Radical Nephrectomy In Patients Research Articles

Partial nephrectomy for T1 renal cancer can achieve an equivalent oncological outcome to radical nephrectomy with better renal preservation: the way to go.

Patients who undergo partial nephrectomy have been shown to be at decreased risk of renal impairment compared with radical nephrectomy. We examined the oncological outcome of patients in our centre who underwent partial or radical nephrectomy for T1 renal cancer (7 cm or smaller), and compared the likelihood of developing chronic kidney disease. This historical cohort study with internal comparison was conducted in a tertiary hospital in Hong Kong. A cohort of 86 patients with solitary T1 renal cancer and a normal contralateral kidney who underwent radical (38 patients) or partial (48 patients) nephrectomy between January 2005 and December 2010 was included. The overall and cancer-free survival, change in glomerular filtration rate, and new onset of chronic kidney disease were compared between the radical and partial nephrectomy groups. A total of 32 (84%) radical nephrectomy patients and 43 (90%) partial nephrectomy patients were alive by 31 December 2012. The mean follow-up was 43.5 (standard deviation, 22.4) months. There was no significant difference in overall survival (P=0.29) or cancer-free survival (P=0.29) between the two groups. Both groups enjoyed good oncological outcome with no recurrence in the partial nephrectomy group. Overall, 18 (21%) patients had pre-existing chronic kidney disease. The partial nephrectomy group had a significantly smaller median reduction in glomerular filtration rate (12.6% vs 35.4%; P<0.001), and radical nephrectomy carried a significantly higher risk of developing chronic kidney disease (hazard ratio=5.44; 95% confidence interval, 1.26-23.55; P=0.02). Compared with radical nephrectomy, partial nephrectomy can prevent chronic kidney disease and still achieve an excellent oncological outcome for T1 renal tumours, in particular T1a tumours and tumours with a low R.E.N.A.L. score.

Prediction of Pulmonary Metastasis in Renal Cell Carcinoma Patients with Indeterminate Pulmonary Nodules

BackgroundIndeterminate pulmonary nodules (IPN) are of uncertain significance in patients with renal cell carcinoma. ObjectiveWe sought to determine predictors of IPN progression to pulmonary metastasis and develop a tool for individualized risk stratification of patients who present with IPN on preoperative chest imaging in the setting of localized or locally advanced renal cell carcinoma. Design, setting, and participantsWe reviewed all patients who had radical nephrectomy with no evidence of distant metastases at a single institution from 2005–2009 who had ≥1 IPN on chest computed tomography that measured <2cm. All chest computed tomographies were rereviewed by a radiologist who was blinded to outcomes, to independently determine number, size, and location of nodules. Outcome measurements and statistical analysisThe primary objective of the study was to develop a prognostic model to predict pulmonary metastases among radical nephrectomy patients who present with IPN based on readily available preoperative imaging and postoperative pathological criteria. Univariable and multivariable Cox regression models were used to assess the predictive factors for development of pulmonary metastasis. We developed a nomogram that predicted the 3-yr and 5-yr lung metastasis-free survival (LMFS), with assessment of discrimination and internal validation. Results and limitationsAmong 251 patients with IPN who underwent nephrectomy, 72 (29%) developed pulmonary metastases. Median follow-up for the cohort was 36.6 mo. Three-yr and 5-yr probability of LMFS for the overall cohort was 71% (95% confidence interval 65–77%) and 65% (95% confidence interval 57–72%), respectively. The nomogram developed included number and size of IPN along with postoperative pathological variables, and showed calibration with a concordance index (c-index) of 0.81 and a bootstrap corrected c-index of 0.78. Limitations include retrospective study with no external validation. ConclusionsWe developed a nomogram to predict the individualized risk LMFS for patients who underwent nephrectomy for localized or locally advanced renal cell carcinoma. Patient summaryWe reviewed outcomes among kidney cancer patients who presented with small lung nodules and developed a clinical tool to predict risk of developing lung metastases.

2589 Adjuvant radiation therapy after radical nephrectomy in patients with localized renal cell carcinoma: a systematic review and meta-analysis

2589 Adjuvant radiation therapy after radical nephrectomy in patients with localized renal cell carcinoma: a systematic review and meta-analysis

Survival analysis of surgically treated renal cell carcinoma: a single Chinese medical center experience from 2002 to 2012.

To analyze the survival and the associated factors affecting the prognosis of renal cell carcinoma (RCC) in China with a sufficiently large sample size. Clinical data with complete follow-up of 1326 RCC patients were successfully obtained. Progression-free survival (PFS) and cancer-specific survival (CSS) were calculated, survival analysis was performed by Kaplan-Meier analysis, and Cox proportional hazards regression models were served to estimate the prognostic significance of each variables. The median length of follow-up was 43.55 months (25-75 %, 25.47-68.75 months). During follow-up, 147 patients developed RCC-related progression, with a median PFS of 18.2 months (25-75 %, 7.50-47.27); 64 patients died from RCC-related progression, with a median CSS of 27.67 months (25-75 %, 14.10-58.53). For RCC patients in T1 stage, 3-, 5-, 8-, and 10-year CSS rates of patients receiving nephron-sparing nephrectomy were 99.33, 98.21, 97.40, and 97.40 %, respectively, which were significantly higher than radical nephrectomy patients (97.88, 96.28, 95.09, and 88.58 %, respectively). Cox proportional hazards regression model showed that tumor N stage, signs of lung metastasis (such as cough and hemoptysis), signs of bone metastasis (such as bone pain and fracture), pathological subtype of RCC, microscopic sarcomatoid change, and progression were prognosis factors for Chinese RCC patients. Tumor stage, nephrectomy type, lung metastasis, bone metastasis, pathological subtype, sarcomatoid change, and type of progression were important risk factors for RCC. For T1 stage RCC patients, nephron-sparing nephrectomy showed better CSS than radical nephrectomy, which may guide the doctors and patients in their choices of surgical procedures.

Management of Small Kidney Cancers in the New Millennium: Contemporary Trends and Outcomes in a Population-Based Cohort.

With the significant downward size and stage migration of localized kidney cancers, the management options for small kidney cancers have expanded and evolved. To describe trends and outcomes in the management of small kidney cancers in the first decade of the new millennium. Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked to Medicare claims were used to identify patients 66 years or older with a pathologically confirmed small kidney cancer (<4 cm) diagnosed between January 1, 2001, and December 31, 2009; analysis was performed between February 1, 2014, and December 31, 2014. Multivariable logistic regression was used to assess the likelihood of nonsurgical management vs surgical intervention. Cox proportional hazards regression was used to assess the relationships between treatment approach and overall and cancer-specific survival. The effect of treatment approach on cancer-specific survival was analyzed in a competing risks framework. The likelihood of receiving no surgery vs surgical intervention as a function of demographic and disease characteristics, as well as the relationships between treatment approach and overall and cancer-specific survival. Of 6664 patients, 5994 individuals (90.0%) had surgical treatment; the care of 670 patients (10.0%) was managed nonsurgically. Use of radical nephrectomy decreased over time (from 69.0% to 42.5%), and the use of nephron-sparing surgery (partial nephrectomy and ablation) increased (from 21.5% to 49.0%); the proportion of patients who did not undergo surgery remained stable (9.5% and 8.5%). During a median follow-up of 63 months (interquartile range, 43-89 months) (follow-up for vital status through December 31, 2011), 2119 patients (31.8%) patients died, including 293 individuals (4.4%) of kidney cancer. Although overall survival was better in patients who received surgical treatment, only nephron-sparing surgery was associated with a benefit in cancer-specific survival (adjusted hazard ratio, 0.47; 95% CI, 0.31-0.69; P < .001). Surgery continues to be the most common treatment for patients with small kidney cancers. The use of nephron-sparing surgery exceeds radical nephrectomy in patients who receive surgery. Although our findings suggest that nonsurgical management is acceptable for certain patients, use of this approach remains low.

IJU this issue

This issue includes 12 Original Articles, two Review Articles, one Case Report and one Urological Note. In one of the Review Articles, Kageyama et al. (Shiga, Japan) traced the history of proteome research in urothelial cancers. In this review, they introduced one promising factor named C7orf24/GGCT as a good candidate target molecule for the therapy. Unfortunately, there are only a few molecules to date that are utilized in the clinical field. The other Review Article by Elsamra et al. (New York, USA) picked up a very practical topic on stenting for malignant ureteral obstruction. Taguchi et al. (Tokyo, Japan) retrospectively reviewed 200 cases of metastatic urothelial carcinoma in terms of neutrophil-to-lymphocyte ratio (NLR). They concluded that elevation of pretreatment neutrophil-to-lymphocyte ratio is a poor prognostic factor for metastatic urothelial cancers. In terms of urothelial cancer, Satake et al. (Tokyo, Japan) reported that preoperative pyuria is a good prognostic marker for non-muscle-invasive bladder cancer. They also concluded that the presence of preoperative pyuria is a useful predictor for recurrence after bacillus Calmette-Guérin therapy. These two articles suggest the important roles of the immune system in the treatment of urothelial cancer. Gershman et al. (Minnesota, USA) examined whether there is a difference in the risk of estimated glomerular filtration rate decline between continent and incontinent urinary diversion after radical cystectomy in patients with preoperative chronic kidney disease stage 2 or 3a. That study gave us very important information that there was no significant difference in long-term renal function between two types of urinary diversions. As Zapata et al. (North Carolina, USA) concluded from the Shared Equal Access Regional Cancer Hospital database, it is interesting that smoking is a predictor of extracapsular extension, positive surgical margin or larger tumor volume. They speculate that smoking might have an impact on the immunological response against prostate cancer. This issue contains two articles related to lymph node dissection. One on penile cancer, by da Costa et al. (Sao Paulo, Brazil), reported that lymphovascular invasion and lymph node ratio (the number of positive nodes/number of total resected nodes) were the independent prognostic factors. The authors successfully showed the impact of risk stratification using lymph node ratio, lymphovascular invasion and extranodal extension on the prognosis of node-positive penile cancer. In another article, Nakamura et al. (Kyoto, Japan) insisted on the importance of resecting both residual retroperitoneal lymph node mass and extraretroperitoneal masses because of the histopathological discordance. Recently, chronic kidney disease has become a serious concern in carrying out kidney surgery. Nephron-sparing surgery for small renal mass is required as much as possible in order to prevent chronic kidney disease after surgery. Lee et al. (Seoul, Korea) compared postoperative estimated glomerular filtration rate between kidney donors and radical nephrectomy patients. According to their propensity-matched study, definite estimated glomerular filtration rate recovery was observed in the donor nephrectomy group rather than the radical nephrectomy group, suggesting kidney cancer itself has an unfavorable nature. In terms of voiding dysfunction, a near-infrared spectroscopic study of interstitial cystitis patients by Matsumoto et al. (Chiba, Japan) is very unique. It sheds light on the neuromodulatory approach to interstitial cystitis. I appreciate you understanding that I cannot introduce all the issues because of the limited space. None declared.

Rhabdomyolysis After Major Urologic Surgery: Epidemiology, Risk Factors, and Outcomes

To study the epidemiology, risk factors, and outcomes of rhabdomyolysis (RM) after major urologic surgery. The National Inpatient Sample (2003-2011) was used to identify patients who underwent radical prostatectomy, radical or partial nephrectomy, or radical cystectomy. Demographics included age, sex, race, and comorbidities. Factors examined included bleeding, hospital teaching status, minimally invasive technique, and development of RM. Multivariate logistic regression was used to identify independent risk factors of RM. Outcomes of mortality, acute kidney injury (AKI), length of stay, and charges in patients with RM were compared with those of controls. A weighted population of 1,016,074 patients was identified with 870 (0.1%) developing RM, which was significantly more likely for radical or partial nephrectomy and radical cystectomy patients compared with radical prostatectomy patients. On multivariate analysis, independent risk factors for RM included younger age, male sex, diabetes, chronic kidney disease, obesity, and bleeding. Race, minimally invasive technique, and teaching status were not associated with RM when controlling for other factors. Patients with RM experienced increases in mortality, AKI, length of stay, and hospital charges. Rhabdomyolysis is a rare complication after urologic surgery. Risk factors include male sex, younger age, diabetes, chronic kidney disease, obesity, and perioperative bleeding. Patients who develop RM have a higher risk of AKI, mortality, prolonged hospital stay, and increased charges.

Compensatory Structural and Functional Adaptation after Radical Nephrectomy for Renal Cell Carcinoma According to Preoperative Stage of Chronic Kidney Disease

We investigated structural hypertrophy and functional hyperfiltration as compensatory adaptations after radical nephrectomy in patients with renal cell carcinoma according to the preoperative chronic kidney disease stage. We retrospectively identified 543 patients who underwent radical nephrectomy for renal cell carcinoma between 1997 and 2012. Patients were classified according to preoperative glomerular filtration rate as no chronic kidney disease--glomerular filtration rate 90 ml/minute/1.73 m(2) or greater (230, 42.4%), chronic kidney disease stage II--glomerular filtration rate 60 to less than 90 ml/minute/1.73 m(2) (227, 41.8%) and chronic kidney disease stage III--glomerular filtration rate 30 to less than 60 ml/minute/1.73 m(2) (86, 15.8%). Computerized tomography performed within 2 months before surgery and 1 year after surgery was used to assess functional renal volume for measuring the degree of hypertrophy of the remnant kidney, and the preoperative and postoperative glomerular filtration rate per unit volume of functional renal volume was used to calculate the degree of hyperfiltration. Among all patients (mean age 56.0 years) mean preoperative glomerular filtration rate, functional renal volume and glomerular filtration rate/functional renal volume were 83.2 ml/minute/1.73 m(2), 340.6 cm(3) and 0.25 ml/minute/1.73 m(2)/cm(3), respectively. The percent reduction in glomerular filtration rate was statistically significant according to chronic kidney disease stage (no chronic kidney disease 31.2% vs stage II 26.5% vs stage III 12.8%, p <0.001). However, the degree of hypertrophic functional renal volume in the remnant kidney was not statistically significant (no chronic kidney disease 18.5% vs stage II 17.3% vs stage III 16.5%, p=0.250). The change in glomerular filtration rate/functional renal volume was statistically significant (no chronic kidney disease 18.5% vs stage II 20.1% vs stage III 45.9%, p <0.001). Factors that increased glomerular filtration rate/functional renal volume above the mean value were body mass index (p=0.012), diabetes mellitus (p=0.023), hypertension (p=0.015) and chronic kidney disease stage (p <0.001). Patients with a lower preoperative glomerular filtration rate had a smaller reduction in postoperative renal function than those with a higher preoperative glomerular filtration rate due to greater degrees of functional hyperfiltration.

Partial and Radical Nephrectomy for Unilateral Synchronous Multifocal Renal Cortical Tumors

To evaluate clinicopathologic characteristics and treatment outcomes of patients undergoing partial nephrectomy (PN) or radical nephrectomy (RN) for unilateral synchronous multifocal renal tumors. We retrospectively reviewed medical records for 128 patients with nonmetastatic, unilateral, synchronous, multifocal renal tumors who underwent surgical resection at our institution from 1995 to 2012. Five patients with hereditary renal cell carcinoma were excluded. Differences between patient and tumor characteristics from the 2 nephrectomy groups were evaluated. Outcomes in terms of recurrence-free survival, overall survival, and chronic kidney disease upstaging were estimated using Kaplan-Meier methods. The log-rank test was used for group comparisons. The study cohort included 78 PN patients (63%) and 45 RN patients (37%); 17 of 95 planned PN (18%) were converted to RN. Tumor diameter and RENAL nephrometry scores were greater in RN patients (P <.0001 and P = .0002, respectively). Pathologic stage T3 was seen in 40% of RN patients and 10% of PN patients (P = .0002). Histologic concordance was apparent in 60 of 123 patients (49%). Median follow-up for patients alive without a recurrence was 4 years. Five-year recurrence-free survival was 98% for PN and 85% for RN. Five-year overall survival was 96% for PN and 86% for RN (P = .5). Five-year freedom from chronic kidney disease upstaging was 74% for PN and 55% for RN (P = .11). Partial nephrectomy for the treatment of unilateral, synchronous, multifocal, renal tumors with favorable characteristics was associated with a low recurrence rate. These findings suggest PN is an appropriate management strategy for this group of carefully selected patients.

Clinically significant association between the maximum standardized uptake value on 18F-FDG PET and expression of phosphorylated Akt and S6 kinase for prediction of the biological characteristics of renal cell cancer.

BackgroundThe relationship between the clinicopathological features and molecular changes associated with standardized uptake value (SUV) determined by Positron emission tomography (PET) with [18F] fluorodeoxyglucose (18F-FDG PET) in human renal cell carcinoma (RCC) has not been elucidated. On the other hand, overactivation of the phosphatidylinositol 3’kinase (PI3K), serine/threonine kinase Akt, and mammalian target of rapamycin (mTOR) pathway has been detected in a variety of human cancers, including RCC. So far, little is known about the relationship between the SUV and these proteins in human RCC. Thus, it is important to study the relevance of SUV with clinicopathological features in human RCCs from a molecular point of view.MethodsSeventy-seven consecutive patients with RCC who underwent nephrectomy and pretreatment determination of the maximum SUV (SUVmax) by 18F-FDG PET were analyzed. We investigated the relationship between the SUVmax, phosphorylated-Akt (Ser-473) (pAkt(Ser-473)), phosphorylated-Akt (Thr-308) (pAkt(Thr-308), and phosphorylated-S6 ribosomal protein (Ser-235/236) (pS6) protein levels in the primary tumor and various clinicopathological features.ResultsThe average SUVmax of the primary tumor was 6.9 (1.5 to 40.3). A higher SUVmax was correlated with higher expression of pAkt(Ser-473), pAkt (Thr-308), and pS6 protein in the primary tumor. A higher SUVmax and increased expression of pAkt (Ser-473), pAkt (Thr-308), and pS6 of the primary tumor was associated with less tumor differentiation, a higher pT stage, regional lymph node involvement, microscopic vascular invasion, and distant metastasis, as well as with early relapse following radical nephrectomy in patients who had localized or locally advanced RCC without distant metastasis (cTanyNanyM0) and with shorter overall survival in all patients.ConclusionsA higher SUVmax on 18F-FDG PET is associated with elevated tumor levels of pAkt and pS6 protein and with aggressive behavior and metastatic potential of RCC, as well as with early relapse following radical nephrectomy and shorter overall survival. These findings suggest that SUVmax may be useful for predicting the biological characteristics of RCC.

Predicting pulmonary metastases among patients with indeterminate pulmonary nodules with renal cell carcinoma.

505 Background: Indeterminate pulmonary nodules (IPN) are of uncertain significance in renal cell carcinoma (RCC) patients. We sought to determine the natural history of IPN in patients undergoing radical nephrectomy and to identify clinical variables associated with the development of lung metastases. Methods: We reviewed all radical nephrectomy patients at a single institution from 2005 – 2009 who had ≥1 IPN on chest computed tomography (CT) within 6 months prior to surgery and no evidence of distant metastates. All chest CTs were re-reviewed by a radiologist who was blinded to outcomes to independently determine number, size, location of nodules and whether the IPN appeared concerning for metastases based on nodule size, tissue density, and morphology. Univariate and multivariate Cox regression was used to assess associated predictive factors. Results: Of 258 patients with IPN, 73 (28%) developed pulmonary metastases. Median follow−up was similar in the groups at 36 months. Patients who developed pulmonary metastases had significantly poorer survival compared to those who did not (3-year DSS 54.5 versus 86.5 months, p&lt;0.001), and 39 (53%) developed pulmonary metastases at the same location as the largest IPN. On univariate analysis, larger renal tumor diameter (HR 1.12, p&lt;0.001), number of pulmonary nodules CT (HR 1.12, p 0.001), presence of hilar lymphadenopathy on chest CT were associated with both lung metastasis development and cancer-specific mortality. After adjusting for age, performance status, comorbidities, histology, and smoking status, higher tumor grade (HR 5.11, p 0.007), presence of tumor thrombus above the diaphragm (HR 4.38, p 0.013), perinephric (HR 4.29, p 0.002) or renal sinus (HR 2.16, p 0.045) fat invasion, and a chest CT concerning for metastasis by the radiologist (HR 2.91, p&lt;0.001) were associated with development of pulmonary metastases. Conclusions: RCC patients with IPN who develop pulmonary metastases have a significantly poorer outcome. Independent predictors of developing lung metastases include tumor grade, presence of tumor thrombus above the diaphragm, perinephric or renal sinus fat invasion, and a chest CT concerning for metastasis.

Percentage of sarcomatoid component as a prognostic indicator for survival in sarcomatoid renal cell carcinoma.

499 Background: Renal cell carcinoma with sarcomatoid component (sRCC) is characterized by the microscopic spectrum of spindle cells within a background of RCC. The presence of sarcomatoid elements is associated with higher stage of presentation and decreased patient survival. The objective of this study is to examine the clinicopathological characteristics associated with overall survival (OS), specifically examining the percentage of sarcomatoid component (PSC) to stratify risk. Methods: We retrospectively reviewed data for all radical nephrectomy patients with pathologically confirmed sarcomatoid component from 1987−2011. All slides were re−reviewed by a GU pathologist to ascertain PSC. Patient characteristics were tabulated overall and by disease status (metastatic vs. localized). Cutpoints in the percent sarcomatoid providing a meaningful difference in OS were identified by recursive partitioning analysis (RPA) as univariate and combined with patient characteristics. Factors selected included age, gender, race, clinical stage, tumor histology, and treatment. The Kaplan−Meier method and two−sided log−rank test was used to assess differences in OS. Results: Among 186 patients with sRCC, 64 (34%) had localized and 122 (66%) metastatic disease. Patients were primarily white (76%) males (63%) with clear cell histology (73%), and did not receive neoadjuvant or adjuvant therapy (87%). The median follow−up time was 12.1 months (range, 0.1 to 242.2 months). The median OS was 12.6 months (95% confidence interval (CI) 10.7−14.9 months). Two subgroups were identified with a cut−point of 12.5% for PSC after univariate RPA. Patients with PSC ≥ %12.5 were at higher risk of death compared to patients with &lt;%12.5 (45% vs. 61% 1 year OS; p value=0.04). Mutlivariate RPA revealed clinical stage and percent sarcomatoid were significantly associated with OS. Patients with localized disease were most likely to be alive at 1 year (74%). Among patients with metastatic disease with PSC&lt;%42.5 had 1−year OS of 44% vs. 27% for patients with ≥%42.5 cutoff (p&lt;0.001). Conclusions: The PSC appears to be a prognostic factor in the OS of patients with RCC, with larger percentage of involvement portending a worse survival.

How does visceral obesity affect surgical performance in laparoscopic radical nephrectomy?

In a previous study, we described the relationship between operating time and obesity, particularly visceral obesity, in laparoscopic surgery. Operating time in laparoscopic surgery is affected by the experience and technique of the surgeon. Here, we investigated whether a difference in the surgeon's experience affects the operating time for laparoscopic radical nephrectomy in patients with visceral obesity. From January 2006 to February 2012, 167 laparoscopic radical nephrectomies were performed at our institution. Visceral fat area was measured at the level of the umbilicus using computed tomography. A visceral fat area ≥ 100 cm(2) was used as the definition of visceral obesity. All laparoscopic radical nephrectomies were performed by six surgeons. Two of the six surgeons perform 50 cases or more laparoscopic surgeries every year and they were defined as the expert group. We analyzed the relationships between clinical findings, methods, surgeon experience, body mass index or visceral fat area and operating time. The expert and non-expert surgeons performed 77 and 90 laparoscopic radical nephrectomies, respectively, and the median operating time was 167.0 ± 44.0 and 227.5 ± 60.6 min. Twenty-five patients underwent laparoendoscopic single-site nephrectomy by the expert surgeons. For all surgeons, visceral obesity was a significant factor for prolonged operating time. Multivariate analysis showed that visceral obesity and clinical T stage were independent risk factors for prolonged operating time for the non-expert surgeons [P = 0.004, hazard ratio (HR): 5.15, P = 0.037, HR:10.41]. However, for the expert surgeons, clinical T stage was the only independent risk factor for prolonged operating time (P = 0.039, HR: 4.33). Visceral obesity was a factor of prolonged operating time in laparoscopic radical nephrectomy. The non-expert surgeons were particularly affected by visceral obesity.

C239: Radical nephrectomy in patients with large kidney tumors – 16 cases presentation

C239: Radical nephrectomy in patients with large kidney tumors – 16 cases presentation

S177: Laparoscopic radical nephrectomy in patients with renal vein invasion: Our initial experience

S177: Laparoscopic radical nephrectomy in patients with renal vein invasion: Our initial experience

FDG PET/CT in the Evaluation of Late Manifestation of Adrenal Metastasis after Radical Nephrectomy in Patients with Renal Cell Carcinoma: A Report of Four Cases and Review of Literature

FDG PET/CT in the Evaluation of Late Manifestation of Adrenal Metastasis after Radical Nephrectomy in Patients with Renal Cell Carcinoma: A Report of Four Cases and Review of Literature

Preoperative cross-sectional imaging allows for avoidance of unnecessary adrenalectomy during RCC surgery

ObjectivesTo assess the frequency of adrenal involvement and the reliability of preoperative imaging to predict adrenal involvement in patients treated for cortical renal masses at a single institution. MethodsUsing a retrospective pathology database, we identified 117 consecutive patients who underwent radical nephrectomy and concomitant ipsilateral adrenalectomy at our institution over the course of 2 decades. Patient demographics, tumor characteristics, and radiographic results were obtained for analysis. ResultsOf 117 patients, only 6 (5.1%) were identified as having adrenal involvement. The average age of the patient was 58.3 years, and the average tumor size was 7.13cm. The mean tumor size in patients without adrenal involvement was 6.79cm, whereas in those with adrenal involvement, it was 9.62cm (P = 0.057). Of 6 patients with adrenal involvement, 5 had imaging studies available for review, and all 5 demonstrated suspicion for adrenal involvement preoperatively. Among 111 patients without adrenal involvement, 53 (47.7%) had imaging available for review, with only 3 (5.7%) demonstrating suspicion for adrenal involvement. The negative predictive value was 100%, whereas the sensitivity and specificity were 100% and 94.3%, respectively. ConclusionsIpsilateral adrenal involvement in renal cell carcinoma is uncommon and reliably predicted by preoperative cross-sectional imaging. Among all adrenalectomies in this series, nearly 95% were performed unnecessarily. With careful review, preoperative imaging can help avoid unnecessary adrenalectomy during radical nephrectomy in patients with renal cortical tumors.

Nephron-sparing Techniques Independently Decrease the Risk of Cardiovascular Events Relative to Radical Nephrectomy in Patients with a T1a–T1b Renal Mass and Normal Preoperative Renal Function

BackgroundSome reports have suggested that nephron-sparing surgery (NSS) may protect against cardiovascular events (CVe) when compared with radical nephrectomy (RN). However, previous studies did not adjust the results for potential selection bias secondary to baseline cardiovascular risk. ObjectiveTo test the effect of treatment type (NSS vs RN) on the risk of developing CVe after accounting for individual cardiovascular risk. Design, setting, and participantsA multi-institutional collaboration including 1331 patients with a clinical T1a–T1b N0 M0 renal mass and normal renal function before surgery (defined as an estimated glomerular filtration rate ≥60ml/min/1.73m2). InterventionRN (n=462, 34.7%) or NSS (n=869, 65.3%) between 1987 and 2013. Outcome measurement and statistical analysesCVe was defined as onset during the follow-up period of coronary artery disease, cardiomyopathy, hypertension, vasculopathy, heart failure, dysrhythmias, or cerebrovascular disease not known before surgery. Cox regression analyses were performed. To adjust for inherent baseline differences among patients, we performed multivariate analyses adjusting for all available characteristics depicting the overall and cardiovascular-specific profile of the patients. Results and limitationsWhen stratifying for treatment type, the proportion of patients who experienced CVe at 1, 5, and 10 yr was 5.5%, 9.9%, and 20.2% for NSS patients compared to 8.7%, 15.6%, and 25.9%, respectively, for RN patients (p=0.001). In multivariate analyses, patients who underwent NSS showed a significantly lower risk of developing CVe compared with their RN counterparts (hazard ratio 0.57, 95% confidence interval 0.34–0.96; p=0.03) after accounting for clinical characteristics and cardiovascular profile. Limitations include the retrospective design of the study because other potential confounders may exist. ConclusionsThe risk of CVe after renal surgery is not negligible. Patients treated with NSS have roughly half the risk of developing CVe relative to their RN counterparts. After accounting for clinical characteristics, comorbidities, and cardiovascular risk at diagnosis, NSS independently decreases the risk of CVe relative to RN. Patient summaryThe risk of having a cardiovascular event after renal surgery decreases if a portion of the affected kidney is spared.

Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Identifying Incidence and Risk Factors for Venous Thromboembolism among Partial and Radical Nephrectomy Patients for Kidney Cancer

Identifying Incidence and Risk Factors for Venous Thromboembolism among Partial and Radical Nephrectomy Patients for Kidney Cancer