Active surveillance of small renal masses offers short-term oncological efficacy equivalent to radical and partial nephrectomy

Sociodemographic disparities in the treatment of small renal masses

OBJECTIVE

To examine the presence of specific sociodemographic disparities in the treatment of individuals with small renal masses.

PATIENTS AND METHODS

Patients diagnosed with pT1aN0M0 renal cell carcinoma (RCC) were identified from the Surveillance, Epidemiology, and End Results database (years 1988-2008). Treatment type was stratified into non-surgical and surgical management and the group of patients who underwent surgical intervention was further stratified into those who underwent partial nephrectomy (PN) and those who underwent radical nephrectomy (RN). The main variables of interest were race and gender, as well as family income and poverty and education levels. Temporal trend analyses and logistic regression models were performed.

RESULTS

Of 26,468 patients with T1aN0M0 RCC, 2797 (10.6%) were non-surgically managed and 23,671 (89.4%) underwent surgery. Of the latter, 14,705 (62.1%) underwent RN and 8966 (37.9%) PN. In multivariable analyses, black patients were 23% more likely to be non-surgically managed than other ethnic groups, and if surgically managed, were 20% less likely to undergo PN (both P ≤ 0.007). Men were 19% more likely than women to be non-surgically managed, but remained 14% more likely to receive a PN (both P < 0.001). Treatment disparities according to income, education and poverty level were recorded. Poverty (odds ratio [OR]: 1.002) and education (OR: 0.998) proxies emerged as important determinants of non-surgical management, whereas income (OR: 1.08, all P ≤ 0.02) was a determinant of PN.

CONCLUSIONS

Social inequalities regarding access to treatment remain prevalent among patients diagnosed with small renal masses. The persistence of such a phenomenon is a concerning trend which merits further investigation.

Clinical Outcome of Small Renal Cell Carcinoma after Delayed Surgery versus Immediate Surgery

Background: This study was undertaken to investigate the growth rate and clinical outcome of patients with a small renal mass (SRM) after delayed surgery versus immediate surgery.

Methods: We reviewed the clinical records of 328 patients with SRM ≦ 4cm at diagnosis, who underwent delayed or immediate surgical intervention from January 2000 to December 2011. Radiographic evaluation using CT scan and MRI were performed at least every 6 months and the tumor size was determined at least twice in the delayed surgery group.

Results: A total of 292 RCC patients with pT1aN0M0 were identified; among them, 32 patients had been managed with delayed surgery intervention. No statistically significant difference was observed in overall survival rate (OSR) and cancer recurrence-free rate (CRFR). But cancer-specific survival rate (CSSR) was significantly lower in the delayed surgery group (p=0.0002).

Conclusions: The overall survival rate of delayed surgery was not inferior compared with that after immediate surgery. Delayed surgery intervention for SRMs is a treatment option in the current study.

Clinical outcome of incidentally discovered small renal cell carcinoma after delayed surgery

Background

This study was undertaken to investigate the growth rate and clinical outcome of patients with a small renal mass (SRM) after delayed surgery.

Methods

We reviewed the clinical records of 34 patients with SRMs ≤ 4 cm at diagnosis, who underwent delayed surgical intervention during surveillance from January 2000 to December 2011. Radiographic evaluations using computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed at least every 6 months, and the tumor size was determined at least twice.

Results

The mean follow-up time was 26.6 ± 18.6 months and mean tumor doubling time was 23.4 ± 16.0 months. Histopathological analysis revealed that 32 of the 34 patients were malignant in pT1aN0M0. Only one patient showed tumor recurrence, who subsequently died due to tumor progression.

Conclusion

The growth rate of the small renal mass was slow in the majority of our patients. Delayed intervention does not have a detrimental effect on cancer-specific outcomes.

Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution

PURPOSE

To review the intermediate term oncologic and functional outcomes after the surgical management of bilateral renal masses (BRM).

MATERIALS AND METHODS

After obtaining Institutional Review Board approval, the Tulane renal surgery database (n = 890 patients) was queried for patients presenting with synchronous bilateral enhancing renal masses (n = 30 renal units). We performed a retrospective chart review evaluating oncologic and functional outcomes, specifically with respect to local recurrence and metastatic disease. We also reviewed changes in glomerular filtration rates.

RESULTS

Of the 30 renal units were operated on for BRM concerning for renal cell carcinoma, 25 kidneys harbored malignancy (83.3 %). The average tumor size was 3.35 cm. Treatment of each kidney was staged; average time period to treatment of contralateral side was 3.5 months. Estimated GFR (eGFR) for these same pre-operative patients was 59 ml/min/1.73 m(2) (range 25-89). The average creatinine after treatment of one kidney was available for all patients and was 1.5 (range 0.7-2.8), with an average eGFR of 51.8 (range 29-87). The average creatinine after the second operation for these same 15 patients was 1.79 (range 0.9-3.7) with an average GFR of 41.9 (range 17-78). No patient had to undergo temporary dialysis. An average change in GFR after the second, contralateral procedure on the kidney was 17.07 mg/dl. Average oncologic follow-up was 608 days. Excluding two patients who presented with metastatic disease, the average recurrence-free survival was 92.8 %.

CONCLUSION

Our data continue to underscore the need for nephron sparing surgery (NSS), especially in the setting of BRM. The average decline in GFR of 28.9 % after treatment of both kidneys and renal cell carcinoma recurrence-free rate of 92.3 % further support the efficacy of NSS in these patients.

Long-term oncologic outcomes after radiofrequency ablation for T1 renal cell carcinoma

BACKGROUND

Radiofrequency ablation (RFA) of renal cell carcinoma (RCC) is used to obtain local control of small renal masses. However, available long-term oncologic outcomes for RFA of RCC are limited by small numbers, short follow-up, and lack of pathologic diagnoses.

OBJECTIVE

To assess the oncologic effectiveness of RFA for the treatment of biopsy-proven RCC.

DESIGN, SETTING, AND PARTICIPANTS

Exclusion criteria included prior RCC or metastatic RCC, familial syndromes, or T2 RCC. We retrospectively reviewed long-term oncologic outcomes for 185 patients with sporadic T1 RCC. Median follow-up was 6.43 yr (interquartile range [IQR]: 5.3-7.7).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The chi-square test and Wilcoxon rank-sum tests were used to compare proportions and medians, respectively. Disease-specific survival and overall survival (OS) were calculated using Kaplan-Meier analysis, then stratified by tumor stage, and comparisons were made using log-rank analysis. The 5-yr disease-free survival (DFS) and OS rates are reported. A p value <0.05 was considered statistically significant.

RESULTS AND LIMITATIONS

Median tumor size was 3 cm (IQR: 2.1-3.9 cm). Tumor stage was T1a: 143 (77.3%) or T1b: 42 (22.7%). Twenty-four patients (13%) were retreated for residual disease. There were 12 local recurrences (6.5%), 6 recurrences in T1a disease (4.2%) and 6 in T1b disease (14.3%) (p=0.0196). Median time to recurrence was 2.5 yr. Local salvage RFA was performed in six patients, of whom five remain disease free at 3.8-yr median follow-up. Tumor stage was the only significant predictor of DFS on multivariate analysis. At last follow-up, 164 patients (88.6%) were disease free (T1a: n=132 [92.3%]; T1b: n=32 [76.2%]; p=0.0038). OS was similar regardless of stage (p=0.06). Five patients developed metachronous renal tumors (2.7%). Four patients developed extrarenal metastases (2.2%), three of whom died of metastatic RCC (1.6%).

CONCLUSIONS

In poor surgical candidates, RFA results in durable local control and low risk of recurrence in T1a RCC. Higher stage correlates with a decreased disease-free survival. Long-term surveillance is necessary following RFA. Patient selection based on tumor characteristics, comorbid disease, and life expectancy is of paramount importance.