5-Year Renal Function Outcomes after SABR for Primary Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium of the Kidney (IROCK)

PURPOSE/OBJECTIVE(S)

Renal cell carcinoma (RCC) presents uncommonly in patients with a congenital solitary kidney or prior contralateral nephrectomy. The objective of this study was to compare renal function outcomes of stereotactic ablative body radiotherapy (SABR) in patients with solitary vs. bilateral kidneys.

MATERIALS/METHODS

Patients with primary RCC with ≥2 years of follow-up at 12 participating International Radiosurgery Consortium for Kidney (IROCK) institutions were included. Patients with upper tract urothelial carcinoma or metastatic disease were excluded. Renal function was measured by estimated glomerular filtration rate (eGFR). For patients where eGFR was not recorded, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to estimate eGFR based on known creatinine. Baseline characteristics and renal function outcomes were compared between solitary vs. bilateral kidneys. Multivariable logistic regression was used to identify factors predictive of eGFR decline ≥ 15 mL/min and any eGFR increase evaluated at 1-year post-SABR.

RESULTS

One hundred and ninety patients with solitary (n = 56) or bilateral kidneys (n = 134) underwent SABR and were followed for a median of 5.0 years (IQR: 3.4-6.8). Pre-SABR eGFR (mean ± SD) was similar in patients with solitary (61.1 ± 23.2 mL/min) vs. bilateral kidneys (58.0 ± 22.3 mL/min, p = 0.324). Mean tumor size was 3.70 ± 1.40 cm in solitary and 4.35 ± 2.50 cm in bilateral kidneys (p = 0.026). After SABR, an initial compensatory increase in eGFR was observed in both cohorts (22.7% solitary and 17.7% bilateral at 1 year). This compensatory increase persisted in patients with bilateral but not a solitary kidney (10.3% vs. 0% at 3-years and 21.1% vs. 0% at 5-years, respectively). At 5-years post-SABR, eGFR decreased by -14.5 ± 7.6 in solitary and -13.3 ± 15.9 mL/min in bilateral kidneys (p = 0.665). At all timepoints assessed, there were no significant differences in eGFR decline between solitary vs. bilateral cohorts (all p > 0.05). There were also no significant differences in post-SABR end-stage renal disease (7.1% vs. 6.7%) or dialysis (3.6% vs. 3.7%) in solitary vs. bilateral, respectively. Multivariable analysis demonstrated that increasing tumor size (OR per 1 cm: 1.57; 95% CI: 1.14-2.16, p = 0.006) and baseline eGFR (OR per 10 mL/min: 1.30; 95% CI: 1.02-1.66, p = 0.034) was more likely to be associated with eGFR decline ≥ 15 mL/min. There was no significant association between solitary vs. bilateral kidney and eGFR decline (OR: 1.22; 95% CI: 0.45-3.34, p = 0.693).

CONCLUSION

There was no observed difference between renal function outcomes in patients with a solitary vs. bilateral kidneys. While larger tumor size may increase the risk of eGFR decline post-SABR, treatment of a solitary kidney does not appear to increase the risk of renal dysfunction long-term.

18F-PSMA-1007 PET/CT for response assessment in patients with metastatic renal cell carcinoma undergoing tyrosine kinase or checkpoint inhibitor therapy: preliminary results

Introduction

Tyrosine kinase (TKI) and checkpoint inhibitors (CI) prolonged overall survival in metastatic renal cell carcinoma (mRCC). Early prediction of treatment response is highly desirable for the individualization of patient management and improvement of therapeutic outcome; however, serum biochemistry is unable to predict therapeutic efficacy. Therefore, we compared ¹⁸F-PSMA-1007 PET imaging for response assessment in mRCC patients undergoing TKI or CI therapy compared to CT-based response assessment as the current imaging reference standard.

Methods

¹⁸F-PSMA-1007 PET/CT was performed in mRCC patients prior to initiation of systemic treatment and 8 weeks after therapy initiation. Treatment response was evaluated separately on ¹⁸F-PSMA-PET and CT. Changes on PSMA-PET (SUV_mean) were assessed on a per patient basis using a modified PERCIST scoring system. Complete response (CR_PET) was defined as absence of any uptake in all target lesions on posttreatment PET. Partial response (PR_PET) was defined as decrease in summed SUV_mean of > 30%. The appearance of new, PET-positive lesions or an increase in summed SUV_mean of > 30% was defined as progressive disease (PD_PET). A change in summed SUV_mean of ± 30% defined stable disease (SD_PET). RECIST 1.1 criteria were used for response assessment on CT. Results of radiographic response assessment on PSMA-PET and CT were compared.

Results

Overall, 11 mRCC patients undergoing systemic treatment were included. At baseline PSMA-PET₁, all mRCC patients showed at least one PSMA-avid lesion. On follow-up PET₂, 3 patients showed CR_PET, 3 PR_PET, 4 SD_PET, and 1 PD_PET. According to RECIST 1.1, 1 patient showed PR_CT, 9 SD_CT, and 1 PD_CT. Overall, concordant classifications were found in only 2 cases (2 SD_CT + PET). Patients with CR_PET on PET were classified as 3 SD_CT on CT using RECIST 1.1. By contrast, the patient classified as PR_CT on CT showed PSMA uptake without major changes during therapy (SD_PET). However, among 9 patients with SD_CT on CT, 3 were classified as CR_PET, 3 as PR_PET, 1 as PD_PET, and only 2 as SD_PET on PSMA-PET.

Conclusion

On PSMA-PET, heterogeneous courses were observed during systemic treatment in mRCC patients with highly diverging results compared to RECIST 1.1. In the light of missing biomarkers for early response assessment, PSMA-PET might allow more precise response assessment to systemic treatment, especially in patients classified as SD on CT.

Advanced Molecular Imaging in Histologically Verified Metanephric Adenoma

Metanephric adenoma (MA) describes a rare renal tumor and is generally considered a benign lesion. However, there are cases with regional lymphogenic and distant metastases. Noninvasive diagnosis of MA using conventional imaging remains challenging. Here, we describe a case of histologically verified MA with additional advanced molecular imaging consisting of ¹⁸F-PSMA-1007 PET/CT, ^99mTc-Sestamibi SPECT and contrast-enhanced ultrasound.

Adjuvant sunitinib in patients with high-risk renal cell carcinoma: safety, therapy management, and patient-reported outcomes in the S-TRAC trial

Background

Adjuvant sunitinib has significantly improved disease-free survival versus placebo in patients with renal cell carcinoma at high risk of recurrence post-nephrectomy (hazard ratio 0.76; 95% confidence interval, 0.59–0.98; two-sided P = 0.03). We report safety, therapy management, and patient-reported outcomes for patients receiving sunitinib and placebo in the S-TRAC trial.

Patients and methods

Patients were stratified by the University of California, Los Angeles Integrated Staging System and Eastern Cooperative Oncology Group performance status score, and randomized (1 : 1) to receive sunitinib (50 mg/day) or placebo. Single dose reductions to 37.5 mg, dose delays, and dose interruptions were used to manage adverse events (AEs). Patients’ health-related quality of life, including key symptoms typically associated with sunitinib, were evaluated with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).

Results

Patients maintained treatment for 9.5 (mean, SD 4.4) and 10.3 (mean, SD 3.7) months in the sunitinib and placebo arms, respectively. In the sunitinib arm, key AEs occurred ∼1 month (median) after start of treatment and resolved within ∼3.5 weeks (median). Many (40.6%) AEs leading to permanent discontinuation were grade 1/2, and most (87.2%) resolved or were resolving by 28 days after last treatment. Patients taking sunitinib showed a significantly lower EORTC QLQ-C30 overall health status score versus placebo, although this reduction was not clinically meaningful. Patients reported symptoms typically related to sunitinib treatment with diarrhea and loss of appetite showing clinically meaningful increases.

Conclusions

In S-TRAC, AEs were predictable, manageable, and reversible via dose interruptions, dose reductions, and/or standard supportive medical therapy. Patients on sunitinib did report increased symptoms and reduced HRQoL, but these changes were generally not clinically meaningful, apart from appetite loss and diarrhea, and were expected in the context of known sunitinib effects.

Clinical trial registration

ClinicalTrials.gov, NCT00375674.

[Epidemiology and diagnostic assessment of small renal masses]

BACKGROUND

The incidence of small renal masses has been rising over the last few decades. At the same time, mortality of renal cell carcinoma (RCC) is decreasing. These trends can be explained by the availability of improved therapeutic measures and the good prognosis of small renal masses (SRM) turning out to be histopathologically benign or of low malignancy in many cases.

OBJECTIVES

The aim of this article is to present epidemiology and diagnostic assessment of SRM.

MATERIALS AND METHODS

Statistics, basic research, guidelines.

RESULTS

The incidence of SRM is rising due to the widespread use of imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and contrast-enhanced ultrasound (CEUS). Sensitivity is excellent for CEUS and for CECT in the characterization of SRM, while good specificity values can be reached by MRI. For characterization of complex cystic renal masses, CEUS has good diagnostic accuracy.

CONCLUSIONS

Due to improved diagnostic possibilities, SRMs can be diagnosed in early asymptomatic stages. As SRM have a good prognosis and often are of low malignancy therapy, options should be carefully considered; especially in older patients, active surveillance should considered.

Adjuvant therapy in renal cell carcinoma: the perspective of urologists

BACKGROUND

Until recently, there was no approved adjuvant therapy (AT) for renal cell carcinoma (RCC) unless sunitinib was approved in the US. We evaluated clinical opinion and estimated use regarding different treatment options and patient selection of AT in RCC patients based on current scientific data and individual experience in Germany.

METHODS

We conducted an anonymous survey during a national urology conference in 01/2017. Answers of 157 urologists treating RCC patients could be included. Questions were related to practice setting, treatment of RCC, follow-up strategy, physicians' personal opinion and individually different important parameters regarding S-TRAC and ASSURE-trial.

RESULTS

82% were office based. 67% were located in larger cities. 83% reported that nephron-sparing surgery (NSS) was performed in tumors with diameter < 4 cm. Follow-up was done mainly in concordance with guideline recommendations. 68% treated an average of 2.9 patients/year with systemic therapy. Therapy was predominantly advocated using sunitinib (94%). Urologists were informed about S-TRAC and ASSURE-trial. For 47%, reported hazard ratio is the most important parameter to understand trial results followed by overall survival (OS) in 46%, disease-free survival in 38%, and results of other trials in 34%. The most convincing parameter to decide on AT is OS (69%). 62% placed their confidence in ASSURE over STRAC-trial. 44% would use AT for 12 months. Nodal involvement was the most common denominator for use of AT. 82% favor sunitinib as AT.

CONCLUSIONS

A minority of urologists would use AT and are more confident in ASSURE-trial. Reluctance of prescribing AT mainly is based on lack of OS data and conflicting trial results.

[Follow-up of renal cell carcinoma in a nonmetastatic stage]

Postoperative follow-up care after curative surgery or ablative treatment is the standard of care in patients with nonmetastatic renal cell carcinoma. The goal is to identify and treat postoperative complications and local recurrences early on. Follow-up investigations and their relevance are widely acknowledged and validated and patients undergoing follow-up seem to benefit from a longer survival in nonmetastatic renal cell carcinoma. Hence there is no consensus on a standardized follow-up strategy. The most disputed question is around the frequency of the investigations and the duration of the follow-up. Without an evidence-based follow-up protocol, urologists should carry out an individualized, potentially lifelong follow-up regimen, which also includes the patients' needs and perspectives.

A new setup for the quantitative analysis of drying by the use of gas-phase FTIR-spectroscopy

Drying rates are important for the manufacture of thin films and in specific for the production of electrodes used in electrochemical devices such as fuel cells and electrolyzers. The known procedures to investigate time-dependent sample compositions and selective evaporation rates are insufficient to obtain mean information about the full area instead of a single point analysis. Therefore, a new setup is presented using gas-phase Fourier-transform infrared spectroscopy. This method analyzes the gas-phase composition to recalculate the layer composition in electrode fabrication at any time during drying. According to the golden rule of measurement technology, manufacturer specifications are often overestimated. Therefore, our alternative procedures were used to evaluate the precision of devices used. The calculated measurement precision is confirmed by validation. The expected deviation is quantified to be less than 2% for the common application. Further on, the relative test-retest standard deviation is determined to be 0.3%-0.4%. As a result of the error propagation, the measurement precision is limited by the background gas flow rate precision for common application. At low volume fractions, the influence of the substance flow rate deviations becomes significant. However, further studies will focus on increasing the gas flow rate precision.

Recommendations on managing lenvatinib and everolimus in patients with advanced or metastatic renal cell carcinoma

INTRODUCTION

There are several second-line treatment options for patients with renal cell carcinoma after first-line failure of a tyrosine kinase inhibitor, especially with the recent approvals of cabozantinib, nivolumab, and the lenvatinib plus everolimus combination. A lack of reliable biomarkers and an overall lack of prospective head-to-head comparisons make it a challenge to choose a second-line treatment in the clinic. Areas covered: In this review/meta-opinion, we describe the safety profile of the lenvatinib plus everolimus combination in renal cell carcinoma. The combination of lenvatinib plus everolimus has achieved the highest rates of objective responses and the longest progression free and overall survival in cross-comparison trials. At the same time, the safety profile of this combination, including the rate of total and severe adverse events, the percentage of dose reductions required, and the rate of treatment discontinuation, was less favorable compared with available monotherapy options, suggesting that better management could help to maximize the activity of this combination while protecting patients from undue harm. Expert opinion: Herein, we aim to postulate multidisciplinary recommendations on the advice to offer to patients and caregivers before starting treatment and how to manage the combination from the perspective of daily clinical practice.

Characterization of histological subtypes of clear cell renal cell carcinoma using contrast-enhanced ultrasound (CEUS)

INTRODUCTION

The aim of this study was to analyze the histological subtypes of clear cell renal cell carcinoma (RCC) examined by means of contrast-enhanced ultrasound (CEUS) and a second generation blood pool agent (SonoVue®, Bracco, Milan, Italy) during the pre-operative phase.

MATERIALS AND METHODS

29 patients with histologically proven subtypes of clear cell RCC were examined. A total of three patients were diagnosed with highly differentiated clear cell RCC, 21 out of 29 cases with moderately differentiated clear cell RCC and five out of 29 patients had insufficiently differentiated clear cell RCC. An experienced radiologist examined the patients with CEUS. The following parameters were analyzed: maximum signal intensity (PEAK), time elapsed until PEAK is reached (MTT), local blood flow (RBF), area under the time intensity curve (AUC) and the signal intensity (SI) during the course of time. For the groups all comparisons are made based on healthy renal parenchyma.

RESULTS

In the clear cell RCC significant differences (significance level p < 0.05) between cancerous tissue and the healthy renal parenchyma were noticed in all four parameters. Therefore, the clear cell RCC stands out due to its reduced blood volume. However, it reached the PEAK reading relatively rapidly and its signal intensity was always lower than that of the healthy renal parenchyma. In the arterial phase retarded absorption of the contrast agent was observed, followed by fast washing out of the contrast agent bubbles.In all three histological subgroups no significant differences were noticed in PEAK and SI. However, the diagrams showed the possible bias, that the group of the insufficiently differentiated clear cell RCC had the highest PEAK-value and the highest signal intensity when compared with highly and moderately differentiated clear cell RCC.

CONCLUSION

Our study suggests that CEUS may be an additional tool for non-invasive characterisation and differentiation of the three histological subtypes of clear cell RCC. Furthermore, it seems to have an additional diagnostic value in daily clinical.

Parametric imaging of clear cell and papillary renal cell carcinoma using contrast-enhanced ultrasound (CEUS)

PURPOSE

The aim of this study was to analyse clear cell and papillary renal cell carcinoma (RCC) examined with contrast-enhanced ultrasound (CEUS) and a second generation blood pool agent (SonoVue®, Bracco, Milan, Italy) before clinical intervention.

MATERIALS AND METHODS

A total of 41 patients with histologically proven subtypes of RCC were examined. 29 patients had a clear cell RCC and 12 patients showed a papillary RCC. Average size in the clear cell RCC group was 6.07 cm and 1.88 cm in the papillary RCC group. An experienced radiologist examined all patients with CEUS. The following parameters were analysed: maximum signal intensity (PEAK), time elapsed until PEAK is reached (MTT), local blood flow (RBF), area under the time intensity curve (AUC) and the signal intensity (SI) during the course of time. For both groups all comparisons were made based on healthy renal parenchyma.

RESULTS

In the clear cell RCC significant differences (significance level p < 0.05) between cancerous tissue and the healthy renal parenchyma were noticed in all four parameters. The clear cell RCC showed a significant reduced blood volume. It reached the PEAK reading relatively rapidly and its signal intensity was always lower than that of the healthy renal parenchyma. In the arterial phase retarded absorption of the contrast agent was observed, followed by fast washing out of the contrast agent bubbles.In the papillary RCC group, significant findings as to PEAK and RBF as well as a slightly significant difference as to AUC were recorded. The papillary RCC had a lower blood supply and reached its PEAK reading later. Its signal intensity was also reduced. The signal intensity of papillary NCC was significantly lower compared with clear cell RCC; absorption and washing out of the contrast agent was delayed.

CONCLUSION

CEUS seems to be an useful additional method to clinically differentiate between clear cell and papillary RCC. In daily clinical use, patients with contraindication for other imaging methods, especially the magnetic resonance imaging, might particularly benefit from this method.

Renal Pseudoaneurysms and Arteriovenous Fistulas as a Complication of Nephron-Sparing Partial Nephrectomy: Technical and Functional Outcomes of Patients Treated With Selective Microcoil Embolization During a Ten-Year Period

PURPOSE

The aim of this study was to evaluate the clinical and functional outcomes in patients who underwent selective interventional embolization of renal pseudoaneurysms or arteriovenous fistulas at our center.

MATERIALS AND METHODS

Our retrospective analysis included all consecutive patients who received selective transcatheter embolization of renal pseudoaneurysms or arteriovenous fistulas after partial nephrectomy in our department from January, 2003 to September, 2013. The technical and clinical success rate and functional outcome of every procedure was collected and analyzed. Furthermore, the change in renal parenchymal volume before and after embolization was determined in a subgroup.

RESULTS

A total of 1425 patients underwent partial nephrectomy at our hospital. Of these, 39 (2.7 %) were identified with a pseudoaneurysm or an arteriovenous fistula after partial nephrectomy. The diagnosis of the vascular lesions was made by means of biphasic CT or CEUS. Technical success by means of selective microcoil embolization was achieved in all 39 patients (100 %). Clinical success, defined as no need for further operation or nephrectomy during follow-up, was achieved in 35 of 39 patients (85.7 %). Renal function, as measured by eGFR before and after the intervention, did not change significantly. However, a mean loss of parenchymal volume of 25.2 % was observed in a subgroup. No major or minor complications were attributable to the embolization procedure.

CONCLUSION

Transcatheter embolization is a promising method for treating vascular complications which may occur after partial nephrectomy. We confirm the high success rate of this technique while discussing renal functional outcomes and potential safety aspects.

KEY POINTS

Arterial pseudoaneurysms and arteriovenous fistulas are rare but severe complications after partial nephrectomy. Selective microcoil embolization is a safe and effective kidney-preserving procedure for treating these complications. Embolization leads to a significant loss of renal parenchymal volume but not to a loss of renal function.

Dual energy can accurately differentiate uric acid-containing urinary calculi from calcium stones

PURPOSE

To retrospectively evaluate the accuracy of dual-energy CT (DECT) in the detection of the chemical composition of urinary calculi in correlation with infrared spectroscopic stone analysis.

METHODS

We reviewed the CT scans of 255 patients who underwent DECT due to a clinical suspicion of urolithiasis. Out of this group, we included 64 patients with clinically symptomatic urolithiasis requiring stone removal. After surgical removal of the stone by ureterorenoscopy, chemical composition was analyzed with infrared spectroscopy. We correlated DECT stone characterization results with chemical stone composition based on dual-energy indices (DEI). A total of 213 renal and ureteral stones could be removed and chemically analyzed.

RESULTS

A total of 213 calculi were evaluated. Thirty eight out of sixty four (59 %) patients had >1 stone. DECT was used to differentiate stones by using DEI. Stones harboring calcium (CA) were color-coded in blue, while stones containing uric acid (UA) were colored red. Median DEI in UA-containing stones were 0.001. Non-UA-containing stones had a DEI between 0.073 for pure CA stones and 0.077 containing CA and other substances (p = 0.001; p = 0.03, respectively). Sensitivity of DECT was 98.4 % for differentiation of UA from non-UA-containing calculi. Specificity was 98.1 %. Mean effective radiation dose of DECT was 4.18 mSv (0.44-14.27 mSv), thus comparable to conventional CT scans of the abdomen. Conventional measurement of Hounsfield units did not correlate with stone composition.

CONCLUSION

DECT with image post-processing reliably discriminates UA-containing calculi from all other stones, but the study offered limitations. Discrimination within the non-UA stones cannot be reliably achieved but is clinically insignificant.

Axitinib versus sorafenib in advanced renal cell carcinoma: subanalyses by prior therapy from a randomised phase III trial

BACKGROUND

In the AXIS trial, axitinib prolonged progression-free survival (PFS) vs sorafenib in patients with advanced renal cell carcinoma (RCC) previously treated with sunitinib or cytokines.

METHODS

In post hoc analyses, patients were grouped by objective response to prior therapy (yes vs no), prior therapy duration (< vs ⩾median), and tumour burden (baseline sum of the longest diameter < vs ⩾median). PFS and overall survival (OS), and safety by type and duration of prior therapy were evaluated.

RESULTS

Response to prior therapy did not influence outcome with second-line axitinib or sorafenib. PFS was significantly longer in axitinib-treated patients who received longer prior cytokine treatment and sorafenib-treated patients with smaller tumour burden following sunitinib. Overall survival with the second-line therapy was longer in patients who received longer duration of prior therapy, although not significant in the sunitinib-to-axitinib sequence subgroup; OS was also longer in patients with smaller tumour burden, but not significant in the cytokine-to-axitinib sequence subgroup. Safety profiles differed modestly by type and duration of prior therapy.

CONCLUSIONS

AXIS data suggest that longer duration of the first-line therapy generally yields better outcome with the second-line therapy and that lack of response to first-line therapy does not preclude positive clinical outcomes with a second-line vascular endothelial growth factor-targeted agent in patients with advanced RCC.

A multinational phase II trial of bevacizumab with low-dose interferon-α2a as first-line treatment of metastatic renal cell carcinoma: BEVLiN

BACKGROUND

Avastin and Roferon in Renal Cell Carcinoma (AVOREN) demonstrated efficacy for bevacizumab plus interferon-α2a (IFN; 9 MIU tiw) in first-line metastatic renal cell carcinoma (mRCC). We evaluated bevacizumab with low-dose IFN in mRCC to determine whether clinical benefit could be maintained with reduced toxicity.

METHODS

BEVLiN was an open-label, single-arm, multinational, phase II trial. Nephrectomized patients with treatment-naive, clear cell mRCC and favourable/intermediate Memorial Sloan-Kettering Cancer Center scores received bevacizumab (10 mg/kg every 2 weeks) and IFN (3 MIU thrice weekly) until disease progression. Descriptive comparisons with AVOREN patients having favourable/intermediate MSKCC scores treated with bevacizumab plus IFN (9 MIU) were made. Primary end points were grade ≥3 IFN-associated adverse events (AEs) and progression-free survival (PFS). All grade ≥3 AEs and bevacizumab/IFN-related grade 1-2 AEs occurring from first administration until 28 days after last treatment were reported.

RESULTS

A total of 146 patients were treated; the median follow-up was 29.4 months. Any-grade and grade ≥3 IFN-associated AEs occurred in 53.4% and 10.3% of patients, respectively. The median PFS and overall survival were 15.3 [95% confidence interval (CI): 11.7-18.0] and 30.7 months (95% CI: 25.7-not reached), respectively. The ORR was 28.8%.

CONCLUSIONS

Compared with a historical control AVOREN subgroup, low-dose IFN with bevacizumab resulted in a reduction in incidence rates of IFN-related AEs, without compromising efficacy [NCT00796757].

[Partial nephrectomy. Rationale and limitations of an organ-preserving approach]

The rising incidence of renal cell cancer in recent decades has led to a revision in the therapy of this malignancy. For small renal masses, partial nephrectomy has become the standard surgical treatment instead of radical nephrectomy. This approach can lead to a higher overall survival due to preservation of renal function. Avoiding chronic kidney disease is mandatory for patients with benign or small non-aggressive tumors; however, partial nephrectomy correlates with higher complication rates and is conditioned by operator skills. The role of partial nephrectomy compared to radical nephrectomy is still to be established particularly for larger tumors. The results of studies so far are mostly based on non-randomized retrospective data. This article will present the pros and cons of partial nephrectomy and will focus on the steps required to promulgate the indications of nephron-sparing surgery.

[Fast track approach in radical cystectomy]

The origins of the fast track concept in the field of elective colon surgery can be traced back to the beginning of the 1990s. The first studies performed by Kehlet et al. sparked interest in this new form of patient management among physicians and hospital administrators. Different fast track programs for patients undergoing radical cystectomy can be found in the current literature. The goal of the prevailing fast track concepts is to reduce the perioperative burden, optimize postoperative convalescence, decrease the postoperative need for analgesics, lower the postoperative morbidity rate, and shorten hospital stays.

Malnutrition and clinical outcome in urological patients

Introduction

In a previous study we evaluated the risk for malnutrition among urological patients in a German university hospital. There are published different studies in other surgical fields that could show a correlation between malnutrition and clinical outcome. As data on this issue is still rare in the urological field we aimed to correlate the risk of malnutrition with different parameters regarding clinical outcome.

Methods

In the time from 2007 to 2009 a total of 320 patients were evaluated regarding the risk of malnutrition and occurrence of complications during the time of hospitalization at our Urological department. The Nutritional risk screening 2002 (NRS) by Kondrup et al. was used for the estimation of the risk level for malnutrition. Patients of a German university hospital were included independently of intervention, age or gender. Parameters for clinical outcome were: pulmonary complications (infectious/noninfectious), cardiovascular complications (infectious/noninfectious), other infections (urinary tract infection etc.), wound healing disorders and time of hospitalization.

Results

In this evaluation 320 patients were included for analysis. Forty patients (13%) presented with a normal nutritional status (NRS score 0) at the time of admission to the hospital and 212 patients (66%) were at risk for forming malnutrition problems (NRS score 1-2). sixty eight patients (21%) of this urological cohort were detected with a malnutrition according to the applied NRS score (≥3). Regarding the occurrence of overall complications in this cohort the rate was rather low compared to other surgical fields. Of 320 patients only 22 patients (7%) presented with relevant complications during their hospitalization. However if data were stratified for peri- and postoperative complications in correlation to nutritional status of patients, an evident trend to a higher complication rate of 9% was obvious.

Conclusions

In our cohort of exclusively urological patients, the risk for post-surgical complications was higher in patients who were malnourished as defined using the Nutritional Risc Screening System (NRS) by Kondrup et al. Further studies need to show whether an adequate nutritional supportive therapy could help to optimize the clinical outcome of malnourished urological patients.

Final results of the European Advanced Renal Cell Carcinoma Sorafenib (EU-ARCCS) expanded-access study: a large open-label study in diverse community settings

BACKGROUND

The European Advanced Renal Cell Carcinoma Sorafenib (EU-ARCCS) expanded-access study provided sorafenib to advanced renal cell carcinoma (RCC) patients in whom previous systemic therapy had failed. The study assessed the safety and use of sorafenib for the treatment of advanced RCC in a large community-based patient population across 11 countries in Europe.

PATIENTS AND METHODS

EU-ARCCS was a single-arm, open-label trial of sorafenib in advanced RCC patients. End points included safety, time to progression, progression-free survival (PFS), and disease control rate (DCR). Subgroup analyses included age, Eastern Cooperative Oncology Group performance status, histology, prior therapy, and number and sites of metastases.

RESULTS

About 1159 advanced RCC patients were enrolled. Most patients (94%) experienced drug-related adverse events (AEs) of any grade, with the most common grade ≥3 AEs including hand-foot skin reaction (13%), diarrhea (7%), fatigue (7%), hypertension (6%), and rash/desquamation (5%). The incidence of AEs in the subgroups was similar to that in the overall population. Median PFS was 6.6 months; DCR at ≥8 and ≥12 weeks was 85% and 78%, respectively.

CONCLUSIONS

The sorafenib safety profile in European community-based practice settings was similar to that reported in clinical trials. The heterogeneous advanced RCC patient population in EU-ARCCS permitted assessment of sorafenib in important subpopulations of advanced RCC patients.

Outcome of treatment discontinuation in patients with metastatic renal cell carcinoma and no evidence of disease following targeted therapy with or without metastasectomy

BACKGROUND

It is unknown if discontinuation of targeted therapy (TT) and readministration in case of recurrence is feasible in patients with metastatic renal cell carcinoma (mRCC) in which complete response (CR) is achieved by TT alone or no evidence of disease (NED) with additional resection of residual metastases.

PATIENTS AND METHODS

Patients in whom TT was discontinued after CR to TT alone or NED after additional metastasectomy were included in this retrospective analysis. Outcome criteria evaluated were time off TT, recurrence of metastases and response to re-exposure to TT. Univariate and multivariate analyses were carried out to identify variables potentially predictive of outcome.

RESULTS

In 36 patients with CR or NED under TT with sunitinib (22), sorafenib (11), bevacizumab/interferon (2) and temsirolimus (1), TT was discontinued. Recurrence was observed in 24 patients (66.7%). Re-exposure to TT was effective in 86.9% of these cases. Twelve patients (33.3%) remained recurrence free at a median follow-up of 12 months (range 3-31). Median time off TT was 7 months (range 1-31). Factors that correlate with outcome could not be identified.

CONCLUSIONS

In the majority of patients with mRCC and CR or NED, discontinuation of TT was followed by recurrence, but re-exposure to TT was effective.

Comparison of guideline recommendations with daily practice in patients with renal cell carcinoma

Objectives and Aims

To compare guideline recommendations with daily practice patterns in a German patient cohort with renal cell carcinoma.

Patients and methods

81 patients with T1 oder T2 renal cell carcinoma (RCC) were included in this prospective single-center study. All patients were operated in a single institution either by open radical nephrectomy (ORN) or nephron sparing surgery (NSS). Patients and doctors were evaluated using a written questionnaire with a follow-up of 12 months. Follow-up intervals, follow-up modalities (e. g. imaging modalities, laboratory controls of blood and urine) and the call on psycho-oncological support were evaluated.

Results

The majority of patients (72%) were followed up by their urologists. Follow-up examinations included abdominal ultrasound, urine and blood diagnostics, conventional chest x-rays, computed tomography (CT) of abdomen, chest or head or abdominal Magnetic Resonance Imaging (MRI). There were no significant differences between patients operated by ORN or NSS. In total, 12.5% of patients were asking for psycho-oncological support.

Conclusions

In general, patients were followed up according to existing guideline recommendations. Only a small proportion of patients asked for psycho-oncological treatment.