T1a Renal Cell Carcinoma Research Articles

Hilar location is an independent prognostic factor for recurrence in T1 renal cell carcinoma after nephrectomy.

We investigated the prognostic significance of tumor location at the renal hilum near the sinus structure on the recurrence in T1 renal cell carcinoma (RCC). A total of 1,818 T1 RCC patients who underwent radical (RN) or partial nephrectomy (PN) from 1997 to 2011 were retrospectively reviewed. A hilar tumor was defined as a tumor abutting the main renal artery and/or vein or its segmental branches, without invasion. We compared the recurrence-free survival (RFS) rates between hilar and nonhilar T1 RCC and analyzed predictors of RFS after nephrectomy. Patients with hilar tumors showed a poorer 5-year RFS compared with nonhilar tumors both in T1a (89.7 vs. 98.5 %, p < 0.001) and T1b (81.6 vs. 95.1 %, p < 0.001) RCCs. Among patients who underwent RN and PN, hilar tumors were associated with lower 5-year RFS (87.6 vs. 97.2 % for RN, 78.1 vs. 98.2 % for PN, both p < 0.001). In T1a hilar tumor, PN was associated with poorer 5-year RFS than RN (79.5 vs. 93.0 %, p < 0.001). In multivariate analysis, a hilar location remained as an independent predictor of recurrence in both T1a and T1b tumors (both p = 0.001). Hilar tumors show a higher recurrence rate than nonhilar counterparts in T1 RCC. In T1a hilar tumors, PN demonstrated poorer RFS than RN. Potential intrinsic renal anatomical or lymphovascular structural differences as well as differences in cancer characteristics need further investigations.

Locoregional therapy of renal cancer

This lecture aims to provide an overview of renal cell carcinoma (RCC) and insights into this rapidly evolving treatment – image guided thermal ablative (IGA) therapy. RCC is the commonest kidney cancer and the detection of RCC has increased over the past decade. There are over 8000 and 50,000 new cases/year in the UK and USA respectively [1,2]. The increased detection is due to wider usage of radiology (e.g. ultrasound or computed tomography) and this usually results in the detection of smaller RCC with earlier stage disease [3,4]. In addition, this is also related to the rise in incidence in the general population as a result of smoking and obesity [5-7]. The historical classical clinical triad where patients presented with flank pain, abdominal mass and haematuria is now a rarity and nowadays the majority of the incidentally detected RCCs are smaller and at an earlier stage –T1 stage. However, historical data has suggested that 60% of these small incidentally detected tumours will grow gradually over a period of time [8]. Therefore, there remains a clinical risk with adopting a ‘watchful waiting’ approach for younger patients as these tumours may become symptomatic or metastasize [9]. Open radical nephrectomy (RN) was the gold standard treatment for RCC since it was introduced in 1869 and Robson et al had popularized this treatment over the last 50 years [10].Over the past 10 years, laparoscopic RN is becoming the standard of care with better cosmetic results and shorter recovery time [11]. More recently for locally confined (T1 disease) RCC treatment with nephron sparing surgery (NSS) e.g. open/ laparoscopic PN has demonstrated similar oncological durability to that of the gold standard RN [12,13]. RN is now largely considered an overtreatment for T1a (<4cm) RCC because it is associated with greater nephron loss and earlier onset of chronic kidney disease and also associated with increased cardiovascular events after RN [14,15]. Therefore, the current consensus is that RCC at stage T1a (<4 cm), should be treated with minimally invasive techniques in order to preserve renal function. Nephron sparing surgery (NSS) with either laparoscopic/open PN is advised whenever it is deemed technically possible [16]. Although, the NSS has similar recurrence free and long term survival outcomes as those with RN, NSS remains technically challenging and associated with significant morbidity even in expert hands [14,15]. Given the surgical challenges and the quest to preserve renal function, IGA treatment of the smaller RCC with radiofrequency ablation (RFA), cryoablation (CRYO) and microwave (MWA) has evolved rapidly over the last decade. Today, IGA of RCC has proven to be a safe and effective treatment option and good oncological outcome data is emerging for RFA [17-22] and CRYO [23,24]. In the hands of an experienced interventional oncologist, the primary technical success is now approaching >95% for both IGA with RFA and CRYO. As RFA was introduced earlier, the emerging larger RFA series have demonstrated cancer specific survival of 97-100% with a follow up of 61-78 months [17-22].

Balancing cardiovascular (CV) and cancer death among patients with small renal masses: modification by CV risk

To assess modification of comparative cancer survival by cardiovascular (CV) risk and treatment strategy among older patients with small renal masses (SRMs). Patients with localised T1a renal cell carcinoma were identified in the Surveillance, Epidemiology and End Results-Medicare database (1995-2007). Patients were stratified by CV risk, using major atherosclerotic CV comorbidities identified by the Framingham Heart Study, to compare overall (OS), cancer-specific (CSS), and CV-specific survival (CVSS) for those who deferred therapy (DT) to those undergoing either partial (PN) or radical nephrectomy (RN). Cox proportional hazards and Fine and Gray competing risks regression adjusted for demographics, comorbidities, and tumour size were performed. In all, 754 (10.5%) patients had DT, 1849 (25.8%) patients underwent PN, and 4574 (63.7%) patients underwent RN. Patients at high CV risk who had DT had the greatest CV-to-cancer mortality rate ratio (2.89), and CV risk was generally associated with worse OS and CVSS. Patients in the high CV risk strata had no difference in CSS between treatment strategies [DT vs PN: hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.25-1.41; DT vs RN: HR 0.81, 95%CI 0.46-1.43)], while there was a 2-4 fold CSS benefit for surgery in the low CV risk strata. Cancer survival was comparable across treatment strategies for older patients with SRMs with high risk CV disease. Greater attention to CV comorbidity as it relates to competing risks of death and life expectancy may be deserved in selecting patients appropriate for active surveillance because patients at low CV risk might benefit from surgery.

Comparison of diameter-axial-polar nephrometry and RENAL nephrometry score for treatment decision-making in patients with small renal mass.

The aim of this study was to evaluate our institution's experience in performing laparoscopic radical nephrectomy (LRN) and partial nephrectomy (PN) in patients with small renal masses. 142 patients with cT1aN0M0 lesions were identified. 68 of these subjects were treated with LRN and 74 were treated with laparoscopic PN (LPN). The clinicopathological characteristics of the two groups of patients, including diameter-axial-polar (DAP) nephrometry and RENAL nephrometry score (RENAL-NS), operative results, and outcomes, were retrospectively analyzed. A multivariate logistic regression analysis for the selection of PN as the treatment showed that tumor size, DAP nephrometry, RENAL-NS and imperative condition were all independent factors. The area under the curve receiver operating characteristics (ROC-AUC) of DAP and RENAL-NS for performing LPN were 0.897 and 0.825, respectively. Although LRN was performed in patients with a high nephrometry score in this study, open partial nephrectomy (OPN) should be considered for patients with a high nephrometry score in T1a renal cell carcinoma (RCC) because of better functional and similar oncological outcomes. Based on ROC analysis, when DAP is 6 or less, LPN should be considered and when DAP is 7 or more, OPN should be considered.

Cancer-free survival and local tumor control after impendence-based radiofrequency ablation of biopsy-proven renal cell carcinomas with a minimum of 1-year follow-up

ObjectivesThere are numerous reports describing the use of radiofrequency ablation (RFA) to treat renal cell carcinoma. Many series, however, describe heterogeneous populations, lack histologic descriptions, use various RFA systems, and indicate tumor destruction by different ablation end points. This study examined the outcomes of computed tomography–guided, impedance-based RFA of biopsy-proven renal cell carcinoma clinically staged as T1a with a minimum of 1 year of postablation follow-up. Methods and materialsThis retrospective study identified all consecutive patients who had undergone renal RFA since May 2005 at our institution. Patients without biopsy-proven renal cell carcinoma (RCCa) were excluded. Of the patients who met these criteria, evaluation was limited to patients with a minimum of 12 months of follow-up. Data collected from the patients׳ electronic medical and radiologic records included demographic data, tumor-related data, procedural details, and clinical follow-up visits. ResultsA total of 39 patients (46 lesions) met the inclusion criteria. The mean tumor diameter was 2.6cm (range: 1.2–4.0cm). The most common histologies were clear cell (n = 27) and papillary (n = 16) renal cancer. The lesion location was equally divided between upper pole (n = 16), middle pole (n = 16), and lower pole (n = 14). Overall, 83% of the tumors were exophytic. No residual or recurrent enhancing mass was identified in the ablation bed on post-RFA imaging during the mean follow-up period of 35.3 months (range: 12–83). All patients were treated in a single encounter and no lesion required a second ablation; technical success (absence of residual tumor) on the initial post-RFA imaging study was 46 of 46 (100%). Clinical success was achieved in 45 of 46 lesions (98%); residual, viable tumor was found in a pretransplant nephrectomy specimen on postprocedure day 127. The mean cancer-free survival was 36.2 months. Comparison of preablation and postablation renal function found no statistically significant change. ConclusionsThe consistent outcomes in our post-RFA imaging and clinical surveillance allow us to offer image-guided ablation to patients with T1a RCCa as a valid treatment option offering long-term cancer-free survival. Impedance-based RFA in a carefully selected patient population with T1a RCCa is a reliable treatment option, with disease-free survival rates that are comparable to partial nephrectomy.

The Prognostic Impact of Tumor Size on Cancer-Specific and Overall Survival Among Patients With Pathologic T3a Renal Cell Carcinoma

BackgroundWe aimed to determine the prognostic role of tumor size in patients with stage pT3a renal cell carcinoma (RCC). Patients and MethodsWe analyzed our database of patients who underwent radical nephrectomy for RCC between July 2000 and December 2013. Clinical and pathologic data were obtained for each patient. Patients with stage pT3a disease were divided into 2 subgroups according to the most informative threshold for pathologic tumor dimension that was able to predict survival outcomes (group 1, ≤ 8 cm; group 2, > 8 cm). ResultsGlobally, 185 consecutive patients were evaluated. The median (interquartile range [IQR]) follow-up was 32 months (18-62 months). The median (IQR) pathologic tumor size was 7.5 cm (5.7-10 cm). Seventy (34.3%) patients died of RCC during the follow-up period. Patients in group 2 experienced worse cancer-specific survival (CSS) rates compared with those in group 1, (5- and 10- year CSS, 52% and 40% vs. 67% and 63%, respectively; P = .001). Overall survival (OS) rates were significantly lower for patients included in group 2 compared with patients in group 1 (5- and 10- year OS rates, 46% and 38% vs. 60% and 57%, respectively; P = .01). Subgroup stratification (hazard ratio [HR], 3.65; P < .001), presence of positive surgical margins (HR, 3.86; P = .22), high Fuhrman grade (HR, 4.33; P < .001), and the presence of sarcomatoid cells (HR, 2.61; P = .02) were found to be independent predictors of CSS. ConclusionWorse oncologic outcomes are observed in patients with stage pT3a RCC tumors > 8 cm. The current TNM classification still does not precisely correlate with CSS. Tumor size should be taken into account in a future revision of the TNM staging system.

Survival advantage of partial over radical nephrectomy in patients presenting with localized renal cell carcinoma.

BackgroundPartial nephrectomy (PN) preserves renal function and has become the standard approach for T1a renal cell carcinoma (RCC). However, there is still an ongoing debate as to which patients will actually derive greater benefit from partial than from radical nephrectomy (RN). The aim of this study was to retrospectively evaluate the impact of the type of surgery on overall survival (OS) in patients with localized RCC.MethodsRenal surgery was performed in 4326 patients with localized RCC (pT ≤ 3a N/M0) at six German tertiary care centers from 1980 to 2010: RN in 2955 cases (68.3%), elective (ePN) in 1108 (25.6%), and imperative partial nephrectomy (iPN) in 263 (6.1%) cases. The median follow-up for all patients was 63 months. Kaplan-Meier and Cox regression analyses were carried out to identify prognosticators for OS.ResultsPN was performed significantly more often than RN in patients presenting with lower tumor stages, higher RCC differentiation, and non-clear cell histology. Accordingly, the calculated 5 (10)-year OS rates were 90.0 (74.6)% for ePN, 83.9 (57.5)% for iPN, and 81.2 (64.7)% for RN (p < 0.001). However, multivariate analysis including age, sex, tumor diameter and differentiation, histological subtype, and the year of surgery showed that ePN compared to RN still qualified as an independent factor for improved OS (HR 0.79, 95% CI 0.66-0.94, p = 0.008).ConclusionEven allowing for the weaknesses of this retrospective analysis, our multicenter study indicates that in patients with localized RCC, PN appears to be associated with better OS than RN irrespective of age or tumor size.

Race and sex disparities in the treatment of older patients with T1a renal cell carcinoma: A comorbidity-controlled competing-risks model

ObjectivesRecognizing population-level disparities for the treatment of patients with renal cell carcinoma (RCC) would inform clinical practice and health policy. Few studies, reporting conflicting results, have investigated race and sex disparities specifically among patients with small renal masses. Methods and materialsThe Surveillance, Epidemiology, and End Results-Medicare database (1995–2007) was queried for patients with localized T1a RCC undergoing radical nephrectomy, partial nephrectomy (PN), or deferred therapy (DT). Demographics, comorbidity, and treatment approach were assessed. Multivariable logistic regression models evaluated predictors of DT and then PN among those receiving surgery. Cox proportional hazards model evaluated survival differences for whites vs. blacks and women vs. men. ResultsA total of 6,092 white and 617 black patients with T1a RCC met the inclusion criteria. Blacks were twice as likely to defer therapy compared with whites (odds ratio = 1.95, 95% CI: 1.52–2.51) and had worse overall survival (hazard ratio = 1.36, 95% CI: 1.19–1.56). However, cancer-specific survival (CSS) was similar (P = 0.429). The greatest discrepancy was among healthy (Charlson comorbidity index≤1) blacks who had a much higher rate of DT compared with their white counterparts. Women were found to have decreased use of PN compared with men (odds ratio = 0.84, 95% CI: 0.74–0.96) and better CSS (hazard ratio = 0.74, 95% CI: 0.58–0.94), but there were no differences by race. ConclusionsThe differential use of DT by race instead of purely by age and comorbidity is concerning but has not led to a significant difference in CSS. Women are less likely to undergo PN compared with men, but they also have a notably improved CSS.

Percutaneous Ablation of the Small Renal Mass—Techniques and Outcomes

An increasing number of T1a renal cell carcinomas are being diagnosed in recent years, in part due to incidental detection from the increased use of cross-sectional imaging. Although partial nephrectomy is still considered the primary treatment for these small renal masses, percutaneous ablation is now being performed as a standard therapeutic, nephron-sparing approach in patients who are poor surgical candidates. Clinical studies to date have demonstrated that percutaneous ablation is an effective therapy with acceptable outcomes and low risk in the appropriate clinical settings. This article will review various clinical aspects regarding the percutaneous ablation of small renal masses, including patient selection, preprocedural preparations, and the procedural considerations of commonly employed ablative technologies. Specific techniques such as radiofrequency ablation, cryoablation, microwave ablation, irreversible electroporation, and high-intensity focused ultrasound will be addressed in detail. In addition, the technical and oncologic outcomes of percutaneous ablation will be discussed and referenced to that of partial nephrectomy.

T1a as the Sole Selection Criterion for RFA of Renal Masses: Randomized Controlled Trials versus Surgery Should Not Be Postponed

To evaluate the long-term effects of radiofrequency ablation (RFA) of renal masses (RM) and compare them with surgery. A total of 203 RM (193 malignant; mean size 30 mm) in 137 patients (95 male subjects; average age 64 years) underwent RFA. Complications and technique effectiveness were evaluated. Overall survival, cancer-specific survival, and disease-free survival were calculated (mean follow-up time 39 months). Predictors for complications, technique effectiveness, and survival were investigated. Seventeen (8.4 %) adverse events were recorded (2 % major complications). Exophytic development and smaller size were protective against adverse events. Complete ablation was obtained in 87 % RM (93 % ≤3 cm, 89 % ≤4 cm). T1a threshold was a positive predictor for complete ablation and central location a negative one. Three- and 5-year overall survival were 84 and 75 %; cancer-specific survival 96 and 91 %; and disease-free survival 80 and 75 %. Considering only the 79 patients with newly diagnosed renal cell carcinoma, T1a disease stage resulted a positive predictor for both overall survival (87 and 83 % at 3 and 5 years) and cancer-specific survival (100 % at 5 years). RFA of noncentral small RM is safe and effective, and it provides favorable long-term oncological outcomes. Selection criteria for RFA can also include T1a renal cell carcinoma in patients without surgical contraindications, even though randomized controlled trials are needed to establish the best treatment.

Incidence and Risk Factors of Chronic Kidney Disease in Korean Patients with T1a Renal Cell Carcinoma Before and After Radical or Partial Nephrectomy

The aim of the study was to investigate the incidence of chronic kidney disease in patients with T1a renal cell carcinoma both before and after partial or radical nephrectomy, and to assess risk factors for chronic kidney disease. From January 2001 to December 2011, 1928 patients with a single renal mass ≤4 cm undergoing partial nephrectomy or radical nephrectomy with the existence of a normal contralateral kidney were retrospectively reviewed for the evaluation of preoperative chronic kidney disease, and reviewed only 1676 patients for the postoperative chronic kidney disease. The estimated glomerular filtration rates were used to define chronic kidney disease <60 ml/min/1.73 m(2) by the Modification of Diet in Renal Disease equation. Demographics and clinicopathological parameters were evaluated to determine the risk factors with the development of chronic kidney disease both before and after surgery. Chronic kidney disease was found preoperatively in 10.0% (n = 192) of patients; 16.1% (n = 269) of patients developed chronic kidney disease postoperatively, including 102 (6.1%) chronic kidney disease patients >65 years of age. Between the non-chronic kidney disease and chronic kidney disease patients, male gender (odds ratio 3.55 vs. 3.78, respectively) and diagnostic age (odds ratio 1.04 vs. 1.05) were significantly distinctive common risk factors for chronic kidney disease both before and after surgery (P < 0.002). In addition, hypertension (odds ratio 0.46), serum albumin (odds ratio 0.23) and calcium (odds ratio 2.06) were significant as preoperative risk factors (P < 0.015), and preoperative serum creatinine (odds ratio 1.90) and surgical type (partial nephrectomy or radical nephrectomy; odds ratio 11.89) were significant as postoperative risk factors (P < 0.030). Old, male hypertensive patients with a small renal mass would be better candidates for partial nephrectomy to prevent postoperative chronic kidney disease.

IJU this issue

This issue deals with a wide range of clinical topics of urology, and contains one Review Article, 12 Original Articles, one Case Report and two Letters to the Editor. Urinary incontinence after radical prostatectomy is a big problem for patients with prostate cancer, and many urologists try to improve postoperative continent rates. Although recent systemic reviews and meta-analyses have shown that robot-assisted radical prostatectomy (RALP) has higher postoperative continence rates than retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP), urinary incontinence has remained one of the most bothersome postoperative complications, even after RARP. The Review Article by Kojima et al. (Fukushima, Japan) showed that the basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. They precisely reported three processes that consisted of preservation, reconstruction and reinforcement, helping us to modify our technique during RALP. Another topic regarding prostate cancer in this issue is pelvic lymph node dissection for prostate cancer. Mitsuzuka et al. (Sendai, Japan) investigated the role of pelvic lymph node dissection for low-risk prostate cancer using their medical records for 1268 patients undergoing open radical prostatectomy. Their conclusion is that pelvic lymph node dissection can be spared at radical prostatectomy for low-risk disease because of its poor diagnostic and therapeutic value, which is useful information when we carry out radical prostatectomy. Open versus laparoscopic, and partial versus radical nephrectomy (RN) for T1a renal cell carcinoma (RCC) are important topics, because the use of partial nephrectomy (PN) remains low in the community setting despite its established benefits. Bianchi et al. (Milan, Italy) examined the trends of open and laparoscopic PN and RN according to sociodemographic and tumor characteristics, using the USA Surveillance, Epidemiology, and End Results Medicare-linked database. They showed that older and female patients are less likely to undergo nephron-sparing surgery, and are more likely to have a radical nephrectomy by the laparoscopic approach instead, although utilization rates of PN are increasing. Further encouragement is required to increase PN for T1a RCC. Another topic regarding RCC in this issue is RCC extending into the inferior vena cava (IVC). Kondo et al. (Tokyo, Japan) investigated the impact of histological subtypes on the survival of patients presenting with RCC extending into the IVC, using their 68 cases who underwent RN and IVC thrombectomy. Their conclusion is that patients with RCC extending into the IVC with a papillary subtype show a considerably shorter survival compared with those with a clear cell subtype, which is helpful when we decide operative indications for patients with RCC extending into the IVC. Laparoendoscopic single site (LESS) surgery is a technical modification of conventional laparoscopy whereby the entire surgical procedure is carried out through a single abdominal wall incision. Tugcu et al. (Istanbul, Turkey) performed a prospective randomized study of LESS versus conventional transperitoneal laparoscopic pyeloplasty. A total of 39 patients were enrolled in their prospective study, and LESS pyeloplasty could offer faster recovery and higher patient satisfaction than conventional laparoscopic pyeloplasty. However, median operative time was longer in the LESS pyeloplasty group compared with the conventional laparoscopic group. Recently, a reduced port surgery using thin forceps, but not LESS, is increasing with technical advancements. In this sense, a comparison of reduced port pyeloplasty using thin forceps with LESS pyeloplasty would be interesting for evaluating the most minimally-invasive pyeloplasty. None declared.

Editorial Comment to Partial nephrectomy versus radical nephrectomy for non-metastatic pathological T3a renal cell carcinoma: A multi-institutional comparative analysis

Editorial Comment to Partial nephrectomy versus radical nephrectomy for non-metastatic pathological T3a renal cell carcinoma: A multi-institutional comparative analysis

Partial nephrectomy versus radical nephrectomy for non‐metastatic pathological T3a renal cell carcinoma: A multi‐institutional comparative analysis

To compare the recurrence-free survival of partial nephrectomy and radical nephrectomy in patients with non-metastatic pathological T3a renal cell carcinoma. We reviewed the records of 3567 patients who had undergone a nephrectomy for renal cell carcinoma at five institutions in Korea from January 2000 to December 2010. The clinical data of 45 patients with pathological T3a renal cell carcinoma in the partial nephrectomy group were compared with 298 patients with pathological T3a renal cell carcinoma in the radical nephrectomy group. The effects of surgical methods on recurrence-free survival were assessed by a multivariate Cox proportional hazard analysis. All comparisons were repeated in subgroup analysis on 63 clinical T1a patients with tumors ≤4 cm. During a median 43-month follow-up period, disease recurrence occurred in two patients (4.4%) in the partial nephrectomy group, and 94 patients (31.5%) in the radical nephrectomy group. The results from a multivariate model showed that radical nephrectomy was a significant predictor of recurrence. However, in subgroup analysis that included 63 clinical T1a pathological T3a patients, the recurrence-free survival rates were not significantly different between the two cohorts. The renal function was significantly better preserved in the partial nephrectomy cohort than in the radical nephrectomy cohort. Partial nephrectomy provides similar recurrence-free survival outcomes compared with radical nephrectomy in patients with clinical T1a pathological T3a renal cell carcinoma. However, there seems to be a higher risk of recurrence for large pathological T3a tumors treated by radical nephrectomy compared with small tumors treated by partial nephrectomy. Thus, large tumors with the same pathological T3a renal cell carcinoma grade could have hidden aggressive features.

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

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

The Value of “Liver Windows” Settings in the Detection of Small Renal Cell Carcinomas on Unenhanced Computed Tomography

ObjectiveTo assess if “liver window” settings improve the conspicuity of small renal cell carcinomas (RCC). MethodsPatients were analysed from our institution's pathology-confirmed RCC database that included the following: (1) stage T1a RCCs, (2) an unenhanced computed tomography (CT) abdomen performed ≤ 6 months before histologic diagnosis, and (3) age ≥ 17 years. Patients with multiple tumours, prior nephrectomy, von Hippel-Lindau disease, and polycystic kidney disease were excluded. The unenhanced CT was analysed, and the tumour locations were confirmed by using corresponding contrast-enhanced CT or magnetic resonance imaging studies. Representative single-slice axial, coronal, and sagittal unenhanced CT images were acquired in “soft tissue windows” (width, 400 Hounsfield unit (HU); level, 40 HU) and liver windows (width, 150 HU; level, 88 HU). In addition, single-slice axial, coronal, and sagittal unenhanced CT images of nontumourous renal tissue (obtained from the same cases) were acquired in soft tissue windows and liver windows. These data sets were randomized, unpaired, and were presented independently to 3 blinded radiologists for analysis. The presence or absence of suspicious findings for tumour was scored on a 5-point confidence scale. ResultsEighty-three of 415 patients met the study criteria. Receiver operating characteristics (ROC) analysis, t test analysis, and kappa analysis were used. ROC analysis showed statistically superior diagnostic performance for liver windows compared with soft tissue windows (area under the curve of 0.923 vs 0.879; P = .0002). Kappa statistics showed “good” vs “moderate” agreement between readers for liver windows compared with soft tissue windows. ConclusionUse of liver windows settings improves the detection of small RCCs on the unenhanced CT.

Predictors of benign histology in clinical T1a renal cell carcinoma tumors undergoing partial nephrectomy

The anatomical characteristics of renal tumors have been classified using several systems. An association between tumor anatomical characteristics and postoperative histological diagnosis can be expected. The present study aimed to assess the rate of and predictive factors for benign histological findings for renal tumors diagnosed as T1a by preoperative imaging. From January 2000 through December 2010, 149 patients underwent partial nephrectomy (either open or laparoscopic) for T1a renal cell carcinoma. The frequency of benign histological findings was evaluated. Logistic regression analysis estimated the relative importance of predictive factors. The overall frequency of benign lesions was 8.1%. Multivariate analysis identified three statistically significant predictive factors for benign lesions: age, sex and exophytic tumor property (P = 0.0356, 0.0183 and 0.0330, respectively). The present findings suggest that exophytic tumors on preoperative imaging are more likely to be benign at histology after partial nephrectomy.

1188 INCIDENCE AND RISK FACTORS OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH T1A RENAL CELL CARCINOMA BEFORE AND AFTER RADICAL OR PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized1 Apr 20131188 INCIDENCE AND RISK FACTORS OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH T1A RENAL CELL CARCINOMA BEFORE AND AFTER RADICAL OR PARTIAL NEPHRECTOMY Sung Han KIM, Sang Eun Lee, YongHyun PARK, SungKyu Hong, Chang Wook Jeong, Yong-June KIM, Seok Ho Kang, Sung-Hoo Hong, and Seok-Soo Byun Sung Han KIMSung Han KIM Seoul, Korea, Republic of More articles by this author , Sang Eun LeeSang Eun Lee Incheon, Korea, Republic of More articles by this author , YongHyun PARKYongHyun PARK Seoul, Korea, Republic of More articles by this author , SungKyu HongSungKyu Hong Incheon, Korea, Republic of More articles by this author , Chang Wook JeongChang Wook Jeong Incheon, Korea, Republic of More articles by this author , Yong-June KIMYong-June KIM Cheongju, Korea, Republic of More articles by this author , Seok Ho KangSeok Ho Kang Seoul, Korea, Republic of More articles by this author , Sung-Hoo HongSung-Hoo Hong Seoul, Korea, Republic of More articles by this author , and Seok-Soo ByunSeok-Soo Byun Incheon, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2542AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES As more incidental, small renal masses are increasingly detected and the negative relationship between long-term Chronic kidney disease(CKD) and morbidity/mortality is uncovered, the preservation of kidney function and its related aggravating factors will continue to be emphasized. Our study will investigate the incidence rate of CKD in patients with T1a renal cell carcinoma before and after the partial or radical nephrectomy and assess risk factors for CKD. METHODS From January 2001 to December 2011, 1928 patients with a single renal mass ¡Â 4cm in size undergoing PN or radical nephrectomy RN with the existence of a normal contralateral kidney were retrospectively reviewed from four major tertiary teaching hospitals. Estimated glomerular filtration rate (eGFR) was used to define the CKD less than 60ml/min per 1.73 m2 by the Modification of Diet in Renal Disease (MDRD) equation. Demographics and clinicopathologic parameters were evaluated using multivariate analysis to determine the risk factors independently affected with the development of CKD before and after the operation. RESULTS Among the 1928 patients with a single small renal mass, CKD was found preoperatively in 10.0%, and 16.1% of patients developed CKD postoperatively. For 447 patients over 65 years of age, 87 (19.5%) patients were found to have CKD at baseline, while 102 (28.4%) new patients developed CKD after the operation. After multivariate analyses for the CKD's risk factors between the non-CKD and CKD patients, male gender (OR 3.54, p=.003 vs. OR 3.88 p<.001, respectively), and diagnostic age (OR 1.04, p<.001 vs. OR 3.88, p<.001), were significantly distinctive common risk factors both before and after the operation. In addition, hypertension (OR 0.46, p=.006), serum albumin (OR 0.228, p<.001), and calcium (OR 2.00, p=.023) are also significant for preoperative risk factors of CKD before operation, as well as preoperative serum creatinine (OR 1.28, p<.001) and surgical types (radical or partial nephrectomy) (OR 8.2, p<.001) for postoperative risk factors of CKD. CONCLUSIONS This study indicates that those patients with a small renal mass and with the normal contralateral kidney should be carefully evaluated for their preoperative renal function to prevent the postoperative CKD if they were male with a history of hypertension, especially for the old ages. In addition, PN should first be considered rather than RN in consideration of developing postoperative CKD. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e485-e486 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sung Han KIM Seoul, Korea, Republic of More articles by this author Sang Eun Lee Incheon, Korea, Republic of More articles by this author YongHyun PARK Seoul, Korea, Republic of More articles by this author SungKyu Hong Incheon, Korea, Republic of More articles by this author Chang Wook Jeong Incheon, Korea, Republic of More articles by this author Yong-June KIM Cheongju, Korea, Republic of More articles by this author Seok Ho Kang Seoul, Korea, Republic of More articles by this author Sung-Hoo Hong Seoul, Korea, Republic of More articles by this author Seok-Soo Byun Incheon, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of Localized Kidney Cancer: Calculating Cancer-specific Mortality and Competing Risks of Death for Surgery and Nonsurgical Management

BackgroundFor elderly individuals with localized renal cell carcinoma (RCC), surgical intervention remains the primary treatment option but may not benefit patients with limited life expectancy. ObjectiveTo calculate the trade-offs between surgical excision and nonsurgical management (NSM) with respect to competing causes of mortality. Design, setting, and participantsRelying on a cohort of Medicare beneficiaries, all patients with nonmetastatic node-negative T1 RCC between 1988 and 2005 were abstracted. InterventionAll patients were treated with partial nephrectomy (PN), radical nephrectomy (RN), or NSM. Outcome measurements and statistical analysisCancer-specific mortality (CSM) and other-cause mortality (OCM) rates were modeled through competing-risks regression methodologies. Instrumental variable analysis was used to account for the potential biases associated with measured and unmeasured confounders. Results and limitationsA total of 10 595 patients were identified. In instrumental variable analysis, patients treated with PN (hazard ratio [HR]: 0.45; 95% confidence interval [CI], 0.24–0.83; p=0.01) or RN (HR: 0.58; 95% CI, 0.35–0.96; p=0.03) had a significantly lower risk of CSM than those treated with NSM. In subanalyses restricted to patients ≥75 yr, the instrumental variable analysis failed to detect any statistically significant difference between PN (HR: 0.48; p=0.1) or RN (HR: 0.57; p=0.1) relative to NSM with respect to CSM. Similar trends were observed in T1a RCC only. ConclusionsPN or RN is associated with a reduction of CSM among older patients diagnosed with localized RCC, compared with NSM. The same benefit failed to reach statistical significance among patients ≥75 yr. The harms of surgery need to be weighed against the marginal survival benefit for some patients.

1199 RADIOFREQUENCY ABLATION ACHIEVES COMPARABLE LOCAL ONCOLOGICAL CONTROL TO PARTIAL NEPHRECTOMY FOR T1 RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Localized1 Apr 20131199 RADIOFREQUENCY ABLATION ACHIEVES COMPARABLE LOCAL ONCOLOGICAL CONTROL TO PARTIAL NEPHRECTOMY FOR T1 RENAL CELL CARCINOMA Sarah Psutka, W. Scott McDougal, Douglas Dahl, Francis McGovern, Peter Mueller, Debra Gervais, and Adam Feldman Sarah PsutkaSarah Psutka Boston, MA More articles by this author , W. Scott McDougalW. Scott McDougal Boston, MA More articles by this author , Douglas DahlDouglas Dahl Boston, MA More articles by this author , Francis McGovernFrancis McGovern Boston, MA More articles by this author , Peter MuellerPeter Mueller Boston, MA More articles by this author , Debra GervaisDebra Gervais Boston, MA More articles by this author , and Adam FeldmanAdam Feldman Boston, MA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2553AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radiofrequency ablation (RFA) of small renal masses (SRM) is increasingly offered to select patients with significant comorbidity as an alternative, less invasive, nephron−sparing (NS) therapy. Long−term comparisons of oncologic efficacy between RFA and partial nephrectomy (PN), the current gold standard for T1 renal cell carcinoma (RCC), are lacking. Our objective was to compare long−term oncologic outcomes between patients with clinical T1a and T1b RCC treated with either RFA or PN. METHODS 551 patients underwent NS treatment for SRM between 1998 and 2008. In general, patients selected for RFA had substantial medical comorbidity, were poor surgical candidates, and/or had a projected life-expectancy of less than 10 yrs. Exclusion criteria for this study included history of RCC, multiple synchronous tumors, metastatic disease at presentation, genetic predisposition to RCC, or non−RCC pathology. A total of 380 patients were included in this analysis, including 186 patients who underwent RFA and 194 patients who underwent PN. All patients undergoing RFA had biopsy−proven RCC. Primary endpoints included recurrence−free survival (RFS) and overall survival (OS). RESULTS The mean (range) follow−up for RFA and PN were 4.8 years (0.5−13.1) and 5.4 years (0.5−12.8). Patients undergoing RFA were more likely to have larger tumors (3.1 vs. 2.6 cm, p<0.0001), be older (71.1 vs. 57.4 years, p<0.0001), and have a higher Charlson comorbidity score (5.6 vs. 3.5, p<0.0001). Of the 194 patients undergoing PN, 17 had positive margins (8.8%) and 14 had pT3a disease (7.2%). There were 12 local recurrences (6.5%) after RFA compared to 6 (3.1%) after PN (p=0.12) with mean time to recurrence of 6.3 years for RFA vs. 2.7 years for PN. Statistically, there was no significant difference in RFS between RFA and PN (Figure 1, p=0.07). Overall survival was higher in the PN group (5.2% vs.17.8%, p<0.0001), as was expected given the increased comorbidity and advanced age of patients in the RFA cohort. Death from RCC occurred in 4 patients treated by RFA and 1 treated with PN (p = 0.15). CONCLUSIONS RFS and cancer−specific mortality were comparable following RFA or PN for cT1a and cT1b RCC. For carefully selected patients with significant comorbidity precluding surgical intervention, RFA appears to provide durable oncological control for cT1 RCC in a nephron−sparing manner. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e491 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah Psutka Boston, MA More articles by this author W. Scott McDougal Boston, MA More articles by this author Douglas Dahl Boston, MA More articles by this author Francis McGovern Boston, MA More articles by this author Peter Mueller Boston, MA More articles by this author Debra Gervais Boston, MA More articles by this author Adam Feldman Boston, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...