Clinical T1a Renal Cell Carcinoma Research Articles

MP47-08 SURGICAL DELAY AFTER BIOPSY AND RISK OF UPSTAGING FOR CLINICAL T1A RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 May 2022MP47-08 SURGICAL DELAY AFTER BIOPSY AND RISK OF UPSTAGING FOR CLINICAL T1A RENAL CELL CARCINOMA Leilei Xia, Ruchika Talwar, Raju Chelluri, Daniel Lee, and Thomas Guzzo Leilei XiaLeilei Xia More articles by this author , Ruchika TalwarRuchika Talwar More articles by this author , Raju ChelluriRaju Chelluri More articles by this author , Daniel LeeDaniel Lee More articles by this author , and Thomas GuzzoThomas Guzzo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002618.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal mass biopsy (RMB) has been increasingly used as the initial management of small renal masses. However, little is known about whether surgical delay after the positive biopsy results increases the risk of upstaging for small renal cell carcinomas (RCCs). METHODS: Patients with clinical T1aN0M0 RCCs (≤4cm) diagnosed between 2010 and 2016 who underwent RMB and then partial nephrectomy (PN) or radical nephrectomy (RN) were identified from the National Cancer Database (NCDB). Surgical delay time (SDT) was defined as days between RMB and definitive surgical resection (PN or RN). SDT was categorized into five groups: 1-30 days, 31-60 days, 61-90 days, 91-120 days, and 121-180 days. Upstaging to pT3a was used as the primary outcome of interest. Positive surgical margin (PSM) was used as a secondary outcome and analyses were restricted to PN cohort only. RESULTS: A total of 4,340 patients were included and 237 (5.5%) patients had pT3a upstaging. Of the 2,874 patients who had PN, PSM rate was 8.2%. pT3a upstaging and PSM rates stratified by SDT is shown in the Figure. Multivariable logistic regression showed that compared with SDT of 1-30 days, SDT of 31-60 days (odds ratio [OR]=1.04, P= 0.833), 61-90 days (OR=1.17, P= 0.481), and 91-120 days (OR=1.14, P= 0.631) were not associated with increased odds of pT3a upstaging. Patients with SDT of 121-180 days had a higher risk of pT3a upstaging (OR= 1.93, P=0.016). When STD was ≤ 120 days, multivariable logistic regression with SDT considered as a continuous variable showed increased SDT was also not associated with higher odds of pT3a upstaging (OR=1.002, P=0.461). In the PN cohort, multivariable logistic regressions showed no significant associations between SDT and PSM with SDT either considered as a categorical or continuous variable. CONCLUSIONS: In this NCDB study, increased SDT from RMB to definitive surgical resection of cT1aN0M0 RCCs was not associated with worse oncologic outcomes within 120 days after the RMB but patients with SDT > 120 days might have increased risk of upstaging. These findings have significant implications for patient counseling regarding active surveillance, RMB, and definitive surgical resection for small renal masses. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e812 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leilei Xia More articles by this author Ruchika Talwar More articles by this author Raju Chelluri More articles by this author Daniel Lee More articles by this author Thomas Guzzo More articles by this author Expand All Advertisement PDF DownloadLoading ...

Outcomes of Percutaneous Thermal Ablation for Biopsy-Proven T1a Renal Cell Carcinoma in Patients With Other Primary Malignancies.

OBJECTIVE. The purpose of this article is to investigate the oncologic effectiveness and survival outcomes of percutaneous image-guided thermal ablation for clinical T1a renal cell carcinoma (RCC) in patients with other primary nonrenal malignancies. MATERIALS AND METHODS. We reviewed records of patients with histologically proven T1a RCC (< 4.0 cm) treated with thermal ablation over a period of 10 years between January 2005 and December 2014. We recorded past or current history of primary malignancy other than RCC, status of the primary malignancy, tumor histology (in remission or under therapy), and whether patient was currently alive or not, and if not, the date and reason of death. Three cohorts were studied: patients with RCC only (group A), patients with RCC and other primary malignancy in remission (group B), and patients with RCC and other primary malignancy under treatment (group C). The Kaplan-Meier product-limit estimator was used to estimate the survival rates. RESULTS. One hundred nine patients met the inclusion criteria (109 lesions, 110 ablation procedures). There were 46, 45, and 18 patients in the A, B, and C groups, respectively. The 5-year survival was 87%, 63%, and 40% for groups A, B, and C, respectively. The local recurrence-free survival for the whole sample was 95% at 3, 5, and 10 years. The disease-free survival was 96%, 93%, and 91% at 3, 5, and 10 years. Although a significant difference is noted between the three cohorts in overall survival (p = .02); for RCC, there were no significance differences in the local recurrence-free, disease-free, metastasis-free, and cancer-specific survivals. In addition, there was no difference in outcomes for patients in group B (in remission) when compared with those in group C (under treatment). CONCLUSION. Thermal ablation is an effective and safe modality of treatment of T1a RCC in patients with other primary malignancies that are in remission or under treatment.

Gender Differences in the Clinical Management of clinical T1a Renal Cell Carcinoma

To evaluate gender differences in the management of clinical T1a (cT1a) renal cell carcinoma (RCC) before and after release of the AUA guidelines for management in 2009, which prioritized nephron-sparing approaches. Patients aged ≥66 years diagnosed with cT1a RCC from 2004 to 2013 in Surveillance, Epidemiology, and End Results-Medicare were analyzed. Multivariable mixed-effects logistic regression models were used to evaluate factors associated with radical nephrectomy (RN) for cT1a RCC before (2004 to 2009) and after (2010 to 2013) guidelines release. Predictors of pathologic T3 upstaging and high grade pathology in the postguidelines period were examined using multivariable logistic regression among patients who underwent RN or partial nephrectomy. Twelve thousand four hundred and two patients with cT1a RCC were identified, 42% of whom were women. Overall, the likelihood of RN decreased postguidelines (odds ratio [OR]=0.44, P <.001), but women were at increased odds of undergoing RN both before and after guideline release (OR=1.27, P <.001 and OR=1.37, P <.001, respectively) upon multivariable mixed-effects logistic regression. Tumor size >2 cm was also associated with increased likelihood of RN before and after guidelines (OR=2.61, P <.001 and OR=2.51, P <.001, respectively). In the postguidelines period, women had significantly lower odds of pathologic upstaging (OR=0.75, P=.024) and harboring high grade pathology (OR=0.71, P <.001) compared to men. Gender differences persist in the management of cT1a RCC, with women having higher odds of undergoing RN, even after release of AUA guidelines and despite having lower odds of pathologic upstaging and high-grade disease.

The incidence, predictors, and survival of disappearing small renal masses on active surveillance

ObjectiveTo evaluate the incidence, predictors, and survival for those small renal masses (SRM, solid mass ≤4 cm suspicious for a clinical T1a renal cell carcinoma) that disappear on imaging while undergoing active surveillance (AS). Subjects/patients and methodsThe Delayed Intervention and Surveillance for SRM registry prospectively enrolled 739 patients with SRMs. Patients having at least 1 image showing no lesion were considered to have a “disappearing” SRM. Logistic regression assessed predictors of having a disappearing SRM and Kaplan-Meier estimates illustrated relative survival. ResultsOf 374 patients enrolled in AS, 22 (5.9%) experienced a disappearing SRM. Mean time to tumor disappearance was 2.0 years (SD = 1.9) and 50.0% reappeared on subsequent CT imaging. SRM disappearance, most commonly encountered on ultrasound imaging surveillance, was independently associated with tumors <1 cm on multivariable analysis (OR = 10.6 (95% CI: 1.1–100.3), P = 0.04). Furthermore, patients with disappearing SRMs were healthier than other patients on AS with no compromise in overall survival during follow-up (5-year survival = 100% vs. 73.2%, P = 0.06). ConclusionsApproximately 5% of SRM on AS will disappear during follow-up on surveillance imaging. Most of these represent artifacts of heterogeneous imaging modalities, including ultrasound, and the SRM will reappear on subsequent imaging. Given the indolent nature of these lesions, disappearance events do not require reflex repeat imaging and patients should continue AS with their original surveillance schedule intact. A smaller percentage of patients undergoing AS for a SRM may have a mass the permanently disappears.

A Comparison of Cryoablation with Heat-Based Thermal Ablation for Treatment of Clinical T1a Renal Cell Carcinoma: A National Cancer Database Study

PurposeTo compare the overall survival (OS) of patients receiving cryoablation versus heat-based thermal ablation for clinical T1a renal cell carcinoma (RCC) in a large national cohort. Materials and MethodsPatients with RCC from 2004 to 2014 who were treated with ablation were identified from the National Cancer Database. OS was estimated with the use of the Kaplan-Meier method and evaluated by means of log-rank test, univariate and multivariate Cox proportional hazard regression, and propensity score–matched analysis. ResultsA total of 3,936 patients who received cryoablation and 2,322 who received heat-based thermal ablation met the inclusion criteria. The mean age was 67 ± 12 year, and the mean size of tumors was 25 ± 8 mm. The 3-, 5-, and 10-year survival rates were, respectively, 91%, 82%, and 62% for cryoablation and 89%, 81%, and 55% for heat-based thermal ablation. After propensity score matching, cryoablation was associated with longer OS compared with heat-based thermal ablation (median 11.3 vs 10.4 years; hazard ratio 1.175, 95% CI 1.03–1.341; P = .016). For patients with tumors ≤2 cm, propensity score–matched analyses demonstrated no significant difference between the 2 treatment groups (P = .772). ConclusionsOverall, cryoablation may be associated with longer OS compared with heat-based thermal ablation in cT1a RCC. No significant difference in survival rates was observed between the 2 treatments for patients with tumor sizes ≤2 cm. Owing to the inherent limitations of this study, further study with details on technology, local outcome, and complications is needed.

Tumor location does not impact oncologic outcomes for percutaneous microwave ablation of clinical T1a renal cell carcinoma.

To evaluate the impact of anterior tumor location on oncologic efficacy, complication rates, and procedure duration for 151 consecutive biopsy-proven clinical T1a renal cell carcinoma (RCC) treated with percutaneous microwave (MW) ablation. This single-center retrospective study was performed under a waiver of informed consent. One hundred forty-eight consecutive patients (103 M/45 F; median age 67years, IQR 61-73) with 151 cT1a biopsy-proven RCC (median diameter 2.4cm, IQR 1.9-3.0) were treated with percutaneous MW ablation between March 2011 and August 2017. Patient and procedural data collected included Charlson comorbidity index (CCI), RENAL nephrometry score (NS), use of hydrodisplacement, MW antennas/generator output/time, and procedure time (PT). Data were stratified by anterior, posterior, and midline tumor location and compared with the Kruskal-Wallis or chi-squared tests. The Kaplan-Meier method was used for survival analyses. Tumor size, NS, and use/volume of hydrodisplacement were similar for posterior and anterior tumors (p> 0.05). Patients with anterior tumors had a higher CCI (3 vs 4, p= 0.001). Median PT for posterior and anterior tumors was similar (100 vs 108min, p= 0.26). Single session technical success and primary efficacy were achieved for all 151 tumors including 61 posterior and 67 anterior tumors. The 4 (3%) Clavien III-IV complications and 6 (4%) local recurrences were not associated with tumor location (p> 0.05). Three-year RFS, CSS, and OS were 95% (95% CI 0.87, 0.98), 100% (95% CI 1.0, 1.0), and 96% (95% CI 0.89, 0.98), respectively. The safety and efficacy of percutaneous microwave ablation for anterior and posterior RCC are similar. • The safety profile for percutaneous microwave ablation of anterior and posterior T1a renal cell carcinoma is equivalent. • Percutaneous microwave ablation of T1a renal cell carcinoma provides durable oncologic control regardless of tumor location. • Placement of additional microwave antennas and use of hydrodisplacement are associated with longer procedure times.

03:00 PM Abstract No. 83 Cryoablation therapy compared with thermal ablation for clinical T1a renal cell carcinoma: a National Cancer Data Base study

03:00 PM Abstract No. 83 Cryoablation therapy compared with thermal ablation for clinical T1a renal cell carcinoma: a National Cancer Data Base study

Association between renal mass biopsy and upstaging to perinephric fat involvement in a contemporary cohort of patients with clinical T1a renal cell carcinoma

BackgroundAlthough tumor tract seeding from renal mass biopsy (RMB) is exceedingly rare, the possibility of tumor capsule violation from RMB leading to perinephric fat invasion has not been quantified. We evaluated the association between RMB and perinephric fat invasion in patients with clinical T1a renal cell carcinoma who underwent partial or radical nephrectomy. Materials and MethodsWe reviewed the National Cancer Database from 2010–2013 and identified patients who underwent surgery for clinical T1a tumors. Patients were classified as upstaged only if final pathology demonstrated perinephric invasion only (pT3a). Mixed-effect logistic regression analysis was performed on inverse probability weighted matched groups to identify predictors of perinephric fat invasion. Multivariable Cox proportional hazards models and Kaplan-Meier survival curves were used to evaluate overall survival (OS). ResultsA total of 24,548 patients met our inclusion criteria. Pathologic upstaging to pT3a perinephric fat involvement occurred in 1.2% of patients. This rate of upstaging was 1.1% in the no biopsy group compared with 2.1% in patients who underwent RMB (P < 0.01). In multivariable logistic model, RMB was associated with pT3a perinephric fat upstaging (OR 1.69, 95% CI 1.17–2.44, P < 0.01). Upstaging to pT3a was also associated with worse OS (HR 1.71, 95% CI 1.13–2.60, P = 0.01). Kaplan-Meier survival curves demonstrated similar OS estimates in patients upstaged to pT3a disease, irrespective of undergoing RMB or not (Log-Rank = 0.87). ConclusionRMB was associated with increased rate of upstaging to pT3a perinephric fat involvement in clinical T1a RCC. This effect is small with unclear clinical significance. This is perhaps balanced by the importance of the information acquired from biopsies. Future studies are needed to elucidate clinical significance of this finding.

In Brief

We assessed the relationship of surgical margins across different surgical approaches to partial nephrectomy in patients with clinical T1a renal cell carcinoma in a population based cohort.We used NCDB (National Cancer Database) to identify all patients who underwent partial nephrectomy for clinical T1a renal cell carcinoma (tumor size less than 4 cm) from 2010 to 2011. The primary outcome was surgical margin status in patients treated with partial nephrectomy by the open, laparoscopic or robotic approach. Multivariable logistic regression analysis was done to identify patient, hospital and surgical factors associated with positive surgical margins.Partial nephrectomy was done in 11,587 patients, including open, laparoscopic and robotic nephrectomy in 5,094 (44%), 1,681 (14%) and 4,812 (42%), respectively. Mean ± SD age was 56 ± 12 years. Overall 806 patients (7%) had positive surgical margins. The positive surgical margin prevalence was 4.9%, 8.1% and 8.7% for the open, laparoscopic and robotic approaches, respectively (p <0.001). Laparoscopic and robotic partial nephrectomy had a higher adjusted OR for positive surgical margins (OR 1.81 and 1.79, respectively, each p <0.001) than open nephrectomy. When stratified by hospital type, differences in positive surgical margin rates remained, such that patients treated at academic medical centers who underwent laparoscopic and robotic partial nephrectomy had a higher adjusted OR (1.38, p = 0.074 and 1.73, p <0.001, respectively) than patients treated with open partial nephrectomy.Laparoscopic and robotic partial nephrectomy is associated with higher positive surgical margin rates compared to open partial nephrectomy for clinical T1a renal cell carcinoma. The effect of margin status on long-term oncologic outcomes in this context remains to be determined.

Can partial nephrectomy provide equal oncological efficiency and safety compared with radical nephrectomy in patients with renal cell carcinoma (≥4 cm)? A propensity score–matched study

ObjectiveAlthough partial nephrectomy (PN) is the standard treatment for localized clinical T1a renal cell carcinoma (RCC), treatment of larger renal tumors is controversial. We evaluated the oncological outcomes and perioperative complications after radical and PN for RCC ≥4cm. Patients and methodsWe retrospectively analyzed the data of 2,373 patients surgically treated for nonmetastatic RCC with clinical T1b or T2 (≥4cm). The propensity scores for surgery type were calculated, and the partial group was matched to the radical group in a 1:3 ratio. The oncological outcomes were compared using Kaplan-Meier analysis and multivariate Cox regression models were used to identify the independent predictors of progression-free, cancer-specific, and overall survival. ResultsAll differences in preoperative clinical characteristics disappeared after matching. There were no significant differences in progression-free, cancer-specific, or overall survival between the partial and radical groups in the matched cohort. The patients’ age, tumor size, cellular grade, and pathologic stage were independent predictors for all 3 survival outcomes. However, early complications (<30d postoperative) were significantly more common in the partial group (P<0.001). In a subgroup analysis of the patients with clinical T2 stage, there were no significant differences in all 3 survival outcomes. ConclusionsThe partial and radical nephrectomy groups had equivalent oncological outcomes. Although the early complication rate was significantly higher after PN, it should be considered as a valuable treatment option even in patients with clinical T1b or higher RCC.

Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses

We assessed the relationship of surgical margins across different surgical approaches to partial nephrectomy in patients with clinical T1a renal cell carcinoma in a population based cohort. We used NCDB (National Cancer Database) to identify all patients who underwent partial nephrectomy for clinical T1a renal cell carcinoma (tumor size less than 4 cm) from 2010 to 2011. The primary outcome was surgical margin status in patients treated with partial nephrectomy by the open, laparoscopic or robotic approach. Multivariable logistic regression analysis was done to identify patient, hospital and surgical factors associated with positive surgical margins. Partial nephrectomy was done in 11,587 patients, including open, laparoscopic and robotic nephrectomy in 5,094 (44%), 1,681 (14%) and 4,812 (42%), respectively. Mean±SD age was 56±12 years. Overall 806 patients (7%) had positive surgical margins. The positive surgical margin prevalence was 4.9%, 8.1% and 8.7% for the open, laparoscopic and robotic approaches, respectively (p<0.001). Laparoscopic and robotic partial nephrectomy had a higher adjusted OR for positive surgical margins (OR 1.81 and 1.79, respectively, each p<0.001) than open nephrectomy. When stratified by hospital type, differences in positive surgical margin rates remained, such that patients treated at academic medical centers who underwent laparoscopic and robotic partial nephrectomy had a higher adjusted OR (1.38, p=0.074 and 1.73, p<0.001, respectively) than patients treated with open partial nephrectomy. Laparoscopic and robotic partial nephrectomy is associated with higher positive surgical margin rates compared to open partial nephrectomy for clinical T1a renal cell carcinoma. The effect of margin status on long-term oncologic outcomes in this context remains to be determined.

732 VISCERAL OBESITY AND RISK OF HIGH-GRADE DISEASE IN CLINICAL T1A RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Evaluation & Staging (II)1 Apr 2013732 VISCERAL OBESITY AND RISK OF HIGH-GRADE DISEASE IN CLINICAL T1A RENAL CELL CARCINOMA Yao Zhu, Hong-Kai Wang, and Ding-Wei Ye Yao ZhuYao Zhu Shanghai, China, People's Republic of More articles by this author , Hong-Kai WangHong-Kai Wang Shanghai, China, People's Republic of More articles by this author , and Ding-Wei YeDing-Wei Ye Shanghai, China, People's Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.295AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Accurate assessment of disease characteristics is a prerequisite for treatment decision making in small renal masses. The aim of the current study was to evaluate the association between visceral obesity and Fuhrman grade (FG) in patients with cT1a renal cell carcinoma (RCC). METHODS We retrospectively collected data on 186 patients with surgically treated cT1a RCC. Single-slice computed tomography images were used to measure the area of visceral and subcutaneous adipose tissue. Visceral obesity was calculated as the proportion of visceral adipose tissue to overall adipose tissue (VAT%). Other analyzed factors included clinical characteristics (age, gender, body mass index and tumor size) and anatomic features of the tumor defined by RENAL nephrometry score. The association between predictors and high-grade disease (FG III or IV) were assessed using logistic regression analyses. RESULTS Fourty-seven (25.3%) tumors were classified as high-grade. VAT% was higher in male participants, but didn't correlate with body mass index, age or tumor size. In univariate analyses, VAT% and tumor size were significantly associated with higher FG. Multivariate analysis showed that VAT% (odds ratio=1.06, p=0.0018) and tumor size (odds ratio=1.91, p=0.047) were independent predictors of high-grade cancer. Addition of VAT% to a model including clinical characteristics and anatomic features of the tumor remarkably improved its discriminatory ability (p=0.0010). CONCLUSIONS Increased visceral obesity was found to be strongly associated with higher FG in patients with cT1a RCC. Further studies are needed to confirm these findings and discover the underlying biological mechanism. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e301 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yao Zhu Shanghai, China, People's Republic of More articles by this author Hong-Kai Wang Shanghai, China, People's Republic of More articles by this author Ding-Wei Ye Shanghai, China, People's Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

10-Year Oncologic Outcomes After Laparoscopic and Open Partial Nephrectomy

Open partial nephrectomy has proven long-term oncologic efficacy. Laparoscopic partial nephrectomy outcomes at 5 to 7 years of followup appear comparable to those of the open approach. We present the 10-year outcomes of patients who underwent laparoscopic or open partial nephrectomy for a single clinical stage cT1 7 cm or less renal cortical tumor. Of 1,541 patients treated with partial nephrectomy for a single cT1 tumor between 1999 and 2007 with a minimum 5-year followup, an actual followup of 10 years or greater was available in 45 and 254 after laparoscopic and open partial nephrectomy, respectively. Median followup after laparoscopic and open surgery was 6.6 and 7.8 years, respectively. At 10 years the overall survival rate was 77.2%. The metastasis-free survival rate was 95.2% and 90.0% after partial nephrectomy for clinical T1a and T1b renal cell carcinoma, respectively (p <0.0001). Baseline differences between patients treated with laparoscopic and open partial nephrectomy accounted for most observed differences between the cohorts. The median glomerular filtration rate decrease was 16.9% after the laparoscopic approach and 14.1% after the open approach (p = 0.5). On multivariable analysis predictors of all cause mortality included advancing age (HR 1.52/10 years, p <0.0001), comorbidity (HR 1.33/1 U, p <0.0001), absolute indication (HR 2.25, p = 0.003) and predicted recurrence-free survival (HR 1.58/10% increased risk, p = 0.004) but not laparoscopic vs open operative approach (p = 0.13). Similarly, predictors of metastasis included absolute indication (HR 4.35, p <0.0001) and predicted recurrence-free survival (HR 2.67, p <0.0001) but not operative approach (p = 0.42). The 10-year outcomes of laparoscopic nephrectomy and open partial nephrectomy are excellent in carefully selected patients with limited risk of recurrence for cT1 renal cortical tumors. Overall survival at 10 years is mediated by patient factors such as age, comorbidity and operative indication, and by cancer factors such as predicted recurrence-free survival but not by the choice of operative technique, which depends on surgeon preference and experience.

Visceral Obesity and Risk of High Grade Disease in Clinical T1a Renal Cell Carcinoma

Accurate assessment of disease characteristics is a prerequisite for treatment decision making regarding small renal masses. In this study we evaluate the association between visceral obesity and Fuhrman grade in patients with cT1a renal cell carcinoma. We retrospectively collected data on 186 patients with surgically treated cT1a renal cell carcinoma. Single slice computerized tomography was used to measure the area of visceral and subcutaneous adipose tissue. Visceral obesity was calculated as the proportion of visceral adipose tissue to overall adipose tissue. Other analyzed factors included clinical characteristics (age, gender, body mass index and tumor size) and anatomical features of the tumor defined by the R.E.N.A.L. nephrometry score. The association between predictors and high grade disease (Fuhrman grade III or IV) were assessed using logistic regression analyses. A total of 47 (25.3%) tumors were classified as high grade. The percentage of visceral adipose tissue was higher in male participants but did not correlate with body mass index, age or tumor size. In univariate analyses the percentage of visceral adipose tissue and tumor size were significantly associated with higher Fuhrman grade. Multivariate analysis showed that the percentage of visceral adipose tissue (OR 1.06, p = 0.0018) and tumor size (OR 1.91, p = 0.047) were independent predictors of high grade cancer. Addition of the percentage of visceral adipose tissue to a model including clinical characteristics and anatomical features of the tumor remarkably improved its discriminatory ability (p = 0.0010). Increased visceral obesity was found to be strongly associated with higher Fuhrman grade in patients with cT1a renal cell carcinoma. Further studies are needed to confirm these findings and discover the underlying biological mechanism.

Editorial Comment to Similar functional outcomes after partial nephrectomy for clinical T1b and T1a renal cell carcinoma

Editorial Comment to Similar functional outcomes after partial nephrectomy for clinical T1b and T1a renal cell carcinoma

Similar functional outcomes after partial nephrectomy for clinical T1b and T1a renal cell carcinoma

To examine the medium-term functional outcomes of partial nephrectomy for clinical T1b renal cell carcinoma, and to compare them with those of radical nephrectomy for clinical T1b and with those of partial nephrectomy for clinical T1a tumors. The participants of this study were patients operated for clinical T1a and clinical T1b tumors operated at Tokyo Women's Medical University, Tokyo, Japan, between January 1979 and June 2011. A total of 67 patients underwent partial nephrectomy for clinical T1b tumor, 195 patients underwent radical nephrectomy for clinical T1b tumors and 324 underwent partial nephrectomy for clinical T1a tumors. The outcomes of these three groups were compared. Partial nephrectomy provided better preservation of residual renal function compared with radical nephrectomy for clinical T1b, and the postoperative estimated glomerular filtration rate was similar in the patients who underwent partial nephrectomy for clinical T1b and those who underwent partial nephrectomy for clinical T1a. Postoperative renal function was steadily maintained after partial nephrectomy during the medium-term follow up. The probability of freedom from new onset of chronic kidney disease after partial nephrectomy for clinical T1b tumors was significantly higher from that after radical nephrectomy for clinical T1b tumors, and similar to that after partial nephrectomy for clinical T1a tumors. The higher anatomical complexity of clinical T1b tumors is unlikely to provide a significant influence on postoperative renal function after partial nephrectomy, when compared with the clinical T1a tumors. These findings support the beneficial role of partial nephrectomy in the preservation of renal function of clinical T1b renal cell carcinoma patients undergoing surgery.

P1.29 Visceral Obesity is Associated With Increased Risk of High-Grade Disease in Clinical T1A Renal Cell Carcinoma

ABSTRACT Objective Accurate assessment of disease characteristics is a prerequisite for treatment decision making in small renal mass. Recent evidence suggests visceral adipose tissue is an important metabolic tissue and secretes factors that systemically alter the metabolic, endocrine and immunological milieu. The aim of the current study was to evaluate the association between visceral obesity and Fuhrman grade (FG) in a cohort of cT1a renal cell carcinoma (RCC). Material and Methods We retrospectively collected 197 patients with surgically treated cT1a RCC from January 2008 to January 2012. In each subject, a single sliced computed tomography image was used to measure the area of visceral and subcutaneous adipose tissue (Figure 1). The percentage of visceral adipose tissue (VAT%) was calculated as the area of visceral adipose tissue divided by the area of total adipose tissue. Other analyzed factors included clinical characteristics (age, gender, body mass index and tumor size) and tumor's anatomic features defined by RENAL nephrometry score. High grade tumor was defined as FG III or IV. Results Fifty-one (25.9%) tumors were classified as high grade. VAT% was increased in male participants, but didn't correlate with body mass index, age and tumor size. Multivariate analysis showed that tumor size (odds ratio = 1.82, p = 0.046) and VAT% (odds ratio = 1.05, p = 0.0026) were significant predictors of high grade cancer. Addition of VAT% to the model included clinical characteristics and tumor's anatomic features remarkably improved the discrimination ability (p = 0.0015) (Figure 2). Conclusions Increased visceral obesity was found to strongly associate with higher FG in cT1a RCC. The new prognostic factor provided a distinctive value other than clinical characteristics and tumor's anatomic features. Further studies are needed to confirm these findings and discover the underlying biological mechanism. Funds: Supported by National Natural Science Foundation of China (Project 81001131). Download : Download full-size image Fig. 1 . Representative examples of the measurement of visceral adipose tissue and subcutaneous adipose tissue in computed tomography images. Download : Download full-size image Fig. 2 . Receiver operating characteristic curves for high grade disease in clinical T1a renal cell carcinoma. The curves represent 3 multivariate models.

Population‐based comparative effectiveness of nephron‐sparing surgery vs ablation for small renal masses

To determine, in a population-based cohort, if disease-specific survival (DSS) was equivalent in patients undergoing ablation vs nephron-sparing surgery (NSS) for clinical stage T1a renal cell carcinoma (RCC). A retrospective cohort study was performed using patients from the Surveillance, Epidemiology and End Results cancer registry with RCC < 4 cm and no evidence of distant metastases, who underwent ablation or NSS. Kaplan-Meier and Cox regression analyses were performed to determine if treatment type was independently associated with DSS. Between 1998 and 2007, a total of 8818 incident cases of RCC were treated with either NSS (7704) or ablation (1114). The median (interquartile range) follow-up was 2.8 (1.2-4.7) years in the NSS group and 1.6 (0.7-2.9) years in the ablation group, although 10% of each cohort were followed up beyond 5 years. After multivariable adjustment, ablation was associated with a twofold greater risk of kidney cancer death than NSS (hazard ratio 1.9, 95% confidence interval 1.1-3.3, P= 0.02). Age, gender, marital status and tumour size were also significantly associated with outcome. The predicted probability of DSS at 5 years was 98.3% with NSS and 96.6% with ablation. After controlling for age, gender, marital status and tumour size, the typical patient presenting with clinical stage T1a RCC, who undergoes ablation rather than NSS, has a twofold increase in the risk of kidney cancer death; however, at 5 years the absolute difference is small, and may only be realized by patients with long life expectancies.

Radiofrequency Ablation Versus Partial Nephrectomy in Patients with Solitary Clinical T1a Renal Cell Carcinoma: Comparable Oncologic Outcomes at a Minimum of 5 Years of Follow-Up

BackgroundLong-term comparative outcomes for radiofrequency ablation (RFA) versus partial nephrectomy (PN) for the primary treatment of clinical T1a renal cell carcinoma (RCC) have not previously been reported. ObjectiveReport comparative 5-yr oncologic outcomes for RFA versus PN in patients with clinical T1a RCC. Design, setting, and participantsObservational single-institution cohort study, involving consecutive patients with a solitary histologically confirmed T1a RCC treated by RFA or PN and followed for a minimum of 5 yr. Those presenting with synchronous multiple, metachronous, bilateral, and/or metastatic disease, a history of hereditary RCC syndromes, a family history of RCC, and with post-treatment follow-up <5 yr were excluded from analysis. MeasurementsThe Kaplan-Meier method was used to determine 5-yr overall survival (OS), cancer-specific survival (CSS), local recurrence-free survival (local RFS), overall disease-free survival (DFS), and metastasis-free survival (MFS) for RFA versus PN. Survival curves were compared using the log-rank test. A p value ≤0.05 was considered statistically significant. Results and limitationsA total of 37 patients in each group met the selection criteria. The RFA cohort was significantly older and had more advanced comorbidities, but other patient characteristics were similar. For RFA versus PN, median follow-up was 6.5 yr (interquartile range [IQR]: 5.8–7.1) versus 6.1 yr (IQR: 5.4–7.3) (p=0.68), respectively. The 5-yr OS was 97.2% versus 100% (p=0.31), CSS was 97.2% versus 100% (p=0.31), DFS was 89.2% versus 89.2% (p=0.78), local RFS was 91.7% versus 94.6% (p=0.96), and MFS was 97.2% versus 91.8% (p=0.35), respectively. Study limitations are retrospective data analysis, loss to follow-up, limited statistical power, and limited generalizability of our data. ConclusionsIn appropriately selected patients, RFA is an effective minimally invasive therapy for the treatment of cT1a RCC, yielding comparable long-term oncologic outcomes to nephron-sparing surgery.

Persistent Overuse of Radical Nephrectomy in the Elderly

To analyze the use of radical nephrectomy (RN) and partial nephrectomy during a 10-year period in patients aged≥75 years compared with their younger counterparts. Using the Surveillance, Epidemiology, and End Results registry, we identified 18 045 cases of localized renal cell carcinoma of ≤4 cm diagnosed from 1998 to 2007. The baseline differences in demographic and tumor characteristics were compared between the 2 age cohorts (<75 vs ≥75 years), and the rates of RN were determined, stratified by tumor size. A multivariate logistic regression analysis was conducted to predict the odds of undergoing radical nephrectomy for clinical Stage T1a disease. Overall, 2733 patients (15%) were aged≥75 years. The use of radical nephrectomy for clinical Stage T1a renal cell carcinoma decreased during the study period for all patients (79% in 1998 to 49% in 2007). Overall, 66% of patients aged≥75 years underwent RN for their disease compared with 59% of patients aged<75 years (P<.001). For patients with tumors of ≤2 cm, 51% of those aged≥75 years underwent RN compared with 41% of the younger cohort. In a multivariate logistic regression model, age≥75 years independently predicted the use of radical nephrectomy (odds ratio 1.18, 95% confidence interval 1.08-1.29). A 1-year increase in age was associated with a 1% increase in the risk of undergoing RN (odds ratio 1.01, 95% confidence interval 1.01-1.01). Elderly patients with clinically localized small renal masses are treated with RN more frequently than younger patients. Additional studies should address the medical implications of the increased use of radical surgery within the geriatric population.