Overall survival and renal function after partial and radical nephrectomy among older patients with localised renal cell carcinoma: a propensity-matched multicentre study

Perioperative outcomes following robot-assisted partial nephrectomy in elderly patients

OBJECTIVE

To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with age ≥ 70 years to age < 70 years.

METHODS

Using Vattikuti Collective quality initiative (VCQI) database for RAPN we compared perioperative outcomes following RAPN between the two age groups. Primary outcome of the study was to compare trifecta outcomes between the two groups. Propensity matching using nearest neighbourhood method was performed with trifecta as primary outcome for sex, body mass index (BMI), solitary kidney, tumor size and Renal nephrometery score (RNS).

RESULTS

Group A (age ≥ 70 years) included 461 patients whereas group B included 1932 patients. Before matching the two groups were statistically different for RNS and solitary kidney rates. After propensity matching, the two groups were comparable for baselines characteristics such as BMI, tumor size, clinical symptoms, tumor side, face of tumor, solitary kidney and tumor complexity. Among the perioperative outcome parameters there was no difference between two groups for operative time, blood loss, intraoperative transfusion, intraoperative complications, need for radical nephrectomy, positive margins and trifecta rates. Warm ischemia time was significantly longer in the younger age group (18.1 min vs. 16.3 min, p = 0.003). Perioperative complications were significantly higher in the older age group (11.8% vs. 7.7%, p = 0.041). However, there was no difference between the two groups for major complications.

CONCLUSION

RAPN in well-selected elderly patients is associated with comparable trifecta outcomes with acceptable perioperative morbidity.

Efficacy and safety of surgery in renal carcinoma patients 75 years and older: a retrospective analysis

Objective

To investigate the efficacy and complications of surgical treatment in patients with renal cell carcinoma aged ≥ 75 years.

Methods

From January 2009 to May 2019, we assessed 166 patients aged 75 years and older, who either had radical nephrectomy (RN) or partial nephrectomy (PN) as treatments for diagnosed renal cell carcinoma. Patients were divided into one group of patients aged 75–79 years and the second group of patients ≥ 80 years. The complications and survival were compared between the two groups.

Results

All 166 patients were successfully operated on. Differences between the two groups were statistically significant in intraoperative and postoperative complications and Clavien–Dindo score of ≥ 1 (P = 0.02, P < 0.001, P = 0.001). Univariate analysis revealed no significant correlation between a Clavien–Dindo score ≥ 1 versus gender, body mass index (BMI), lack of symptoms, KPS, baseline GFR, postoperative GFR, tumor size, tumor location, surgical method, and transfusion or no transfusion (ALL P > 0.05). Multifactor analysis showed that age ≥ 80 years, partial nephrectomy, and operation time were independent predictors of a Clavien–Dindo score ≥ 1. No significant difference was found in OS between the two groups, (P < 0.0001), and no significant difference in CSS (P = 0.056). There was no significant difference in OS and CSS between the RN and PN groups (P = 0.143, P = 0.281, respectively).

Conclusions

According to our findings, the overall safety of surgical therapy for elderly patients with renal cell carcinoma is adequate. PN should be carefully examined, especially over the age of 80. To select suitable patients based on an assessment of the tumor's complexity and patients' physical condition, such as age, underlying diseases and other conditions, technical feasibility, balance of benefits and a case-by-case.

Overview of clinical management for older patients with renal cell carcinoma

The rapidly increasing pool of older patients being diagnosed with and surviving their cancer is creating many challenges. Regarding localized renal cell carcinoma, surgery is considered as gold standard treatment options even in older men, whereas active surveillance and ablation therapy are alternative options for a proportion of these patients. With regard to advanced disease, anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) and immune check point inhibitor are standard treatment modalities, although treatment choice from multiple regimens and prevention of adverse events need to be considered. Better assessment techniques, such as comprehensive geriatric assessment to meet the unique needs of older patients, are a central focus in the delivery of high-quality geriatric oncology care. Through this process, shared decision-making should be adopted in clinical care to achieve optimal goals of care that reflect patient and caregiver hopes, needs and preferences. It is necessary to continue investigating oncological outcomes and complications associated with treatment in this population to ensure appropriate cancer care. In this narrative review, we completed a literature review of the various treatments for renal cell carcinoma in older patients that aimed to identify the current evidence related to the full range of the treatments including active surveillance, surgery, ablation therapy and systemic therapy. Prospectively designed studies and studies regarding geriatric assessment were preferentially added as references. Our goals were to summarize the real-world evidence and provide a decision framework that guides better cancer practices for older patients with renal cell carcinoma.

Pharmaceutical advances in the treatment of gastric adenocarcinoma

INTRODUCTION

Gastric adenocarcinoma (GAC) continues to be a prevalent global concern. Differences in incidence are predominantly due to geographic locations with Asia contributing to majority of cases. Another parallel challenge is due to heterogenous molecular and immune profiles of GAC along with varying clinicopathological features of patients. In most countries, GACs are diagnosed late in an advanced stage as the early detection infrastructure cannot be implemented or not feasible. Future advances in liquid biopsies could change all that.

AREAS COVERED

The authors focus on the recent advances in the management of advanced GAC patients w but also address localized GAC. Herein, the authors review the most contemporary treatments and promising breakthroughs.

EXPERT OPINION

The addition of immunotherapy to standard of care has changed the outlook of advanced GAC patients. The authors anticipate continued advances in the development of immunotherapy both in surgically resectable and unresectable GACs. Targeting the ERBB2 (HER2) protein pathway remains uniquely important in GACs with ERBB2 (HER2) protein positivity. Currently, many novel anti-ERBB2 (HER2) protein therapies are under investigation. The next generation of GAC patients will derive considerably more benefit as the therapeutic landscape becomes more complex coupled with challenges in biomarker platforms and new drug development.

Systematic Review With Meta-Analysis: Diagnostic, Prognostic and Clinicopathological Significance of CircRNA Expression in Renal Cancer

Background

Renal cancer (RC) is one of the most common malignant tumors of the urinary system, and molecular targets for the specific diagnosis and treatment of RC have been widely explored. The purpose of this study was to systematically analyze circular RNAs (circRNAs), which may serve as novel tumor markers in terms of the diagnosis, prognosis and clinicopathological characteristics of RC.

Methods

PubMed and Web of Science were systematically searched for literature as up to July 30, 2021. All included studies were evaluated by the evaluation system, and the results were satisfactory. Hazard ratios (HRs) and odds ratios (ORs) were used to assess the association of circRNAs with diagnostic and clinicopathological indicators. The sensitivity (SEN), specificity (SPE), positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio and area under the summary receiver operating characteristic curve (AUC) were combined to evaluate the diagnostic performance of circRNAs in RC.

Results

We included 22 studies that met the criteria, including 18 that were prognostic, 4 that were diagnostic, and 12 that were clinicopathologically relevant. In terms of prognosis, we found that upregulated circRNAs were positively associated with poor overall survival in patients with RC (HR=1.63, 95% CI=1.43–1.85). In terms of diagnosis, the combined SEN, SPE and AUC of circRNAs in the diagnosis of RC were 0.82, 0.84 and 0.89 (0.86–0.91), respectively. In terms of clinicopathological features, upregulated circRNAs were associated with the Fuhrman grade (OR=0.641, 95% CI=0.471–0.873), T stage (OR=0.236, 95% CI=0.141–0.396), TNM stage (OR=0.225, 95% CI=0.158–0.321) and lymphatic metastasis (OR=0.329, 95% CI=0.193–0.560).

Conclusion

Our meta-analysis confirms that circRNAs may be candidate biomarkers for the diagnosis, prognosis, and clinicopathological indicators of RC.

Test clamp procedure in robot-assisted partial nephrectomy: is it a safe procedure?

We performed test clamp procedure in robot-assisted partial nephrectomy (RAPN) to prevent massive bleeding during tumor resection and to omit dissection of non-feeding arteries around the tumor. We subsequently analyzed the safety and usefulness of the procedure. The Test clamp procedure was performed for 1 to 3 min during renal artery test ischemia prior to the actual ischemia and tumor resection. We confirmed the disappearance of blood flow around the renal tumor using color Doppler ultrasonography. If arterial blood flow around the tumor remained, we surveyed the site for other arteries that needed to be clamped and repeated the test clamp procedure until renal blood flow around the tumor disappeared. We retrospectively analyzed consecutive RAPN cases performed from July 2016 to March 2020 at our institutions and reviewed medical records. The clinical data of the RAPN cases were statistically analyzed. Sixty-four RAPN cases underwent the test clamp procedure, which was categorized as the TEST group. Test clamping was performed safely without any clamping-related complications in all cases. Eleven cases (17%) underwent partial ischemia, which was a significantly higher number than that in the control group. Massive bleeding during tumor resection was more frequent in the control group. Postoperative deterioration of estimated glomerular filtration rate did not differ significantly between both groups. Although further investigation was still necessary, our findings indicate that the test clamp procedure may be a safe and secure procedure to perform in RAPN for both patients and surgeons.

Surgical treatment for renal masses in the elderly: analysis of oncological, surgical and functional outcomes

PURPOSE

Radical treatment in elderly patients with renal tumor remains debatable due to uncertainties regarding the risk of surgical complications, risk of end-stage renal disease (ESRD) and survival benefit. The aim of the study was to assess outcomes of radical treatment for renal cancer in elderly patients.

MATERIALS AND METHODS

This retrospective analysis enrolled 507 consecutive patients treated with partial or radical nephrectomy due to renal mass. Patients with upfront metastatic disease (n=46) and patients lost to follow-up (n=110) were excluded from the analysis. Surgical, functional (screen for ESRD development) and survival outcomes were analyzed in patients aged >75 years in comparison to younger individuals.

RESULTS

The analyzed group included 55 elderly patients and 296 younger controls. Within the cohort a total of 148 and 203 patients underwent radical and partial nephrectomies respectively. The rate of surgical complications, including grade >3 Clavien- Dindo complications, did not differ between groups (3.6% vs. 4.4%, p=0.63). Median length of hospital stay was equal in both groups (7 days). During a follow-up (median 51.9 months, no difference between groups), ESRD occurred in 3.4% of controls and was not reported in elderly group (p=0.37). Younger patients demonstrated a statistically significant advantage in both overall survival and cancer-specific survival over elderly patients (OS 94.6% vs. 87% p=0.036, CSS 97.3% vs. 89.1% p=0.0008).

CONCLUSIONS

Surgical treatment in elderly patients with renal tumor is as safe as in younger individuals and does not increase the risk of ESRD. However, cancer specific survival among these patients remains shorter than in younger patients.

RX-3117 (fluorocyclopentenyl cytosine): a novel specific antimetabolite for selective cancer treatment

INTRODUCTION

RX-3117 is an oral, small molecule cytidine analog anticancer agent with an improved pharmacological profile relative to gemcitabine and other nucleoside analogs. The agent has excellent activity against various cancer cell lines and xenografts including gemcitabine-resistant variants and it has excellent oral bioavailability; it is not a substrate for the degradation enzyme cytidine deaminase. RX-3117 is being evaluated at a daily oral schedule of 700 mg (5 days/week for 3 weeks) which results in plasma levels in the micromolar range that have been shown to be cytotoxic to cancer cells. It has shown clinical activity in refractory bladder cancer and pancreatic cancer. Areas covered: The review provides an overview of the relevant market and describes the mechanism of action, main pharmacokinetic/pharmacodynamic features and clinical development of this investigational small molecule. Expert opinion: RX-3117 is selectively activated by uridine-cytidine kinase 2 (UCK2), which is expressed only in tumors and has a dual mechanism of action: DNA damage and inhibition of DNA methyltransferase 1 (DNMT1). Because of its tumor selective activation, novel mechanism of action, excellent oral bioavailability and candidate biomarkers for patient selection, RX-3117 has the potential to replace gemcitabine in the treatment of a spectrum of cancer types.

Risk-adjusted proposal for >60 months follow up after surgical treatment of organ-confined renal cell carcinoma according to life expectancy

OBJECTIVES

To determine the long-term oncological outcome of organ-confined (<pT3) renal cell carcinoma.

METHODS

We identified 889 patients with complete long-term follow-up data, who had been surgically treated for renal cell carcinoma (<T3) at our institution between 1976 and 2009. Kaplan-Meier analysis was used to assess the incidence and time interval of recurrence defined as local recurrences or metastases. We further compared patients who had tumor progression before or after 60 months.

RESULTS

After a median follow-up period of 74.33 months (range 3-329 months), 44 patients (4.9%) had disease recurrence. A total of 38.6% of the recurrences occurred after 60 months; 76.2% of patients had distant metastases and 23.8% of patients had local recurrences. In patients with low-grade (G1) and low-stage (pT1a) tumors, there was a trend to develop recurrence or metastases after longer intervals. Patients with lung metastasis and patients with multiple metastatic locations developed these metastases earlier than patients with bone metastasis. The risk of dying of other causes correlated with age, but the time interval to metastases did not.

CONCLUSIONS

Current guidelines recommend a follow-up period of 60 months after surgical treatment of organ-confined renal cell carcinoma. Our data shows that one-third of recurrences of <pT3 renal cell carcinoma occur after 60 months. According to our oncological analysis, we suggest an age-adjusted strategy of follow-up balancing the risk of tumor recurrence and the life expectancy of the patient.

Partial versus Radical Nephrectomy for T1-T2 Renal Cell Carcinoma in Patients with Chronic Kidney Disease Stage III: a Multiinstitutional Analysis of Kidney Function and Survival Rate

BACKGROUND

To examine survival rates and renal function after partial nephrectomy (PN) and radical nephrectomy (RN) in patients with chronic kidney disease (CKD).

METHODS

We studied 4,332 patients who underwent PN or RN for pathological T1a-T2N0M0 renal cell carcinoma from 1988 to 2014. Patients were divided into two subgroups of CKD stage I-II and stage III. Kidney function, and survival outcomes were compared between groups.

RESULTS

We included 1,756 patients with CKD I-II and 276 patients with CKD III in the final pair-matched analysis. Kidney function was significantly better preserved in the PN than in the RN group among all patients. However, the beneficial effect of PN on kidney function gradually disappeared over time in CKD III patients. The 5-year overall survival (OS) rates after PN and RN differed in patients with CKD I-II disease (99.4% vs. 96.5%, respectively, P = 0.015). The 5-year OS rates after surgery were not affected by mode of nephrectomy in CKD III patients (97.8% vs. 93.5%, P = 0.103). The 5-year cancer-specific survival rates did not differ between treatment groups in all CKD stage. Cox hazard analysis showed that the operative method was a significant factor for OS in CKD I-II patients (hazard ratio [HR], 0.320; confidence interval [CI], 0.122-0.840; P = 0.021). However, PN was not beneficial in terms of OS in CKD III patients (HR, 0.395; CI, 0.086-1.172; P = 0.117).

CONCLUSION

PN is associated with a higher OS rate and better kidney function in patients with preoperative CKD stage I and II, but not in those with CKD stage III.

Age at diagnosis and the surgical management of small renal carcinomas: findings from a cross-sectional population-based study

OBJECTIVES

To describe the use of partial nephrectomy (PN) for patients with stage T1a renal cell carcinoma (RCC) by age group (<65 and ≥65 years) in two Australian states.

MATERIALS AND METHODS

All adults diagnosed with RCC in 2012 and 2013 were identified through population-based cancer registries in the Australian states of Queensland and Victoria. For each patient, research assistants extracted patient, tumour and treatment data from medical records. Percentages of patients treated by PN were determined for the two age groups. Multivariable logistic regression analyses examined factors associated with PN. Clinicians treating RCC were sent surveys to assess attitudes towards PN.

RESULTS

Data were collected on 956 patients (Victoria: n = 548; Queensland: n = 404) with stage T1a RCC. Of those undergoing surgery (n = 865), PN was more common for those aged <65 years (61%) than for those aged ≥65 years (44%), with this difference significant after adjusting for patient, tumour (odds ratio 0.50, 95% confidence interval 0.36-0.70). There were significant interactions between age and treatment centre volume (P < 0.05) and residential state (P < 0.05). PN was less likely for younger patients treated at lower-volume hospitals (<24 patients a year) but hospital volume was not associated with PN for older patients. PN was less likely for older patients in Queensland than Victoria. In multivariable analyses, age was not related to laparoscopic surgery. Queensland clinicians were less likely than those from Victoria to agree that PN was the treatment of choice for most T1aN0M0 tumours (P < 0.001).

CONCLUSIONS

In Australia, patients aged > 65 years with small renal cancers were less likely to be treated by PN than younger patients. The variation in the surgical procedure used to treat older T1a RCC patients by state and hospital volume indicates that better evidence is needed to direct practice in this area.

Treatment approaches to small renal masses in patients of advanced age (≥75 years)

The elderly population is increasing in Turkey and across the world. With the frequent use of imaging modalities, the detection rate of coincidental small renal mass has also increased. Since small renal masses are generally not malignant, most of them can be followed up by active surveillance. In the current study, we examined the treatment options that can be offered to elderly patients with small renal masses. The optimum treatment method for patients of advanced age presenting with renal masses should be determined based on the presence of comorbidities such as age, renal function, and tumor characteristics.

Survival outcomes in patients with large (≥7cm) clear cell renal cell carcinomas treated with nephron-sparing surgery versus radical nephrectomy: Results of a multicenter cohort with long-term follow-up

Background

Does the dogma of nephron sparing surgery (NSS) still stand for large renal masses? Available studies dealing with that issue are considerably biased often mixing imperative with elective indications for NSS and also including less malignant variants or even benign renal tumors. Here, we analyzed the oncological long-term outcomes of patients undergoing elective NSS or radical tumor nephrectomy (RN) for non-endophytic, large (≥7cm) clear cell renal carcinoma (ccRCC).

Methods

Prospectively acquired, clinical databases from two academic high-volume centers were screened for patients from 1980 to 2010. The query was strictly limited to patients with elective indications. Surgical complications were retrospectively assessed and classified using the Clavien-Dindo-classification system (CDS). Overall survival (OS) and cancer specific survival (CSS) were analyzed using the Kaplan-Meier-method and the log-rank test.

Results

Out of in total 8664 patients in the databases, 123 patients were identified (elective NSS (n = 18) or elective RN (n = 105)) for ≥7cm ccRCC. The median follow-up over all was 102 months (range 3–367 months). Compared to the RN group, the NSS group had a significantly longer median OS (p = 0.014) and median CSS (p = 0.04).

Conclusions

In large renal masses, NSS can be performed safely with acceptable complication rates. In terms of long-term OS and CSS, NSS was at least not inferior to RN. Our findings suggest that NSS should also be performed in patients presenting with renal tumors ≥7cm whenever technically feasible. Limitations include its retrospective nature and the limited availability of data concerning long-term development of renal function in the two groups.

Nephron Sparing Surgery Has Better Oncologic Outcomes Than Extirpative Nephrectomy in T1a but Not in T1b or T2 Stage Renal Cell Carcinoma

BACKGROUND The aim of this study was to investigate the benefit of nephron sparing surgery (NSS) compared with extirpative nephrectomy in different tumor stages of renal cell carcinoma. MATERIAL AND METHODS We reviewed the Surveillance, Epidemiology and End Results (SEER) database for NSS and extirpative nephrectomy in localized (stages T1-2N0M0) renal cell carcinoma diagnosed after 2004. We used the variable screening function of the SEER database to identified 55,947 cases that met inclusion and exclusion criteria for survival analysis. Overall mortality and cancer-specific mortality were the primary index outcomes. Stratification analysis was done by T stage subgroups. We also performed survival analysis using propensity score analysis, and changed the survival model to the competing-risk model for cancer-specific mortality analysis. RESULTS Overall, NSS significantly decreased the risk of overall mortality (HR 0.717, 0.668-0.769) and cancer-specific mortality (HR 0.604, 0.525-0.694) when compared to extirpative nephrectomy. In subgroup analysis, NSS had a lower overall mortality risk and cancer-specific mortality compared to extirpative nephrectomy only for T1a stage renal cell carcinoma (HR 0.654, 0.599-0.714, p<0.01 and HR 0.554, 0.458-0.670, p<0.01, respectively), but not for T1b or T2 stage. The propensity score analysis, which included standardized mortality ratio weight adjustment, showed the same results. Additionally, for cancer-specific mortality, a competing-risk model gave the exactly same outcome. CONCLUSIONS Compared to extirpative nephrectomy, NSS provided superior overall survival and cancer-specific survival for localized renal cell carcinoma only in T1a stage, not in T1b or T2 stage. NSS should be recommended when the surgery is possible. Further prospective study is needed to confirm this result.

Renal Functional Outcomes after Surgery, Ablation, and Active Surveillance of Localized Renal Tumors: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Management strategies for localized renal masses suspicious for renal cell carcinoma include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Given favorable survival outcomes across strategies, renal preservation is often of paramount concern. To inform clinical decision making, we performed a systematic review and meta-analysis of studies comparing renal functional outcomes for radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1997 to May 1, 2015 to identify comparative studies reporting renal functional outcomes. Meta-analyses were performed for change in eGFR, incidence of CKD, and AKI.

RESULTS

We found 58 articles reporting on relevant renal functional outcomes. Meta-analyses showed that final eGFR fell 10.5 ml/min per 1.73 m2 lower for radical nephrectomy compared with partial nephrectomy and indicated higher risk of CKD stage 3 or worse (relative risk, 2.56; 95% confidence interval, 1.97 to 3.32) and ESRD for radical nephrectomy compared with partial nephrectomy. Overall risk of AKI was similar for radical nephrectomy and partial nephrectomy, but studies suggested higher risk for radical nephrectomy among T1a tumors (relative risk, 1.37; 95% confidence interval, 1.13 to 1.66). In general, similar findings of worse renal function for radical nephrectomy compared with thermal ablation and active surveillance were observed. No differences in renal functional outcomes were observed for partial nephrectomy versus thermal ablation. The overall rate of ESRD was low among all management strategies (0.4%-2.8%).

CONCLUSIONS

Renal functional implications varied across management strategies for localized renal masses, with worse postoperative renal function for patients undergoing radical nephrectomy compared with other strategies and similar outcomes for partial nephrectomy and thermal ablation. Further attention is needed to quantify the changes in renal function associated with active surveillance and nephron-sparing approaches for patients with preexisting CKD.

The second wave of immune checkpoint inhibitor tsunami: advance, challenges and perspectives

After the first wave of the tsunami of immune checkpoint inhibitors, 2016 was marked by the second wave, revealed by numerous US FDA approvals, publications and abstracts in relation with these drugs in different cancers and settings. First, we reported all new indications of anti-CTLA4, anti-programmed cell death protein 1 and anti-PDL1 approved by the FDA, the positive clinical trials published and the abstracts reported at important scientific meetings during 2016. Then, we highlighted the updates on debatable issues related to checkpoint inhibitors, since the first wave published in a previous issue. We focused on the predictive biomarkers, combination therapies, tumor response patterns and efficacy in particular settings and the side effect management. Finally, the impact of checkpoint inhibitors development on the care management of cancer centers will be discussed.

Partial nephrectomy versus radical nephrectomy for clinical localised renal masses

BACKGROUND

Partial nephrectomy and radical nephrectomy are the relevant surgical therapy options for localised renal cell carcinoma. However, debate regarding the effects of these surgical approaches continues and it is important to identify and summarise high-quality studies to make surgical treatment recommendations.

OBJECTIVES

To assess the effects of partial nephrectomy compared with radical nephrectomy for clinically localised renal cell carcinoma.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, Embase, Web of Science, BIOSIS, LILACS, Scopus, two trial registries and abstracts from three major conferences to 24 February 2017, together with reference lists; and contacted selected experts in the field.

SELECTION CRITERIA

We included a randomised controlled trial comparing partial and radical nephrectomy for participants with small renal masses.

DATA COLLECTION AND ANALYSIS

One review author screened all of the titles and abstracts; only citations that were clearly irrelevant were excluded at this stage. Next, two review authors independently assessed full-text reports, identified relevant studies, evaluated the eligibility of the studies for inclusion, assessed trial quality and extracted data. The update of the literature search was performed by two independent review authors. We used Review Manager 5 for data synthesis and data analyses.

MAIN RESULTS

We identified one randomised controlled trial including 541 participants that compared partial nephrectomy to radical nephrectomy. The median follow-up was 9.3 years.Based on low quality evidence, we found that time-to-death of any cause was decreased using partial nephrectomy (HR 1.50, 95% CI 1.03 to 2.18). This corresponds to 79 more deaths (5 more to 173 more) per 1000. Also based on low quality evidence, we found no difference in serious adverse events (RR 2.04, 95% CI 0.19 to 22.34). Findings are consistent with 4 more surgery-related deaths (3 fewer to 78 more) per 1000.Based on low quality evidence, we found no difference in time-to-recurrence (HR 1.37, 95% CI 0.58 to 3.24). This corresponds to 12 more recurrences (14 fewer to 70 more) per 1000. Due to the nature of reporting, we were unable to analyse overall rates for immediate and long-term adverse events. We found no evidence on haemodialysis or quality of life.Reasons for downgrading related to study limitations (lack of blinding, cross-over), imprecision and indirectness (a substantial proportion of patients were ultimately found not to have a malignant tumour). Based on the finding of a single trial, we were unable to conduct any subgroup or sensitivity analyses.

AUTHORS' CONCLUSIONS

Partial nephrectomy may be associated with a decreased time-to-death of any cause. With regards to surgery-related mortality, cancer-specific survival and time-to-recurrence, partial nephrectomy appears to result in little to no difference.

Partial nephrectomy vs. radical nephrectomy for renal tumors: A meta-analysis of renal function and cardiovascular outcomes

OBJECTIVES

The widespread use of partial nephrectomy (PN) has led to the preservation of functional renal parenchyma. However, the benefits of PN on renal function and cardiovascular outcomes remain controversial. Thus, a meta-analysis was performed to reconcile the conflicting results.

MATERIALS AND METHODS

PubMed, Embase, and the Cochrane Library were searched from inception to August 2015, and databases with all relevant comparative studies were included. The Mantel-Haenszel method with random-effects models was used to determine the pooled hazard ratios (HRs) for each outcome.

RESULTS

In total, 26 studies were pooled for new-onset chronic kidney disease, and 6 studies were pooled for cardiovascular outcomes. According to the pooled estimates, PN correlated with a 73% risk reduction of new-onset chronic kidney disease in all included patients (HR = 0.27, P<0.0001) and a 65% risk reduction in patients with tumors>4cm (HR = 0.35, P<0.0001) compared with radical nephrectomy. There were no significant differences between groups regarding postsurgery cardiovascular events (HR = 0.86, P = 0.238) and cardiovascular death (HR = 0.79, P = 0.196). Despite inherent selection biases, the pooled estimates were robust in sensitivity and subgroup analyses.

CONCLUSIONS

Our findings suggest that PN lowers the postoperative risk of new-onset chronic kidney disease. Nevertheless, the protection of renal function by PN did not reduce the risk of cardiovascular outcomes. However, this result remains controversial, and additional large-scale evaluations are warranted.

Immunotherapy for oesophagogastric cancer

INTRODUCTION

Gastric and oesophageal cancers are a pressing global health problem with high mortality rates and poor outcomes for advanced disease. The mainstay of treatment in the palliative setting has traditionally been chemotherapy, which accrues only modest survival benefits. As with other cancer types, there is increasing interest in the use of immunotherapy approaches to improve outcomes.

AREAS COVERED

This paper reviews the aetiological and genetic characteristics of oesophagogastric (OG) cancers relevant to the application of immunotherapy and outlines the historical, present-day and potential future applications of immunotherapy in their management.

EXPERT OPINION

The use of agents targeting the PD1 pathway have led to impressive and durable responses in a minority of OG cancer patients and it would be expected that combinatorial approaches with chemotherapy, radiotherapy and other biological agents will improve responses further. Identification of clinically robust biomarkers is crucial in refining such approaches moving forwards. The application of modern sequencing technology to the development of personalized neoantigen-based vaccines represents an exciting amalgamation of genomics and immunotherapy, with potentially important clinical implications in OG cancer.

Surgical treatment of renal-cell carcinoma in elderly people

OBJECTIVE

To describe the oncological characteristics and evolution of patients 65 years or older who underwent surgery for renal-cell carcinoma (RCC).

METHODS

We reviewed our prospectively maintained database of patients with RCC treated surgically. Those ≥ 65 years old were selected. We analyzed clinical and pathological characteristics as well as oncological and functional outcomes. Overall survival (OS) was estimated with the Kaplan-Meier method. Multivariate Cox-proportional hazards model was used to determine predictors of OS.

RESULTS

A total of 156 elderly patients with mean age 72.0±5.5 years (range 65-92) and median follow-up of 33 months were included. Surgical approach was open radical nephrectomy in 114 (73.5%), laparoscopic radical nephrectomy in 13 (8.4%), open partial nephrectomy in 23 (14.2%) and laparoscopic partial nephrectomy in 6 (3.9%). Pathological stage was: Stage I, 71 (45.5%); Stage II, 27 (17.3%); Stage III, 48 (30.8%); and Stage IV, 10 (6.4%). Lastly, 51 (32.6%) patients died, 22 (43.1%) from cancer. The 5-year OS according to pathological stage was 77.6%, 71.9%, 45.1% and 11.7% for stage I, II, III and IV, respectively (P<.001). On multivariate analysis, pathological stage independently predicted OS (HR 1.96, 95% CI [1.36-2.84], P=.0003).

CONCLUSIONS

The surgical management of RCC appears to be safe in properly selected patients 65 years or older. Pathological stage predicts survival in this population.

Renal Function and All-Cause Mortality Risk Among Cancer Patients

Renal dysfunction predicts all-cause mortality in general population. However, the prevalence of renal insufficiency and its relationship with mortality in cancer patients are unclear.We retrospectively studied 9465 patients with newly diagnosed cancer from January 2010 to December 2010. Renal insufficiency was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m using the Chronic Kidney Disease Epidemiology Collaboration equation. The hazard ratio (HR) of all-cause mortality associated with baseline eGFR was assessed by Cox regression.Three thousand sixty-nine patients (32.4%) exhibited eGFR <90 mL/min/1.73 m and 3% had abnormal serum creatinine levels at the time of diagnosis. Over a median follow-up of 40.5 months, 2705 patients (28.6%) died. Compared with the reference group (eGFR ≥ 60 mL/min/1.73 m), an elevated all-cause mortality was observed among patients with eGFR < 60 mL/min/1.73 m stratified by cancer stage in the entire cohort, the corresponding hazard ratios were 1.87 (95% CI, 1.41-2.47) and 1.28 (95% CI, 1.01-1.62) for stage I to III and stage IV, respectively. However, this relationship was not observed after multivariate adjustment. Subgroup analysis found that eGFR < 60 mL/min/1.73 m independently predicted death among patients with hematologic (adjusted HR 2.93, 95% CI [1.36-6.31]) and gynecological cancer (adjusted HR 2.82, 95% CI [1.19-6.70]), but not in those with other cancer. Five hundred fifty-seven patients (6%) had proteinuria. When controlled for potential confounding factors, proteinuria was a risk factor for all-cause mortality among patients in the entire cohort, regardless of cancer stage and eGFR values. When patients were categorized by specific cancer type, the risk of all-cause death was only significant in patients with digestive system cancer (adjusted HR, 1.85 [1.48-2.32]).The prevalence of renal dysfunction was common in patients with newly diagnosed cancer. Patients with eGFR < 60 mL/min/1.73 m or proteinuria were associated with increased risk for all-cause mortality, this relation depended on cancer site.

The establishment of KORCC (KOrean Renal Cell Carcinoma) database

PURPOSE

The purpose of this article is to report establishment of the 1st Web-based database (DB) system to collect renal cell carcinoma (RCC) data in Korea.

MATERIALS AND METHODS

The new Web-based DB system was established to collect basic demographic and clinicopahtological characteristics of a large cohort of patients with RCC in Korea. Data from a total of 6,849 patients were collected from 8 tertiary care hospitals that agreed to participate in organizing the Korean Renal Cell Carcinoma (KORCC) study group as of 1 July 2015. Basic demographic and clinicopathological characteristics were collected. The data of patients who underwent surgical treatments were analyzed to characterize Korean RCC.

RESULTS

We established the 1st Web-based DB of Korean RCC, a database comprising renal mass management cases from multiple centers in Korea. The data of 5,281 patients who underwent surgical management (mean follow-up, 32 months) were analyzed. The most common symptom was incidentally detected renal mass (76.9%). Clinical T1a was the most common (54.3%) stage and mean tumor size was 4.8±4.2 cm. Radical nephrectomy accounted for 62.7% of cases and an open approach was used in 50.7% and 52.2% of radical and partial nephrectomies, respectively. The 5-year overall, cancer-specific and recurrence-free survival rates were 88.1%, 92.2%, and 88.0%, respectively.

CONCLUSIONS

We report the 1st establishment of a Web-based DB system to collect RCC data in Korea. This DB system will provide a solid basis for the characterization of Korean RCC.

Retrospective analysis of the predictive factors of renal function loss after uninephrectomy in patients with chronic kidney disease G3 to G5

Background

The rapid increase in glomerular filtration rate in a normal contralateral kidney after uninephrectomy is well known in living kidney donors but much less well described in chronic kidney disease (CKD). The purpose of this study is to determine the magnitude of this initial compensatory capacity in (CKD) groups 3 to 5 (G3 to G5) patients undergoing uninephrectomy and the clinical factors predicting it. This is a retrospective study of all cases (142) of uninephrectomy in patients with estimated glomerular filtration rate (eGFR; with MDRD equation) <60 ml/min/1.73 m², between 2003 and 2010, in two University of Montreal-affiliated teaching hospitals.

Methods

Baseline eGFR, patients’ comorbidities, and surgical characteristics and complications were noted. The change of eGFR after nephrectomy was evaluated; moreover, the expected post-op eGFR, i.e. without compensation by the contralateral kidney following surgery, was estimated in a sub-group of patients who had a preoperative renal scintigraphy and compared to the actual eGFR at hospital discharge.

Results

The mean change of eGFR from baseline to hospital discharge was −5 ± 12 ml/min/1.73 m² (−11 %; 95 % CI −16 to −6 %; P < 0.001). In univariate and multivariate analyses, baseline eGFR did not influence significantly these results. However, in the multivariate model, radical nephrectomy vs. partial nephrectomy and preoperative hypertension predicted a worse renal outcome. In the sub-group of patients with preoperative renal scintigraphy, the actual eGFR at hospital discharge was also higher than expected from the renal split function (13 ml/min/1.73 m²; 95 % CI 10 to 16; P < 0.001).

Conclusions

After uninephrectomy, the contralateral kidney in patients with CKD G3 to G5 still has a clinically significant initial compensatory capacity. The compensation is statistically smaller if the patient had hypertension or a radical uninephrectomy. This initial compensation is rapid and most probably haemodynamic (hyperfiltration). However, most of the included patients had a CKD G3, limiting the strength of the conclusion for the G4 toG5 patients; the length of observation covers the early postoperative period, i.e. less than 2 weeks, in more than half of the cohort.

Comparison of survival rates in stage 1 renal cell carcinoma between partial nephrectomy and radical nephrectomy patients according to age distribution: a propensity score matching study

OBJECTIVE

To assess differences in overall survival (OS) between patients receiving partial nephrectomy (PN) and radical nephrectomy (RN) for stage 1 renal cell carcinoma (RCC) according to age distribution, as the survival advantage of PN vs RN has been unclear owing to conflicting data.

PATIENTS AND METHODS

We studied 952 patients with stage 1 RCC who underwent either PN or RN. Patients were divided into three groups according to age: Group 1 (≤54 years), Group 2 (55-64 years), and Group 3 (≥65 years). Patient variables including age, body mass index, sex, presence of hypertension (HT) and/or diabetes mellitus (DM), performance status, tumour size, pathological diagnosis, nuclear grade, and preoperative estimated glomerular filtration rate (eGFR), were adjusted using 1:1 propensity score matching between PN and RN.

RESULTS

Group 1 included 66 matched patients; Group 2, 72; and Group 3, 70. Group 1 tended to have higher preoperative eGFR values and lower rates of HT and DM compared with Groups 2 and 3. Postoperative eGFR dropped by 11-13% in PN patients and by 34-36% in RN patients. In Group 3, PN patients had longer OS than RN patients (5-year OS: PN 96%, RN 81%, P = 0.043); however, there was no significant difference in Group 1 (5-year OS: PN 100%, RN 93%, P = 0.302) or Group 2 (5-year OS: PN 94%, RN 87%, P = 0.358).

CONCLUSIONS

Only the oldest group of patients showed significantly better OS for PN compared with RN; however, we still recommend PN in young patients.

Survival and functional stability in chronic kidney disease due to surgical removal of nephrons: Importance of the new baseline glomerular filtration rate. Eur Urol. 2015;68:996-1003. [PMID: 26012710 DOI: 10.1016/j.eururo.2015.04.043]

BACKGROUND

Chronic kidney disease (CKD) can be associated with a higher risk of progression to end-stage renal disease and mortality, but the etiology of nephron loss may modify this. Previous studies suggested that CKD primarily due to surgical removal of nephrons (CKD-S) may be more stable and associated with better survival than CKD due to medical causes (CKD-M).

OBJECTIVE

We addressed limitations of our previous work with comprehensive control for confounding factors, differentiation of non-renal cancer-related mortality, and longer follow-up for more discriminatory assessment of the impact of CKD-S.

DESIGN, SETTING, AND PARTICIPANTS

From 1999 to 2008, 4299 patients underwent surgery for renal cancer at a single institution. The median follow-up was 9.4 yr (7.3-11.0). The new baseline glomerular filtration rate (GFR) was defined as the highest GFR between the nadir and 42 d after surgery. Three cohorts were retrospectively evaluated: no CKD (new baseline GFR >60 ml/min/1.73 m(2)); CKD-S (new baseline GFR<60 but preoperative >60 ml/min/1.73 m(2)); and CKD-M/S (new baseline and preoperative GFR both <60 ml/min/1.73 m(2)). Cohort status was permanently set at 42 d after surgery.

INTERVENTION

Renal surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Decline in renal function (50% reduction in GFR or dialysis), all-cause mortality, and non-renal cancer mortality were examined using a multivariable Cox proportional hazards model.

RESULTS AND LIMITATIONS

CKD-M/S had a higher incidence of relevant comorbidities and the new baseline GFR was lower. On multivariable analysis (controlling for age, gender, race, diabetes, hypertension, and cardiac disease), CKD-M/S had higher rates of progressive decline in renal function, all-cause mortality, and non-renal cancer mortality when compared to CKD-S and no CKD (hazard ratio [HR] 1.69-2.33, all p<0.05). All-cause mortality was modestly higher for CKD-S than for no CKD (HR 1.19, p=0.030), but renal stability and non-renal cancer mortality were similar for these groups. New baseline GFR of <45 ml/min/1.73 m(2) significantly predicted adverse outcomes. The main limitation is the retrospective design.

CONCLUSIONS

CKD-S is more stable than CKD-M/S and has better survival, approximating that for no CKD. However, if the new baseline GFR is <45 ml/min/1.73 m(2), the risks of functional decline and mortality increase. These findings may influence counseling for patients with localized renal cell carcinoma and higher oncologic potential when a normal contralateral kidney is present.

PATIENT SUMMARY

Survival is better for surgically induced chronic kidney disease (CKD) than for medically induced CKD, particularly if the postoperative glomerular filtration rate is ≥45 ml/min/1.73 m(2). Patients with preexisting CKD are at risk of a significant decline in kidney function after surgery, and kidney-preserving treatment should be strongly considered in such cases.