Radical Nephrectomy For Renal Cell Carcinoma Research Articles

Robot-assisted radical nephrectomy for renal-cell carcinoma during twin pregnancy

Large renal masses are rare findings in pregnant patients and generate complex challenges regarding when and how to treat. We report a case of a 23-year-old woman found to have a large renal mass during twin pregnancy. Here we describe the evaluation and decision making for this patient who was ultimately treated with robot-assisted radical nephrectomy during her pregnancy.

Creatinine to cystatin C ratio and mortality in renal cell carcinoma.

697 Background: Creatinine and cystatin C are routinely used to assess renal function. Given creatinine originates from skeletal muscle and cystatin C is produced by nucleated cells, a creatinine to cystatin C ratio (Cr/Cys-C) may positively correlate with muscle mass. Low Cr/Cys-C has also been associated with decreased overall survival (OS) in cancer, including in a combined cohort of genitourinary malignancies. Furthermore, elevated cystatin c has been associated with shorter OS and recurrence free survival (RFS) in renal cell carcinoma (RCC). Cr/Cys-C may be a simple and affordable tool to assist with patient-specific risk stratification. We assess the ability of Cr/Cys-C to predict OS and RFS in patients with RCC. Methods: Retrospective review of a prospectively maintained database identified patients that underwent partial or radical nephrectomy for RCC from 2018-2021. Included patients had preoperative creatinine and cystatin C and 1+ year of follow up. Cr/Cys-C associations with patient/tumor characteristics were determined by generalized chi-square or Fisher’s exact tests for categorical variables and Wilcoxon rank-sum test for continuous variables. Cr/Cys-C ability to predict OS and RFS was analyzed with Kaplan-Meier method and Cox hazards models. Statistical tests were two-sided with type I error set at 0.05. Results: 219 patients were identified. Median age was 64, with most being male (67%). 62% and 29% of patients were white and black, respectively. Median eGFR was 72mL/min/1.73m2. Median (IQR) Cr/Cys-C was 1 (0.8-1.2). 55% were stage T3-T4, with 12% N1 and 16% M1 at time of surgery. 72% had clear cell histology. Low Cr/Cys-C was significantly associated with older age, males, Eastern Cooperative Oncology Group score ≥ 1, radical nephrectomy, T3-T4 stage, and metastasis. Kaplan-Meier curves showed low Cr/Cys-C association with decreased OS (p=0.0003) and RFS (p=0.0094). Cox regression analysis revealed lower Cr/Cys-C as independent predictor of decreased OS (binary HR=3.66, 95% CI 1.2-11.3, p=0.02; continuous HR=0.05, 95% 0.0-0.8, p=0.03) and RFS (binary HR=4.8, 95% CI 1.6-14.6, p=0.006; continuous HR=0.02, 95% 0.0-0.3, p=0.006;Table). Conclusions: Lower Cr/Cys-C may be associated with decreased OS and RFS in patients with RCC. [Table: see text]

Validating the Palacios’ future glomerular filtration rate equation with and without race.

616 Background: Accurate prediction of future glomerular function rate (fGFR) following nephrectomy in renal cell carcinoma (RCC) patients is of interest. A postoperative estimated glomerular filtration (eGFR) rate ≥ 45 mL/min/1.73m2 is considered favorable, with guidelines reflecting these findings. Though nephron sparing surgery is preferable, radical nephrectomy is often the preferred oncologic surgery. Various models to predict postoperative renal function have been proposed, with a new 2021 equation by Palacios et al. exhibiting strong performance in predicting fGFR. We aim to validate this fGFR equation in a large institutional cohort using both the Chronic Kidney Disease Epidemiology (CKD-EPI) 2009 equation with race, used in the creation of the formula, as well as the CKD-EPI 2021 equation without race, which is currently the recommended CKD-EPI creatinine equation. Methods: Using an institutional database, patients that underwent partial or radical nephrectomy for RCC from 2005-2021 were identified. Patients with creatinine values preoperatively and 3-12 months postoperatively were included, with end stage renal disease serving as exclusion criteria. Correlation/bias/accuracy/precision of the fGFR equation (fGFR=35+ [preoperative eGFR x 0.65]- 18 [if radical] - [age x 0.25]+ 3 [if tumor >7cm]-2 [if diabetes]) with observed postoperative eGFR was determined by both the CKD-EPI-2021 and CKD-EPI 2009 equations. Results: 1,443 patients were included in our analysis. 71% (1,024) and 22.9% (331) patients were white and black, respectively. A majority of patients underwent radical nephrectomy (60.3%). 40% of patients had T3-T4 RCC, with 14.8% of patients having M1 disease. Median observed vs predicted fGFR was 58.0 vs 58.7 ml/min/1.73m2 for CKD-EPI 2021 and 56.0 vs 57.5 for CKD-EPI 2009. The correlation/bias/accuracy/precision of the fGFR equation was 0.805/-0.5/81.7/7.9-9.0 for CKD-EPI 2021 and 0.809/-0.8/81.3/-8.1-8 for CKD-EPI 2009 equations (Table). Conclusions: The fGFR equation accurately predicted renal function in our large and diverse institutional cohort using both the CKD-EPI 2009 including race and CKD-EPI 2021 excluding race equations. [Table: see text]

Clinical- pathological features and surgical outcome of renal cell carcinoma: Experience from a zonal referral hospital-northern of Tanzania

Background: Renal cell carcinoma (RCC) is the most common primary malignant tumour of kidney in adults. Recent studies from developed countries have shown that most renal tumour are currently diagnosed incidentally during screening for other disease which leads to better prognosis while few studies done in Africa still shows significant proportion of patients present with classic triad ( >10%) which is a sign of advanced disease. Objectives: This study aimed at determining clinical pathological feature and outcome of RCC in Northern zone of Tanzania. Patients and Methods: This was a hospital based descriptive retrospective cohort study conducted at Kilimanjaro Christian Medical (KCMC) from January 2002 to December 2017. Data were analysed using statistical package for social science (SPSS) version 16. 0 and summarized in tables and figures. Results: Forty three patients (43) underwent radical nephrectomy for RCC during the study period. Male to female ratio was1. 7: 1 with mean age of 53+/- 12 years. Flank pain (84%), abdominal mass (76%) and hematuria (44%) were the most common clinical presentation while classical triad was found in 40%. The most common clinical tumor stage was T3(72. 1%) whilst clear cell carcinoma was the commonest histological pattern. Five years survival length for T1, T2, T3 and T4 were 100%, 62. 5%, 32. 3% and 0% respectively. Conclusion: The most common presenting symptom of RCC in our centre is flank pain, and abdominal mass. Majority of the patients presented with advanced disease with less than five year survival rate. Clear cell type was the predominant histological type.

Risk Factors and Patterns of Locoregional Recurrence after Radical Nephrectomy for Locally Advanced Renal Cell Carcinoma.

PurposeWe aimed to investigate the risk factors and patterns of locoregional recurrence (LRR) after radical nephrectomy (RN) in patients with locally advanced renal cell carcinoma (RCC).Materials and MethodsWe retrospectively analyzed 245 patients who underwent RN for non-metastatic pT3–4 RCC from January 2006 to January 2016. We analyzed the risk factors associated with poor locoregional control using Cox regression. Anatomical mapping was performed on reference computed tomography scans showing intact kidneys.ResultsThe median follow-up duration was 56 months (range, 1 to 128 months). Tumor extension to renal vessels or the inferior vena cava (IVC) and Fuhrman’s nuclear grade IV were identified as independent risk factors of LRR. The 5-year actuarial LRR rates in groups with no risk factor, one risk factor, and two risk factors were 2.3%, 19.8%, and 30.8%, respectively (p < 0.001). The locations of LRR were distributed as follows: aortocaval area (n=2), paraaortic area (n=4), retrocaval area (n=5), and tumor bed (n=11). No LRR was observed above the celiac axis (CA) or under the inferior mesenteric artery (IMA).ConclusionTumor extension to renal vessels or the IVC and Fuhrman’s nuclear grade IV were the independent risk factors associated with LRR after RN for pT3–4 RCC. The locations of LRR after RN for RCC were distributed in the tumor bed and regional lymphatic area from the bifurcation of the CA to that of the IMA.

Comparative analysis of histopathological subtypes of renal cell carcinoma in the Middle East compared to other world regions.

Introduction:Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide.Methods:A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents.Results:One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7–13.6), Europe (11.1%, 95% CI: 10.0–12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America.Conclusions:The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Impact of margin status on survival after radical nephrectomyfor renal cell carcinoma.

Data about the impact of surgical margin positivity on patient outcomes following radical nephrectomy (RN) for renal cell carcinoma (RCC) is limited. We evaluate the effect of positive surgical margins (PSMs) on relapse-free survival (RFS) and overall survival (OS.) METHODS: Clinicopathologic data of patients who underwent RN for RCC was analyzed based on margin status. χ2 and Student ttest were used to compare groups. Cox regression analysis was used for the analysis. Kaplan-Meier method was used for survival curves. A total of 485 patients who underwent RN for RCC were analyzed. Most patients with T1/T2 stage had NSM. Most patients with T4 had PSM. T3 patients were split between the two groups. Analysis of the T3 group showed shorter RFS in the PSM group at 3 years (hazard ratio[HR]: 4.3, p = .01), and 5 years (HR: 4.3, p = .01.) OS analysis showed worse OS in PSM but not statistically significant. There was a significant association between PSM and laterality (p = .023) and histologic type (p = .025.) CONCLUSIONS: PSM was associated with shorter RFS after RN in T3 RCC patients. There was a trend towards worse OS in the PSM group, but it did not reach statistical significance. Laterality and histologic type were associated with surgical margin status.

PD11-09 ELEVATED C-REACTIVE PROTEIN IS ASSOCIATED WITH POSTOPERATIVE DEVELOPMENT OF PROTEINURIA AND SUBSEQUENT RENAL FUNCTIONAL DECLINE AND MORTALITY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (PD11)1 Apr 2020PD11-09 ELEVATED C-REACTIVE PROTEIN IS ASSOCIATED WITH POSTOPERATIVE DEVELOPMENT OF PROTEINURIA AND SUBSEQUENT RENAL FUNCTIONAL DECLINE AND MORTALITY Margaret Meagher*, Zachary Hamilton, Dattatraya Patil, Kazutaka Saiko, Aaron Bradshaw, Sunil Patel, Brittney Cotta, Facundo Davaro-Comas, Yosuke Yasuda, Ahmed Eldefrawy, Fady Ghali, Ryan Nasseri, Fang Wan, Yasuhisa Fujii, Viraj Master, and Ithaar Derweesh Margaret Meagher*Margaret Meagher* More articles by this author , Zachary HamiltonZachary Hamilton More articles by this author , Dattatraya PatilDattatraya Patil More articles by this author , Kazutaka SaikoKazutaka Saiko More articles by this author , Aaron BradshawAaron Bradshaw More articles by this author , Sunil PatelSunil Patel More articles by this author , Brittney CottaBrittney Cotta More articles by this author , Facundo Davaro-ComasFacundo Davaro-Comas More articles by this author , Yosuke YasudaYosuke Yasuda More articles by this author , Ahmed EldefrawyAhmed Eldefrawy More articles by this author , Fady GhaliFady Ghali More articles by this author , Ryan NasseriRyan Nasseri More articles by this author , Fang WanFang Wan More articles by this author , Yasuhisa FujiiYasuhisa Fujii More articles by this author , Viraj MasterViraj Master More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000845.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Proteinuria is associated with renal functional decline and may also be a risk factor for mortality, and C-reactive protein (CRP) has been associated with survival outcomes in renal cell carcinoma (RCC). We examined relationship of CRP and proteinuria and renal functional decline in patients with RCC. METHODS: We conducted a multi-institutional retrospective analysis of patients who underwent partial or radical nephrectomy for RCC. Primary outcome was non-cancer mortality (NCM). Secondary outcomes included development of de novo estimated glomerular filtration rate <45 mL/min/m2 (eGFR<45), as well as development of de novo post-operative proteinuria. Multivariate analysis (MVA) was utilized to analyze factors associated with primary and secondary outcomes. Kaplan Meier analysis (KMA) was performed to analyze NCM for patients with or without de novo proteinuria. RESULTS: 2105 patients were analyzed (905 PN/1200 RN). 336 (16%) patients developed de novo post-operative proteinuria. MVA demonstrated African-American race (OR 2.82, p=0.001), radical nephrectomy (OR 1.91, p=0.006), and CRP >0.5 (OR 1.71, p=0.035) as independent risk factors for development of de novo post-operative proteinuria. MVA for development of de novo eGFR <45 revealed increasing age (OR=1.04, p=0.001), African-American race (OR 1.97, p=0.012) and post-operative proteinuria (OR=4.32, p<0.001) as independent risk factors. MVA for NCM revealed increasing age (OR 1.05, p<0.001), male sex (OR 2.73, p=0.005), CRP >0.5 (OR 3.91, p=0.003), and post-operative proteinuria (OR 1.9, p=0.024) as independent risk factors. KMA revealed a significant difference in 5 year survival from NCM between de novo proteinuria and no de novo proteinuria overall (93% vs. 81%, p<0.001) and in stage 1 (94% vs. 85%, p=0.001), stage 2 (88% vs. 75%, p<0.001), and stage 3 RCC (95% vs. 58%, p<0.001) (Figure). CONCLUSIONS: Development of postoperative proteinuria was associated with renal functional decline and non-cancer mortality across stages in RCC patients. Elevation of CRP and African-American race were associated with proteinuria development. Consideration of nephron preserving strategies in patients at risk for postoperative proteinuria should be prioritized when feasible. Source of Funding: Stephen Weissman Kidney Cancer Research Fund © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e257-e257 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Margaret Meagher* More articles by this author Zachary Hamilton More articles by this author Dattatraya Patil More articles by this author Kazutaka Saiko More articles by this author Aaron Bradshaw More articles by this author Sunil Patel More articles by this author Brittney Cotta More articles by this author Facundo Davaro-Comas More articles by this author Yosuke Yasuda More articles by this author Ahmed Eldefrawy More articles by this author Fady Ghali More articles by this author Ryan Nasseri More articles by this author Fang Wan More articles by this author Yasuhisa Fujii More articles by this author Viraj Master More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic Nephrectomy vs Open Nephrectomy: Comparison of Complications and Oncological Outcomes

Background: Many patients present in the late stage of renal cell carcinoma (RCC) which need to be resected, there are two surgical approaches (open and robotic). We aim to identify and compare the complications and outcomes following radical robotic nephrectomy and open radical nephrectomy. Materials and Method: Cross-sectional study, compares demographical characteristic, surgical procedure details, oncological results and operative complications between open and robotic. Patients were followed for six months after the surgery. Data were collected from the year of 2008 to 2016 for patients who underwent radical nephrectomy. Results: The study included 70 patients, (n:42) 60% open and (n:28) 40% robotic. Mean age was 55±14 years. Demographics were similar in both groups. Mean blood loss was significantly higher in open nephrectomy (p=0.042). Mean operation time was almost similar. Mean hospitalization length was less by half in the robotic group (p=0.007). Mean tumor size was larger in open group by 2.2 cm (p=0.018). A high number of complications was noted in the open approach compared with robotic in most categories. Seventy-five percent of the complications occurred in the first month, and only twenty-five percent was between 1 to 6 months following the surgery. Conclusion: Robotic radical nephrectomy for RCC has the advantage over open surgery in the amount of blood loss, operative time, hospitalization length and some complications.

A useful method for assessing differences of compensatory hypertrophy in the contralateral kidney before and after radical nephrectomy in patients with renal cell carcinoma: ellipsoid formula on computed tomography.

To investigate the usefulness of the ellipsoid formula for assessing compensatory hypertrophy of the contralateral kidney on pre-operative and post-operative CT in renal cell carcinoma(RCC) patients. We retrospectively identified 389 patients who had radical nephrectomy for RCC between 2011 and 2015. Contrast-enhanced CT was performed within 3 months pre-operative and at 1 year post-operative. The kidney volumes were calculated from CT using the ellipsoid formula. We subdivided patients into three groups based on tumour size(I:≤4 cm, II:4-7 cm, III:>7 cm). Volumetric renal parameters were compared and multivariate analyses were performed to determine predictors associated with pre-operative and post-operative compensatory hypertrophy. Kidney volume calculation using the ellipsoid method took a median of 51 s. Group III had a significantly larger median pre-operative contralateral renal volume than Groups I and II(I: 140.4, II: 141.6, III: 166.7 ml, p < 0.05). However, the median ratio of post-operative contralateral renal volume change was significantly higher in Groups I and II than Group III(I:0.36, II:0.23, III:0.12, p < 0.001). On multivariate analysis, tumour size revealed the strongest positive association with pre-operative contralateral kidney volume (partial regression coefficient: β = 30.8,>7 cm) and ratio of post-operative contralateral kidney volume change(β = 0.214, I vs III; β = 0.168, II vs III). Kidney volume calculation for assessing pre- and post-operative compensatory hypertrophy of the contralateral kidney in RCC patients can be easily and rapidly performed from CT images using the ellipsoid formula. Advances in knowledge: The ellipsoid formula allows reliable method for assessing pre-operative and post-operative compensatory hypertrophy of the contralateral kidney in RCC.

Positive surgical margin following radical nephrectomy is an independent predictor of local recurrence and disease-specific survival

BackgroundPositive surgical margins (PSM) are recognized as an adverse prognostic sign and are often associated with higher rates of local and systemic disease recurrence. The data regarding the oncological outcome for PSM following radical nephrectomy (RN) is limited. We examined the predictive factors for PSM and its influence on survival and site of recurrence in patients treated with RN for renal cell carcinoma (RCC).MethodsClinical, pathologic and follow-up data on 714 patients undergoing RN for kidney cancer were analyzed. Secondary analysis included 44 patients with metastatic RCC upon diagnosis who underwent cytoreductive nephrectomy (CRN). Univariate and multivariable logistic regression models were fit to determine clinicopathologic features associated with PSM. A Cox proportional-hazards regression model was used to test the independent effects of clinical and pathologic variables on survival.ResultsPSM was documented in 17 cases (2.4%). PSM were associated with tumour size, advanced pathologic stage (pT3 vs. ≤ pT2) and presence of necrosis. On multivariate analysis, cancer-specific survival (CSS) was associated with tumour stage, size, presence of necrosis and PSM. PSM was also associated with local recurrence but not distant metastasis or overall survival (OS). CSS and OS were comparable between the PSM and metastatic RCC groups, but significantly lower than the negative margin group.ConclusionsThe prevalence of PSM following RN is rare. Pathological data, including advanced stage (> pT2), tumour necrosis and tumour size, are associated with the presence of PSM. PSM is associated with tumour recurrence and CSS. Patients with PSM are a potential group for adjuvant therapy or for more careful and thorough follow-up following surgery.

Novel hematological biomarkers predict survival in renal cell carcinoma patients treated with nephrectomy.

IntroductionThe association between novel blood-based inflammatory indices and patient survival has been reported with reference to various cancers. The aim of this study was to investigate the prognostic value of preoperative platelet-lymphocyte ratio (PLR), neutrophil-lymphocyte ratio (NLR), derived neutrophil-lymphocyte ratio (dNLR) and lymphocyte-monocyte ratio (LMR) in patients with renal cell carcinoma (RCC) treated with nephrectomy.Material and methodsFrom 2003 to 2012, 455 patients who underwent partial or radical nephrectomy for RCC were enrolled in the study. The study endpoints were overall survival (OS) and cancer-specific survival (CSS).ResultsThe median follow-up was 70 months. Groups of patients with high levels of PLR, NLR and dNLR and a low level of LMR more often underwent radical nephrectomy, had a higher cancer stage in the TNM classification, and were more frequently diagnosed with tumor necrosis in histopathological examination. Both cancer-specific mortality and overall mortality were significantly higher in patients with high PLR, NLR and dNLR and low LMR. Multivariate analysis of CSS, adjusted for standard clinicopathological factors, identified only dNLR (p = 0.006) as an independent prognostic factor. PLR (p = 0.0002), dNLR (p = 0.0003) and NLR (p = 0.002), but not LMR (p = 0.1), achieved prognostic significance in multivariable analysis regarding OS.ConclusionsOnly dNLR was an independent prognostic factor for CSS and OS. Nevertheless, our study indicates that all examined complete blood count-based biomarkers may be useful tools in managing RCC patients treated with a surgical approach.

Impact of margin status on survival after radical nephrectomy for renal cell carcinoma (RCC).

e16084 Background: Data is limited regarding outcomes in patients with RCC with positive surgical margins. We sought to evaluate the impact of margin status after radical nephrectomy (RN) on relapse free survival (RFS) and overall survival (OS). Methods: A retrospective study was conducted evaluating patients with RCC having undergone RN at Methodist University Hospital in Memphis, Tennessee, between January 2009 and December 2013. Patients were identified from the tumor registry at this institution, and IRB approval obtained. Patient and tumor characteristics and survival were analyzed by GraphPad Prism, Microsoft Excel and IBM SPSS. Results: 156 patients that underwent RN for RCC were identified; 12 patients (7.7%) had positive margins and 144 had negative margins. Mediation duration of follow-up was 3.4 years. 5 of 12 patients with positive margins relapsed, versus 20 of 144 with negative margins (41.7% v. 13.9%, p = 0.022) with a RR of 3.10 (95% CI 1.417-6.799). Among those who relapsed, there was a statistically significant difference in time to relapse between patients with positive and negative margins (mean number of days to relapse 275 versus 621, respectively, with p = 0.038). On multivariate analysis of age, gender, ethnicity, laterality, tumor histology, margin status, and tumor size, margin status was not a statistically significant determinant of OS at 1, 3, and 5 years (p = 0.051, 0.124 and 0.185 respectively) or RFS at 1, 3, and 5 years (p = 0.372, 0.271 and 0.242 respectively). Pearson correlation analysis showed significant correlation between tumor size and margin status, R = 0.478, p &lt; 0.001. Conclusions: Positive margins were associated with earlier time to relapse among patients following RN. However, in multivariate analysis, margin status was not a statistically significant determinant of OS or RFS. In the current era of multiple available agents in RCC capable of cytoreduction, the risk factors that are predictive of a positive surgical margin at RN should be considered in the design of neoadjuvant systemic therapy trials, with the goal of improving long-term outcomes.

Renal fossa recurrence after nephrectomy for renal cell carcinoma: prognostic features and oncological outcomes.

To describe the clinicopathological features associated with increased risk of renal fossa recurrence (RFR) after radical nephrectomy (RN) and to describe the prognostic features associated with cancer-specific survival (CSS) among patients with RFR treated with primary locally directed therapy, systemically directed therapy or expectant management. The records of 2 502 patients treated with RN for unilateral, sporadic, localized renal cell carcinoma (RCC) between 1970 and 2006 were reviewed. CSS after RFR was estimated using the Kaplan-Meier method. Associations with the development of RFR and CSS after RFR were evaluated using Cox proportional hazards regression models. A total of 33 (1.3%) patients developed isolated RFR (iRFR) and 30 (1.2%) patients developed RFR in the setting of synchronous metastases after RN (study cohort, N = 63). The median follow-up for the series was 9.0 years after RN and 6.0 years after RFR diagnosis. On multivariable analysis, advanced pathological stage (pT2: hazard ratio [HR] 4.36, P = 0.004; pT3/4: HR 4.39, P = 0.003) and coagulative necrosis (HR 2.71, P = 0.006) were independently associated with increased risk of iRFR. The median time to recurrence was 1.5 years after RN among the 33 patients with iRFR, and 1.4 years among all patients. Overall, the median CSS was 2.5 years after diagnosis of iRFR, 1.3 years after RFR in the setting of synchronous metastases, and 2.2 years overall. After primary locally directed therapy (surgery, ablation or radiation), systemic therapy or expectant management, the 3-year CSS rates among patients with iRFR were 63%, 50% and 13% (P = 0.001) and were 64%, 50% and 28% (P = 0.006) among all patients, respectively. On multivariable analysis, when compared with observation, locally directed therapies were associated with a significantly decreased risk of death from RCC (HR 0.26, P < 0.001). Renal fossa recurrence is a rare event after RN for RCC and portends a poor prognosis, even in the absence of synchronous metastases. Development of iRFR is associated with advanced stage and aggressive tumour biology. Patients who underwent primary locally directed therapy had superior CSS compared with those treated with expectant management, supporting the use of aggressive local treatment in carefully selected patients with RFR. Future research is needed to determine the optimum role and sequencing of combined therapy in patients with this rare entity.

The natural history of renal function after surgical management of renal cell carcinoma: Results from the Canadian Kidney Cancer Information System

Introduction and objectivePatients who undergo surgical management of renal cell carcinoma (RCC) are at risk for chronic kidney disease and its sequelae. This study describes the natural history of renal function after radical and partial nephrectomy and explores factors associated with postoperative decline in renal function. MethodsThis is a multi-institutional cohort study of patients in the Canadian Kidney Cancer Information System who underwent partial or radical nephrectomy for RCC. Estimated glomerular filtration rate (eGFR) and stage of chronic kidney disease were determined preoperatively and at 3, 12, and 24 months postoperatively. Linear regression was used to determine the association between postoperative eGFR and type of surgery (radical vs. partial), duration of ischemia, ischemia type (warm vs. cold), and tumor size. Results and limitationsWith a median follow-up of 26 months, 1,379 patients were identified from the Canadian Kidney Cancer Information System database including 665 and 714 who underwent partial and radical nephrectomy, respectively. Patients undergoing radical nephrectomy had a lower eGFR (mean = 19ml/min/1.73m2 lower) at 3, 12, and 24 months postoperatively (P<0.001). Decline in renal function occurred early and remained stable throughout follow-up. A lower preoperative eGFR and increasing age were also associated with a lower postoperative eGFR (P<0.01). Ischemia type and duration were not predictive of postoperative decline in eGFR (P>0.05). Severe renal failure (eGFR<30ml/min/1.73m2) developed postoperatively in 12.5% and 4.1% of radical and partial nephrectomy patients, respectively (P<0.001). ConclusionsAfter the initial postoperative decline, renal function remains stable in patients undergoing surgery for RCC. Patients undergoing radical nephrectomy have a greater long-term reduction in renal function compared with those undergoing partial nephrectomy. Ischemia duration and type are not predictive of postoperative renal function when adhering to generally short ischemia durations.

Incidental detection of pancreatic hemangioma mimicking a metastatic tumor of renal cell carcinoma

Adult pancreatic hemangioma is a rare disease. We presented a case of a woman with pancreatic tail mass mimicking a distant metastasis from the kidney. A 68-year-old woman was found with a left kidney mass on medical checkup. Computed tomography scan showed a 4.3 cm-sized mass in the left kidney, suggesting renal cell carcinoma (RCC), and a strongly enhancing tiny nodule in the pancreatic tail. We could not rule the possibility of RCC metastasis, hence, surgical resection of the pancreatic mass simultaneously with radical nephrectomy for RCC was conducted. Gross pathologic examination revealed hemangioma. Immunohistochemistry revealed that the tumor was positive for CD34, CD31 and factor VIII-related antigen. There were no significant postoperative events, and the patient was discharged on postoperative day 7 without any complications. Treatment strategies for pancreatic hemangioma have not been established. To our knowledge, this was the first case report of asymptomatic pancreatic hemangioma. In previous literature, treatment differed on a case-by-case basis, ranging from observation to surgical resection. The most important factor in deciding whether to perform surgery is possibly risk-benefit effectiveness; however, tumor location, patient symptoms, and other factors are also important.

Surgical resection of recurrent inferior vena cava tumor following radical nephrectomy for renal cell carcinoma: A case report.

Late recurrence is a known characteristic of the biological behavior of renal cell carcinoma (RCC) following radical nephrectomy. However, the development of recurrent inferior vena cava (IVC) tumors following radical nephrectomy for RCC is a rare event, and surgical resection of recurrent IVC tumors is a challenge for urologists. The present study reports the case of a patient with a local recurrent tumor in the IVC following a right radical nephrectomy 4 years previously for RCC. The patient was referred to the Department of Urology, First Affiliated Hospital of Anhui Medical University, due to bilateral lower extremity edema, and magnetic resonance imaging showed an intraluminal tumor thrombus in the IVC. Therefore, a thrombectomy and partial IVC resection with defect reconstruction were performed successfully. The results of follow-up for 72 months showed that there were no signs of recurrence as local or distant metastasis. This case of local recurrence in the IVC highlights that active long-term surveillance for RCC patients of all stages is important for the early diagnosis of tumor recurrence, which improves the potential resectability.

Preoperative renal parenchymal volumetrics and prediction of renal insufficiency following radical nephrectomy.

471 Background: To identify predictors of post-operative renal insufficiency by analyzing pre-operative imaging volumetrics among patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC). Methods: A retrospective review of all patients undergoing RN for RCC between January 2011 and August 2013 was performed. Estimated glomerular filtration rate (eGFR) was calculated employing the modified diet in renal disease (MDRD) formula using the pre-operative and one-year serum creatinine values. Pre-operative and 1-year post-operative CT/MRI scans were reviewed. AW Volume Share 5 workstations were utilized to calculate volumes. Statistical analysis using Chi-square and Fisher exact test were employed. Results: Of the 147 patients undergoing RN 65 patients met the inclusion criteria. Patients with smaller tumor volumes (&lt;375 cm3) were more likely to have a greater decline in their post-operative eGFRs (&gt;35%) when compared to patients with larger tumors (58 vs. 21%; p=0.0165). Patients with a pre-operative eGFR &gt;60 ml/min/1.73m2 had a greater (&gt;25%) drop in their 1-year eGFR (81 vs. 47%; p=0.0084). A smaller volume (&lt;150 cm3) of parenchyma of the ipsilateral kidney was associated less compensatory (&lt;25%) hypertrophy (100 vs. 69, p=0.0348). Smaller tumors (&lt;300 cm3) were more likely to have a greater degree (&gt;10%) of compensatory hypertrophy (78 vs. 43% p=0.0234) and less blood loss (&lt;300 cc, 82 vs. 44%, p=0.0082). Older patients and patients with a combined history of diabetes (DM) and hypertension (HTN) were more likely to have compensatory (&gt;25%) hypertrophy (age &gt;65, 100% vs. 31%, p&lt;0.001; DM+HTN, 100% vs. 75%, p=0.0084). The degree of compensatory hypertrophy (&gt;25%) however, did not predict 1-year eGFR (35%) change (p=0.2203). New kidney disease (eGFR&lt;60 ml/min/1.73m2) occurred in 71% patients. Conclusions: Volumetric imaging shows promising potential and may become a valuable tool in predicting post-operative renal insufficiency for patients undergoing nephrectomy and should be investigated further both in RN and partial nephrectomy cohorts.

Outcomes and Management Considerations in Patients on Dialysis Undergoing Laparoscopic Radical Nephrectomy for Renal-Cell Carcinoma.

To analyze the perioperative outcomes and management considerations in patients with dialysis-dependent end-stage renal disease (ESRD) undergoing laparoscopic radical nephrectomy for renal-cell carcinoma (RCC). There were 224 consecutive laparoscopic radical nephrectomies reviewed. Of those, 37 patients with ESRD were identified and compared with 187 patients with sporadic RCC. Evaluable parameters included age, sex, race, side of surgery, medical comorbidities, body mass index, American Society of Anesthesiologist (ASA) scoring, and age adjusted Charlson Comorbidity Index. All complications occurring intraoperatively and within the first 30 days were classified as per the Clavien classification system. Presurgical workup and transplant considerations were evaluated. Demographic and clinical characteristics were compared using Student t tests and chi-square tests for categoric variables. Compared with non-ESRD patients, those with ESRD were younger and had smaller tumors. ASA was significantly higher in the ESRD group (P<0.001). Mean blood loss was similar between ESRD patients and non-ESRD patients. Overall complication rates were higher in patients with ESRD. Pathologic characteristics of ESRD renal masses included a higher proportion of papillary RCC. Patients with RCC associated with ESRD tend to have a higher ASA class and lower grade tumors. In addition, this population is at increased risk of surgical complications and more likely to need transfusions. Careful preoperative preparation and intraoperative anesthetic management are crucial to minimize patient morbidity and improve outcomes.

Isolated loco-regional recurrence after radical nephrectomy for renal cell carcinoma: A study of 22 patients

ObjectiveThis study aimed to assess prognosis of isolated local recurrence (ILR) of renal cell carcinoma (RCC) after radical nephrectomy (RN). Patients and MethodsThis retrospective study involved 22 cases (16 men and 6 women) of ILR from two centers with a mean age of 60.1±8.5years. All cases were managed surgically. ResultsPrimary tumors were mainly clear cell carcinoma (n=17). Nine patients had T3 and T4 tumors. Local recurrence involved mainly the operative bed (n=17); 4 among them had nodal recurrence as well. The median interval to local recurrence was 13.5months (7–25months). Stages T3 and T4 were significantly associated with shorter interval. Complete excision was possible in 9patients (41%); 8 tumors were irresectable. It was associated with significantly higher overall and median disease-free survival (DFS). Advanced disease stage (p=0.002) and shorter interval to recurrence (p<0.001) were associated with higher proportion of incomplete excision. The median overall survival and DFS were 15months (95% CI: 4.4–25.6) and 10months (95% CI: 4.5–15.5), respectively. Overall and DF survival were significantly better in patients with nodal recurrence only, complete excision of the recurrence and interval from nephrectomy to recurrence >15months. ConclusionILR after radical nephrectomy for RCC is more common with more advanced stages, where interval to recurrence tends to be shorter. The management should be surgical, which was possible in nearly 60% of cases. Complete excision was associated with better overall and disease free survival.