Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management

Long-Term Follow-Up in Patients Undergoing Renal Mass Biopsy: Seeding is not Anecdotal

INTRODUCTION

Renal biopsy is recommended if the outcome might alter therapeutic decisions for patients who present with renal masses of unclear etiology. However, little is known about long-term risks related to this procedure.

PATIENTS AND METHODS

We performed a retrospective analysis of an institutional database maintained by a tertiary referral center that included patients who underwent renal biopsies between 2003 and 2005 with a follow-up of at least 15 years. Renal biopsies were taken percutaneously with a coaxial technique according to guideline recommendations and included off-line ultrasound guidance.

RESULTS

We identified 106 patients who underwent biopsies for a renal mass of unclear etiology. The median age was 58.7 years (43.7-66.2). A median of 4.2 (3-6) biopsies were collected from each patient. Tumor seeding leading to local growth was identified in 6 patients (5,7%) after a median follow-up of 8.2 years. Four of these lesions that were resected exhibited the same histology as the original biopsy result; these patients experienced no further recurrence. In 45 patients (42%), the biopsy results led to a therapy other than surgery (n = 28 lymphoma, n = 6 metastasis from other malignancies, n = 11 oncocytoma). The remaining 61 patients (58%) were diagnosed with renal cell carcinoma treated either surgically or with ablation. None of the patients developed metastatic spread related to tumor seeding.

CONCLUSION

Tumor seeding after renal mass biopsy is a rare, but relevant risk associated with this procedure. As indications for renal mass biopsy increase, longer-term follow-up and improved biopsy techniques should be considered to address this complication.

Development and validation of a nomogram for predicting the impact of tumor size on cancer-specific survival of locally advanced renal cell carcinoma: a SEER-based study

This study was aimed to integrate tumor size with other prognostic factors into a prognostic nomogram to predict cancer-specific survival (CSS) in locally advanced (≥pT3a Nany M0) renal cell carcinoma (RCC) patients. Based on the Surveillance, Epidemiology, and End Results (SEER) database, 10,800 patients diagnosed with locally advanced RCC were collected. They were randomly divided into a training cohort (n = 7,056) and a validation cohort (n = 3,024). X-tile program was used to identify the optimal cut-off value of tumor size and age. The cut-off of age at diagnosis was 65 years old and 75 years old. The cut-off of tumor size was 54 mm and 119 mm. Univariate and multivariate Cox regression analyses were performed in the training cohort to identify independent prognostic factors for construction of nomogram. Then, the nomogram was used to predict the 1-, 3- and 5-year CSS. The performance of nomogram was evaluated by using concordance index (C-index), area under the Subject operating curve (AUC) and decision curve analysis (DCA). Moreover, the nomogram and tumor node metastasis (TNM) staging system (AJCC 8th edition) were compared. 10 variables were screened to develop the nomogram. The area under the receiver operating characteristic (ROC) curve (AUC) indicated satisfactory ability of the nomogram. Compared with the AJCC 8th edition of TNM stage, DCA showed that the nomogram had improved performance. We developed and validated a nomogram for predicting the CSS of patients with locally advanced RCC, which was more precise than the AJCC 8th edition of TNM staging system.

Racial and ethnic disparities in surgery for kidney cancer: a SEER analysis, 2007-2014

BACKGROUND AND OBJECTIVES

Compared with White patients, Black and American Indian/Alaskan Native (AI/AN) patients experience higher rates of kidney cancer incidence, and Black, AI/AN, and Hispanic patients face later stages of disease at diagnosis, poorer survival rates, and greater risk of mortality. Despite the importance that appropriate treatment has in ensuring positive outcomes, little is known about the association between race and ethnicity and receipt of treatment for kidney cancer. Accordingly, the aim of this study was to explore differences in receipt of treatment and patterns of refusal of recommended treatment by race and ethnicity.

DESIGN

96,745 patients ages 45-84 with kidney cancer were identified in the Surveillance, Epidemiology, and End Results (SEER) program between 2007 and 2014. Logistic regression models were used to examine the association of race and ethnicity with treatment and with patient refusal of recommended treatment. Outcomes of interest were (1) receiving any surgical procedure, and (2) refusing recommended surgery.

RESULTS

Relative to White patients, Black and AI/AN patients had lower odds of undergoing any surgical procedure (OR = 0.76; 95% CI: 0.72-0.81; p < 0.001, and OR = 0.92; 95% CI: 0.76-1.10; p = 0.36, respectively) after adjusting for gender, age, insurance status, stage at diagnosis, unemployment status, education status, and income as additive effects. Black and AI/AN patients also had higher odds of refusing recommended surgery (OR = 1.93; 95% CI: 1.56-2.39; p < 0.001, and OR = 1.99; 95% CI: 1.05-3.76; p = 0.035, respectively). Hispanic patients had slightly higher odds of undergoing any surgical procedure (OR = 1.10; 95% CI: 1.04-1.17; p = 0.001) and lower odds of refusal (OR = 0.67; 95% CI: 0.50-0.90; p = 0.007, respectively).

CONCLUSIONS

Compared with White patients, Black patients were less likely to receive potentially life-saving surgery, and both Black and AI/AN patients were more likely to refuse recommended surgery.

Morbidity of elective surgery for localized renal masses among elderly patients: A contemporary multicenter study

BACKGROUND

The aging population and the incidence of renal cell carcinoma (RCC) are increasing worldwide. Over 25% of newly diagnosed LRM (localized renal masses) occur in patients over the eighth decade of life. The decision-making and treatment approach to LRM in this population represents a clinical dilemma due to inherited decreased functional reserve and competing mortality risks. Current literature reports conflicting evidence regarding age as a risk factor for worst surgical outcomes. As such, we aimed to evaluate the contemporary morbidity of elective surgery for LRM among elderly patients, focusing on intraoperative and postoperative complications.

METHODS

After Ethical Committee approval, we queried our prospectively maintained databases to identify patients with preoperative eGFR ≥60 ml/min/1.73 m [(David and Bloom, 2022) 22 and a normal contralateral kidney who underwent partial or radical nephrectomy (PN or RN) for a single cT1-T2N0M0 LRM between 1/2015-12/2021 at four high-volume European Academic Institutions. Patients were categorized by age groups: <50 yrs (young) vs. 50-75 (middle-aged) yrs vs.> 75 yrs (elderly). Postoperative complications were recorded according to Clavien-Dindo (CD) classification. The primary objectives were the proportion of patients experiencing intraoperative (IOC), any grade (AGC), and high-grade postoperative complications (HGC), defined as CD grade 3-5.

RESULTS

Overall, 2469/3076 (80.2%) patients met the inclusion criteria. Of these, 363 (14.7%) were young, 1682 (68.1%) were middle-aged, and 424 (17.2%) were elderly. Compared to middle-aged and young patients, elderly patients had a higher median Charlson Comorbidity Index (6 vs. 4 vs. 0, p < 0.01) and a higher proportion of cT1 renal mass (87.6% vs. 93.0% vs. 93.6%, p < 0.01). No differences among the study groups were found regarding surgical approach (open vs. minimally-invasive) and type of surgery (PN vs. RN). We found that older patients experienced similar IOC (4.5% vs. 4.2% vs. 3.3%, p = 0.7) and AGC (23.1% vs. 20.0% vs. 21.5%, p = 0.4) compared to middle-aged and young patients, respectively. Similarly, there were no significant differences in HGC between the study cohorts (0.7% vs. 1.4% vs. 1.7%, p = 0.8). At multivariable analysis, open approach and PN significantly predicted the occurrence of AGCs, while only the open surgical approach was associated with the occurrence of HGCs.

CONCLUSION

In kidney cancer tertiary referral centers, the risk of IOC and postoperative HGC after PN or RN for localized renal masses (LRM) is low, despite a non-negligible risk of AGC, especially in elderly patients. Further efforts should focus on identifying multidisciplinary strategies to select patients most likely to benefit from surgery among elderly candidates with LRMs and decrease the morbidity of surgery in this specific setting.

Prognostic Significance of Advanced Age in Patients with T1a Renal Cell Carcinoma Treated by Microwave Ablation: A 16-Year Experience

BACKGROUND

Previous studies have failed to investigate the specific effects of advanced age on survival outcomes by considering the Charlson Comorbidity Index (CCI) and age permutation in patients with T1a renal cell carcinoma (T1a RCC) treated by microwave ablation (MWA). Notably, RCC guidelines recommended radiofrequency ablation (RFA) and active surveillance (AS) are both treatment options for elderly T1a RCC, but whether MWA is superior to AS in light of higher heating efficiency and larger ablation zone compared with RFA is not clear. This study aimed to investigate the specific effects of advanced age on survival outcomes of T1a RCC patients stratified by CCI score and indicate better intervention for elderly T1a RCC between MWA and AS.

METHODS

This was a retrospective study. We retrospectively reviewed 237 patients with T1a RCC who had undergone MWA over the last 16 years. Data were analyzed by Cox regression and Landmark analysis. Interaction tests and propensity score matching were used to account for potential biases. We compared the overall survival (OS) and cancer-specific survival (CSS) rates of patients ≥75 years in our study with corresponding figures from 4251 counterparts undergoing AS in published articles.

RESULTS

Using patients ＜75 years with a CCI ≤2 as a reference, the hazard ratio (HR) and 95% confidence interval (CI) of OS for patients＜75 years with a CCI ≥3, patients ≥75 years with a CCI ≤2, and patients ≥75 years with CCI ≥3, were 2.954 (1.139-7.663), 3.48 (1.487-8.146), and 3.357 (1.162-9.698), respectively. The adverse effect of an age ≥75 years on OS was attenuated in patients with a CCI ≥3. The attenuation lasted for 62.5 months of follow-up (P = .017). Notably, advanced age exerted a protective effect on progression-free survival (PFS) in patients with a CCI ≥3, increasing the 8-year PFS from 67.8% to 100% (P = .049). Relative to 1-, 3-, 5-, and 8-year survival data for patients aged ≥75 undergoing AS, the OS rates for 5-year follow-up were always better in MWA. However, beyond 5 years, the OS rates dropped to levels that were similar to AS.

CONCLUSIONS

Advanced age exerts adverse effects and significantly protective effects on OS and PFS, respectively, in T1a RCC patients with a CCI ≥ 3. According to our study, elderly patients with T1a RCC underwent radical MWA may yield a better medium-term OS relative to AS.

Predicting the probability of malignant pathological type of kidney cancer based on mass size: A retrospective study

BACKGROUND

Different degrees of malignancy of renal cell carcinoma (RCC) correspond to dissimilar therapies, and the prediction of malignancy of kidney cancer based on tumor size is still not fully studied.

METHODS

We evaluated a total of 50,776 patients with T1-T2, N0, M0 RCC diagnosed between 2004 to 2015 based on the Surveillance, Epidemiology, and End Results database. Three and four fuhrman grade clear cell RCC, three and four fuhrman grade papillary RCC, collecting duct RCC, sarcomatoid differentiation RCC and unclassified RCC were classified as aggressive RCC. The other RCC was classified as indolent RCC. The probability of aggressive and indolent was estimated according to tumor size using a logistic regression model. Differences in survival between subgroups were assessed using the Kaplan-Meier method.

RESULTS

There were 38,003 cases of indolent tumor and 12,773 cases of aggressive tumor totally. As tumor size increases, the predicted probability of an aggressive tumor also increases. Concretely, kidney cancers of 2cm, 3cm and 4cm were estimated to be 19.6%, 21.6% and 23.7% more likely to be aggressive. And for the same tumor size, clear cell RCC in men is more likely to be invasive relative to women and other kidney cancer pathology types. In addition, both the overall and tumor-specific survival are longer for indolent tumors than for aggressive tumors.

CONCLUSION

We evaluated the degree of malignancy of different sizes RCC in a retrospective study. This result may be helpful in the choice of initial therapy strategies for kidney cancer patients.

A “3S+f” Nephrometry Score System to Predict the Clinical Outcomes of Laparoscopic Nephron-Sparing Surgery

Background

When we treat renal cell carcinoma by laparoscopic nephron-sparing surgery (NSS), it is essential to use an evaluation system to predict clinical outcomes. Hitherto, there are more than a dozen nephrometry score systems. In this study, through assessing the correlations between nephrometry score systems and clinical outcomes, we aim to provide a novel nephrometry score system—the “3S+f” score system—to simplify the evaluation of technical complexity of partial nephrectomy.

Methods

We retrospectively collected the data of 131 patients who underwent NSS, which was performed by a single surgeon (SZ) from January 2013 to July 2018 at Peking University Third Hospital. The “3S+f” score system contains four parameters: “size, side, site, and fat”, all of which can be obtained from preoperative imaging data. We evaluated the correlations between the “3S+f” score and clinical outcomes, and compared R.E.N.A.L. score and PADUA score.

Results

All the three nephrometry score systems were related to some clinical outcomes in univariate analyses. In multivariate regression models, the “3S+f” score, the R.E.N.A.L. score, and the PADUA score were significantly associated with operative time (p = 0.016, p = 0.035, and p = 0.001, respectively) and warm ischemia time (all p = 0.008, p < 0.001, and p < 0.001, respectively). “3S+f” was also significantly related to extubation time > 5 days (p = 0.018). In predicting operative time > 120 min and extubation time >5 days from ROC curves, the AUCs of the “3S+f” score (0.717 and 0.652, respectively) were larger than both the R.E.N.A.L (0.598 and 0.554, respectively) and PADUA (0.600 and 0.542, respectively) score systems.

Conclusion

A novel nephrometry score system—the “3S+f” score system—shows equivalent correlation and the ability in predicting clinical outcomes when compared to the R.E.N.A.L. score system and the PADUA score system, which can describe renal tumors.

Robotic-assisted tumor enucleation versus standard margin partial nephrectomy: Perioperative, renal functional, and oncologic outcomes for low and intermediate complexity renal masses

PURPOSE

Standard margin partial nephrectomy (SPN) with sharp incision across normal renal parenchyma carries perioperative morbidity and renal functional implications. Tumor enucleation (TE) is an alternative approach using a natural plane of dissection around the tumor pseudocapsule to maximize parenchymal preservation. We compared perioperative, functional, and oncologic outcomes for robotic-assisted TE to SPN.

MATERIALS AND METHODS

Patients ≥18 years of age undergoing robotic-assisted TE or SPN were included (2008-2020). Baseline demographics and tumor characteristics were compared. Perioperative, renal functional, and oncologic outcomes were assessed for comparative effectiveness.

RESULTS

A total of 467 patients were included with 176 (37.7%) TE and 291 (62.3%) SPN. Baseline characteristics and final histology were comparable; 18% of patients had baseline stage 3 chronic kidney disease. TE had lower median blood loss, operative time, length of stay, and fewer complications compared to SPN. Positive margin rates were higher for TE vs. SPN (8.5% vs. 3.4%, P = 0.04) with similar recurrence rates (2.3% vs. 3.4%, P = 0.48) and no difference in cancer-specific or overall survival with median 4.0 years follow-up. Baseline estimated glomerular filtration rate was comparable (76.1 vs. 78.2, P = 0.63) while renal function in the first year was better preserved with TE (74.6 vs. 68.1, P < 0.001) showing an 8-point estimated glomerular filtration rate (P = 0.001) advantage after adjustment. The rate of stage ≥3 chronic kidney disease by 12 months was lower for TE compared to SPN (21.5% vs. 34.1%, P = 0.006).

CONCLUSIONS

TE is an alternative approach to SPN associated with favorable perioperative and renal functional outcomes. While positive margin rates are higher, longer-term recurrence rates are no different suggesting pseudocapsule disruption during TE has limited impact on oncologic outcomes.

Role of PSMA-ligands imaging in Renal Cell Carcinoma management: current status and future perspectives

Background

Renal masses detection is continually increasing worldwide, with Renal Cell Carcinoma (RCC) accounting for approximately 90% of all renal cancers and remaining one of the most aggressive urological malignancies. Despite improvements in cancer management, accurate diagnosis and treatment strategy of RCC by computed tomography (CT) and magnetic resonance imaging (MRI) are still challenging. Prostate-Specific Membrane Antigen (PSMA) is known to be highly expressed on the endothelial cells of the neovasculature of several solid tumors other than prostate cancer, including RCC. In this context, recent preliminary studies reported a promising role for positron emission tomography (PET)/CT with radiolabeled molecules targeting PSMA, in alternative to fluorodeoxyglucose (FDG) in RCC patients.

Purpose

The aim of our review is to provide an updated overview of current evidences and major limitations regarding the use of PSMA PET/CT in RCC.

Methods

A literature search, up to 31 December 2021, was performed using the following electronic databases: PubMed, SCOPUS, Web of Science, and Google Scholar.

Results

The findings of this review suggest that PSMA PET/CT could represent a valid imaging option for diagnosis, staging, and therapy response evaluation in RCC, particularly in clear cell RCC.

Conclusions

Further studies are needed for this “relatively” new imaging modality to consolidate its indications, timing, and practical procedures.

A Clinical Decision Aid to Support Personalized Treatment Selection for Patients with Clinical T1 Renal Masses: Results from a Multi-institutional Competing-risks Analysis

BACKGROUND

Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics.

OBJECTIVE

To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS).

DESIGN, SETTING, AND PARTICIPANTS

Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation.

RESULTS AND LIMITATIONS

The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m², estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume.

CONCLUSIONS

We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs.

PATIENT SUMMARY

We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.

Survival benefits analyses of T1a renal cell carcinoma patients treated with microwave ablation

PURPOSE

The individual decision-making reference of Microwave ablation (MWA) for T1a RCC treatment is not clear, and it may not benefit all the patients equally. Therefore, we quantitatively evaluated the distinct survival benefits of patients with T1a RCC stratified by survival predictors.

MATERIALS AND METHODS

A total of 237 patients with T1a RCC who underwent MWA over the last 16 years were retrospectively reviewed for survival benefit analysis. Cox proportional hazard models were used to control for the prognostic variables of OS, CSS, and PFS. Survival rates were calculated using the Kaplan-Meier method and compared by log-rank analysis. Linear extrapolation was used to compute median survival periods.

RESULTS

The OS benefit was significantly dependent on age (HR:2.499, 95% CI: 1.245-5.016, p = 0.010) and age-adjusted Charlson comorbidity index (CCI) score (HR:3.956, 95% CI, 1.409-11.110, p = 0.009). OS in patients aged <75 years or with an age-adjusted CCI score <7 was significantly prolonged (44.68, 65.55 months) compared to OS in patients aged ≥75 years or with CCI score ≥7 (p < 0.001 for both). PFS benefit was significantly dependent on age-adjusted CCI (HR:3.325, 95% CI, 1.390-7.956, p = 0.007), patient type (HR:0.4, 95% CI, 0.214-0.745, p = 0.004), and tumour growth pattern (HR:12.562, 95% CI, 1.552-101.696, p = 0.018). PFS in incipient patients was significantly prolonged (33.75 months) compared to that in the relapsed patients (p = 0.037). Patients with an age-adjusted CCI score <7 or without tumour protruding into the renal pelvis, lived free from recurrence or metastasis (55.69 or 101.61 months) longer than that in patients with an age-adjusted CCI score ≥7 or with tumour protruding into the renal pelvis (p < 0.01 for both). None of the variables was associated with CSS benefit.

CONCLUSIONS

The OS and PFS benefits from MWA were not equal for all T1a RCC patients. Age ≥75 years and age-adjusted CCI ≥ 7 significantly shortened OS. Age-adjusted CCI ≥ 7, relapsed RCC, and RCC protruding into the renal pelvis significantly shortened the PFS period. For a better survival prognosis, appropriate patient triage is still needed.

Delayed surgery for localised and metastatic renal cell carcinoma: a systematic review and meta-analysis for the COVID-19 pandemic

Purpose

The COVID-19 pandemic has led to the cancellation or deferment of many elective cancer surgeries. We performed a systematic review on the oncological effects of delayed surgery for patients with localised or metastatic renal cell carcinoma (RCC) in the targeted therapy (TT) era.

Method

The protocol of this review is registered on PROSPERO(CRD42020190882). A comprehensive literature search was performed on Medline, Embase and Cochrane CENTRAL using MeSH terms and keywords for randomised controlled trials and observational studies on the topic. Risks of biases were assessed using the Cochrane RoB tool and the Newcastle–Ottawa Scale. For localised RCC, immediate surgery [including partial nephrectomy (PN) and radical nephrectomy (RN)] and delayed surgery [including active surveillance (AS) and delayed intervention (DI)] were compared. For metastatic RCC, upfront versus deferred cytoreductive nephrectomy (CN) were compared.

Results

Eleven studies were included for quantitative analysis. Delayed surgery was significantly associated with worse cancer-specific survival (HR 1.67, 95% CI 1.23–2.27, p < 0.01) in T1a RCC, but no significant difference was noted for overall survival. For localised ≥ T1b RCC, there were insufficient data for meta-analysis and the results from the individual reports were contradictory. For metastatic RCC, upfront TT followed by deferred CN was associated with better overall survival when compared to upfront CN followed by deferred TT (HR 0.61, 95% CI 0.43–0.86, p < 0.001).

Conclusion

Noting potential selection bias, there is insufficient evidence to support the notion that delayed surgery is safe in localised RCC. For metastatic RCC, upfront TT followed by deferred CN should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03734-1.

Microsimulation Model for Evaluating the Cost-Effectiveness of Surveillance in BAP1 Pathogenic Variant Carriers

PURPOSE

Pathogenic BAP1 germline variants cause a tumor-predisposition syndrome (BAP1-TPDS) linked to uveal melanoma, mesothelioma, cutaneous melanoma, and renal cell carcinoma. Surveillance of carriers of pathogenic BAP1 variants provides an opportunity for early tumor detection; however, there are no evidence-based guidelines for management of BAP1-TPDS, nor health economic evaluation; this study aims to provide this evidence.

METHODS

We created a Markov microsimulation health state transition model of BAP1 germline carriers to predict if active surveillance for the four main tumors influences survival and improves associated economic costs with a time horizon of 100 years from the perspective of the healthcare system (N = 10,000). Model inputs were derived from data published by the BAP1 Interest Group Consortium and other studies. Management and healthcare costs were extracted from Australian costing schedules (final figures converted to US dollars [USD]), and outcomes compared for individuals receiving surveillance with those in a nonsurveillance arm. Robustness was evaluated on 10,000 iterations of a 100-sample random sampling of the model output.

RESULTS

On average, surveillance of BAP1 carriers increased survival by 4.9 years at an additional cost of $6,197 USD for the healthcare system including surveillance costs ($1,265 USD per life year gained). The nonsurveillance arm had more diagnosed late tumors (62.8% v 10.7%) and a higher rate of BAP1-related deaths (50.2% v 35.4%; a 29.5% increase). The model was cost-effective under all sensitivity analyses. Our secondary robustness analysis estimated that 99.86% of 100-sample iterations were cost-effective and 19.67% of these were cost-saving.

CONCLUSION

It is recommended that carriers of BAP1 germline variants are identified and undertake active surveillance, as this model suggests that this could improve survival and be cost-effective for the healthcare system.

Overall Survival of Biopsy-confirmed T1B and T2A Kidney Cancers Managed With Observation: Prognostic Value of Tumor Histology

INTRODUCTION

The natural history of T1b (4-7 cm) or T2a (> 7-10 cm) kidney cancers managed with observation is not well-understood. The aim of our study was to determine if the addition of histologic subtype to a predictive model of overall survival (OS) that includes covariates for competing risks in observed, biopsy-proven, T1b and T2a renal cell carcinomas (RCCs) improves the model's performance.

MATERIALS AND METHODS

We queried the National Cancer Database for patients with biopsy-proven stage T1b or T2a RCC and managed nonoperatively between 2004 and 2015. OS was estimated by Kaplan-Meier curves based on histologic subtype. The concordance index (c-index) from a Cox proportional hazards model was used to estimate the extent to which histologic subtypes predict survival for each stage when included in a model along with competing risks of age, gender, race/ethnicity, insurance status, area-level socioeconomic indicators, Charlson-Deyo index, and tumor grade.

RESULTS

A total of 937 patients (754 with T1b and 185 with T2a) with biopsy-proven RCC were identified. Kaplan-Meier analysis suggested differences in OS by histologic subtype where sarcomatoid, followed by clear cell, papillary, and chromophobe, had the highest mortality risk at 1, 3, and 5 years. However, there was marginal improvement in the multivariable model of OS using competing risks and histology (c-index, 0.64 and 0.697) compared with competing risks alone (c-index, 0.631 and 0.671) for T1b and T2a RCCs, respectively.

CONCLUSIONS

In patients with T1b or T2a RCC managed with observation, incorporation of histologic subtype into a risk-stratification model to determine prognostic OS did not improve modeling of OS compared with variables representing competing risks. Histologic subtype of observed T1b and T2a RCC appears to have prognostic OS value when not considering competing risks. These findings may impact the usefulness of renal biopsy to inform decision-making when managing patients with T1b and T2a renal tumors with observation.

Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative

BACKGROUND

While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%.

OBJECTIVE

To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative.

DESIGN SETTING AND PARTICIPANTS

The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test.

RESULTS AND LIMITATIONS

Out of 965 patients, observation was employed in 48% (n = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p <  0.0001) and had smaller tumors (2.3 vs 3.4 cm, p <  0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III-IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III-IV vs solid, p =  0.017), tumor stage (cT1a vs cT1b, p <  0.001), and higher age (p <  0.001). A short duration of follow-up limits the assessment of longer-term patient management.

CONCLUSIONS

Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study.

PATIENT SUMMARY

The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic tumor type.

Assessment of other-cause mortality in localized renal cell carcinoma patients within 15 years: A population-based analysis

BACKGROUND AND OBJECTIVE

Five-year other cause mortality (OCM) after nephrectomy for non-metastatic renal cell carcinoma (RCC) should be marginal in properly selected surgical candidates. We examined 5-year OCM rates as a quality of care indicator for patient selection.

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results database (1997-2011), we identified 59267 RCC patients treated with either radical (n = 27 804, 46.9%) or partial nephrectomy (n = 31 463, 53.1%). Temporal trends and multivariable Cox regression analyses assessed 5-year OCM. Data were stratified according to age group, year of diagnosis, race, marital status, gender, and socio-economic status. The overall OCM rates for the entire cohort at 5 years of follow-up was 4.7% and decreased from 9.4% to 5.6% over the study span (-3.8%, P < .001). The greatest decrease in 5-year OCM rates over time was recorded in patients >70 years (17.0%-9.6%, slope, -0.6%/y), as well as in African-Americans (12.0-6.2%; slope, -0.3%/y) and in males (8.9%-4.7%; slope, -0.3%, all P < .001).

CONCLUSIONS

An important OCM decrease was recorded over the study span. Nonetheless, further improvement may be accomplished, especially in African-Americans, unmarried and older individuals, who exhibited higher OCM rates than others. These three groups may represent ideal targets for better patient selection based on OCM considerations.

Management of Metastatic Nonclear Renal Cell Carcinoma: What Are the Options and Challenges?

This case presents a 68-yr-old female patient with primary metastatic nonclear renal cell carcinoma (RCC) with multiple bone lesions. The patient underwent a single resection of skull bone lesion (diagnostic for poorly differentiated carcinoma of unknown origin) and cytoreductive nephrectomy. The pathology of the kidney specimen demonstrated an oncocytic papillary RCC. Within 3 mo, she developed skeletal progressive disease and was started on systemic therapy (sunitinib). After initial stabilization, bone metastasis progressed during the third cycle of sunitinib and required second-line therapy (cabozantinib). One of the major unmet needs in non-clear cell RCC is the lack of specific systemic therapy. Data on immunotherapy are still limited. Inclusion of these patients in clinical trials is strongly recommended. PATIENT SUMMARY: Patients with metastatic kidney cancer who present with the less common histological subtype (non-clear cell) have poor survival. In this case, the patient responded to second-line therapy. Very few therapies provide response to treatment. Patients should be offered participation in clinical trials testing combinations with immunotherapy.

Prognostic Value of Histologic Subtype and Treatment Modality for T1a Kidney Cancers

INTRODUCTION

To evaluate overall survival (OS) of T1a kidney cancers stratified by histologic subtype and curative treatment including partial nephrectomy (PN), percutaneous ablation (PA), and radical nephrectomy (RN).

MATERIALS AND METHODS

We queried the National Cancer Data Base (2004-2015) for patients with T1a kidney cancers who were treated surgically. OS was estimated by Kaplan-Meier curves based on histologic subtype and management. Cox proportional regression models were used to determine whether histologic subtypes and management procedure predicted OS.

RESULTS

46,014 T1a kidney cancers met inclusion criteria. Kaplan Meier curves demonstrated differences in OS by treatment for clear cell, papillary, chromophobe, and cystic histologic subtypes (all p < 0.001), but no differences for sarcomatoid (p = 0.110) or collecting duct (p = 0.392) were observed. Adjusted Cox regression showed worse OS for PA than PN among patients with clear cell (HR 1.58, 95%CI [1.44-1.73], papillary RCC (1.53 [1.34-1.75]), and chromophobe RCC (2.19 [1.64-2.91]). OS was worse for RN than PN for clear cell (HR 1.38 [1.28-1.50]) papillary (1.34 [1.16-1.56]) and chromophobe RCC (1.92 [1.43-2.58]). Predictive models using Cox proportional hazards incorporating histology and surgical procedure alone were limited (c-index 0.63) while adding demographics demonstrated fair predictive power for OS (c-index 0.73).

CONCLUSIONS

In patients with pathologic T1a RCC, patterns of OS differed by surgery and histologic subtype. Patients receiving PN appears to have better prognosis than both PA and RN. However, the incorporation of histologic subtype and treatment modality into a risk stratification model to predict OS had limited utility compared with variables representing competing risks.

Prognostic value of epithelial-mesenchymal transition markers in clear cell renal cell carcinoma

Epithelial-to-mesenchymal transition (EMT) is important in tumor invasiveness and metastasis. We aimed to determine prognostic value of six key EMT markers (CDH1, CDH2, SNAI1, SNAI2, VIM, TWIST1) in clear cell renal cell carcinoma (ccRCC). A total of 533 ccRCC patients with RNASeq data from The Cancer Genome Atlas (TCGA) cohort were included for analysis. Gene expression of these EMT markers was compared between tumor and normal tissues based on Oncomine database and TCGA cohort. Their correlations with progression-free survival (PFS) and overall survival (OS) were also examined in both TCGA cohort and FUSCC (Fudan University Shanghai Cancer Center) cohort. Cox proportional hazards regression model and Kaplan-Meier plot were used to assess the relative factors. Functional enrichment analyses were utilized to describe biologic function annotations and significantly involved hallmarks pathways of each gene. We found that Epithelial marker, CDH1 expression was lower, while mesenchymal markers (CDH2, SNAI1, VIM, TWIST1) expression was higher in ccRCC primary tumors. In the TCGA cohort, we found that patients with higher expression of VIM, TWIST1 or lower expression of CDH1 had worse prognosis. Further, in the FUSCC cohort, we confirmed the predictive ability of mesenchymal markers and epithelial marker expression in PFS and OS of ccRCC patients. After generating Cox regression models, EMT markers (CDH1, SNAI1, VIM, and TWIST1) were independent prognostic factors of both PFS and OS in ccRCC patients. Our preliminary EMT prediction model can facilitate further screening of EMT biomarkers and cast a better understanding of EMT gene function in ccRCC.

Radiofrequency ablation of small renal masses in comorbid patients

Introduction

Over the recent years, the progress in imaging techniques has led to increased detection of small renal masses (SRMs), including in elderly and high-risk patients. Partial nephrectomy (nephron-sparing surgery - NSS), the current standard of care in T1a kidney tumours, has some limitations in patients who are poor candidates for surgery, as it is associated with potential perioperative complications and possible renal function loss. Radiofrequency ablation (RFA), a minimally invasive method that can be performed percutaneously, is an option in such cases.

Aim

To present our experience in treatment of SRMs using RFA in comorbid patients.

Material and methods

In the years 2006-2012, 103 percutaneous, ultrasound-guided RFA procedures were performed in the Oncology Centre in Bydgoszcz in patients with an ASA score ≥ 3. Abdominal computed tomography and tumour biopsy were performed before the procedure. The average follow-up time was 46 months.

Results

The 1, 3 and 5-year overall survival rates were respectively 97%, 90% and 75%, while cancer-specific survival was 100%. No Clavien-Dindo grade ≥ 3 complications were observed.

Conclusions

Radiofrequency ablation performed percutaneously is a minimally invasive treatment and may be applied in patients who are, due to comorbidities, poor candidates for surgery. In comorbid patients, where other causes of death play an important role, the application of a minimally invasive treatment method with satisfactory oncological effectiveness is justified.

Association of body mass index with mortality and postoperative survival in renal cell cancer patients, a meta-analysis

Obesity is one of the major risk factors of cancer. However, how body mass index (BMI) influences the prognosis of renal cell cancer (RCC) patient is unclear. In this work, we have performed a meta-analysis to elucidate the role of abnormal weight in RCC mortality and postoperative survival. Articles related to BMI and RCC mortality as well as postoperative survival has been identified by searching PUBMED and ENBASE. Totally, 19 articles have been selected for this meta-analysis, 5 articles for RCC mortality and 14 for postoperative survival. Compared to normal weight, the estimated relative risks of RCC mortality are 0.71 (95% CI: 0.34–1.49), 1.19 (95% CI: 1.05–1.35) and 1.71 (95% CI: 1.27–2.00) respectively for the underweight, overweight and obesity patients. The risk of RCC mortality increase 5% for each 1 kg/m² increment of BMI. However, the estimated hazard ratios of cancer specific postoperative survival are 2.62 (95% CI: 1.67–4.11), 0.72 (95% CI: 0.63–0.83) and 0.66 (95% CI: 0.49–0.89) respectively for underweight, overweight and obesity RCC patients. The risk of hazard ratio decrease 5% for each 1 kg/m² increment of BMI. In addition, the hazard ratios of postoperative overall survival show a similar tendency. These results indicate an opposite association of BMI with mortality and postoperative survival in renal cell cancer patients.

Pooled analysis of stereotactic ablative radiotherapy for primary renal cell carcinoma: A report from the International Radiosurgery Oncology Consortium for Kidney (IROCK)

BACKGROUND

Stereotactic ablative radiotherapy (SABR) is an emerging therapy for primary renal cell carcinoma. The authors assessed safety, efficacy, and survival in a multi-institutional setting. Outcomes between single-fraction and multifraction SABR were compared.

METHODS

Individual patient data sets from 9 International Radiosurgery Oncology Consortium for Kidney institutions across Germany, Australia, the United States, Canada, and Japan were pooled. Toxicities were recorded using Common Terminology Criteria for Adverse Events, version 4.0. Patient, tumor, and treatment characteristics were stratified according to the number of radiotherapy fractions (single vs multiple). Survival outcomes were examined using Kaplan-Meier estimates and Cox proportional-hazards regression.

RESULTS

Of 223 patients, 118 received single-fraction SABR, and 105 received multifraction SABR. The mean patient age was 72 years, and 69.5% of patients were men. There were 83 patients with grade 1 and 2 toxicity (35.6%) and 3 with grade 3 and 4 toxicities (1.3%). The rates of local control, cancer-specific survival, and progression-free survival were 97.8%, 95.7%, and 77.4%, respectively, at 2 years; and they were 97.8%, 91.9%, and 65.4%, respectively, at 4 years. On multivariable analysis, tumors with a larger maximum dimension and the receipt of multifraction SABR were associated with poorer progression-free survival (hazard ratio, 1.16 [P < .01] and 1.13 [P = .02], respectively) and poorer cancer-specific survival (hazard ratio, 1.28 [P < .01] and 1.33 [P = .01], respectively). There were no differences in local failure between the single-fraction cohort (n = 1) and the multifraction cohort (n = 2; P = .60). The mean ( ± standard deviation) estimated glomerular filtration rate at baseline was 59.9 ± 21.9 mL per minute, and it decreased by 5.5 ± 13.3 mL per minute (P < .01).

CONCLUSIONS

SABR is well tolerated and locally effective for treating patients who have primary renal cell carcinoma and has an acceptable impact on renal function. An interesting observation is that patients who receive single-fraction SABR appear to be less likely to progress distantly or to die of cancer. Cancer 2018;124:934-42. © 2017 American Cancer Society.

Active Surveillance in Small Renal Masses in the Elderly: A Literature Review

CONTEXT

Small renal masses have become increasingly common due to widespread imaging; however, optimal management of these lesions in the elderly can be complex due to the competing risks of intervention, natural history of disease, patient comorbidities, and expectations. In the properly selected elderly patient, active surveillance remains an accepted and attractive treatment approach.

OBJECTIVE

We completed a literature review of small renal masses (enhancing, <4cm, T1aN0M0 disease) in the elderly, aged ≥70 yr, aimed at identifying the utility of active surveillance in this population. The primary outcomes were conversion to active treatment while on active surveillance and cancer-specific mortality. Secondary outcomes included predictors of treatment, type of treatment performed (partial nephrectomy, radical nephrectomy, and ablation), progression to metastases, all-cause mortality, tumor growth rate, and demographic data including age and Charlson Comorbidity Index.

EVIDENCE ACQUISITION

A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library) using search terms "small renal mass" OR "SRM", AND "elderly," "senior," "aging," "geriatric," OR "octogenarian" was completed. All randomized controlled trials, nonrandomized comparison studies, and case series were included and screened by the reviewers. All comparison studies included in the systematic review were assessed for methodological quality using the Cochrane Risk of Bias tools.

EVIDENCE SYNTHESIS

Seventeen primary studies including 36495 patients met the inclusion criteria for the systematic review. All studies were retrospective institutional chart or the Surveillance, Epidemiology, and End Results database reviews. There was a low (4-26%) rate of conversion to active treatment for active surveillance in the identified studies over a follow-up interval of up to 91.5 mo. Overall mortality was substantial in this elderly cohort, with 15-51% of patients being deceased over the course of study follow-up; however, there was minimal cancer-specific mortality due to patients succumbing to alternative comorbid disease. In the future, patient comorbidity and biological age versus the natural history of the individualized tumor biology may play an increasing role in the discussion regarding treatment options and consideration of active surveillance.

CONCLUSIONS

Active surveillance is an effective management strategy in the elderly population. Few patients required the conversion to active treatment and there was low cancer-specific mortality. The majority of patients who expired over the course of the identified studies succumbed to alternative disease. The goal of treatment strategies should include weighing patient-specific prognosis relative to their competing health risks and treatment goals against the natural history of disease and risks of intervention.

PATIENT SUMMARY

In this review article, the authors examined the utility of active surveillance in the setting of a small localized renal mass in the elderly population. Despite being on surveillance, we found that cancer-specific outcomes were excellent, and overall mortality was often a result of comorbid disease. However, there is significant heterogeneity among elderly patients, and treatment approaches should be focused around patient-centered goals and prognosis.

A Systematic Review of Research Gaps in the Evaluation and Management of Localized Renal Masses

The management of clinically localized renal masses suspicious for renal cell carcinoma varies, partially because of gaps in the evidence base. We conducted a systematic review to summarize research gaps for the evaluation of composite models for predicting malignancy; use of percutaneous renal sampling for diagnosis; and comparative effectiveness of surgery, thermal ablation, and active surveillance. A total of 147 studies, published in 150 articles, were identified. To promote improved patient care and health outcomes, we recommend incorporation of emerging biomarkers into validated composite models, standardization of biopsy protocols, standard reporting of clinical stage, and performance of prospective studies with objective selection criteria.

A Prospective, Comparative Study of Quality of Life among Patients with Small Renal Masses Choosing Active Surveillance and Primary Intervention

PURPOSE

To our knowledge quality of life has not been evaluated in rigorous fashion in patients undergoing active surveillance for small renal masses. The prospective, multi-institutional DISSRM (Delayed Intervention and Surveillance for Small Renal Masses) Registry was opened on January 1, 2009, enrolling patients with cT1a (4.0 cm or less) small renal masses who elected primary intervention or active surveillance.

MATERIALS AND METHODS

Patients were enrolled following a choice of active surveillance or primary intervention. The active surveillance protocol includes imaging every 4 to 6 months for 2 years and every 6 to 12 months thereafter. The SF12® quality of life questionnaire was completed at study enrollment, at 6 and 12 months, and annually thereafter. MCS (Mental Component Summary), PCS (Physical Component Summary) and overall score were evaluated among the groups and with time using ANOVA and linear regression mixed modeling.

RESULTS

At 82 months among 3 institutions 539 patients were enrolled with a mean ± SD followup of 1.8 ± 1.7 years. Of the patients 254 were on active surveillance, 285 were on primary intervention and 21 were on active surveillance but crossed over to delayed intervention. A total of 1,497 questionnaires were completed. Total and PCS quality of life scores were better for primary intervention at enrollment through 5 years. There were generally no differences in MCS scores among the groups and there was a trend of improving scores with time.

CONCLUSIONS

In a prospective registry of patients undergoing active surveillance or primary intervention for small renal masses those undergoing primary intervention had higher quality of life scores at baseline. This was due to a perceived benefit in the physical health domain, which persisted throughout followup. Mental health, which includes the domains of depression and anxiety, was not adversely affected while on active surveillance, and it improved with time after selecting a management strategy.

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

OBJECTIVES

To analyze the survival and the associated factors affecting the prognosis of renal cell carcinoma (RCC) in China with a sufficiently large sample size.

METHODS

Clinical data with complete follow-up of 1326 RCC patients were successfully obtained. Progression-free survival (PFS) and cancer-specific survival (CSS) were calculated, survival analysis was performed by Kaplan-Meier analysis, and Cox proportional hazards regression models were served to estimate the prognostic significance of each variables.

RESULTS

The median length of follow-up was 43.55 months (25-75 %, 25.47-68.75 months). During follow-up, 147 patients developed RCC-related progression, with a median PFS of 18.2 months (25-75 %, 7.50-47.27); 64 patients died from RCC-related progression, with a median CSS of 27.67 months (25-75 %, 14.10-58.53). For RCC patients in T1 stage, 3-, 5-, 8-, and 10-year CSS rates of patients receiving nephron-sparing nephrectomy were 99.33, 98.21, 97.40, and 97.40 %, respectively, which were significantly higher than radical nephrectomy patients (97.88, 96.28, 95.09, and 88.58 %, respectively). Cox proportional hazards regression model showed that tumor N stage, signs of lung metastasis (such as cough and hemoptysis), signs of bone metastasis (such as bone pain and fracture), pathological subtype of RCC, microscopic sarcomatoid change, and progression were prognosis factors for Chinese RCC patients.

CONCLUSIONS

Tumor stage, nephrectomy type, lung metastasis, bone metastasis, pathological subtype, sarcomatoid change, and type of progression were important risk factors for RCC. For T1 stage RCC patients, nephron-sparing nephrectomy showed better CSS than radical nephrectomy, which may guide the doctors and patients in their choices of surgical procedures.

Diagnostic Utility of Diffusion-weighted Magnetic Resonance Imaging in Differentiating Small Solid Renal Tumors (≤ 4 cm) at 3.0T Magnetic Resonance Imaging

BACKGROUND

The aim of this study was to assess the performance of apparent diffusion coefficient (ADC) measurement obtained with diffusion-weighted magnetic resonance imaging (DW-MRI) to distinguish renal cell carcinomas (RCCs) from small benign solid renal tumors (≤ 4 cm).

METHODS

In this cross-sectional study, 49 consecutive patients with histopathologically confirmed small solid renal tumors, and seven healthy volunteers were imaged using nonenhanced MRI and DW-MRI. The ADC map was calculated using the b values of 0, 50, 400, and 600 s/mm 2 and values compared via the Kruskal-Wallis and Mann-Whitney tests. The utility of ADC for differentiating RCCs and benign lesions was assessed using a receiver operating characteristic curve. Multiple nonenhanced MRI features were analyzed by Logistic regression.

RESULTS

The tumors consisted of 33 cases of clear-cell RCCs (ccRCCs) and 16 cases of benign tumors, including 14 cases of minimal fat angiomyolipomas and 2 cases of oncocytomas. The ADCs showed significant differences among benign tumors ([0.90 ± 0.52] × 10-3 mm 2 /s), ccRCCs ([1.53 ± 0.31] × 10-3 mm 2 /s) and the normal renal parenchyma ([2.22 ± 0.12] × 10-3 mm 2 /s) (P < 0.001). Moreover, there was statistically significant difference between high and low-grade ccRCCs (P = 0.004). Using a cut-off ADC of 1.36 × 10-3 mm 2 /s, DW-MRI resulted in an area under the curve (AUC), sensitivity, and specificity equal to 0.839, 75.8%, and 87.5%, respectively. Nonenhanced MRI alone and the combination of imaging methods led to an AUC, sensitivity and specificity equal to 0.919, 93.9%, and 81.2%, 0.998, 97%, and 100%, respectively. The Logistic regression showed that the location of the center of the tumor (inside the contour of the kidney) and appearance of stiff blood vessel were significantly helpful for diagnosing ccRCCs.

CONCLUSIONS

DW-MRI has potential in distinguishing ccRCCs from benign lesions in human small solid renal tumors (≤ 4 cm), and in increasing the accuracy for diagnosing ccRCCs when combined with nonenhanced MRI.

Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry

BACKGROUND

A growing body of retrospective literature is emerging regarding active surveillance (AS) for patients with small renal masses (SRMs). There are limited prospective data evaluating the effectiveness of AS compared to primary intervention (PI).

OBJECTIVE

To determine the characteristics and clinical outcomes of patients who chose AS for management of their SRM.

DESIGN, SETTING, AND PARTICIPANTS

From 2009 to 2014, the multi-institutional Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry prospectively enrolled 497 patients with solid renal masses ≤4.0cm who chose PI or AS.

INTERVENTION

AS versus PI.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The registry was designed and powered as a noninferiority study based on historic recurrence rates for PI. Analyses were performed in an intention-to-treat manner. Primary outcomes were overall survival (OS) and cancer-specific survival (CSS).

RESULTS AND LIMITATIONS

Of the 497 patients enrolled, 274 (55%) chose PI and 223 (45%) chose AS, of whom 21 (9%) crossed over to delayed intervention. AS patients were older, had worse Eastern Cooperative Oncology Group scores, total comorbidities, and cardiovascular comorbidities, had smaller tumors, and more often had multiple and bilateral lesions. OS for PI and AS was 98% and 96% at 2 yr, and 92% and 75% at 5 yr, respectively (log rank, p=0.06). At 5 yr, CSS was 99% and 100% for PI and AS, respectively (p=0.3). AS was not predictive of OS or CSS in regression modeling with relatively short follow-up.

CONCLUSIONS

In a well-selected cohort with up to 5 yr of prospective follow-up, AS was not inferior to PI.

PATIENT SUMMARY

The current report is among the first prospective analyses of patients electing for active surveillance of a small renal mass. Discussion of active surveillance should become part of the standard discussion for management of small renal masses.

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

OBJECTIVE

To assess modification of comparative cancer survival by cardiovascular (CV) risk and treatment strategy among older patients with small renal masses (SRMs).

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

The type of nephrectomy has little effect on overall survival or cardiac events in patients of 70 years and older with localized clinical t1 stage renal masses

Purpose

To compare the outcomes of nephron-sparing options (e.g., partial nephrectomy [PN]) and low-surgical-morbidity options (e.g., radical nephrectomy [RN]) in elderly patients with limited life expectancy.

Materials and Methods

We retrospectively reviewed 135 patients aged 70 years or older who underwent RN (n=82) or PN (n=53) for clinical T1 stage renal masses between January 2000 and December 2012. Clinicopathologic data were thoroughly analyzed and compared between the RN and PN groups. The modification of diet in renal disease equation was used to estimate glomerular filtration. Overall survival and cardiac events were assessed by using Kaplan-Meier survival analysis and Cox proportional-hazards regression modeling.

Results

Over a median follow-up period of 59.72 months, 17 patients (20.7%) in the RN group and 3 patients (5.7%) in the PN group died. Chronic kidney disease (<60 mL/min/1.73 m²) developed more frequently in RN patients than in PN patients (75.6% vs. 41.5%, p<0.001). The 5-year overall survival rate did not differ significantly between the RN and PN groups (90.7% vs. 93.8%; p=0.158). According to the multivariate analysis, the Charlson comorbidity index score was an independent predictor of overall survival (hazard ratio [HR], 2.679, p=0.037). Type of nephrectomy was not significantly associated with overall survival (HR, 2.447; p=0.167) or cardiac events (HR, 1.147; p=0.718).

Conclusions

Although chronic kidney disease was lower after PN, overall survival and cardiac events were similar regardless of type of nephrectomy.

Comorbidities and causes of death in the management of localized T1a kidney cancer

OBJECTIVE

The objectives of the present study were analyze specific comorbidities associated with survival and actual causes of death for patients with small renal masses, and to suggest a simplified measure associated with decreased overall survival specific to this population.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database (1995-2007) was queried to identify patients with localized T1a kidney cancer undergoing partial nephrectomy, radical nephrectomy or deferring therapy. We explored independent associations of specific comorbidities with causes of death, and developed a simplified cardiovascular index. Cox proportional hazards, and Fine and Gray competing risks regression were used.

RESULTS

Of 7177 Medicare beneficiaries in the study population, 754 (10.5%) deferred therapy, 1849 (25.8%) underwent partial nephrectomy and 4574 (63.7%) underwent radical nephrectomy with none of the selected comorbidities identified in 3682 (51.3%) patients. Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival. The cardiovascular index provided good survival risk stratification, and reclassified 1427 (41%) patients with a score ≥1 on the Charlson Comorbidity Index to a 0 on the cardiovascular index with minimal concession of 5-year survival.

CONCLUSIONS

Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival among Medicare beneficiaries with small renal masses. The cardiovascular index could serve as a clinically useful prognostic aid when advising older patients that are borderline candidates for surgery or active surveillance.

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

OBJECTIVES

Recognizing 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 MATERIALS

The 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.

RESULTS

A 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.

CONCLUSIONS

The 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.