Renal Cortical Tumors Research Articles

Association of Elevated C-Reactive Protein with Worsened Outcomes in Different Histologies of Renal Cortical Tumors: Analysis of the INMARC Registry

BackgroundTo evaluate relationship between histological subtypes of renal cell carcinoma (RCC) and preoperative c-reactive protein (CRP). Patients and MethodsWe queried the International Marker Consortium for Renal Cancer database for patients affected by RCC. Patients were classified according to their histology: benign tumors, clear cell (cc) RCC, chromophobe (ch) RCC, papillary (p) RCC, and variant histology (vh) RCC; and according to CRP (mg/L): low CRP ≤5 and high CRP >5. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cancer-specific mortality (CSM), recurrence and association between CRP and histology. Multivariable analysis (MVA) via Cox regression and multivariable logistic regression were fitted to elucidate predictors of outcomes. ResultsTotal 3902 patients (high CRP n = 1266) were analyzed; median follow up 51 (IQR 20-91) months. On MVA elevated CRP was an independent risk factor associated with increased risk of ACM in benign tumors (HR 5.98, P < .001), ccRCC (HR 2.69, P < .001), chRCC (HR 3.99, P < .001), pRCC (HR 1.76, P = .009) and vhRCC (HR 2.97, P =.007). MVA for CSM showed CRP as risk factor in ccRCC (HR 2.77, P < .001), chRCC (HR 6.16, P = .003) and pRCC (HR 2.29, P = .011), while in vhRCC was not (P = .27). MVA for recurrence reported CRP as risk factor for ccRCC (HR 1.30, P = .013), while in chRCC (P = .33), pRCC (P = .34) and vhRCC (P = .52) was not. On multivariable logistic regression CRP was a predictor of pRCC (OR 1.003, P = .002), while decreasing CRP was associated with benign tumors (OR 0.994, P = .048). ConclusionElevated CRP was a robust predictor of worsened ACM in all renal cortical neoplasms. While most frequently observed in pRCC patients, elevated CRP was independently associated with worsened CSM in non-vhRCC. Conversely, elevated CRP was least likely to be noted in benign tumors, and elevation in this subgroup of patients should prompt further consideration for surveillance given increased risk of ACM. Further investigation is requisite.

DIFFERENTIATION OF SOLID RENAL TUMOURS WITH MULTIPARAMETRIC MR IMAGING WITH HISTOLOGICAL CORRELATION

OBJECTIVES: To identify the radiologic ndings of the most common solid renal masses found in adult age group, illustrate imaging and histology correlates, and draw a clear diagnostic approach. 62 MATERIALS &amp; METHODS: patients suspected to have solid renal masses were evaluated with mp-MRI. T2 SIR, ADC value and ADC ratio on DWI, SII on chemical shift imaging and wash in and wash out indices on dynamic contrast enhanced imaging were calculated for each tumor and the values were compared among different histologically proven renal tumors. ccRCC showed maximum T2 SIR wherea RESULTS: s pRCC and lp-AML showed lowest mean T2 SIR. There is signicant difference in SII of clear cell RCC (15.03±7.62) and non-clear cell renal cortical tumor (1.54±10.67), p&lt;0.001. We found signicant difference in mean tumor ADC of benign vs malignant lesions (p &lt;0.006), higher stage (III &amp; IV) vs lower stage (stage I &amp;II) p &lt;0.001. We found signicant differences between clear cell and non-clear cell renal tumors in wash in indexes in all phases (p = 0.001) and late wash out index (p&lt; 0.001). There is signicant difference of papillary RCCs and other renal tumors in arterial and parenchymal WiI (p&lt;0.001), early WoI (p=0.018) as well as late WoI (p&lt;0.001). There is also signicant difference between chromophobe RCCs and oncocytomas for arterial WiI (p=0.009), parenchymal and late WiI (p= 0.006); Multiparametric renal MRI is useful CONCLUSION: for differentiating solid renal tumors, predict their histologic grading and thus guide further management

Radical nephrectomy in medically underserved patients: Selection bias and disparity in surgical health care delivery.

609 Background: Disparities in outcomes of renal cell carcinoma (RCC) exist with respect to survival outcomes between different ethnic, and socioeconomic groups. We sought to evaluate disparities in delivery of surgical care between medically underserved (MU) and non-medically underserved (NMU) patients. Methods: We conducted a single-center retrospective analysis of consecutive patients presenting with localized renal cortical neoplasms who underwent surgical excision [Radical (RN) or Partial Nephrectomy (PN)] at an academic tertiary-care referral center. The cohort was divided into MU and NMU groups and descriptive analyses were conducted for demographics and clinical disease characteristics, type of surgery, time to surgery, estimated blood loss, and 30-day total and major complications (Clavien-Dindo, ≥3). Cochran-Armitage trend analysis was conducted to evaluate for surgical trends, and logistic regression multivariable analyses (MVA) were conducted for type of surgery and major complications. Results: 1418 patients were analyzed (MU n=334/NMU n=1084). Comparing MU vs. NMU, no differences were noted for age (p=0.612), Charlson Comorbidity Index (p=0.803), tumor size (p=0.236), or time to surgery (p=0.482). Significantly greater proportions of white patients were noted in NMU (60.6% vs. MU=45.5%, p&lt;0.001) and higher proportion of RN in MU (47% vs. NMU=40.4%, p=0.028). Subgroup analyses of PN groups revealed no differences with respect to demographics, tumor size (p=0.33), major complications (p=0.66), or blood loss (p=0.583). Subgroup analysis of RN revealed significantly higher proportion of non-white patients (p=0.019) and patients with diabetes (p=0.019). MVA for predictors for receipt of RN were non-white (OR1.4, p=0.002), MU (OR=1.32, p=0.043), age (OR=1.01, p=0.009) and treatment year (OR=0.913, p&lt;0.001). MVA for predictors for 30 day major complications demonstrated RN (OR=0.913 p&lt;0.001). Cochran-Armitage trend analysis indicated that both MU and NMU had significant increases in PN between 2003 and 2021 (p&lt;0.0001). Conclusions: Despite overall similarities with respect to demographics and clinical disease characteristics and time to surgery, MU status was associated with a significantly higher odds of receiving a RN at a tertiary care referral center, which represents a disparity in care and possible selection bias. Nonetheless, RN was also associated with a decreased risk of complications. While trends have demonstrated an increase in proportion of PN for both NMU and MU groups, comparative underutilization of PN in MU patients may be associated with increased downstream risks to health. Further investigation is requisite.

Diagnostic Efficacy of Multiparametric Magnetic Resonance Imaging Parameters in Differentiating Common Subtypes of Renal Cortical Tumors

Diagnostic Efficacy of Multiparametric Magnetic Resonance Imaging Parameters in Differentiating Common Subtypes of Renal Cortical Tumors

Glutathione peroxidase family and survival prognosis in patients with renal cell carcinoma.

Renal cell carcinoma (RCC) is a renal cortical tumor with high clinical incidence. The effect of glutathione peroxidases (GPXs) on RCC and the possible mechanism are still unclear. This study aims to explore the expression level of GPXs gene in RCC and its effect on the clinical prognosis of patients with RCC via bioinformatics analysis. The mRNA expressions of GPXs family genes were obtained from the public data of The Cancer Genome Atlas (TCGA) database. The Kruskal-Wails test was used to analyze the differences in mRNA expression of GPXs family genes between samples from patients with RCC and the normal population. UALAN databases were used to analyze the differences in protein expression of GPXs family genes between samples from patients with renal clear cell carcinoma and the normal population, and to evaluate the role of GPXs family genes in RCC. The Kaplan-Meier Plotter was used to analyze the correlation between different types of RCC and overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), and progression-free survival (PFS). Kaplan-Meier survival curve was drawn based on the GPX8 gene expression to study the relationship between GPX8 gene expression and prognosis of RCC patients. Based on the results of multivariate Cox regression analysis, a Nomogram scoring model for RCC prediction was established by introducing GPX8 gene. The mRNA expressions of GPX1 and GPX4 were higher in the sample of renal chromophobe cell carcinoma, renal clear cell carcinoma, and renal papillary cell carcinoma than those in the normal population (all P<0.01), and GPX7 and GPX8 were significantly over-expressed in patients with renal papillary cell carcinoma and renal clear cell carcinoma (all P<0.01). Compared with the normal group, the protein expressions of GPX1, GPX2, GPX7, and GPX8 were increased significantly in renal clear cell carcinoma (all P<0.01), while GPX3 and GPX4 expressions were decreased significantly (both P<0.01). The protein expressions of GPX1, GPX2, GPX7, and GPX8 were increased significantly in patients with renal clear cell carcinoma at different tumor grades (all P<0.01), while GPX3 and GPX4 expressions were decreased significantly (both P<0.01). Survival analysis showed that OS, DFS, DSS, and PFS were all decreased in patients with clear cell carcinoma compared with patients with papillary cell carcinoma and chromophobe cell carcinoma. According to the GPX8 level, patients were assigned into the low, medium, and high expression groups. Compared with the low GPX8 level group, the OS (P<0.01), DFS (P=0.03), DSS (P<0.01), and PFS (P=3.18×10-7) were significantly decreased in the high level group. Univariate Cox proportional regression analysis showed that the high level of GPX8 was associated with poor OS of 3 different types of renal cancer. Multifactorial analysis showed that GPX8 was an independent factor affecting the OS of patients with renal papillary cell carcinoma. Race and post tumor node metastasis (pTNM) typing were independent factors influencing the OS of patients with renal clear cell carcinoma. GPX8 and pTMN were independent factors influencing the OS of patients with renal chromophobe cell carcinoma. Based on these variables, the Nomogram risk models of 3 types of cell carcinoma were established, and the discrimination and calibration of the models were evaluated using the Consistency index (C-index) and calibration curves. The C-index of the risk model of renal papillary cell carcinoma was 0.62 (95% CI 0.51 to 1.00, P=0.03). The results of receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) was 0.88. The C-index of the risk model of renal clear cell carcinoma was 0.72 (95% CI 0.52 to 1.00, P=0.03). The results of ROC curve showed that the AUC was 0.90. The C-index of the risk model of chromophobe cell carcinoma of kidney was 0.90 (95% CI 0.85 to 1.00, P<0.01). The results of ROC curve showed that the AUC was 0.59. GPXs family genes, especially GPX8, are potential markers for poor prognosis of RCC, and the occurrence and development of RCC can be predicted in clinical practice based on the expressions of GPXs family genes.

Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses?

IntroductionThe role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. MethodsWe analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. ResultsA total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 – 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. ConclusionsFor patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.

Bioinformatics analysis reveals biomarkers with cancer stem cell characteristics in kidney renal clear cell carcinoma.

BackgroundKidney renal clear cell carcinoma (KIRC) is a renal cortical tumor. KIRC is the most common subtype of kidney cancer, accounting for 70%–80% of kidney cancer. Early identification of the risk of KIRC patients can facilitate more accurate clinical treatment, but there is a lack of effective prognostic markers. We aimed to identify new prognostic biomarkers for KIRC on the basis of the cancer stem cell (CSC) theory.MethodsRNA-sequencing (RNA-seq) data and related clinical information were downloaded from The Cancer Genome Atlas (TCGA) database. Weighted gene co-expression network analysis (WGCNA) was used to identify significant modules and hub genes, and predictive hub genes were used to construct prognostic characteristics.ResultsThe messenger RNA expression-based stemness index (mRNAsi) in tumor tissues of patients in the TCGA database is higher than that of the corresponding normal tissues. In addition, some clinical features and results are highly correlated with mRNAsi. WGCNA found that the green module is the most prominent module associated with mRNAsi; the genes in the green module are mainly concentration in Notch binding, endothelial cell development, Notch signaling pathway, and Rap 1 signaling pathway. A protein-protein interaction (PPI) network showed that the top 10 central genes were significantly associated with the transcriptional level. Moreover, the 10 hub genes were up-regulated in KIRC. Regarding survival analysis, the nomogram of the prognostic markers of the seven pivotal genes showed a higher predictive value. The classical receiver operating characteristic (ROC) curve analysis showed that risk score biomarkers had the highest accuracy and specificity with an area under the curve (AUC) value of 0.701.ConclusionsmRNAsi-related genes may be good prognostic biomarkers for KIRC.

The Consequences of Inadvertent Radical Nephrectomy in the Treatment of Upper Tract Urothelial Carcinoma

ObjectiveTo determine factors associated with performing inadvertent radical nephrectomy (RN) for upper tract urothelial carcinoma (UTUC), and to assess the impact of radical nephrectomy on overall survival (OS) compared to radical nephroureterectomy (NU). MethodsUsing the National Cancer Database (NCDB), patients with UTUC of the renal pelvis who were diagnosed with renal cortical tumors and underwent RN (n = 820) with subsequent surgical pathology demonstrating urothelial carcinoma were identified. These patients were compared to those diagnosed with renal pelvis tumors who appropriately underwent NU (n = 16,464) between 2005 and 2015. Multivariable logistic regression was used to determine patient, facility and tumor-related factors associated with undergoing RN. The impact of surgery (RN vs NU) on OS was determined by Cox-regression after propensity score matching. ResultsA total of 4.7% patients with UTUC underwent inadvertent RN. Black race (adjusted odds ratio [aOR] 1.62, 95%CI 1.23-2.13), larger tumors, advanced tumor stage, and high-grade tumors (P < 0.0001) were associated with RN. However, surgery at a facility performing a higher volume of NU/year was associated with lower odds of having RN performed (aOR 0.85, 95%CI 0.75-0.97). After propensity score matching, the 5-year OS was 39.9% for those undergoing RN vs 49.9% for those undergoing NU (hazard ratio 1.45, 95%CI 1.30-1.62). ConclusionInadvertent RN is not uncommon, occurring in almost 5% of patients with UTUC in the NCDB. Patients who underwent RN had significantly worse OS as compared to those treated with NU. These data highlight that accurate diagnosis of UTUC is paramount and clinicians should not hesitate to perform further workup when imaging findings are equivocal.

EDITORIAL COMMENT

The authors utilize the surveillance epidemiology and end results (SEER) data base, which covers approximately 35% of the US population, between 2007-2015 to analyze 8421 patients with clear cell renal cell carcinoma (ccRCC). They calculate 5-year cause specific survival using co-variates of race, age, sex, insurance, marital status, and tumor stage at diagnosis. Cause specific survival in this setting is defined as survival specifically from ccRCC, 1 of at least 31 types of renal cortical tumors with distinct genomic, metabolic, and histopathological features.

Infiltrative Renal Malignancies: Imaging Features, Prognostic Implications, and Mimics.

Infiltrative renal malignancies are a subset of renal masses that are morphologically characterized by a poorly defined interface with the renal parenchyma. Infiltrative renal malignancies are less common but more aggressive than more typical renal malignancies and carry an overall worse prognosis. Although an infiltrative renal process often represents a malignant neoplasm, infiltrative masses include a wide spectrum of diseases including primary renal cortical, medullary, and pelvic tumors; lymphoproliferative processes; metastases; and various infectious, inflammatory, immune-mediated, and vascular mimics. The imaging features of these masses are often nonspecific, but with the appropriate history, laboratory results, and clinical context, the radiologist can help narrow the diagnosis and guide further treatment. An invited commentary by Lee is available online.Online supplemental material is available for this article. ©RSNA, 2021.

Diffusion weighted imaging in differentiation of the clear cell RCC from the major non-clear cell RCC subtypes

Introduction. Renal cell carcinoma (RCC) is the most common malignant renal tumor in adults accounting for 80-90% of primary malignant adult renal neoplasms. RCC represents a very heterogenous groups of tumors with a number of distinct histological varieties, of which the major 3 subtypes are clear cell RCC (70-80%), papillary RCC (13-20%), and chromophobe RCC (5%). Imaging features are varied from solid and relatively homogenous appearance to markedly heterogenous appearance with cystic changes, hemorrhage and necrosis. The use of diffusion weighted imaging (DWI) for RCC subtyping and also for differentiation of high grade and low grade tumors has been showed to be useful in many studies in the literature. Aim. In this study, we aimed to determine the comparative contribution of DWI in differentiation of the clear cell RCC from the major non-clear cell RCC subtypes at standard high b-value (1000 s/mm2) versus low b-value (500 s/mm2). In addition, we also aimed to assess the diagnostic performance of DWI for differentiating high grade clear cell RCC from low grade clear cell RCC based on Fuhrman grades in our patients. Material and methods. 62 cases with a prediagnosis of RCC according to MRI findings including DWI sequence with histological verification and subtyping of renal cortical tumor following a total or partial nephrectomy were included in the study. Results. Among 62 cases, 46 were male and 16 were female, with mean age of 59.5 ± 15.7. Pathological diagnoses of 62 cases were as follows, clear cell RCC, (44) papillary cell RCC (14) and chromophobe cell RCC (4). They were divided into two groups as clear cell RCC group (44 cases) and non-clear cell RCC group (18 cases). There was no statistically significant difference between the mean ADC values of clear cell and non-clear cell groups at b-value of 1000 s/mm2 (p&gt;0.05). However, the mean ADC level for clear cell RCC group at b-value of 500 s/mm2 were significantly higher than for non-clear cell RCC group (p&lt;0.05). When a value of 0.99x10-3 mm2/s was set as cut-off for ADC at b-factor of 500 s/mm2, differentiation was achieved with a high sensitivity (91%) and specificity (56%). Regarding the diagnostic performance of DWI for differentiating high from low Fuhrman grades clear cell RCCs, there was no statistically significant difference between the ADC values of Grade I-II clear cell RCC cases and Grade III-IV clear cell RCC cases at b-factor of 1000 s/mm2 (p&gt;0.05). However, ADC values for grade III-IV group was statistically significantly lower than ADC values for Grade I-II group at b-factor of 500 s/mm2 level. Conclusion. ADC measurements at moderate b-value of 500 s/mm2 were more sensitive in subtyping and grading of RCC cases. This technique can be used in clinical practice as a fast and additional sequence in abdominal MRI.

Management of Residual or Recurrent Disease Following Thermal Ablation of Renal Cortical Tumors.

Management of residual or recurrent disease following thermal ablation of renal cortical tumors includes surveillance, repeat ablation, or surgical extirpation. We present a multicenter experience with regard to the management of this clinical scenario. Prospectively maintained databases were reviewed to identify 1265 patients who underwent cryoablation (CA) or radiofrequency ablation (RFA) for enhancing renal masses. Disease persistence or recurrence was classified into one of the three categories: (i) residual disease in ablation zone; (ii) recurrence in the ipsilateral renal unit; and (iii) metastatic/extra-renal disease. Seventy seven patients (6.1%) had radiographic evidence of disease persistence or recurrence at a median interval of 13.7 months (range, 1–65 months) post-ablation. Distribution of disease included 47 patients with residual disease in ablation zone, 29 with ipsilateral renal unit recurrences (all in ablation zone), and one with metastatic disease. Fourteen patients (18%) elected for surveillance, and the remaining underwent salvage ablation (n = 50), partial nephrectomy (n = 5), or radical nephrectomy (n = 8). Salvage ablation was successful in 38/50 (76%) patients, with 12 failures managed by observation (3), tertiary ablation (6), and radical nephrectomy (3). At a median follow-up of 28 months, the actuarial cancer-specific survival and overall survival in this select cohort of patients was 94.8 and 89.6%, respectively.

MP68-09 DISPARITIES IN SURVIVAL OUTCOMES IN AFRICAN AMERICANS IN RENAL CELL CARCINOMA

INTRODUCTION AND OBJECTIVE: African-Americans have an increased incidence of renal cortical tumor subtypes of lower oncological potential in the setting of lower risk disease when compared to other ethno-racial groups. On the other hand, survival outcomes are similar. We investigated the impact of African-American race on functional outcomes and non-cancer mortality. METHODS: Multi-institutional (Emory, TMDU, UCSD, SLU) retrospective analysis of patients with localized renal cell carcinoma (AJCC clinical stage 1-3 RCC) who underwent partial or radical nephrectomy between 1998-2018. The cohort was divided into African-American and Non-African American subgroups for descriptive analyses. Patients were analyzed for demographics, clinical parameters, and post-surgical outcomes. Primary outcome was non-cancer mortality (NCM). Secondary outcome was eGFR decline. Multivariable logistic regression (MVA) was used to elucidate predictive factors for NCM and de novo eGFR<45 and <30 ml/min/1.73m2. Kaplan Meier Analysis (KMA) was performed to analyze 5-year freedom from non-cancer mortality. RESULTS: 3751 patients who received either partial or radical nephrectomy for renal masses were grouped into African American (AA, n=602) and Non-African American (NAA, n=3149) sub-groups for analysis. No difference was noted between groups with respect to mean tumor size (p=0.166). Risk factors for development of de novo eGFR<45 included increasing age (OR 1.059, p<0.001), AA race (OR 1.47, p=0.047, diabetes mellitus (OR 1.84, p<0.001), and radical nephrectomy (OR 3.28, p<0.001). MVA for worsened NCM demonstrated AA race (OR 1.4, p=0.013), increasing age (OR 1.05, p<0.001), and post-operative eGFR<45 (OR 2.8, p<0.001) to be independent risk factors. KMA revealed a significant difference between African-Americans and Non-African Americans in terms of 5 year NCM (AA 81% vs. NAA 88%, p<0.001). CONCLUSIONS: African Americans undergoing renal surgery for RCC appear to have poorer NCM than non-African American patients. The cause of this disparity is likely multi-faceted but may be associated with functional decline. Nephron-sparing management when feasible and appropriate should be considered in African-Americans presenting with renal cortical tumors.Source of Funding: Stephen Weissman Kidney Cancer Research Fund

Diffusion-weighted MRI in the assessment of nephroblastoma: results of a multi-center trial.

To assess the value of diffusion-weighted MRI in the pre-therapeutic evaluation of pediatric renal cortical tumors. This IRB-approved, retrospective multi-center study included 122 pediatric patients with 130 renal tumors, who underwent MRI including DWI before neoadjuvant chemotherapy and nephrectomy. Two radiologists independently assessed each tumor volumetrically, and apparent diffusion coefficient (ADC) values were calculated on a voxel-wise basis, including parameters derived from histogram and texture analysis. Inter-reader agreement was excellent (ICC 0.717-0.975). For both readers, patients with locally aggressive tumor growth (SIOP 3 stage) or with metastases (M1) had significantly lower 12.5th-percentile ADC values (p ≤ 0.028) compared to those with lower-stage tumors, and the parameter energy differed significantly between patients with M1 and those with M0 status (p ≤ 0.028). Contrast and homogeneity differed significantly between benign nephroblastomatosis and malignant nephroblastoma (p ≤ 0.045, both readers). As compared to all other subtypes, the blastemal subtype demonstrated significantly higher skewness (p ≤ 0.022, both readers) and the diffuse anaplastic subtype demonstrated significantly higher 75th-percentile ADC values (p ≤ 0.042, both readers). Diffusion-weighted MRI may be of value in identifying benign nephroblastomatosis and assessing nephroblastoma subtypes. Therefore, further research is warranted to assess its value in risk stratification for pediatric patients with renal tumors in the future.

Impact of oncological versus nononcological on survival outcomes in African Americans with renal cell carcinoma.

749 Background: African-Americans have an increased incidence of renal tumors of lower oncological potential when compared to other ethno-racial groups. Yet, survival outcomes are similar. We investigated the impact of African-American race on overall survival, oncological and functional outcomes, and non-cancer mortality. Methods: Multi-institutional (Emory, TMDU, UCSD) retrospective analysis of patients who underwent partial or radical nephrectomy between 1998-2018. Primary outcome was overall survival (OS). Secondary outcomes were non-cancer mortality (NCM), recurrence free survival (RFS), and eGFR decline. Multivariable logistic regression (MVA) was used to analyze OS, NCM, and RFS, and estimated glomerular filtration rate (eGFR)&lt;45 and &lt;30 ml/min/1.73m2. Results: 3632 patients were grouped into African American (AA, n=531) and Non-African American (NAA, n=3101). No difference was noted between groups with respect to mean tumor size (p=0.31). NAA had a higher proportion of metastases at presentation (9.9% vs. 7.0%, p=0.04). AA race was an independent risk factor for functional decline to de novo eGFR &lt;45 (OR=1.43, p=0.04) and de novo eGFR&lt;30 (OR 2.01, p&lt;0.001). MVA for worsened NCM demonstrated AA race (OR=1.63, p=0.02), increasing age (OR=1.05, p&lt;0.001), male sex (OR=1.56, p=0.01), and hypertension (OR=1.73, p=0.001) to be independent risk factors. Significant factors on MVA for worsened OS included increasing age (OR=1.03, p&lt;0.001), radical nephrectomy (OR=1.47, p=0.01), increasing tumor size (OR=1.11, p&lt;0.001), hypertension (OR=2.63, p&lt;0.001), high tumor grade (OR=1.97, p&lt;0.001), and post-operative eGFR &lt;45 (OR=1.50, p=0.01). MVA for worsening RFS demonstrated high tumor grade (OR=2.04, p&lt;0.001) and increasing clinical tumor size (OR=1.15, p&lt;0.001) to be independent factors. Conclusions: African Americans undergoing surgical management for RCC appear to have similar OS and RFS, but poorer NCM than non-African American patients. The cause of these disparities is multi-faceted but likely is associated with functional decline. Nephron-sparing management when feasible and appropriate should be considered in African-Americans presenting with renal cortical tumors.

Single-port robotic partial and radical nephrectomies for renal cortical tumors: initial clinical experience.

To describe our institution's initial experience with radical (RN) and partial nephrectomy (PN) using the SP robotic system. The recent FDA approval of the da Vinci® SP robotic platform has led to its use in minimally invasive approaches to urologic malignancies. There are little data on its feasibility and safety after implementation for radical and partial nephrectomy. All patients who underwent PN or RN using the SP system at our institution were reviewed. All PNs were performed off-clamp. Patient demographics, preoperative imaging, operative approaches, and perioperative outcomes were collected and analyzed. Sixteen patients underwent PN (n = 13) or RN (n = 3) utilizing the SP robotic system between January 2019 and June 2019. Average age was 58.6 ± 13.9 and 61.0 ± 1.7years in each group, respectively. A retroperitoneal approach was performed in 7 (53.8%) PN patients and 1 (33.3%) RN patient. A transperitoneal approach was performed in 6 (46.1%) PNs and 2 (66.7%) RNs. Mean operative time and median estimated blood loss for PN was 176.9 ± 64.0min and 200 (50-800) ml compared to 176.3 ± 73.8min and 50 (50-400) ml for RN. There was one operative conversion (7.7%) to an open approach in the PN group. Length of hospital stay postoperatively averaged 1.9 ± 1.3days and 3.3 ± 1.2days for patients undergoing partial and radical nephrectomy, respectively. SP partial and radical nephrectomies through transperitoneal and retroperitoneal approaches appear to be feasible surgical techniques in the management of cortical renal masses. Off-clamp PN is also a feasible approach using the SP system. However, further study is needed to establish its safety and use in renalsurgeryacross multiple institutions and larger patient cohorts.

Value of Partial Nephrectomy for Renal Cortical Tumors of cT2 or Greater Stage: A Risk-benefit Analysis of Renal Function Preservation Versus Increased Postoperative Morbidity

BackgroundIndications for partial nephrectomy (PN) have expanded to include larger tumors. Compared with radical nephrectomy (RN), PN reduces the risk of chronic kidney disease but is associated with higher morbidity. ObjectiveTo explore whether the benefit of PN (preservation of estimated glomerular filtration rate [eGFR] ≥60ml/min/1.73m2 1yr postoperatively) over RN is offset by higher morbidity for cT2-cT3a tumors. Design, setting, and participantsA total of 1921 patients with renal cortical tumors who underwent nephrectomy between 2000 and 2012 were analyzed, with 297 having clinical stage T2 or higher disease. Outcome measurements and statistical analysisMultivariable logistic regression models adjusted for age, tumor size, and comorbidities were used to calculate the risk of complications within 90d and the risk of low eGFR across a range of tumor sizes. Models were created separately for RN and PN, and the difference between risk estimates was calculated. Results and limitationsFor tumors with diameters between 7 and 12cm, the risk of eGFR downgrade associated with RN was higher than the risk of complications associated with PN. The magnitude of the risk of eGFR downgrade was similar to the magnitude of complications risk across all tumor sizes. Our analysis was performed at a single institution, and used only tumor size to compare the risk and benefits of surgery. ConclusionsOur study suggests that PN is associated with higher eGFR preservation than RN for cT2 or greater renal tumors. The magnitude of this advantage offsets the higher morbidity observed with PN. Patient summaryWhen treating a large kidney tumor, it is difficult to decide whether it is better to remove the whole kidney or remove just the tumor. The second option improves postoperative renal function but is more complex. We tried to find whether there is a tumor size at which one technique should be used over the other.

Disparities in survival outcomes in African Americans in renal cell carcinoma: Impact of oncological versus nononcological factors.

595 Background: African-Americans have increased incidences of renal cortical tumor subtypes of lower oncological potential in the setting of lower risk disease when compared to other ethno-racial groups. However, survival outcomes are similar. We investigated the impact of African-American race on overall survival, oncological outcomes, functional outcomes, and non-cancer mortality. Methods: Multi-institutional retrospective analysis of patients who underwent partial or radical nephrectomy between 1998-2018. Primary outcome was overall survival (OS). Secondary outcomes included non-cancer mortality (NCM), recurrence free survival (RFS), and estimated glomerular filtration rate (eGFR) decline. Multivariable logistic regression (MVA) were used to elucidate predictive factors for OS, NCM, and RFS, and eGFR &lt;45 and &lt;30 ml/min/1.73m2. Results: 3,088 patients were divided into African American (AA, n=353) and Non-African American (NAA, n=2735) sub-groups. No difference was noted between groups with respect to mean tumor size (p=0.211) or metastases presence (p=0.846). African-American race was an independent risk factor for functional decline to eGFR&lt;45 (OR 4.43, p&lt;0.001) and eGFR&lt;30 (OR 5.15, p&lt;0.001). MVA for worsened NCM demonstrated African-American race (OR=1.72, p=0.042), increasing age (OR=1.03, p=0.001), radical nephrectomy (OR=2.98, p&lt;0.001), and increasing tumor size (OR=1.26, p&lt;0.001) to be independent risk factors. MVA for worsened OS included increasing age (OR=1.04, p&lt;0.001), tumor size (OR=1.182, p&lt;0.001), clear cell histology (OR=1.62, p&lt;0.001), high tumor grade (OR=2.12, p&lt;0.001), and post-operative eGFR &lt;45 (OR=2.12, p&lt;0.001). MVA for worsening RFS demonstrated high tumor grade (OR=2.38, p&lt;0.001) and increasing clinical tumor size (OR=1.152, p&lt;0.001) to be independent factors. Conclusions: African Americans undergoing renal surgery for RCC appear to have similar OS and RFS, but poorer NCM than non-African American patients. The cause of these disparities is multi-faceted and likely associated with functional decline. Nephron-sparing management should be considered in African-Americans presenting with renal cortical tumors.

Editorial Comment

Over the last 20 years, our understanding of renal cortical tumors (RCT) and their best management has evolved. Formerly, surgeons felt that tumors of all sizes and locations were best managed by radical nephrectomy (RN) if there was a functional contra lateral kidney. Partial nephrectomy (PN), initially used sparingly, was reserved for essential indications such as tumor in a solitary kidney, tumor in a patient with renal calculus disease or renal insufficiency, and for patients with bilateral renal tumors. Now we understand that RCT are a complex family of tumors with at least 31 separate subtypes described based on genomic and metabolomic studies. 1 Chen F. Zhang Y. Şenbabaoğlu Y. et al. Multilevel genomics-based taxonomy of renal cell carcinoma. Cell Rep. 2016; 14 (Epub 2016 Mar 3): 2476-2489https://doi.org/10.1016/j.celrep.2016.02.024 Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar , 2 Hakimi A.A. Reznik E. Lee C.H. et al. An integrated metabolic atlas of clear cell renal cell carcinoma. Cancer Cell. 2016; 29: 104-116https://doi.org/10.1016/j.ccell.2015.12.004 Abstract Full Text Full Text PDF PubMed Scopus (391) Google Scholar These tumors pose a spectrum of oncologic threats ranging from benign (20%), indolent with limited metastatic potential (25%), and malignant (55%). This variable threat from RCT coupled with the understanding that PN provides equivalent tumor control to RN while at the same time preserving renal function, preventing, or delaying chronic kidney disease and its associated cardiovascular disease lead to enhanced utilization of PN in the elective setting. 3 Russo P. Oncological and renal medical importance of kidney-sparing surgery. Nat Rev Urol. 2013; 10: 292-299 Crossref PubMed Scopus (25) Google Scholar

Primary angiosarcoma arising in an angiomyolipoma of the kidney: case report and literature review

BackgroundPrimary angiosarcoma of the kidney is a rare and aggressive malignant tumor presenting with a recognizable vascular differentiation. Its prognosis is fatal and the pathogenesis remains unclear. Renal angiomyolipoma is a relatively infrequent renal cortical neoplasm and is composed of variable proportions of adipose tissue, spindle cells, epithelioid smooth muscle cells and abnormal thick-walled blood vessels.Case presentationHere, we reported a case in which a 64-year-old woman presenting with the chief complaint of a progressively enlarged mass in the left abdomen. Abdominal computed tomography confirmed presence of a tumor measuring 18 cm × 11 cm in the left posterior renal fascia. Microscopic examination and immunohistochemical staining confirmed co-existence of angiomyolipoma and angiosarcoma. Furthermore, the two components interspersed with each other and there were transitional zones between them.ConclusionsIn this case, we described for the first time a primary renal angiosarcoma possibly arising in a pre-existing angiomyolipoma of the kidney.