Systematic review of oncological outcomes following surgical management of localised renal cancer

Ex vivo nephron-sparing surgery and kidney autotransplantation for renal tumors

The nephron-sparing techniques allow the excision of kidney tumors preserving renal function and ensuring adequate oncological results. We describe a case of a 77-year-old patient who underwent an ex vivo partial nephrectomy with orthotopic autotransplantation for kidney cancer. The postoperative course was marked by bleeding which required radiological embolization. Postoperative dialysis was required for about 1 month. The anatomopathological examination showed a clear cell carcinoma staged pT1b, pNX, R0. At 2 years follow-up, no recurrence was detected with a complete renal function restoration. Our experience shows that ex vivo nephron-sparing surgery with autotransplantation is a good alternative to total nephrectomy in the case of voluminous or perihilar tumors. Considering the high morbidity of this procedure, it should be only performed in specialized centers.

Intratumoral CXCL13+CD8+T cell infiltration determines poor clinical outcomes and immunoevasive contexture in patients with clear cell renal cell carcinoma

Background

Chemokine (C-X-C motif) ligand 13 (CXCL13) was known as a selective chemotaxis for B cells, a product of follicular helper CD4⁺T cells (T_FH) and a contributor to tertiary lymphoid structures (TLS). Although secretion and function of CXCL13 produced by T_FH have been deeply explored, the immune function and prognostic significance of CXCL13 secreted by CD8⁺T cells still remain unrevealed. This study aims to investigate the clinical merit of CXCL13⁺CD8⁺T cells in clear cell renal cell carcinoma (ccRCC).

Methods

We analyzed prognostic value and immune contexture that associated with CXCL13⁺CD8⁺T cells infiltration level in a total of 755 patients from Zhongshan Hospital cohort (n=223) and The Cancer Genome Atlas cohort (n=532). In vitro analyses were conducted on 42 samples of resected tumor tissue from Zhongshan Hospital in order to detect the immune status of CXCL13⁺CD8⁺T cells and total CD8⁺T cells. Immunohistochemistry (IHC) and flow cytometry were applied to characterize immune cells and portray the tumor microenvironment (TME) in ccRCC.

Results

Intratumoral CXCL13⁺CD8⁺T cells abundance was associated with inferior overall survival and disease-free survival. CXCL13⁺CD8⁺T cells possessed higher level of immune checkpoints like programmed cell-death protein 1 (PD-1), T-cell immunoglobulin mucin 3 (Tim-3), T cell immunoreceptor with Ig and ITIM domains (TIGIT) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), higher Ki-67 expression and lower tumor necrosis factor α (TNF-α), interferon γ (IFN-γ) expression. Total CD8⁺T cells in high-level CXCL13⁺CD8⁺T cells infiltration subgroup exhibited elevated exhausted markers (PD-1, Tim-3, TIGIT) and descended activated markers (TNF-α, IFN-γ) without quantity variance. Furthermore, the abundance of intratumoral CXCL13⁺CD8⁺T cell was correlated with immunoevasive TME accompanied by increased T helper 2 cells, tumor-associated macrophages, Foxp3⁺ regulatory T cells, TLS and decreased natural killer cells, GZMB⁺ cells.

Conclusions

Intratumoral CXCL13⁺CD8⁺T cells infiltration indicated inferior clinical outcome in patients with ccRCC. CXCL13⁺CD8⁺T cells possessed increased exhausted markers, decreased effector molecules and better proliferation ability. CXCL13⁺CD8⁺T cells abundance impaired total CD8⁺T cells’ immune function. Intratumoral CXCL13⁺CD8⁺T cells abundance was associated with immunoevasive contexture. The abundance of CXCL13⁺CD8⁺T cells was an independent prognosticator and a potential immunotherapeutic target marker for ccRCC treatment.

External validation of SPARE nephrometery score in predicting overall complications, trifecta and pentafecta outcomes following robot-assisted partial nephrectomy

BACKGROUND

There is an ongoing need and search for a simple yet accurate nephrometry scoring system for predicting the postoperative outcomes after partial nephrectomy (PN). Simplified PADUA Renal (SPARE) Nephrometry Scoring System, a simplified version of Preoperative Aspects and Dimensions Used for an Anatomical Classification (PADUA) has been proposed as a predictor of postoperative complications following PN recently. However, this score has never been externally validated and assessed as a predictor of trifecta and pentafecta outcomes of PN. In the current study, we applied the SPARE scoring system to our robot-assisted PN cohort (RAPN).

METHODS

Prospectively maintained data of patients, who underwent RAPN from November 2014 to December 2018, was abstracted. Imaging was analyzed to calculate SPARE and RENAL nephrometry scores (RNS) by two urologists, independently. SPARE was compared with complications, trifecta outcomes, pentafecta outcomes, and RENAL nephrometry scoring (RNS).

RESULTS

Data of 201 RAPN patients were analyzed. The mean SPARE score was 3 (range 0-11). One hundred thirteen patients were classified as low risk, 64 as intermediate risk, and 24 as high risks. On multivariate analysis SPARE score alone predicted complications (OR=1.37, P=0.014) and trifecta outcomes (OR=0.75, P=0.000) while age (OR=0.96, P=0.042), preoperative eGFR (OR=0.97, P=0.001) and SPARE scores (OR=0.81, P=0.016) were predictors for pentafecta outcomes. Receiver operated curve (ROC) analysis between SPARE and RNS in predicting the complications; trifecta and pentafecta outcomes had a comparable area under the curve.

CONCLUSIONS

Our study validates the SPARE nephrometry scoring system in predicting postoperative complications, trifecta, and pentafecta outcomes in a RAPN cohort. The predictive accuracy of SPARE is similar to RNS.

Pathological features and outcomes of incidental renal cell carcinoma in candidate solid organ donors

Background

We report the findings of a single Italian center in the evaluation of renal lesions in deceased donors from 2001 to 2017. In risk evaluation, we applied the current Italian guidelines, which include donors with small (< 4 cm, stage pT1a) renal carcinomas in the category of non-standard donors with a negligible risk of cancer transmission.

Methods

From the revision of our registries, 2,406 donors were considered in the Emilia Romagna region of Italy; organs were accepted from 1,321 individuals for a total of 3,406 organs.

Results

The evaluation of donor safety required frozen section analysis for 51 donors, in which a renal suspicious lesion was detected by ultrasound. Thirty-two primary renal tumors were finally diagnosed 26 identified by frozen sections and 6 in discarded kidneys. The 32 tumors included 13 clear cell renal cell carcinomas (RCCs), 6 papillary RCCs, 6 angiomyolipomas, 5 oncocytomas, 1 chromophobe RCC, and 1 papillary adenoma. No cases of tumor transmission were recorded in follow-up of the recipients.

Conclusion

Donors with small RCCs can be accepted to increase the donor pool. Collaboration in a multidisciplinary setting is fundamental to accurately evaluate donor candidate risk assessment and to improve standardized protocols for surgeons and pathologists.

Open partial nephrectomy: current review

Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.

The role of open radical nephrectomy in contemporary management of renal cell carcinoma

Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.

Hereditary leiomyomatosis and renal cell carcinoma syndrome-associated renal cell carcinoma: Morphological appraisal with a comprehensive review of differential diagnoses

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is an autosomal dominant syndrome wherein affected individuals are at risk for the development of cutaneous leiomyomas, early-onset multiple uterine leiomyomas, and an aggressive subtype of renal cell cancer. HLRCC is caused by germline mutations in the fumarate hydratase (FH) gene, which inactivates the enzyme and alters the function of the tricarboxylic acid/Krebs cycle. This article reviews the hitherto described morphologic features of HLRCC-associated renal cell carcinoma (RCC) and outlines the differential diagnosis and ancillary use of immunohistochemistry and molecular diagnostics for these tumors. The morphologic spectrum of HLRCC-associated RCC is wide and histologic features, including tumor cells with prominent nucleoli, perinucleolar halos, and multiple architectural patterns within the same tumor, which are suggestive of this diagnosis. FH immunohistochemistry in conjunction with genetic counseling and germline FH testing are the important parameters for detection of this entity. These kidney tumors warrant prompt treatment as even smaller sized lesions can demonstrate aggressive behavior and systemic oncologic treatment in metastatic disease should, if possible, be part of a clinical trial. Screening procedures in HLRCC families should preferably be evaluated in large cohorts.

Oncologic outcomes and safety of percutaneous cryoablation for biopsy-proven renal cell carcinoma up to 4 cm in diameter: a prospective observational study

BACKGROUND

Percutaneous cryoablation is widely used for the treatment of renal cell carcinoma. We prospectively evaluated the oncologic outcomes and safety of percutaneous cryoablation for the treatment of tumors ≤ 4 cm in diameter.

METHODS

We included patients aged ≥ 20 years, who had histologically proven renal cell carcinoma, tumor diameter ≤ 4 cm, a performance status of ≤ 1, acceptable laboratory parameters, were inoperable or refused to undergo surgery, and had signed a written informed consent. The primary endpoint was the cause-specific survival rate. The secondary endpoints were overall and progression-free survival, and adverse event frequency and grade. All procedures were percutaneously performed under computed tomography fluoroscopy guidance.

RESULTS

From October 2013 to October 2015, 33 patients (mean age: 68 ± 14 years; sex: six women, 27 men) were enrolled. The mean tumor diameter was 2.1 ± 0.6 (range 1.0-3.4) cm. The median follow-up period was 60.1 (range 18.4-76.6) months. One patient died of non-renal cell carcinoma-related disease 46 months after percutaneous cryoablation. The cause-specific and overall survival rates were 100% and 96.8% at 3 years, and 100% and 96.8% at 5 years, respectively. There was no local tumor progression or distant metastasis. The incidence of severe urological (urinary fistula and perinephric infection) and non-urological adverse events (increased creatine kinase and skin ulceration) was 6% each.

CONCLUSION

Percutaneous cryoablation for renal cell carcinoma ≤ 4 cm in diameter achieved good tumor control with a low complication frequency.

Prognostic Significance of Sarcomatoid Differentiation in Patients With Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Background

To date, the prognostic value of sarcomatoid differentiation in patients having metastatic renal cell carcinoma (mRCC) remains inconclusive. A systematic review and meta-analysis were conducted.

Materials and Methods

Relevant literatures were obtained from PubMed, Embase, and Cochrane Library published prior to May, 2020. All patients were diagnosed with mRCC and treated with surgery, cytokine therapy, targeted therapy, and immunotherapy. Sarcomatoid differentiation in the pathological specimens was identified. Each endpoint [overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS)] was assessed using a multivariable adjusted hazard ratio (HR) and 95% confidence interval (CI).

Results

Fifteen observational studies having 5,828 patients with mRCC were included. The merged results showed that patients presenting sarcomatoid differentiation had a significantly inferior OS (HR: 2.26, 95% CI: 1.82-2.81; P < 0.001), PFS (HR: 2.28, 95% CI: 1.63-3.19; P < 0.001), and CSS (HR: 2.27, 95% CI: 1.51-3.40; P < 0.001) compared to those without sarcomatoid differentiation. Subgroup analysis based on publication year, patient population, country, number of cases, and NOS score did not change the direction of results. A significant publication bias was identified for OS, but no publication bias was identified for PFS. Moreover, sensitivity analysis also verified the robustness of the results.

Conclusion

This study suggested that sarcomatoid differentiation was correlated to unfavorable clinical outcomes in mRCC and may be a poor prognostic factor incorporating to prognostic models for mRCC patients.

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.

Laparoscopic and Robotic-Assisted Partial Nephrectomy: An Overview of Hot Issues

Laparoscopic partial nephrectomy and robot-assisted partial nephrectomy are attracting increased attention from urologists. They can achieve the same effect of oncology control as radical nephrectomy; moreover, they can offer better preservation of renal function, thus obtaining long-term living benefits. The indications are also expanding, making it possible for larger and more difficult tumors. Laparoscopic partial nephrectomy and robot-assisted partial nephrectomy can be performed by transperitoneal and retroperitoneal approaches, with their individual advantages and limitations. In addition, the renal tumor scoring systems have been widely used and studied in laparoscopic partial nephrectomy and robot-assisted partial nephrectomy. In -order to better preserve renal function, the zero-ischemia technique is widely used. The application of intraoperative imaging technology provides convenience and greater benefits. Besides, whether minimal invasive partial nephrectomy can be performed without stop antiplatelet treatment is still disputed. Clinicians perform substantial exploration and practice to achieve the "trifecta" of surgery: complete resection of the tumor, maximum protection of renal function, and no complications.

Prognostic Value of DNA Methylation-Driven Genes in Clear Cell Renal Cell Carcinoma: A Study Based on Methylation and Transcriptome Analyses

Background

Few previous studies have comprehensively explored the level of DNA methylation and gene expression in ccRCC. The purpose of this study was to identify the key clear cell renal cell carcinoma- (ccRCC-) related DNA methylation-driven genes (MDG) and to build a prognostic model based on the level of DNA methylation.

Methods

RNA-seq transcriptome data and DNA methylation data were obtained from The Cancer Genome Atlas. Based on the MethylMix algorithm, we obtain ccRCC-related MDG. The univariate and multivariate Cox regression analyses were employed to investigate the correlation between patient overall survival and the methylation level of each MDG. Finally, a prognosis risk score was established based on a linear combination of the regression coefficient derived from the multivariate Cox regression model (β) multiplied with the methylation level of the gene.

Results

19 ccRCC-related MDG were identified. Three MDG (NCKAP1L, EVI2A, and BATF) were further screened and integrated into a prognostic risk score model, risk score = (3.710∗methylation level of NCKAP1L) + (-3.892∗methylation level of EVI2A) + (-3.907∗methylation level of BATF). The risk model was independent from conventional clinical characteristics as a prognostic factor for ccRCC (HR = 1.221, 95% confidence interval: 1.063-1.402, and P = 0.005). The joint survival analysis showed that the gene expression and methylation levels of the prognostic genes EVI2A and BATF were significantly related with prognosis.

Conclusion

This study provided an important bioinformatics foundation for in-depth studies of ccRCC DNA methylation.

Impact of short warm ischemic time on longitudinal kidney function and survival rate after partial nephrectomy for renal cell carcinoma in patients with pre-existing chronic kidney disease stage III: A multi-institutional propensity score-matched study

PURPOSE

It remains unclear whether a short warm ischemic time (WIT) improves long-term renal function after partial nephrectomy (PN) for patients with pre-existing chronic kidney disease (CKD). We evaluated renal function after PN according to WIT duration in patients with stage III CKD.

MATERIALS AND METHODS

We identified 277 patients with stage III CKD who underwent PN during 2004-2017. Propensity score matching was used to created two matched groups of patients: Group A (WIT of <25 min) and Group B (WIT of ≥25 min). The outcomes of interest were longitudinal kidney function change, new-onset stage IV CKD (eGFR <30 mL/min/1.73 m²) and overall survival.

RESULTS

The two matched groups contained 85 patients each. The median follow-up durations were 49 months in Group A and 42 months in Group B. The median pre-treatment eGFRs were 52.4 mL/min/1.73 m² in Group A and 52.6 mL/min/1.73 m² in Group B. There were no differences in kidney function between the two groups throughout the follow-up period (P > 0.05). The 5-year rates of new-onset stage IV CKD were not significantly different between Group A and Group B (8.2% vs. 7.1%), with no significant difference in the risk of developing stage IV CKD in Group A (vs. group B, hazard ratio: 0.527, 95% confidence interval: 0.183-1.521; P = 0.236). The 5-year overall survival rates were 90.3% for Group A and 96.2% for Group B (P = 0.549).

CONCLUSIONS

A short WIT was not associated with better postoperative kidney function or survival after PN in patients with stage III CKD.

Partial vs. radical nephrectomy and the risk of all-cause mortality, cardiovascular, and nephrological outcomes

INTRODUCTION

The study's objective was to examine the effects of renal-preservation surgery on long-term mortality, cardiovascular outcomes, and renal-related outcomes.

METHODS

We performed a retrospective cohort study of all partial (n=575) and radical nephrectomies (n=882) for tumors ≤7 cm in diameter between 2002 and 2010 across three academic centers in Ontario, Canada. We linked records from provincial databases to assess patient characteristics and outcomes (median seven years' followup using retrospective data). A weighted propensity score was used to reduce confounding. The primary outcome was all-cause mortality. Secondary outcomes included hospitalization with major cardiovascular events, non-cancer related mortality, kidney cancer-related mortality, and dialysis.

RESULTS

Mean one-year postoperative estimated glomerular filtration rate (eGFR) was 71 mL/min/1.73 m² in the partial group and 52 mL/min/1.73 m² in the radical group. Partial nephrectomy was associated with a lower risk of all-cause mortality in the first five years after surgery (hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.27-0.66), which did not extend beyond five years (HR 1.01, 95% CI 0.68-1.49). Kidney cancer-related mortality was lower in the partial compared to the radical group for the first four years after surgery (HR 0.16, 95% CI 0.04-0.72). There were no significant differences between the groups for cardiovascular outcomes or non-cancer related deaths.

CONCLUSIONS

Overall survival and cancer-specific survival was reduced in radical nephrectomy patients. However, despite reduced renal function in the radical nephrectomy group, non-cancer-related death, cardiovascular events, and dialysis were not significantly different between groups. Long-term benefits of partial nephrectomy may be less than previously believed.

Robotic and open partial nephrectomy for intermediate and high complexity tumors: a matched-pairs comparison of surgical outcomes at a single institution

Objective: To compare peri-operative factors and renal function following open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) for intermediate and high complexity tumors when controlling for tumor and patient complexity.Methods: A retrospective review of 222 patients undergoing partial nephrectomy was performed. Patients with intermediate (nephrometry score NS 7-9) or high (NS 10-12) complexity tumors were matched 2:1 for RPN:OPN using NS, Charlson Comorbidity Index (CCI), and BMI. Patient demographics, peri-operative values, renal function, and complication rates were analyzed and compared.Results: Seventy-four OPN patients were matched to 148 RPN patients with no difference in patient demographics. Estimated blood loss in OPN patients was significantly higher (368.5 vs 210.5 mL, p < 0.001) as was transfusion rate (17% vs 1.6%, p < 0.001). Warm ischemia time was longer in OPN (25.5 vs 19.7 min, p = 0.001) while operative time was reduced (200.5 vs 226.5 min, p = 0.010). RPN patients had significantly shorter hospitalizations (5.3 vs 3.0 days, p < 0.001). GFR decrease after one month was not statistically significant (12.9 vs 6.6 ml/min, p = 0.130). Clavien III-V complications incidence was higher for OPN compared to RPN although not significantly (20.3% vs 10.8%, p = 0.055).Conclusion: When matching for tumor and patient complexity, RPN patients had fewer high grade post-operative complications, decreased blood loss, and shorter hospitalizations. RPN is a safe option for patients with intermediate and high complexity tumors.

Clinical Significance of Tumor Size, Pathological Invasion Sites Including Urinary Collecting System and Clinically Detected Renal Vein Thrombus as Predictors for Recurrence in pT3a Localized Renal Cell Carcinoma

The recent eighth tumor-node-metastasis (TMN) staging system classifies renal cell carcinoma (RCC) with perirenal fat invasion (PFI), renal sinus fat invasion (SFI), or renal vein invasion (RVI) as stage pT3a. However, limited data are available on whether these sites have similar prognostic value or recurrence rate. We investigated the recurrence rate based on tumor size, pathological invasion sites including urinary collecting system invasion (UCSI), and clinically detected renal vein thrombus (cd-RVT) with pT3aN0M0 RCC. We retrospectively reviewed 91 patients with pT3aN0M0 RCC who underwent surgical treatment. Patients with tumor size > 7 cm, UCSI, three invasive sites (PFI + SFI + RVI), and cd-RVT showed a significant correlation with high recurrence rates (hazard ration (HR) 2.98, p = 0.013; HR 8.86, p < 0.0001; HR 14.28, p = 0.0008; and HR 4.08, p = 0.0074, respectively). In the multivariate analysis, tumor size of >7 cm, the presence of UCSI, and cd-RVT were the independent predictors of recurrence (HR 3.39, p = 0.043, HR 7.31, p = 0.01, HR 5.06, p = 0.018, respectively). In pT3a RCC, tumor size (7 cm cut-off), UCSI, and cd-RVT may help to provide an early diagnosis of recurrence.

Limited utility of qPCR-based detection of tumor-specific circulating mRNAs in whole blood from clear cell renal cell carcinoma patients

Background

RNA sequencing data is providing abundant information about the levels of dysregulation of genes in various tumors. These data, as well as data based on older microarray technologies have enabled the identification of many genes which are upregulated in clear cell renal cell carcinoma (ccRCC) compared to matched normal tissue. Here we use RNA sequencing data in order to construct a panel of highly overexpressed genes in ccRCC so as to evaluate their RNA levels in whole blood and determine any diagnostic potential of these levels for renal cell carcinoma patients.

Methods

A bioinformatics analysis with Python was performed using TCGA, GEO and other databases to identify genes which are upregulated in ccRCC while being absent in the blood of healthy individuals. Quantitative Real Time PCR (RT-qPCR) was subsequently used to measure the levels of candidate genes in whole blood (PAX gene) of 16 ccRCC patients versus 11 healthy individuals. PCR results were processed in qBase and GraphPadPrism and statistics was done with Mann-Whitney U test.

Results

While most analyzed genes were either undetectable or did not show any dysregulated expression, two genes, CDK18 and CCND1, were paradoxically downregulated in the blood of ccRCC patients compared to healthy controls. Furthermore, LOX showed a tendency towards upregulation in metastatic ccRCC samples compared to non-metastatic.

Conclusions

This analysis illustrates the difficulty of detecting tumor regulated genes in blood and the possible influence of interference from expression in blood cells even for genes conditionally absent in normal blood. Testing in plasma samples indicated that tumor specific mRNAs were not detectable. While CDK18, CCND1 and LOX mRNAs might carry biomarker potential, this would require validation in an independent, larger patient cohort.

SEOM clinical guideline for treatment of kidney cancer (2019)

In this article, we review de state of the art on the management of renal cell carcinoma (RCC) and provide recommendations on diagnosis and treatment. Recent advances in molecular biology have allowed the subclassification of renal tumours into different histologic variants and may help to identify future prognostic and predictive factors. For patients with localized disease, surgery is the treatment of choice with nephron-sparing surgery recommended when feasible. No adjuvant therapy has demonstrated a clear benefit in overall survival. Considering the whole population of patients with advanced disease, the combination of axitinib with either pembrolizumab or avelumab increase response rate and progression-free survival, compared to sunitinib, but a longer overall survival has only been demonstrated so far with the pembrolizumab combo. For patients with IMDC intermediate and poor prognosis, nephrectomy should not be considered mandatory. In this subpopulation, the combination of ipilimumab and nivolumab has also demonstrated a superior response rate and overall survival vs. sunitinib. In patients progressing to one or two antiangiogenic tyrosine-kinase inhibitors, both nivolumab and cabozantinib in monotherapy have shown benefit in overall survival compared to everolimus. Although no clear sequence can be recommended, medical oncologists and patients should be aware of the recent advances and new strategies that improve survival and quality of life in patients with metastatic RCC.

Prognostic Significance of Cyclin D1 Expression in Renal Cell Carcinoma: a Systematic Review and Meta-analysis

Previous studies indicated that cyclin D1 shown the potential as a tumor biomarker. However, the prognostic value of cyclin D1 in renal cell carcinoma (RCC) remains controversial. This study investigated the correlation of cyclin D1 expression with the prognostic and clinicopathological features in RCC patients. We systematically searched the database of PubMed, Embase, Cochrane, and Web of Science updated on November 26, 2017. Eighteen studies with 2282 patients satisfied the inclusion criteria. Results demonstrated that cyclin D1 overexpression in RCC showed significant favorable prognostic impact on disease-free survival (DFS) (HR 0.57, 95% CI: 0.43-0.74) and disease-specific survival (DSS) (HR 0.59, 95% CI 0.41-0.85) without significant heterogeneity. In subgroup of clear cell RCC, the prognostic effect on DFS was robust and the pooled HR was 0.39 (95% CI: 0.27-0.57). However, no association between overall survival (OS) and cyclin D1 expression was observed. Stratified analysis in DFS studies by sample size, staining patterns race and metastasis status showed similar results. Otherwise, cyclin D1 overexpression predicted a reduced prevalence of high TNM stage (T3 + T4) (OR 0.63, 95% CI: 0.40-0.99), high-grade tumor (G3 + G4) (OR 0.51, 95% CI: 0.31-0.81) and large tumor size (OR 0.35, 95% CI: 0.19-0.62). Our meta-analysis indicated that cyclin D1 overexpression could predict the favorable prognosis in patients with RCC.

Health-related quality of life in localized renal masses: A matter of sparing nephrons or minimizing the incision?

PURPOSE

Longitudinal assessment of health-related quality of life (HRQoL) differences in patients with localized renal masses according to treatment strategy.

METHODS

Consecutive patients ≥ 18 years with localized renal masses treated with different approaches (open [O], laparoscopic [L], and percutaneous [P]) and modalities (radical nephrectomy [RN], nephron sparing surgery [NSS] and cryoablation [CA]). The SF-36, Functional Assessment of Cancer Therapy-Kidney Symptom Index-15 questionnaires and pain visual analog scale were completed pretreatment and at 1, 3, and 12 months posttreatment. Questionnaire results were stratified according to approach and treatment modality using a longitudinal multilevel linear regression model. Clinical patient and tumor characteristics, complications, and histopathology results were tested as confounders.

RESULTS

Ninety eight patients completed baseline and at least one follow-up questionnaires; 27.5%, 16.3%, 22.5%, 9.2%, 13.3%, and 11.2% patients received LNSS, ONSS, LRN, ORN, LCA, and PCA, respectively. Higher baseline SF-36 (3 domains) and Functional Assessment of Cancer Therapy-Kidney Symptom Index-15 scores were reported in L group compared with the O approach. Overall, HRQoL decreased at 1 month and gradually normalized to baseline level or higher at 1 year. For treatment modality at baseline, higher mean visual analog scale was observed in CA than RN group. A trend to decreased HRQoL was observed at 1 month for RN and NSS; thereafter, scores normalized to baseline levels or higher. Approach or treatment modality HRQoL did not change substantially when corrected for confounders.

CONCLUSION

At short-term, HRQoL outcome favored minimally invasive treatment of RCC; at mid-term, these advantages were no longer apparent. This suggest that in selecting the best surgical treatment for the patient, oncological outcome should be the primary consideration as both approach and treatment modality result in similar HRQoL outcomes.

Role Of Robot-Assisted Partial Nephrectomy For Renal Cell Carcinomas In The Purpose Of Nephron Sparing

Introduction

Surgery remains the standard treatment for localized renal cell carcinomas, and partial nephrectomy is considered before radical nephrectomy with the aim of preserving renal function. This study aimed to compare robot-assisted and open partial nephrectomy for the purpose of nephron sparing.

Materials and methods

We retrospectively enrolled consecutive patients who received partial nephrectomy at a single tertiary medical center from January 2008 to January 2015. Medical records and radiographic images were reviewed. We analyzed the patients’ general characteristics, underlying disease, complications, length of hospital stay, renal tumor complexity, surgery type, renal function, and specimen and tumor size. A comparison between open and robot-assisted nephrectomy groups was performed.

Results

A total of 136 patients were enrolled, with a male to female ratio of 2:3 and a mean age of 57.8 years. Of these, 71 and 65 patients received open and robot-assisted surgery, respectively. Compared with the open group, patients who underwent robot-assisted surgery were significantly younger (56.0 versus 60.1 years old), had a longer operative time (303 versus 224 min), and a lower kidney ischemic time (33.4 versus 46.9 min). Given similar tumor sizes, the tumor-to-excision ratio was significantly higher in the robot-assisted group (51.7% versus 39.8%), and the excisional volume loss (EVL) was smaller (12.7 versus 19.6 mL). Preoperative glomerular filtration rate and EVL were significant predictors of long-term renal function preservation in the multivariate analysis.

Conclusion

When performing partial nephrectomy, a robot-assisted procedure could increase the accuracy of excision without increasing the risk of positive surgical margin. Lower EVL could assist in better long-term postoperative renal function preservation.

Is there a role for stereotactic radiotherapy in the treatment of renal cell carcinoma?

Renal cell carcinoma (RCC) has traditionally been regarded as radioresistant tumor based on preclinical data and negative clinical trials using conventional fractionated radiotherapy. However, there is emerging evidence that radiotherapy delivered in few fractions with high single-fraction and total doses may overcome RCC s radioresistance. Stereotactic radiotherapy (SRT) has been successfully used in the treatment of intra- and extracranial RCC metastases showing high local control rates accompanied by low toxicity. Although surgery is standard of care for non-metastasized RCC, a significant number of patients is medically inoperable or refuse surgery. Alternative local approaches such as radiofrequency ablation or cryoablation are invasive and often restricted to small RCC, so that there is a need for alternative local therapies such as stereotactic body radiotherapy (SBRT). Recently, both retrospective and prospective trials demonstrated that SBRT is an attractive treatment alternative for localized RCC. Here, we present a comprehensive review of the published data regarding SBRT for primary RCC. The radiobiological rationale to use higher radiation doses in few fractions is discussed, and technical aspects enabling the safe delivery of SBRT despite intra- and inter-fraction motion and the proximity to organs at risk are outlined.

Transplanting kidneys from donors with small renal masses - a strategy to expand the donor pool

INTRODUCTION

Renal transplantation is the optimal treatment for end-stage renal disease, but organ demand continues to outstrip supply. The transplantation of kidneys from donors with small renal masses (SRMs) represents a potential avenue to expand the donor pool. We reviewed all published cases of transplants from donors with SRMs and we present followup data, best practices, and outline an actionable series of steps to guide the implementation of such transplants at individual centers.

METHODS

A detailed literature search of the MEDLINE/PubMed and SCOPUS databases was performed. Thirty unique data sets met inclusion criteria and described the transplantation of tumor-ectomized kidneys; nine data sets described the transplantation of contralateral kidneys from donors with SRMs.

RESULTS

A total of 147 tumorectomized kidneys have been transplanted. Pathology revealed 120 to be renal cell carcinomas (RCCs), of which 116 were stage T1a (0.3-4 cm). The mean followup time was 44.2 months (1-200). A single suspected tumor recurrence occurred in one patient nine years post-transplantation and it was managed with active surveillance. Twenty-seven kidneys have been transplanted from deceased donors with contralateral renal masses. Pathology revealed 25 to be RCCs, of which 19 were confirmed to be stage T1 (<7 cm). The mean followup time was 46.7 months (0.5-155). One recipient developed an RCC and underwent curative allograft nephrectomy.

CONCLUSIONS

Careful use of kidneys from donors with SRMs is feasible and safe, with an overall recurrence rate of less than 1.5%. The use of such kidneys could help alleviate the organ shortage crisis.

Management of kidney cancer patients: 2018 guidelines of the Italian Medical Oncology Association (AIOM)

In the past two decades, the treatment landscape for patients with metastatic renal cell carcinoma has significantly changed thanks to the approval of several targeted molecular therapies (VEGF and mTOR inhibitors) and recently immune-checkpoint inhibitors. The Italian Association of Medical Oncology (AIOM) Renal Cell Cancer (RCC) Guidelines Panel has developed clinical guidelines to provide evidence-based information and recommendations to oncologists, urologists and all professionals involved in the management of patients with renal cell cancer.

Novel technique: direct access partial nephrectomy approach through a transperitoneal working space (Roskilde technique)

Objectives: To describe a direct access partial nephrectomy technique through a transperitoneal working space (Roskilde technique).Materials and methods: Prospective single-center descriptive study between April 2015 and January 2017. The surgical outcomes are evaluated according to the Trifecta criteria (negative margins, warm ischemia time < 20 min and a Clavien-Dindo complication score < 3).Surgical procedure: The same access to the transperitoneal cavity as in a Standard transperitoneal Partial Nephrectomy was used. A direct access was established by incision of the peritoneum directly onto the renal fascia. The renal vessels and tumor were identified and the tumor removed with standard technique. The perinephric fat and peritoneum were then closed with a running suture.Results: In total, 122 patients underwent the Roskilde technique. The mean age was 62.2 years, the median Padua score was 12 (IQR = 9-12) and the median tumor size was 32 mm (IQR = 12-90). The median operative time was 101 min (IQR = 90-125). The trifecta achievement criteria goal was achieved in 116/122 (95%), with a median warm ischemia time of 8 min (IQR = 0-12).Conclusions: The Roskilde technique is safe and feasible. It can be performed on complex renal masses, and it seems to result in short operative times and high Trifecta achievement.Trial registration: None.

Differential diagnostic ability of 18F-FDG PET/CT radiomics features between renal cell carcinoma and renal lymphoma

BACKGROUND

The aim of this study is to determine the differential diagnostic value of texture parameters of PET/CT on renal cell carcinoma and renal lymphoma.

METHODS

Twenty renal lymphoma and 18 renal cell carcinoma (RCC) patients were analyzed in this study. The pathological information and basic characteristics were extracted from the electronic medical record system of our hospital. We used LIFEx package to extract data from the radiomics images. Receiver operating characteristic analysis and binary logistic regression analysis was applied in determining the diagnostic accuracy of texture parameters as well as the synthetic parameter, of which the sensitivity and specificity was improved.

RESULTS

There were 14 (two in Histogram, two in Grey Level Co-occurrence Matrix, five in Grey-Level Run Length Matrix, five in Grey-Level Zone Length Matrix) out of the texture parameters showing an area under the curve (AUC) >0.7 and P<0.05. Synthesized parameters of each section showed even higher differentiation ability, with AUC varying from 0.725 to 1.000.

CONCLUSIONS

Texture analysis of ¹⁸F-FDG PET/CT could effectively differentiate between RCCs and renal lymphomas.

National Norwegian Practice Patterns for Surgical Treatment of Kidney Cancer Tumors ≤7cm: Adherence to Changes in Guidelines May Improve Overall Survival

BACKGROUND

Guidelines on surgical treatment for kidney cancer (KC) have changed over the last 10 yr. We present population-based data for patients with KC tumors ≤7cm from 2008 to 2013 to investigate whether surgical practice in Norway has changed according to guidelines.

OBJECTIVE

To assess the predictors of treatment and survival after KC surgery.

DESIGN, SETTING, AND PARTICIPANTS

We identified all surgically treated KC patients with tumors ≤7cm without metastasis diagnosed during 2008-2013 (2420 patients) from the Cancer Registry of Norway.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships with outcomes were analyzed using joinpoint regression, multivariate logistic regression, Kaplan-Meier survival estimates, Cox regression, relative survival (RS), and competing-risk analyses.

RESULTS AND LIMITATIONS

The mean follow-up was 5.2 yr. There was a 28% increase in the number of patients undergoing surgical treatment over the study period. Joinpoint regression revealed a significant annual increase in partial nephrectomy (PN) and a small reduction in radical nephrectomy (RN). PN increased from 43% to 66% for tumors ≤4cm and from 10% to 18% for tumors of 4.1-7cm. Minimally invasive (MI) RN increased from 53% to 72% and MI PN from 25% to 64%, of which 55% of procedures were performed with robotic assistance in 2013. The geographical distribution of treatment approaches differed significantly. Both PN and MI approaches were more frequent in high-volume hospitals. Cox regression analysis revealed that PN, age, and Fuhrman grade and stage were independent predictors of survival. There were no significant differences in cancer-specific survival (p=0.8). The 5-yr RS for T1a disease was higher after PN than after RN.

CONCLUSIONS

The rate of PN for tumors ≤7cm increased in the 6-yr study period. MI approaches increased for both RN and PN. This treatment shift coincides with the new guideline recommendations in 2010. The possible better survival for patients undergoing PN compared to RN indicates the importance of following evidence-based guidelines.

PATIENT SUMMARY

The use of partial nephrectomy and minimally invasive surgery for kidney cancer tumors increased in Norway from 2008 to 2013 according to population-based data, coinciding with guideline changes. The study illustrate that adherence to guidelines may improve patient outcomes.

Predictive factors for the development of renal insufficiency following partial nephrectomy and subsequent renal function recovery: A multicenter retrospective study

Patients who undergo partial nephrectomy (PN) may exhibit renal function insufficiency, and a subset of these patients achieves renal function recovery. We evaluated the predictors of renal insufficiency and subsequent renal function recovery following PN. Data on 393 patients who underwent PN for solid renal tumors between March 2001 and November 2013, obtained from 6 institutions, were retrospectively reviewed. Renal insufficiency was defined as new onset of chronic kidney disease stage ≥3 postoperatively on the second of 2 consecutive tests. Renal function recovery was defined as an estimated glomerular filtration rate ≥60 ml/minute/1.73 m following renal insufficiency. Tumor complexity was stratified according to the RENAL classification system. The median (interquartile range) age, tumor size, and follow-up period were 53 (45-63) years, 2.6 (1.9-3.8) cm, and 36 (12-48) months, respectively. Tumors were of low complexity in 258/393 (65.6%) of cases. Renal insufficiency developed in 54/393 (13.5%) patients, in which age ≥60 years and preoperative creatinine ≥1.1 mg/ml were independent predictors. Tumor complexity, clamp type, and operative method were not significant prognostic factors. Among patients with newly developed renal insufficiency, 18/54 (33.3%) patients exhibited renal function recovery within a median period of 18 months, of which preoperative creatinine <1.1 mg/ml was an independent predictor. Age ≥60 years and preoperative creatinine ≥1.1 mg/ml were risk factors for renal insufficiency following PN. Patients with renal insufficiency whose preoperative creatinine was <1.1 mg/ml were likely to have renal function recovery.

European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update

CONTEXT

The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.

OBJECTIVE

To provide an updated RCC guideline based on standardised methodology including systematic reviews, which is robust, transparent, reproducible, and reliable.

EVIDENCE ACQUISITION

For the 2019 update, evidence synthesis was undertaken based on a comprehensive and structured literature assessment for new and relevant data. Where necessary, formal systematic reviews adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were undertaken. Relevant databases (Medline, Cochrane Libraries, trial registries, conference proceedings) were searched until June 2018, including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm, systematic reviews, and meta-analyses. Where relevant, risk of bias (RoB) assessment, and qualitative and quantitative syntheses of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Clinical practice recommendations were developed and issued based on the modified GRADE framework.

EVIDENCE SYNTHESIS

All chapters of the RCC guidelines were updated based on a structured literature assessment, for prioritised topics based on the availability of robust data. For RCTs, RoB was low across studies. For most non-RCTs, clinical and methodological heterogeneity prevented pooling of data. The majority of included studies were retrospective with matched or unmatched cohorts, based on single- or multi-institutional data or national registries. The exception was for the treatment of metastatic RCC, for which there were several large RCTs, resulting in recommendations based on higher levels of evidence.

CONCLUSIONS

The 2019 RCC guidelines have been updated by the multidisciplinary panel using the highest methodological standards. These guidelines provide the most reliable contemporary evidence base for the management of RCC in 2019.

PATIENT SUMMARY

The European Association of Urology Renal Cell Carcinoma Guideline Panel has thoroughly evaluated the available research data on kidney cancer to establish international standards for the care of kidney cancer patients.

Performing an early systematic Doppler-ultrasound fails to prevent hemorrhagic complications after complex partial nephrectomy

Background:

The aim of this work was to assess the clinical relevance of a systematic postoperative Doppler-ultrasound (DU) after complex partial nephrectomy (PN).

Materials and methods:

All patients who underwent open, laparoscopic or robotic PN from 2014 to 2017 at our institution were included. Postoperative hemorrhagic complications (HCs) were defined as the occurrence of blood transfusion, hemorrhagic shock, arterial embolization, or re-hospitalization for hematoma. DU was systematically performed between post-op day 4 and 7 for every complex tumor (RENAL score ⩾ 7). DU was considered positive in the presence of pseudoaneurysm (PA) or arteriovenous fistula (AVF).

Results:

Among 194 patients, 117 underwent DU (60.3%). We reported 22 HCs (11.3%) requiring 8 selective embolization procedures (4.1%). HCs occurred during the hospital stay in 17 patients (77.3%), thus directly diagnosed on a computed tomography scan. Among the five patients (22.7%) with HC occurring after hospital discharge, between day 7 to 15, four had a previously negative systematic DU. Overall, systematic DU was positive in only five patients (4.3%) with only one patient of 194 (0.5%) undergoing preventive embolization of a PA-AVF. The negative predictive values (NPVs) and positive predictive values of DU were respectively 96.5% and 5%, with 20% sensitivity and 96.5% specificity.

Conclusions:

Our results may suggest offering systematic DU in patients under antiplatelet therapies, with high tumor size (>T1b), or early postoperative hemoglobin variations. A high NPV of DU might be counterbalanced by its low sensibility. Since all secondary HCs occurred between postoperative day 7 to 15, our results may suggest differing DU in selected cases.

Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer

Background

Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial.

We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3.

Methods

Data of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function.

Results

IT was identified as significant risk factor for short-term relative changes in eGFR (ß = − 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = − 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = − 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = − 0.20) and long-term (ß = − 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89).

Conclusions

IT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.

Caspase 3 as a Novel Marker to Distinguish Chromophobe Renal Cell Carcinoma from Oncocytoma

Despite advances in our understanding of the biology of chromophobe renal cell carcinoma (ChRCC) and renal oncocytoma (RO), the differential diagnosis among these tumors remains one of the most problematic in renal pathology. Today, CK7 is the most recommended marker to distinguish these entities, however it appears insufficiently accurate by itself. This study aimed to find an easily accessible IHC stain that might out-compete CK7 in this field. Expressions of CK7, cyclin D1, p16, survivin, CD138, Ki-67 and caspase 3 (CASP3) were analyzed in a total of 27 cases (20 ROs and 7 ChRCCs). Immunoreactivity was assessed based on a combined score of the extent and intensity of staining. Compared to RO, a higher percentage of the total ChRCCs stained positive for CK7 (67% vs. 22%, respectively) and CASP3 (86% vs. 25%) (P < 0.005). The differences in staining with cyclin D1, p16, survivin, CD138 and Ki-67 turned out to be statistically insignificant in differentiating ChRCC from RO. CASP3 is a promising marker in distinguishing ChRCC from RO and may represent an alternative for CK7. Cyclin D1, p16, survivin, CD138 and Ki-67 cannot be used to distinguish these neoplasms.

Non-ischemic laparoscopic partial nephrectomy using 1318-nm diode laser for small exophytic renal tumors

Purpose

Warm ischemia (WI) and bleeding constitute the main challenges for surgeons during laparoscopic partial nephrectomy (LPN). Current literature on the use of lasers for cutting and coagulation remains scarce and with small cohorts. We present the largest case series to date of non-ischemic LPN using a diode laser for small exophytic renal tumors.

Methods

We retrospectively evaluated 29 patients with clinically localized exophytic renal tumors who underwent non-ischemic laser–assisted LPN with a 1318-nm wavelength diode laser. We started applying the laser 5 mm beyond the visible tumor margin, 5 mm away from the tissue in a non-contact fashion for coagulation and in direct contact with the parenchymal tissue for cutting. 

Results

The renal vessels were not clamped, resulting in a WIT (warm ischaemic time) of 0 min, except for one case that required warm ischemia for 12 min and parenchymal sutures. No transfusion was needed, with a mean Hemoglobin drop of 1,4 mg/dl and no postoperative complications. The eGFR did not significantly change by 6 months. Histologically, the majority of lesions (n = 22/29) were renal-cell carcinoma stage pT1a. The majority of malignant lesions (n = 13/22) had a negative margin. However, margin interpretation was difficult in 9 cases due to charring of the tumor base. A mean follow-up of 1.8 years revealed no tumor recurrence. The mean tumor diameter was 19.4 mm.

Conclusion

The 1318-nm diode laser has the advantages of excellent cutting and sealing properties when applied to small vessels in the renal parenchyma, reducing the need for parenchymal sutures. However, excessive smoke, charring of the surgical margin, and inability to seal large blood vessels are encountered with this technique.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in Renal-Cell Carcinoma Incidence and Mortality in the United States in the Last 2 Decades: A SEER-Based Study

BACKGROUND

Renal-cell carcinoma (RCC) is one of the common malignancies in the United States. RCC incidence and mortality have been changing for many reasons. We performed a thorough investigation of incidence and mortality trends of RCC in the United States using the cell Surveillance, Epidemiology, and End Results (SEER) database.

PATIENTS AND METHODS

The 13 SEER registries were accessed for RCC cases diagnosed between 1992 and 2015. Incidence and mortality were calculated by demographic and tumor characteristics. We calculated annual percentage changes of these rates. Rates were expressed as 100,000 person-years.

RESULTS

A total of 104,584 RCC cases were reviewed, with 47,561 deaths. The overall incidence was 11.281 per 100,000 person-years. Incidence increased by 2.421% per year (95% confidence interval, 2.096, 2.747; P < .001) but later became stable since 2008. However, the incidence of clear-cell subtype continued to increase (1.449%; 95% confidence interval, 0.216, 2.697; P = .024). RCC overall mortality rates have been declining since 2001. However, mortality associated with distant RCC only started to decrease in 2012, with an annual percentage change of 18.270% (95% confidence interval, -28.775, -6.215; P = .006).

CONCLUSION

Despite an overall increase in the incidence of RCC, there has been a recent plateau in RCC incidence rates with a significant decrease in mortality.

Salinomycin suppresses cancer cell stemness and attenuates TGF-β-induced epithelial-mesenchymal transition of renal cell carcinoma cells

Metastatic Renal cell carcinoma (RCC) remains a difficult oncologic challenge. Salinomycin is a monocarboxylic polyether antibiotic, which has been proved to possess anti-tumor activities in multiple types of cancer cells. However, its effects on RCC cells remains unclear. In our study, salinomycin could inhibit the proliferation and viability of RCC cell lines 786-O and ACHN. The TUNEL assay revealed that treatment with salinomycin induced DNA breaking in RCC cells. Consistently, Western blotting showed up-regulation of pro-apoptotic biomarkers (cleaved caspase3/9 and cleaved PARP1) and down-regulation of anti-apoptotic biomarker (survivin) in RCC cells after salinomycin treatment, suggesting that salinomycin could induce RCC cell apoptosis. salinomycin treatment also suppressed the sphere formation ability of RCC cells and decreased the expressions of CD105, ALDH1 and CD44, biomarkers for reflecting the stemness of RCC cells. salinomycin treatment effectively down-regulated SMO and Gli1, two key proteins in Hedghog signaling pathway, in a dose-dependent manner. Moreover, salinomycin could suppress the invasion and migration of RCC cells in the presence of TGF-β1, as observed in wound-healing and Transwell assays. salinomycin treatment attenuated TGF-β1-induced epithelial-mesenchymal transition (EMT), as evidenced by its ability to increase E-cadherin expression and decrease N-cadherin, Snail and MMP-2 expressions in RCC cells. Finally, salinomycin inhibited the tumorigenecity of RCC cells in vivo. Our study provides the evidence that salinomycin possess multiple anti-tumor activities against RCC, as it, in particular, suppressed the cancer stem cell properties and attenuated TGF-β-induced EMT. Therefore, it may serve as a potentially therapeutic candidate for metastatic RCC and improve the prognosis of RCC patients.

Accurate Risk Assessment of Patients with Pathologic T3aN0M0 Renal Cell Carcinoma

To develop a more precise risk-stratification system by investigating the prognostic impact of tumor growth within fatty tissues surrounding the kidney and/or renal vein. We conducted a retrospective review of the medical records of 211 patients with a pathologic diagnosis of T3aN0M0RCC among 4,483 renal cell carcinoma (RCC) patients from February 1988 to December 2015 according to the number of T3a pathologies—extrarenal fat invasion (EFI) and/or renal venous invasion (RVI). During a mean follow-up duration of 38.8 months, the patients with both pathologies (EFI + RVI) had lower recurrence free survival (RFS) rate than those with only a single pathology (p = 0.001). Using multivariable Cox regression analysis, the presence of both factors was shown to be an independent predictor of RFS (HR = 1.964, p = 0.032); cancer specific survival rate was not different among patients with EFI and/or RVI. Patients with pathologic T3aN0M0 RCC presenting with both EFI and RVI were at an increased risk of recurrence following nephrectomy. Therefore, pathologic T3a RCC could be sub-divided into those with favorable and unfavorable disease according to presence of EFI and/or RVI pathologies.

Endoscopic Robot-assisted Simple Enucleation Versus Laparoscopic Simple Enucleation With Single-layer Renorrhaphy in Localized Renal Tumors: A Propensity Score-matched Analysis From a High-volume Centre

OBJECTIVE

To compare perioperative results and early oncological outcomes of endoscopic robot-assisted simple enucleation (ERASE) and laparoscopic simple enucleation (LSE) by using a propensity score-matched analysis.

METHODS

We evaluated 383 patients who underwent transperitoneal ERASE or LSE for renal tumors from November 2012 to October 2016. Propensity score matching was performed on age, gender, body mass index, Eastern Cooperative Oncology Group score, tumor side and size, preoperative estimated GFR and PADUA score.

RESULTS

In total, 278 and 105 patients underwent ERASE and LSE, respectively. The PADUA score was ≥10 for 61 (21.9%) and 13 (12.4%), respectively (P = .034). After matching, mean operative time and warm ischemic time were significantly lower with ERASE than LSE (171.9 vs 188.2 minutes; P = 0.016 and 20.9 vs 24.2 minutes; P = .001). The estimated mean blood loss was similar (167.7 vs 183.3 mL; P = .315). The conversion rate to open surgery or radical nephrectomy was similar with ERASE and LSE (1.0% vs 5.0%, P = .214) and the rate of intraoperative complications was lower (2.0% vs 8.9%, P = .030). The overall incidence of positive surgical margins was similar (P = .614). The median follow-up was less for ERASE than LSE patients (22 vs 38 months). Recurrence did not differ between the 2 groups: 2 ERASE cases (2.0%) versus 4 LSE cases (4.0%) (P = .679).

CONCLUSION

ERASE is a safe and acceptable alternative to LSE. ERASE appears to confer shorter operative time, shorter warm ischemic time and lower rate of intraoperative complication.

The prognostic value and clinicopathological features of sarcomatoid differentiation in patients with renal cell carcinoma: a systematic review and meta-analysis

Background and purpose

Numerous studies have demonstrated that sarcomatoid differentiation is linked to the risk of renal cell carcinoma (RCC). However, its actual clinicopathological impact remains inconclusive. Therefore, we undertook a meta-analysis to evaluate the pathologic and prognostic impacts of sarcomatoid differentiation in patients with RCC by assessing cancer-specific survival, overall survival, recurrence-free survival, progression-free survival, and cancer-specific mortality.

Materials and methods

In accordance with the preferred reporting items for systematic reviews and meta-analysis statement, relevant studies were collected systematically from PubMed, Embase, and Web of Science to identify relevant studies published prior to January 2018. The pooled effects (hazard ratios, odds ratios, and standard mean differences) and 95% confidence intervals were calculated to investigate the association of sarcomatoid differentiation with cancer prognosis and clinicopathological features.

Results

Thirty-five studies (N=11,261 patients [n=59-1,437 per study]) on RCC were included in this meta-analysis. Overall, the pooled analysis suggested that sarcomatoid differentiation was significantly associated with unfavorable cancer-specific survival (HR=1.46, 95% CI: 1.26-1.70, p<0.001), overall survival (HR=1.59, 95% CI: 1.42-1.78, p<0.001), progression-free survival (HR=1.61, 95% CI: 1.35-1.91, p<0.001), recurrence-free survival (HR=1.60, 95% CI: 1.29-1.99, p<0.001), and cancer-specific mortality (HR=2.36, 95% CI: 1.64-3.41, p<0.001) in patients with RCC. Moreover, sarcomatoid differentiation was closely correlated with TNM stage (III/IV vs I/II: OR=1.84, 95% CI: 1.12-3.03, p=0.017), Fuhrman grade (III/IV vs I/II: OR=8.37, 95% CI: 2.92-24.00, p<0.001), lymph node involvement (N1 vs N0: OR=1.88, 95% CI: 1.08-3.28, p=0.026), and pathological types (clear cell RCC-only vs mixed type: OR=0.48, 95% CI: 0.29-0.80, p=0.005), but was not related to gender (male vs female, OR=0.86, 95% CI: 0.58-1.28, p=0.464) and average age (SMD=-0.02, 95% CI: -0.20-0.17, p=0.868).

Conclusion

This study suggests that sarcomatoid differentiation in histopathology is associated with poor clinical outcome and advanced clinicopathological features in RCC and could serve as a poor prognostic factor for RCC patients.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

High IDO-1 expression in tumor endothelial cells is associated with response to immunotherapy in metastatic renal cell carcinoma

Nivolumab belongs to the standard therapy in the second‐line setting of metastatic renal cell carcinoma (mRCC). Although deep and long‐lasting responses are seen in some patients, the majority of patients will further progress. PD‐L1 is still under critical evaluation as a predictive biomarker. Thus, more accurate biomarkers are clearly warranted. Here, we investigated for the first time the predictive role of IDO‐1, a negative immune‐regulatory molecule, on clear cell RCC tissues of 15 patients undergoing nivolumab therapy. IDO‐1 and other immune inhibitory molecules (PD‐L1, PD‐L2, FOXP3) as well as immune cell subsets (CD3, CD4 and CD8) were measured on formalin‐fixed, paraffin‐embedded sections of RCC specimens by immunohistochemistry. IDO‐1 was predominantly expressed in tumor endothelial cells, and was totally absent from tumor cells itself. IDO‐1 overexpression (>10%) could be detected more frequently in responders (100%, n = 6/6) compared to non‐responders (33.3%, n = 3/9; P = .028), resulting in a better progression‐free survival during immunotherapy (IDO‐1 ≤ 10% vs >10%, median: 3.5 vs not estimated (NE) months, P = .01 by log‐rank test). In addition, IDO‐1 was positively correlated with CD8⁺ T cell expression (r_s = .691, P = .006). PD‐L1 expression on tumor cells was negative in 13 (86.7%) of 15 patients, irrespective of therapeutic response (responders vs non‐responders: 83.3% vs 88.9%). No differences were noticed in the PD‐L1 expression on tumor‐infiltrating immune cells (PD‐L1 < 1% in 66.7% of both responders and non‐responders). In contrast to PD‐L1, these results suggest that IDO‐1 may be a more promising predictive biomarker for response to immune‐based cancer therapy in mRCC.