regression models were used to analyse the impact of clinical prognostic factors on cancer-specific survival (CSS). Kaplan-Meier analysis with the log-rank test was used to compare CSS. Receiver operating characteristic (ROC) analysis was performed to test accuracy of prognostic groups. The α error for statistical significance was set at 0.05.

Results and limitations

Multivariable analysis revealed that primary tumour T stage ≥3 (hazard ratio [HR]: 2.8; p < 0.01), primary tumour Fuhrman grade ≥3 (HR: 2.3; p < 0.03), nonpulmonary metastases (HR: 3.1; p < 0.03), disease-free interval ≤12 mo (HR: 2.3; p < 0.058), and multiorgan metastases (HR: 2.5; p < 0.04) were independent pretreatment prognostic factors. Leuven-Udine (LU) prognostic groups based on these covariates were created and analysed with Kaplan-Meier and log-rank tests. The 2- and 5-yr CSS were significantly different; the respective group A CSS rates were 95.8% and 83.1%; group B, 89.9% and 56.4%; group C, 65.6% and 32.6%; and group D, 24.7% and 0% (p < 0.0001). ROC analysis on the accuracy of prognostic grouping revealed respective areas under the curve of 0.87 and 0.88 at 2 and 5 yr. Main limitations to present study are the retrospective design and the presence of different metastasis sites.

Conclusions

LU prognostic groups could be considered an accurate clinical tool to stratify patients according to prognosis and aid clinicians in the management of mRCC.     

Treatment with Sunitinib Enabled Complete Resection of Massive Lymphadenopathy not Previously Amenable to Excision in a Patient with Renal Cell Carcinoma

We present a case of previously unresectable lymphadenopathy in a patient with renal cell carcinoma treated with sunitinib. Complete resection of a 15-cm left renal cell carcinoma was initially impossible due to massive retroperitoneal disease and encasement of the great vessels and mesenteric vessels. Residual retroperitoneal disease from a radical nephrectomy was treated with the oral, multitargeted receptor tyrosine kinase inhibitor, sunitinib. Tumour shrinkage following five cycles of treatment allowed uncomplicated complete resection of the lymphadenopathy. Follow-up after 6 mo showed no evidence of disease recurrence.