Oncologic and Functional Outcomes of Radical and Partial Nephrectomy in pT3a Pathologically Upstaged Renal Cell Carcinoma: A Multi-institutional Analysis

BackgroundThe efficacy of partial nephrectomy (PN) in setting of pT3a pathologic-upstaged renal cell carcinoma (RCC) is controversial. We compared oncologic and functional outcomes of radical nephrectomy (RN) and PN in patients with upstaged pT3a RCC.Patients and MethodsThis was a multicenter retrospective analysis of patients with cT1-2N0M0 RCC upstaged to pT3a postoperatively. The primary outcome was recurrence-free survival, with secondary outcomes of overall survival and de novo estimated glomular filtration rate (eGFR) < 60. Multivariable analysis was performed to identify predictive factors for oncologic outcomes. Kaplan-Meier analyses (KMA) were obtained to elucidate survival outcomes.ResultsA total of 929 patients had pT3a upstaging (686 [72.6%] RN; 243 [25.7%] PN; mean follow-up, 48 months). Tumor size was similar (RN 7.7 cm vs. PN 7.3 cm; P = .083). PN had decreased ΔeGFR (6.1 vs. RN 19.4 mL/min/1.73m²; P < .001) and de novo eGFR < 60 (9.5% vs. 21%; P = .008). Multivariable analysis for recurrence showed increasing RENAL score (hazard ratio [HR], 3.8; P < .001), clinical T stage (HR, 1.8; P < .001), positive margin (HR, 1.57; P = .009), and high grade (HR, 1.21; P = .01) to be independent predictors, whereas surgery was not (P = .076). KMA revealed 5-year recurrence-free survival for cT1-upstaged PN, cT1-upstaged RN, cT2-upstaged PN, and cT2-upstaged RN of 79%, 74%, 70%, and 51%, respectively (P < .001). KMA revealed 5-year overall survival for cT1-upstaged PN, cT1-upstaged RN, cT2-upstaged PN, and cT2-upstaged RN of 64%, 65.2%, 56.4%, and 55.2%, respectively (P = .059).ConclusionsIn pathologically upstaged pT3a RCC, PN did not adversely affect risk of recurrence and provided functional benefit. Surgical decision-making in patients at risk for T3a upstaging should be individualized and driven by tumor as well as functional risks.     

部分切除术与根治术治疗pT1bN0M0期肾癌的临床疗效对比

目的 比较肾癌部分切除术（partial nephrectomy, PN）和肾癌根治术（radical nephrectomy, RN）治疗pT1bN0M0期肾癌的临床疗效及预后评估,为pT1b期肾癌的治疗选择提供参考。方法 回顾性研究湖北省肿瘤医院从2004年1月至2010年12月诊断为pT1bN0M0的肾癌患者（PN=16例,RN=52例）。比较两组之间的5年总生存率（overall survival, OS）,5年无复发生存率（recurrence-free survival, RFS）,和5年癌症特异性生存率（cancer-specific survival, CSS）。同时收集了术前和术后肌酐和肾小球滤过率（estimated glomerular filtration rate, eGFR）以评价肾功能的改变。结果 PN与RN的5年OS（90.3% vs. 88.6%, P=0.552）、RFS（90.3% vs. 75.4%, P=0.121）和CSS（90.3% vs. 92.8%, P=0.875）方面差异均无统计学意义。而术后肾功能下降患者所占比例在PN组显著优于RN组（0 vs. 12.6%, P<0.01）。术后一年血肌酐和eGFR水平在RN组中要高于PN组 [（0.3±0.6）vs.（0.2±0.1）、（20.1±12.6）vs.（9.8±12.1）],但是差异无统计学意义（P=0.115, P=0.064）。结论 PN或RN对于pT1bN0M0期肾癌的治疗在预后和安全性方面差异均无统计学意义,PN术后肾功能指标显著优于RN,PN是治疗pT1b期肾癌的一个可行方案。     

Percutaneous Ablation Versus Robotic Partial Nephrectomy in the Treatment of cT1b Renal Tumors: Oncologic and Functional Outcomes of a Propensity Score-weighted Analysis

IntroductionThe purpose of this study was to assess oncologic and functional outcomes of both percutaneous ablation (cryoablation and radiofrequency ablation) and robot-assisted partial nephrectomy (RAPN) in the treatment of renal tumors larger than 4 cm.Materials and MethodsWe retrospectively analyzed prospectively collected data from 102 consecutive patients, who underwent minimally invasive treatment for cT1b renal tumors at our institution. Primary renal function outcome was assessed by estimated glomerular filtration rate preservation at baseline and 1 year postoperatively. Perioperative data and functional and oncologic outcome were collected. Multivariate regression models were used to compare functional outcomes between groups. Cancer-specific survival and recurrence-free survival were estimated at 2 years using the Kaplan-Meier method and compared with Cox proportional hazards regression model to calculate hazard ratios (HRs). To control for selection bias between the different treatments, we adjusted our models with an inverse probability of treatment weighting propensity score.ResultsThere was no significant difference in renal preservation between the groups (P = .664). Multivariate analysis did not show a statistically significant difference in terms of renal function outcomes between the RAPN and percutaneous thermal ablation groups. The adjusted HR regarding the local recurrence-free survival was significantly shorter for the cryoablation group (HR, 4.3; 95% confidence interval, 1.78-10.37; P = .001).ConclusionsOur study demonstrated the equivalence between RAPN and percutaneous ablative techniques for the preservation of renal function in the treatment of T1b tumors. RAPN offers a better local control than percutaneous ablation, in terms of primary success rate.     

Oncologic Outcomes of Partial Nephrectomy for Stage T3a Renal Cell Cancer

Background

Partial nephrectomy (PN) for clinical stage T3 tumors is controversial. Radical nephrectomy (RN) has been associated with a greater rate of chronic kidney disease, an increased risk of cardiovascular disease, and increased mortality compared with PN. We present our long-term 2-center experience with PN for stage pT3a tumors and compare the oncologic outcomes with those of similar patients treated with RN.

Differing Risk of Cancer Death Among Patients With Pathologic T3a Renal Cell Carcinoma: Identification of Risk Categories According to Fat Infiltration and Renal Vein Thrombosis

ObjectivesThe study objectives were to evaluate the prognostic impact of fat infiltration and renal vein thrombosis in patients with pT3a renal cell carcinoma (RCC) and to identify new prognostic groups.Material and MethodsWe analyzed 122 consecutive patients with pT3a who underwent radical nephrectomy for RCC between 2000 and 2011 at the University of Bologna. Cancer-specific survival (CSS) rates were estimated using Kaplan–Meier survival curves; univariable and multivariable analyses were performed with Cox analysis.ResultsThe mean follow-up was 41.7 ± 35.4 months. Patients with peritumoral/hilar fat infiltration (n = 63) and patients with renal vein thrombosis (n = 18) experienced comparable CSS rates, whereas patients with both fat infiltration plus renal vein thrombosis (n = 41) showed worse survival outcomes than the first group (P = .026). Patients were divided in 2 groups: group A, with fat invasion or renal vein thrombosis, and group B, with concomitant fat invasion and renal vein invasion. Group B showed worse cancer-specific survival than group A (P = .024). At multivariate analysis, this new risk-group stratification was found to be an independent prognostic predictor of CSS (P < .05).ConclusionsPatients with T3a RCC with both fat invasion and renal vein thrombosis experience worse survival rates when compared with those patients with only 1 prognostic factor. The TNM classification should consider the concomitant presence of those parameters as a different prognostic predictor.     

The Effect of Patient and Surgical Characteristics on Renal Function After Partial Nephrectomy

Background

The purpose of the study was to identify patient and disease characteristics that have an adverse effect on renal function after partial nephrectomy.

Prognosis in Renal Cell Carcinoma: Analysis of Clinical Course following Nephrectomy

The clinical courses and survivals of 159 patients who underwentnephrectomy for renal cell carcinoma are reviewed. A longerdiseae-free period after nephrectomy was correlated with significantlybetter survival. Among patients in whom metastases in the lungsor bones were detected after nephrectomy, those with betweenone and five pulmonary or solitary bone metastases, wihtoutdefinite increases in their number and size in the six monthsfollowing their first appearance, survived significantly longerthan patients with a similar number of metastases but whichdid increase in number and size in the following six months,or patients with six or more pulmonary or multiple bone metastases.Even when metastases detected after nephrectomy were confinedto the lungs or bones throughout the observation period, thepatients did not necessarily show significantly better survivalsthan patients with metastases detected in multiple sites.     

Factors Associated With Receipt of Partial Nephrectomy or Minimally Invasive Surgery for Patients With Clinical T1a and T1b Renal Masses: Implications for Regionalization of Care

PurposeTo identify factors associated with receipt of partial nephrectomy (PN) and minimally invasive surgery (MIS) in patients with clinical T1 renal cell carcinoma (RCC) using the National Cancer Data Base (NCDB).MethodsWe queried the NCDB from 2010 to 2014 identifying patients treated surgically for cT1a-bN0M0 RCC. Logistic regression was used to examine associations between socioeconomic, clinical, and treatment factors, and receipt of MIS or PN within the T1 patient population.ResultsOur cohort included 69,694 patients (cT1a, n = 44,043; cT1b, n = 25,651). For cT1a tumors, 70% of patients received PN and 65% underwent MIS. For cT1b tumors, 32% of patients received PN and 62% underwent MIS. cT1a and cT1b patients with household income < $62,000, without private insurance, and treated outside academic centers were less likely to receive MIS or PN. cT1a patients traveling > 31 miles were more likely to undergo MIS. For both cT1a/b, the farther a patient traveled for treatment, the more likely a PN was performed.ConclusionData showed an increase in utilization of MIS and PN from 2010 to 2014. However, patients in the lowest socioeconomic groups were less likely to travel and were more likely to receive more invasive treatments. On the basis of these findings, additional research is needed into how regionalization of RCC surgery affects treatment disparities.     

Spontaneous Renal Cell Tumors in Long-Evans Cinnamon Rats

Neoplastic lesions of the kidneys in untreated Long-Evans Cinnamon (LEC) rats of 57–118 weeks old (85 males and 34 females) and male F344 rats of 64–93 weeks old (59 males) were examined histologically. The incidences of renal cell tumors in male and female LEC rats were 6/80 (8%) in weeks 57–65, 3/19 (16%) in weeks 66–75, 3/8 (38%) in weeks 76–105 and 7/12 (58%) in weeks 106–118. Of these tumors, 13 were microscopic adenomas and 7 were renal cell carcinomas. The copper content of the kidneys was about three times higher in LEC rats than in F344 rats ( P <0.001), but the iron content of the kidneys was similar in the two strains.     

The Necessity of Cytoreductive Nephrectomy in Patients With Metastatic Renal Cell Carcinoma Using Antiangiogenic Targeted Therapy After Interferon Alfa-2b

BackgroundTargeted therapy has improved the survival of patients with metastatic RCC. In the present study, we evaluated whether there was an effect of cytoreductive surgery on prognosis of patients with metastatic RCC using antiangiogenic tyrosine kinase inhibitor (TKI) agents.Patients and MethodsA total of 52 patients with metastatic RCC from Akdeniz University, Afyon Kocatepe University, and Medipol University participated in the study. All the patients had received targeted antiangiogenic therapy after interferon alfa-2b. According to previous CRN, the patients were divided into 2 groups as CRN (+) and CRN (−).ResultsThe CRN (+) group was younger than the CRN (−) group (P < .001) and the hemoglobin levels were significantly higher in the CRN (+) group (P = .023). The median progression-free survival time from the date of starting TKIs were 8.5 and 3.0 months for the CRN (+) and CRN (−) groups, respectively (P = .104). The median overall survival was 15.1 and 5.4 months for the CRN (+) and CRN (−) groups, respectively (P = .034).ConclusionWe speculate that CRN is still an important part of treatment modalities in patients with metastatic RCC in modern era targeted therapy, which is currently the best systemic therapy. However, the indications of CRN might be limited to good-risk patients with metastatic RCC. Further randomized studies are warranted to clarify the necessity of CRN in patients with metastatic RCC.     

Application of 3-D Printed Kidney Model in Partial Nephrectomy for Predicting Surgical Outcomes: A Feasibility Study

Three-dimensional printing is likely to revolutionize clinical practice, and urologic surgeons could greatly benefit from early adoption of this technology. Additionally, 3-D printed kidney models have the potential to improve patients’ understanding of their disease, which might ultimately result in better patient satisfaction. Overall, the use of 3-D printed models improves the efficacy of surgical procedures because they facilitate surgical planning, simplify the orientation of the target tissue, explain risk structure, and predict renal function postoperatively, thereby possibly improving surgical outcomes.     

Efficacy of sunitinib in patients with metastatic or unresectable renal cell carcinoma and renal insufficiency

AimThe aim of this retrospective, registry-based study was to analyse treatment outcomes in patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib and renal insufficiency (RI).MethodsThe cohort included 790 patients treated with sunitinib between 2006 and 2013. At the start of sunitinib therapy 22, 234, and 534 patients had severe (glomerular filtration rate [GFR] <30 ml/min/1.73 m²), moderate (GFR 30–60 ml/min/1.73 m²) or mild RI/normal renal function (GFR >60 ml/min/1.73 m²), respectively.ResultsFor the three groups defined above, median progression-free survival (PFS) (95% confidence interval [CI]) was 5.3 months (0.1–18.5), 8.1 months (6.2–9.9) and 11.3 months (9.4–13.2) (p = 0.244), and median overall survival (OS) was 26.3 months (1.2–51.4), 21.2 months (13.2–29.1) and 26.3 months (22.6–29.9) (p = 0.443), respectively. The disease control rates were 45.5%, 56.4% and 59.2%, respectively (p = 0.374). No unexpected toxicity was reported in the patients with RI, but the treatment was more frequently discontinued because of adverse events and the duration of therapy was significantly shorter in these patients (p = 0.007).ConclusionsDuration of first-line targeted treatment for mRCC was significantly shorter for patients with RI, and may have translated into a trend to shorter PFS. These results highlight the need for optimal management of side-effects in patients with mRCC and RI.     

The Impact of Frozen Section Analysis During Partial Nephrectomy on Surgical Margin Status and Tumor Recurrence: A Clinicopathologic Study of 433 Cases

BackgroundFrozen section analysis (FSA) is frequently performed during partial nephrectomy (PN) to ensure complete tumor resection. We investigate the utility of intraoperative FSA by evaluating its impact on final surgical margin (SM) status and on patient outcomes.Patients and MethodsWe retrospectively analyzed a consecutive series of patients (n = 433, including 326 with renal cell carcinomas [RCCs]) undergoing PN (n = 447; 136 open/311 laparoscopic) for a suspected renal tumor at the University of Rochester Medical Center from 2004 to 2012.ResultsFSA was performed in 293 patients (67.7%) undergoing 300 PNs (67.1%). Overall, positive SMs were found significantly more often (P < .001) in the no FSA group (17.7%) than in the FSA group (4.3%). Performing FSA also resulted in significant decreases in the rate of positive SM in the following subgroups of patients with RCC undergoing PN laparoscopically: clear-cell (P = .002)/papillary (P = .041) subtypes, upper (P = .004)/mid (P = .022) pole tumors, exophytic (P = .029)/endophytic (P = .014) tumors, pT1a (P < .001)/pT1 (P < .001) tumors, and Fuhrman grades 1 to 2 (P = .004)/2 (P = .007) tumors. Kaplan–Meier analysis in RCC cases revealed that FSA did not considerably contribute to preventing recurrence (P = .114). However, performing FSA during laparoscopic PN strongly correlated with improved recurrence-free survival in patients with pT1 (P = .004) or exophytic (P = .011) RCC. No impact of FSA on recurrence was seen in any subgroup of patients undergoing open surgery.ConclusionsAlthough FSA reduces the risk of positive SMs, our data may argue against routine FSA during PN that does not affect patient outcomes overall. However, FSA may be useful in select patients who have pT1 or exophytic tumor and undergo laparoscopic PN.     

Regression of Pulmonary and Multiple Skeletal Metastases from Renal Cell Carcinoma by Nephrectomy and Alpha-interferon Therapy: A Case Report

We report a rare case of advanced renal cell carcinoma in apatient who showed complete resolution of metastases to thelung and bones after nephrectomy, partial jejunectomy and subsequentalpha-interferon therapy. The patient was a 54-year-old manwhose right lung and left femur metastases were detected beforenephrectomy. In the seventh week after nephrectomy, a partialjejunectomy was carried out because of the obstructive ileuscaused by intraluminal multiple metastases of the jejunum. Apathological fracture of the metastasized right humerus occurredsubsequently. After four months of intramuscular alpha-interferonadministration (3x106 units/day), however, x-rays revealed thecomplete disappearance of the metastatic lung shadow and a solidunion of the humerus, and there were no tumor cells in the femurspecimen resected at the subsequent reconstruction surgery ofthe left leg. Seven years have passed from onset, and the patientis still alive and disease free.     

Overall survival and renal function after partial and radical nephrectomy among older patients with localised renal cell carcinoma: A propensity-matched multicentre study

BackgroundThis study aimed to evaluate the overall survival (OS) rate and renal function after radical nephrectomy (RN) and partial nephrectomy (PN) in patients aged ⩾65 years.MethodsPatients who underwent RN (n = 622) or PN (n = 622) for renal cell carcinoma (pT1N0M0) between 1999 and 2011 were propensity-score matched in our multicentre database. To investigate the relative effect of PN on OS according to age, we divided the patients into two age subgroups (<65 and ⩾65 years). The 5-year OS rates and probabilities of freedom from chronic kidney disease (CKD III or IV) were estimated using the Kaplan–Meier method and separate Cox proportional hazards models.ResultsThe 5-year OS rates after surgery were 94.7% for PN and 91.9% for RN in the older patients (P = 0.698). The corresponding rates in the younger patients were 99.7% for PN and 96.3% for RN (P = 0.015). In separate Cox hazards models for OS, the older patients who underwent PN were not significantly different from their RN-treated counterparts (hazard ratio (HR): 0.960; 95% confidence interval (CI): 0.277–2.321, P = 0.797). Kidney function was significantly better preserved after PN than after RN at all ages. However, stage IV CKD in the older patients did not occur more frequently in the RN arm than in the PN arm.ConclusionsAlthough PN was associated with improved renal function compared with RN, it did not confer a benefit of higher survival rate in elderly patients (⩾65 years old).     

Renal Functional Outcome of Partial Nephrectomy for Complex R.E.N.A.L. Score Tumors With or Without Neoadjuvant Sunitinib: A Multicenter Analysis

Background

Sunitinib might optimize the feasibility of partial nephrectomy (PN) for complex renal tumors with imperative indications. We compared the renal functional outcomes of patients with complex renal masses who had undergone sunitinib before PN with those of patients who had not required neoadjuvant sunitinib before PN.

The Relationship Between Red Cell Distribution Width and Cancer-Specific Survival in Patients With Renal Cell Carcinoma Treated With Partial and Radical Nephrectomy

Introduction

The aim of the study was to evaluate the influence of red cell distribution width (RDW) on cancer-specific survival (CSS) in patients who undergo nephrectomy for renal cell carcinoma (RCC).

Real-world Experience of Cabozantinib as Second- or Subsequent Line Treatment in Patients With Metastatic Renal Cell Carcinoma: Data From the Polish Managed Access Program

BackgroundCabozantinib is an approved treatment for metastatic renal cell carcinoma (mRCC). This report presents an analysis of the safety profile and efficacy of cabozantinib in an unselected population from Poland.Patients and MethodsPatients with mRCC, who had been treated with at least 1 previous agent targeting the vascular endothelial growth factor pathway, were eligible to receive cabozantinib at a once-daily dose of 60 mg orally, according to the Managed Access Program (MAP). Data were collected in 4 Polish centers. Patients who had received ≥ 1 dose of cabozantinib were monitored for adverse events (AEs) using Common Terminology Criteria for Adverse Events (CTCAE) v.4.0.ResultsA total of 115 patients were enrolled between October 2016 and March 2018, including 50% with bone metastases, 10% with brain metastases and 4.3% with non–clear-cell RCC; 76% had received ≥ 2 lines of therapy. The median time of follow-up was 12.6 months (95% confidence interval [CI], 11.5-14.1 months). The most common grade 3 and 4 AEs were fatigue (23%), hand-foot syndrome (12%), and diarrhea (10%). Only 4% of patients discontinued treatment owing to AEs, and there were no treatment-related deaths. Partial response was observed in 19% of patients, whereas 56% had stable disease. The median progression-free survival was 12.5 months (95% CI, 9.2-14.2 months), with a 12-month overall survival rate of 70.4% (95% CI, 60.2%-78.5%).ConclusionsCabozantinib demonstrated acceptable tolerability and activity in a large unselected population of patients with mRCC under clinical conditions.