Robot-assisted partial nephrectomy with minimum follow-up of 5 years: A multi-center prospective study in Japan

Stereotactic ablative body radiotherapy for primary kidney cancer (TROG 15.03 FASTRACK II): a non-randomised phase 2 trial

BACKGROUND

Stereotactic ablative body radiotherapy (SABR) is a novel non-invasive alternative for patients with primary renal cell cancer who do not undergo surgical resection. The FASTRACK II clinical trial investigated the efficacy of SABR for primary renal cell cancer in a phase 2 trial.

METHODS

This international, non-randomised, phase 2 study was conducted in seven centres in Australia and one centre in the Netherlands. Eligible patients aged 18 years or older had biopsy-confirmed diagnosis of primary renal cell cancer, with only a single lesion; were medically inoperable, were at high risk of complications from surgery, or declined surgery; and had an Eastern Cooperative Oncology Group performance status of 0-2. A multidisciplinary decision that active treatment was warranted was required. Key exclusion criteria were a pre-treatment estimated glomerular filtration rate of less than 30 mL/min per 1·73 m2, previous systemic therapies for renal cell cancer, previous high-dose radiotherapy to an overlapping region, tumours larger than 10 cm, and direct contact of the renal cell cancer with the bowel. Patients received either a single fraction SABR of 26 Gy for tumours 4 cm or less in maximum diameter, or 42 Gy in three fractions for tumours more than 4 cm to 10 cm in maximum diameter. The primary endpoint was local control, defined as no progression of the primary renal cell cancer, as evaluated by the investigator per Response Evaluation Criteria in Solid Tumours (version 1.1). Assuming a 1-year local control of 90%, the null hypothesis of 80% or less was considered not to be worthy of proceeding to a future randomised controlled trial. All patients who commenced trial treatment were included in the primary outcome analysis. This trial is registered with ClinicalTrials.gov, NCT02613819, and has completed accrual.

FINDINGS

Between July 28, 2016, and Feb 27, 2020, 70 patients were enrolled and initiated treatment. Median age was 77 years (IQR 70-82). Before enrolment, 49 (70%) of 70 patients had documented serial growth on initial surveillance imaging. 49 (70%) of 70 patients were male and 21 (30%) were female. Median tumour size was 4·6 cm (IQR 3·7-5·5). All patients enrolled had T1-T2a and N0-N1 disease. 23 patients received single-fraction SABR of 26 Gy and 47 received 42 Gy in three fractions. Median follow-up was 43 months (IQR 38-60). Local control at 12 months from treatment commencement was 100% (p<0·0001). Seven (10%) patients had grade 3 treatment-related adverse events, with no grade 4 adverse events observed. Grade 3 treatment-related adverse events were nausea and vomiting (three [4%] patients), abdominal, flank, or tumour pain (four [6%]), colonic obstruction (two [3%]), and diarrhoea (one [1%]). No treatment-related or cancer-related deaths occurred.

INTERPRETATION

To our knowledge, this is the first multicentre prospective clinical trial of non-surgical definitive therapy in patients with primary renal cell cancer. In a cohort with predominantly T1b or larger disease, SABR was an effective treatment strategy with no observed local failures or cancer-related deaths. We observed an acceptable side-effect profile and renal function after SABR. These outcomes support the design of a future randomised trial of SABR versus surgery for primary renal cell cancer.

FUNDING

Cancer Australia Priority-driven Collaborative Cancer Research Scheme.

Bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy

Renal cell carcinoma often metastasizes to the adrenals; however, bilateral adrenal metastases are rare. We here report a patient with bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy and review relevant published reports. A 64-year-old man underwent robot-assisted partial nephrectomy for a left renal tumor. During follow-up, he was diagnosed with bilateral adrenal metastases. He underwent left adrenalectomy followed by right partial adrenalectomy to preserve adrenal function. The renal tumor later metastasized to other parts of the body. He continues to receive systemic treatment and remains in partial remission. Patients with pT1aN0M0 renal cell carcinoma generally have a favorable prognosis. However, occasional such patients develop multiple metastases. To the best of our knowledge, this is the first reported case of bilateral adrenal metastases after partial nephrectomy. Clinicians should keep this rare scenario in mind.

Long-Term Oncological and Functional Outcomes after Laparoscopic Partial Nephrectomy with Hyperselective Embolization of Tumor Vessels in a Hybrid Operating Room

Laparoscopic partial nephrectomy (LPN) after hyperselective embolization of tumor vessels (HETV) in a hybrid operating room (HOR) that combines traditional surgical equipment with advanced imaging technology, is a non-clamping surgical approach to treat localized kidney tumors that has shown promising short-term results. The aim of this study was to evaluate the long-term oncological and functional outcomes of this procedure. All consecutive patients treated for a localized kidney tumor by LPN after HETV between May 2015 and October 2022 in a single academic institution were included in the study. Clinical, pathological and biological data were collected prospectively in the uroCCR database. We evaluated intraoperative data, postoperative complications, surgical margin and modification of renal function after surgery. We included 245 patients. The median tumor size was 3.2 (2.5-4.4) cm. The R.E.N.A.L. complexity was low, medium and high for 104 (43.5%), 109 (45.6%) and 26 (10.9%) patients, respectively. Median LPN time was 75 (65-100) min and median blood loss was 100 (50-300) mL. Surgical postoperative complications occurred in 56 (22.9%) patients with 17 (5.7%) major complications. The median Glomerular Function Rate variation at 6 months was -7.5 (-15--2) mL/min. Malignant tumors were present in 211 (86.1%) patients, and 12 (4.9%) patients had positive surgical margins. After a median follow-up of 27 (8-49) months, 20 (8.2%) patients had a tumor recurrence and 4 (1.6%) died from cancer. At 5 years, disease free survival, cancer specific survival and overall survival rates were 84%, 96.8% and 88.3%, respectively. Performing LPN after HETV in a HOR is a safe and efficient non-clamping approach to treat localized kidney tumors.

Robot-Assisted Partial Nephrectomy Mid-Term Oncologic Outcomes: A Systematic Review

Background: Robot-assisted partial nephrectomy (RAPN) is used more and more in present days as a therapy option for surgical treatment of cT1 renal masses. Current guidelines equally recommend open (OPN), laparoscopic (LPN), or robotic partial nephrectomy (PN). The aim of this review was to analyze the most representative RAPN series in terms of reported oncological outcomes. (2) Methods: A systematic search of Webofscience, PUBMED, Clinicaltrials.gov was performed on 1 August 2022. Studies were considered eligible if they: included patients with renal cell carcinoma (RCC) stage T1, were prospective, used randomized clinical trials (RCT) or retrospective studies, had patients undergo RAPN with a minimum follow-up of 48 months. (3) Results: Reported positive surgical margin rates were from 0 to 10.5%. Local recurrence occurred in up to 3.6% of patients. Distant metastases were reported in up to 6.4% of patients. 5-year cancer free survival (CFS) estimates rates ranged from 86.4% to 98.4%. 5-year cancer specific survival (CSS) estimates rates ranged from 90.1% to 100%, and 5-year overall survival (OS) estimates rated ranged from 82.6% to 97.9%. (4) Conclusions: Data coming from retrospective and prospective series shows very good oncologic outcomes after RAPN. Up to now, 10-year survival outcomes were not reported. Taken together, RAPN deliver similar oncologic performance to OPN and LPN.