The evolving presentation of renal carcinoma in the United States: trends from the Surveillance, Epidemiology, and End Results program

Renal clear cell carcinoma: diffusion tensor imaging diagnostic accuracy and correlations with clinical and histopathological factors

AIM

To investigate whether diffusion tensor imaging (DTI) can be used to assess renal clinical histopathology, including the nuclear grade (NG), cell density (CD), and the presence of ki-67.

MATERIALS AND METHODS

Thirty patients were enrolled in the study and were confirmed at surgical histopathology to have clear cell renal cell carcinoma (CCRCC). For DTI, a coronal echo-planar imaging sequence was performed (1400 ms repetition time, 76 ms echo time, diffusion direction=6, number of excitations=4; b=0 and 800 s/mm², 6 mm section thickness with no intersection gap). CD and the presence of ki-67 were compared between the different NGs. Correlations between apparent diffusion coefficients (ADCs), E1, fractional anisotropy (FA), CD, and ki-67 were evaluated.

RESULTS

ADC, E1, and FA values are important tools used to identify NG. The cut-off values were 1.003×10^-3 mm²/s, 1.277×10^-3 mm²/s, and 0.218 mm²/s, respectively. The difference between high- and low-grade CD was significant (t=-4.50, p<0.05). Similarly, a significant difference between high and low grade was also found in ki-67 (t=-4.03, p<0.05). ADC, E1, and FA values were decreased with increased CD; a significant negative correlation was found (r=-0.796, -0.865, and -0.996, respectively). Significant negative correlations between ADC, E1, and FA values, and ki-67 were found (r=-0.739, -0.826, and -0.876, respectively).

CONCLUSIONS

DTI can be used to non-invasively assess CCRCC.

Englerin A induces an acute inflammatory response and reveals lipid metabolism and ER stress as targetable vulnerabilities in renal cell carcinoma

Renal cell carcinoma (RCC) is among the top ten most common forms of cancer and is the most common malignancy of the kidney. Clear cell renal carcinoma (cc-RCC), the most common type of RCC, is one of the most refractory cancers with an incidence that is on the rise. Screening of plant extracts in search of new anti-cancer agents resulted in the discovery of englerin A, a guaiane sesquiterpene with potent cytotoxicity against renal cancer cells and a small subset of other cancer cells. Though a few cellular targets have been identified for englerin A, it is still not clear what mechanisms account for the cytotoxicity of englerin A in RCC, which occurs at concentrations well below those used to engage the targets previously identified. Unlike any prior study, the current study used a systems biology approach to explore the mechanism(s) of action of englerin A. Metabolomics analyses indicated that englerin A profoundly altered lipid metabolism by 24 h in cc-RCC cell lines and generated significant levels of ceramides that were highly toxic to these cells. Microarray analyses determined that englerin A induced ER stress signaling and an acute inflammatory response, which was confirmed by quantitative PCR and Western Blot analyses. Additionally, fluorescence confocal microscopy revealed that englerin A at 25 nM disrupted the morphology of the ER confirming the deleterious effect of englerin A on the ER. Collectively, our findings suggest that cc-RCC is highly sensitive to disruptions in lipid metabolism and ER stress and that these vulnerabilities can be targeted for the treatment of cc-RCC and possibly other lipid storing cancers. Furthermore, our results suggest that ceramides may be a mediator of some of the actions of englerin A. Lastly, the acute inflammatory response induced by englerin A may mediate anti-tumor immunity.

Incremental Expression of 14-3-3 Protein Beta/Alpha in Urine Correlates with Advanced Stage and Poor Survival in Patients with Clear Cell Renal Cell Carcinoma

We investigated the urinary levels of 14-3-3 protein beta/alpha to evaluate their diagnostic significance with regard to clear cell renal cell carcinoma (ccRCC) and angiomyolipoma (AML). Urine samples from 91 patients with ccRCC, 16 patients with AML and 24 healthy volunteers were assessed. We used an enzyme-linked immunosorbent assay (ELISA) to quantify 14-3-3 protein beta/alpha levels in urine. Values were higher in patients with ccRCC than in those with AML and in healthy volunteers. High levels were associated with pathologic stage, lymph node status, distant metastasis and poor survival. Urinary levels of 14-3-3 protein beta/alpha were significantly increased in patients with small-sized carcinoma, irrespective of being less than 4.0 cm and 2.0 cm, compared with levels in patients with AML. This study is the first to report that increased expression of 14-3- 3 protein beta/alpha in urine is associated with advanced stage and poor survival in patients with ccRCC. In addition, urinary 14-3-3 protein beta/alpha may differentiate AML from RCC, even when small sized. These results suggest that examination of urinary 14-3-3 protein beta/alpha could serve as a diagnostic and prognostic marker in patients with ccRCC.

Mutations in the Mitochondrial ND1 Gene Are Associated with Postoperative Prognosis of Localized Renal Cell Carcinoma

We analyzed mutations in the mitochondrial ND1 gene to determine their association with clinicopathological parameters and postoperative recurrence of renal cell carcinoma (RCC) in Japanese patients. Among 62 RCC cases for which tumor pathology was confirmed by histopathology, ND1 sequencing revealed the presence of 30 mutation sites in 19 cases. Most mutations were heteroplasmic, with 16 of 19 cases harboring one or more heteroplasmic sites. Additionally, 12 sites had amino acid mutations, which were frequent in 10 of the cases. The 5-year recurrence-free survival (RFS) rate was significantly worse in patients with tumors >40 mm in diameter (p = 0.0091), pathological T (pT) stage ≥3 (p = 0.0122), Fuhrman nuclear atypia grade ≥III (p = 0.0070), and ND1 mutations (p = 0.0006). Multivariate analysis using these factors revealed that mutations in ND1 were significantly associated with the 5-year RFS rate (p = 0.0044). These results suggest a strong correlation between the presence of ND1 mutations in cancer tissue and postoperative recurrence of localized RCC in Japanese patients.

Update on active surveillance for clinical T1 renal tumors

PURPOSE OF REVIEW

The purpose is to discuss current data on the utilization and outcomes of active surveillance for T1a renal masses. Specifically, to address which patients are optimal for active surveillance and how their outcomes differ from those undergoing immediate treatment.

RECENT FINDINGS

Although nephron sparing surgery is the standard of care for small renal masses (SRMs), active surveillance is becoming a more popular intervention given the results of prospective studies revealing active surveillance to be safe and have excellent cancer-specific survival with intermediate follow-up. Older and sicker patients have competing risk of death from other causes when diagnosed with a SRM.

SUMMARY

Active surveillance is becoming a more popular treatment modality for SRMs given the increasing number of incidental diagnoses and better understanding of their often indolent course. Active surveillance with delayed intervention is a well-tolerated treatment modality and appears to have the most benefit for those patients that are older with more comorbidities.

Cost Comparisons Between Different Techniques of Percutaneous Renal Biopsy for Small Renal Masses

PURPOSE

To compare the costs associated with ultrasound (US)-guided hospital-based (UGHB), CT-guided hospital-based (CTG), and US-guided office-based (UGOB) percutaneous renal biopsy (PRB) for small renal masses (SRMs).

METHODS

We retrospectively analyzed patient demographics, tumor characteristics, R.E.N.A.L. nephrometry scores, and cost data of patients undergoing PRB for SRM at our institution from May 2012 to September 2015. Cost data, including facility costs, professional fees, and pathology, were obtained from the departments of urology, radiology, and pathology.

RESULTS

A total of 78 patients were included in our analysis: 19, 31, and 28 UGHB, CTG, and UGOB, respectively. There was no difference in age, gender distribution, or tumor size among the three groups (p-values 0.131, 0.241, and 0.603, respectively). UGOB tumors had lower R.E.N.A.L. nephrometry scores (p=0.008). There were no differences in nondiagnostic rates between the UGHB, CTG, and UGOB groups [4 (21%), 5 (16%), and 6 (21%)] (p=0.852). There were no differences in final tumor treatment strategies utilized among the UGHB, CTG, and UGOB groups (p=0.447). There were 0, 2 (6%), and 0 complications in the UGHB, CTG, and UGOB biopsy groups. Total facility costs were $3449, $3280, and $1056 for UGHB, CTG, and UGOB PRB, respectively (p<0.0001). There was no difference between the urologist's and radiologist's professional fees (p=0.066). Total costs, including facility costs, pathology fees, and professional fees, were $4598, $4470, and $2129 for UGHB, CTG, and UGOB renal biopsy, respectively (p<0.0001).

CONCLUSION

For select patients with less anatomically complex, exophytic, and posteriorly located tumors, UGOB PRB provides equivalent diagnostic and complication rates while being significantly more cost-effective than either UGHB or CTG renal biopsy.

The Usefulness of Chest X-Rays for T1a Renal Cell Carcinoma Surveillance

PURPOSE

The overall incidence of pulmonary metastasis of T1 renal cell carcinoma is low. We evaluated the usefulness of chest x-rays based on the current AUA (American Urological Association) guidelines and NCCN Guidelines® for T1a renal cell carcinoma surveillance.

MATERIALS AND METHODS

Between 2006 and 2012, 258 patients with T1a renal cell carcinoma were treated with partial nephrectomy, radical nephrectomy or radio frequency ablation with surveillance followup at our institution. A retrospective chart review was performed to identify demographics, pathological findings and surveillance records. The primary outcome was the incidence of asymptomatic pulmonary recurrences diagnosed by chest x-ray in cases of T1a disease. Our secondary outcome was a comparison of diagnoses by treatment modality (partial nephrectomy, radical nephrectomy or radio frequency ablation).

RESULTS

Pulmonary metastases developed in 3 of 258 patients (1.2%) but only 1 (0.4%) was diagnosed by standard chest x-ray surveillance. Median followup in the entire cohort was 36 months (range 6 to 152) and 193 of 258 patients (75%) had greater than 24 months of followup. A mean of 3.3 surveillance chest x-rays were completed per patient. When assessed by treatment type, there was no significant difference in the recurrence rate for partial nephrectomy (0 of 191 cases), radical nephrectomy (0 of 22) or radio frequency ablation (1 of 45 or 2.2%) (p = 0.09).

CONCLUSIONS

Chest x-rays are a low yield diagnostic tool for detecting pulmonary metastasis in patients treated for T1a renal cel carcinoma. Treatment mode does not appear to influence the need for chest x-ray surveillance.

Clinicopathologica Epidemiological Characteristics and Change Tendencies of Renal Cell Carcinoma in Shanxi Province of China from 2005 to 2014

OBJECTIVES

RCC is the most common solid renal malignancy in adults worldwide. To provide the insight of clinicopathologica epidemiological characteristics and change tendencies of renal cell carcinoma (RCC), 2154 cases were collected from Shanxi Province of China, including diagnose time, age, gender, tumor size, Fuhrman grade, tumor stage, tumor location, local advance or distant metastasis and first symptom from 2005 to 2014. This retrospectively investigation, as its general objective, was to analyze the clinicopathologica epidemiological characteristics and the change tendencies of RCC.

METHODS

Between 2005 and 2014, 2154 patients who were diagnosed with RCC in three large tertiary hospitals at Shanxi Province were included. The patients' demographic features, pathological diagnoses and metastatic statuses were analyzed. Statistics methods include the chi-squared test, analysis of variance, Spearman's correlation analysis, Logistic regression and ARIMA modeling.

RESULTS

Of the 2154 included patients, the constituent ratio of female /male was 63.1% and 36.9%, with the median age of 57 years old. Fuhrman grade distributions differed significantly between males and females (p = 0.024). Also, a significant difference in tumor size was found by different clinical stages (p < 0.001), with a linear correlation (p < 0.001). Moreover, Spearman's analysis indicated tumor grade has a negative correlation with female (p = 0.009) and a positive correlation with tumor size (p = 0.000). It was found that the tumor diameter is bigger in the left side (p = 0.022). Furthermore, the metastasis rate was higher in the bigger tumor (p < 0.001) and the left-sided tumors (p = 0.027). Logistic regression also showed that tumor size is a risk factor for metastasis (OR = 1.724). The risk of local advance or distant metastasis in the left kidney was 1.6-fold greater than that of the right kidney. From 2005 to 2014 the number of RCC cases gradually increased (mainly for pathological grade II and III, but grade I and IV), while the average tumor size decreased, showing the severity increase mildly. Base on the results of a time series analysis-prediction the average RCC size would continue to decrease from the first quarter of 2015 to the fourth quarter of 2016.

CONCLUSIONS

The cases of RCC increased from 2005 to 2014 with clear cell type as the main pathological type in this population. The characteristics in the constituent ratios of the RCC vary depending on gender, pathological grade, tumor size, and location, which may be the important factors impacting treatment and prognosis.

Clinicopathological features and outcomes in patients with late recurrence of renal cell carcinoma after radical surgery

OBJECTIVES

To characterize patients experiencing late recurrence after primary radical surgery for renal cell carcinoma and to approach the mechanism of late recurrence.

METHODS

We retrospectively analyzed 657 consecutive patients who underwent radical surgery for pathologically confirmed ≤stage III renal cell carcinoma in a single institution between January 1981 and December 2008. Early or late recurrence was defined as a recurrence occurring before or after 60 months after primary surgery.

RESULTS

Of 657 patients, 96 (14.6%) experienced early recurrence, and 41 (6.2%) developed late recurrence. Patients with late recurrence had smaller diameter of primary tumor (median 5 cm vs 8 cm, P < 0.001), lower pathological stage (P < 0.001) and lower nuclear grade (P = 0.004) at primary surgery than those with early recurrence. On multivariate analysis, vascular invasion (including microscopic and gross invasion) was the predictor of late recurrence (P < 0.01, HR 3.79). Overall survival and disease-specific survival after recurrence were longer in patients with late recurrence (median 64 and 76 months, respectively) than in those with early recurrence (34.5 and 35 months, respectively; P = 0.008 and 0.002).

CONCLUSIONS

These results suggest that micrometastasis at the time of surgery associated with vascular invasion at primary tumor site and their relatively lower malignant potential could lead to late recurrence. Further studies are warranted for better understanding and managing late recurrence of renal cell carcinoma.

Percutaneous biopsy for risk stratification of renal masses

The increased use of abdominal imaging has led to identification of more patients with incidental renal masses, and renal mass biopsy (RMB) has become a popular method to evaluate unknown renal masses prior to definitive treatment. Pathologic data obtained from biopsy may be used to guide decisions for treatment and may include the presence or absence of malignant tumor, renal cell cancer subtype, tumor grade and the presence of other aggressive pathologic features. However, prior to using RMB for risk stratification, it is important to understand whether RMB findings are equivalent to pathologic analysis of surgical specimens and to identify any potential limitations of this approach. This review outlines the advantages and limitations of the current studies that evaluate RMB as a guide for treatment decision in patients with unknown renal masses. In multiple series, RMB has demonstrated low morbidity and a theoretical reduction in cost, if patients with benign tumors are identified from biopsy and can avoid subsequent treatment. However, when considering the routine use of RMB for risk stratification, it is important to note that biopsy may underestimate risk in some patients by undergrading, understaging or failing to identify aggressive tumor features. Future studies should focus on developing treatment algorithms that integrate RMB to identify the optimal use in risk stratification of patients with unknown renal masses.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes

INTRODUCTION

We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN).

METHODS

We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement.

CONCLUSIONS

The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Chronic hepatitis C infection as a risk factor for renal cell carcinoma

BACKGROUND

Chronic hepatitis C virus (HCV) infection causes cirrhosis and hepatocellular carcinoma but is also etiologically linked to several extrahepatic medical conditions including renal disorders. HCV is also associated with extrahepatic malignancies and may be oncogenic. Whether HCV confers an increased risk of renal cell carcinoma (RCC) remains controversial.

AIMS

Prospectively determine whether chronic HCV is associated with an increased risk of RCC.

METHODS

At an integrated medical center in Detroit, Michigan, adult patients with suspected RCC or newly diagnosed colon cancer (controls) were screened for hepatitis C antibody (HCAB) and HCV RNA. Renal or colon cancers were confirmed histologically. The proportion of patients with HCAB and HCV RNA in each group was compared, and risk factors for renal cell carcinoma were determined by multivariable logistic regression analysis.

RESULTS

RCC patients had a higher rate of HCAB positivity (11/140, 8 %) than colon cancer patients (1/100, 1 %) (p < 0.01). Of the HCAB-positive patients, 9/11 RCC and 0/1 controls had detectable HCV RNA. HCV RNA positivity was a significant risk factor for RCC (OR 24.20; 95 % CL 2.4, >999.9; p = 0.043). Additionally, viremic RCC patients were significantly younger than RCC patients who were HCV RNA negative (p = 0.013).

CONCLUSIONS

Patients with chronic HCV are at heightened risk of RCC.

Accuracy of Contrast-enhanced US for Differentiating Benign from Malignant Solid Small Renal Masses

PURPOSE

To test the hypothesis that qualitative and quantitative features of contrast material-enhanced ultrasonography (US) can be used to differentiate benign from malignant small renal masses.

MATERIALS AND METHODS

This is an institutional review board approved, HIPAA-compliant prospective study with written informed consent. Patients with histologically characterized solid small renal masses, excluding lipid-rich angiomyolipomas, underwent qualitative contrast-enhanced US with a combination of three different US machines. A subgroup of patients underwent quantitative contrast-enhanced US. Patients received a bolus injection of 0.2 mL of contrast material for qualitative and quantitative evaluations and were followed for 3 minutes. Two radiologists independently reviewed videotaped qualitative contrast-enhanced US examinations and were blinded to the final diagnoses. Features that were evaluated included lesion vascularity relative to the adjacent cortex in the arterial phase, the presence of a capsule, homogeneity, the pattern of vascularity, and washout. One radiologist separately reviewed a subset of contrast-enhanced US examinations that were performed with all three machines. Parameters of a first-pass time intensity curve were calculated for quantitative analysis. The Mann-Whitney test was used for quantitative parameters, the χ(2) or Fisher exact test was used for qualitative parameters, and κ statistics and Fleiss methodology were used to determine interobserver and intermachine agreement.

RESULTS

The study population consisted of 91 patients (35 women and 56 men) with 94 lesions. The mean age was 62 years ± 14 (range, 21-91). Three patients had two lesions each, which were evaluated at two different sessions. There were 26 benign small renal masses (including 18 oncocytomas, seven lipid-poor angiomyolipomas, and one hemangioblastoma) and 68 malignant masses (including 41 clear cell, 20 papillary, and seven chromophobe renal cell carcinomas [RCCs[) that were 1.1-4.0 cm in diameter (mean, 2.7 cm ± 0.9). All patients underwent contrast-enhanced US on the same one machine, and 68 patients were imaged on all three machines. Vascularity was present in all lesions (n = 94) at contrast-enhanced US. Lesion hypovascularity relative to the adjacent cortex in the arterial phase was seen in only malignant lesions by both reviewers; reviewer 1 saw hypovascularity in 24 of 94 lesions (P = .0001), and reviewer 2 saw hypovascularity in 21 of 94 lesions (P = .0006), for a specificity of 100% (95% confidence interval [CI]: 84, 100). This feature had κ values of 0.91 (95%CI: 0.82, 1.00) between the two reviewers and 0.85 (95% CI: 0.72, 0.99) between the three machines. Eighteen of 20 papillary RCCs were hypovascular. Quantitative parameters of area under the receiver operating characteristics curve, peak intensity, wash-in slope of 10%-90% and 5%-45%, and washout slope of 100%-10% and 50%-10% were significantly higher in malignant renal masses (P = .018, P = .002, P = .036, P = .016, P = .001, and P = .005, respectively) than in benign lesions.

CONCLUSION

Excluding lipid-rich angiomyolipoma, hypovascularity-which has high interobserver and intermachine agreement-of solid small renal masses relative to the cortex in the arterial phase has 100% specificity (95% CI: 84, 100) for detecting malignancy, most often papillary RCC.

The natural history and predictors for intervention in patients with small renal mass undergoing active surveillance

Aim. To describe the natural history of small renal mass on active surveillance and identify parameters that could help in predicting the need for intervention in patients with small renal masses undergoing active surveillance. We also discuss the need for renal biopsy in the management of these patients. Methods. A retrospective analysis of 78 renal masses ≤4 cm diagnosed at our Urology Department at Bnai Zion Medical Center between September 2003 and March 2012. Results. Seventy patients with 78 small renal masses were analyzed. The mean age at diagnosis was 68 years (47-89). The mean follow-up period was 34 months (12-112). In 54 of 78 masses there was a growth of at least 2 mm between imaging on last available follow-up and diagnosis. Eight of the 54 (15%) masses which grew in size underwent a nephron-sparing surgery, of which two were oncocytomas and six were renal cell carcinoma. Growth rate and mass diameter on diagnosis were significantly greater in the group of patients who underwent a surgery. Conclusions. Small renal masses might eventually be managed by active surveillance without compromising survival or surgical approach. All masses that were eventually excised underwent a nephron-sparing surgery. None of the patients developed metastases.

Renal functional outcomes after surgery for renal cortical tumors

Historically, radical nephrectomy represented the gold standard for the treatment of small (≤ 4cm) as well as larger renal masses. Recently, for small renal masses, the risk of ensuing chronic kidney disease and end stage renal disease has largely favored nephron-sparing surgical techniques, mainly partial nephrectomy. In this review, we surveyed the literature on renal functional outcomes after partial nephrectomy for renal tumors. The largest randomized control trial comparing radical and partial nephrectomy failed to show a survival benefit for partial nephrectomy. With regards to overall survival, surgically induced chronic kidney disease (GFR < 60 ml/min/ 1.73m²) caused by nephrectomy might not be as deleterious as medically induced chronic kidney disease. In evaluating patients who underwent donor nephrectomy, transplant literature further validates that surgically induced reductions in GFR may not affect patient survival, unlike medically induced GFR declines. Yet, because patients who present with a renal mass tend to be elderly with multiple comorbidities, many develop a mixed picture of medically, and surgically-induced renal disease after extirpative renal surgery. In this population, we believe that nephron sparing surgery optimizes oncological control while protecting renal function.

International variations and trends in renal cell carcinoma incidence and mortality

CONTEXT

Renal cell carcinoma (RCC) incidence rates are higher in developed countries, where up to half of the cases are discovered incidentally. Declining mortality trends have been reported in highly developed countries since the 1990s.

OBJECTIVE

To compare and interpret geographic variations and trends in the incidence and mortality of RCC worldwide in the context of controlling the future disease burden.

EVIDENCE ACQUISITION

We used data from GLOBOCAN, the Cancer Incidence in Five Continents series, and the World Health Organisation mortality database to compare incidence and mortality rates in more than 40 countries worldwide. We analysed incidence and mortality trends in the last 10 yr using joinpoint analyses of the age-standardised rates (ASRs).

EVIDENCE SYNTHESIS

RCC incidence in men varied in ASRs (World standard population) from approximately 1/100,000 in African countries to >15/100,000 in several Northern and Eastern European countries and among US blacks. Similar patterns were observed for women, although incidence rates were commonly half of those for men. Incidence rates are increasing in most countries, most prominently in Latin America. Although recent mortality trends are stable in many countries, significant declines were observed in Western and Northern Europe, the USA, and Australia. Southern European men appear to have the least favourable RCC mortality trends.

CONCLUSIONS

Although RCC incidence is still increasing in most countries, stabilisation of mortality trends has been achieved in many highly developed countries. There are marked absolute differences and opposing RCC mortality trends in countries categorised as areas of higher versus lower human development, and these gaps appear to be widening.

PATIENT SUMMARY

Renal cell cancer is becoming more commonly diagnosed worldwide in both men and women. Mortality is decreasing in the most developed settings, but not in low- and middle-income countries, where access to and the availability of optimal therapies are likely to be limited.

Image-guided ablation of primary liver and renal tumours

Image-guided ablation (IGA) techniques have evolved considerably over the past 20 years and are increasingly used to definitively treat small primary cancers of the liver and kidney. IGA is recommended by most guidelines as the best therapeutic choice for patients with early stage hepatocellular carcinoma (HCC)-defined as either a single tumour smaller than 5 cm or up to three nodules smaller than 3 cm-when surgical options are precluded, and has potential as first-line therapy, in lieu of surgery, for patients with very early stage tumours smaller than 2 cm. With regard to renal cell carcinoma, despite the absence of any randomized trial comparing the outcomes of IGA with those of standard partial nephrectomy, a growing amount of data demonstrate robust oncological outcomes for this minimally invasive approach and testify to its potential as a standard-of-care treatment. Herein, we review the various ablation techniques, the supporting evidence, and clinical application of IGA in the treatment of primary liver and kidney cancers.

Patient and tumor characteristics can predict nondiagnostic renal mass biopsy findings

PURPOSE

Identification of patient and tumor characteristics associated with nondiagnostic biopsies is necessary to improve prebiopsy counseling and patient selection.

MATERIALS AND METHODS

We reviewed the clinical records and prebiopsy imaging of all patients treated with percutaneous biopsy for a renal mass 7 cm or less. Univariate and multivariate logistic regression models were constructed to examine the association between biopsy outcome and clinical/radiographic features.

RESULTS

A total of 565 biopsies of renal tumors 7 cm or less in 525 patients were included in the study. There was no significant difference in age, body mass index, Charlson comorbidity score or gender between the patient cohorts with diagnostic and nondiagnostic biopsy. In 83 of 565 patients (14.7%) overall and in 72 of the 413 (17.4%) with a mass of 4 cm or less the biopsy findings were nondiagnostic. Overall 14.7% of masses were cystic and 85.3% were solid with a median tumor size of 2.75 cm (IQR 2.05-4.25). Independent predictors of nondiagnostic biopsy included cystic features, enhancement less than 20 HU, left tumor, tumor diameter and skin-to-tumor distance. The nondiagnostic rate of repeat biopsies was 20.8%, which did not statistically differ from the nondiagnostic rate at the initial renal mass biopsy attempt. Radiologist or pathologist experience was not associated with the biopsy nondiagnostic rate. In 7 of 565 patients (1.2%) hospital admission was required for adverse events after biopsy.

CONCLUSIONS

Nondiagnostic renal mass biopsies are more common in cystic, nonenhancing, small masses when patients have a skin-to-tumor distance of 13 cm or greater. Excluding patients with these criteria decreased the nondiagnostic rate from 14.7% to 8.7%.

Preoperative predictors of malignancy and unfavorable pathology for clinical T1a tumors treated with partial nephrectomy: a multi-institutional analysis

PURPOSE

To determine preoperative predictors associated with renal cell carcinoma (RCC) and unfavorable pathology in small renal masses treated with partial nephrectomy (PN).

MATERIALS AND METHODS

PN records from 5 centers were retrospectively queried for patients with a clinically localized single tumor <4 cm on imaging (clinical T1a). Between 2007 and 2013, 1,009 patients met the inclusion criteria. Unfavorable pathology was defined as any grade III or IV RCC or tumors upstaged to pathologic T3a disease. Logistic regression models were used to determine preoperative characteristics associated with RCC and with unfavorable pathology.

RESULTS

A total of 771 (76.4%) patients were found to have RCC and 198 (19.6%) had unfavorable pathology. On multivariate, bootstrap-adjusted logistic regression analysis, factors associated with the presence of malignancy were imaging tumor size ≥ 3 cm (odds ratio [OR] = 1.46; P = 0.040), male sex (OR = 1.88; P<0.0001), and nephrometry score ≥ 8 (OR = 1.64; P = 0.005). These same factors were independently associated with risk of unfavorable pathology: size ≥ 3 cm (OR = 1.46; P = 0.021), male sex (OR = 2.35; P<0.0001), and nephrometry score ≥ 8 (OR = 1.49; P = 0.015). The c statistic was 0.62 for the predicting malignancy and 0.63 for unfavorable pathology.

CONCLUSIONS

In this multi-institutional cohort, male sex, imaging tumor size ≥ 3 cm, and nephrometry score ≥ 8 were predictors of RCC and adverse pathology following PN. These factors may assist in risk stratification and selective renal mass biopsy before decision making. Further studies are necessary to validate these findings.

Lessons learned from the comparative study between renal mass biopsy and the analysis of the surgical specimen

INTRODUCTION

The role of renal mass (RM) biopsy is currently under discussion. As a result of the progressive increase in the incidental diagnosis of RMs (which have a higher percentage of benignity and well-differentiated cancers), new approaches have emerged such as observation, especially with elderly patients or those with significant comorbidity. RM biopsy (RMB) should provide sufficient information for making this decision, but so far this has not been the case. We examine our prospective series of in-bench RMBs after surgery and compare them with the anatomy of the removed specimen.

MATERIAL AND METHODS

We obtained (prospectively, in-bench and with a 16-gauge needle) 4 biopsies of RMs operated on in our department from October 2008 to December 2009. These RMs were analyzed by 2 uropathologists and compared with the results of the specimen.

RESULTS

We analyzed 188 biopsies (47 RMs); 12.75% were "not valid". The ability of biopsy to diagnose malignancy or benignity was 100%, and the coincidence in the histological type was 95%. The success in determining the tumor grade was 100% when the cancer was low-grade and 62% when high-grade. None of the analyzed data (necrosis, size, etc.) influenced the results in a statistically significant manner.

CONCLUSION

RMB with a 16-G needle enables the differentiation between malignancy and benignity in 100% of cases, with a very similar diagnostic accuracy in the tumor type. Tumor grade is still the pending issue with renal mass biopsy.

Single-site laparoscopic partial nephrectomy: Where are we going?

AIM: To review an evolution of laparoscopic surgery, there has been a growing interest in laparoendoscopic single-site surgery (LESS).

METHODS: A comprehensive electronic literature search was conducted using PubMed database to identify all publications relating to LESS-partial nephrectomy (PN). The research includes articles published from April 2008 to January 2014. We focused our attention only on articles in which were cited the single-site surgical technique (laparoscopic and robotic), tumour stage and grade, mean tumour size, intraoperative variables, blood loss and transfusion rate, length of post-operative stay and complication rates, Clavien classification, positive of surgical margins, pain assessment at discharge.

RESULTS: A total of 9 studies were collected with 221 patients included. The mean patients age was 62 years. The mean tumor size was 2.35 cm with a mean operative time of 181 min (range 111-270 min) and 58.3% were done by robot. The mean ischemia time was 23.6 min. The 25.8% of patients underwent an unclamp LESS-PN. Mean estimated blood loss was 296 mL and median length of hospital stay was 4 d. The rate of severe post-operative complications (≥ Clavien grade III) was 5.4%. Not all surgical series of LESS-PN or Robotic-LESS-PN shows conversion in Multiport Laparoscopic or Open Surgery. Regarding oncologic outcomes, surgical margins were positive 4% of patients (9/221), no distant or port-site metastases were recorded.

CONCLUSION: LESS-PN and RLESS-PN are feasible and associated with reduced postoperative pain, shorter median hospital stay, shorter recovery time, and better cosmetic satisfaction without compromising surgical and oncological safety.

Contemporary incidence and mortality rates of kidney cancer in the United States

INTRODUCTION

This is a timely update of incidence and mortality for renal cell carcinoma (RCC) in the United States.

METHODS

Relying on the Surveillance, Epidemiology, and End Results (SEER) database, we computed age-adjusted incidence, mortality rates and 5-year cancer-specific survival (CSS) for patients with histologically confirmed kidney cancer between 1975 and 2009. Long-term (1975-2009) and short-term (2000-2009) trends were examined by joinpoint analysis, and quantified using the annual percent change (APC). The reported findings were stratified according to disease stage.

RESULTS

Age-adjusted incidence rates of RCC increased by +2.76%/year between 1975 and 2009 (from 6.5 to 17.1/100 000 person-years, p < 0.001), and by +2.85%/year between 2000 and 2009 (p < 0.001). For the same time points, the corresponding APC for the incidence of localized stage were +4.55%/year (from 3.0 to 12.2/100 000 person years, p < 0.001), and +4.42%/year (p < 0.001), respectively. The incidence rates of regional stage increased by +0.88%/year between 1975 and 2009 (p < 0.001), but stabilized in recent years (2000-2009: +0.56%/year, p = 0.4). Incidence rates of distant stage remained unchanged in long- and short-term trends. Overall mortality rates increased by +1.72%/year between 1975 and 2009 (from 1.2 to 5.0/100 000 person-years, P<0.001), but stabilized between 1994 and 2004 (p = 0.1). Short-term mortality rates increased in a significant fashion by +3.14%/year only for localized stage (p < 0.001).

INTERPRETATION

In contemporary years, there is a persisting upward trend in incidence and mortality of localized RCC.

Landmarks in the diagnosis and treatment of renal cell carcinoma

The most common renal cancer is renal cell carcinoma (RCC), which arises from the renal parenchyma. The global incidence of RCC has increased over the past two decades by 2% per year. RCC is the most lethal of the common urological cancers: despite diagnostic advances, 20-30% of patients present with metastatic disease. A clearer understanding of the genetic basis of RCC has led to immune-based and targeted treatments for this chemoresistant cancer. Despite promising results in advanced disease, overall response rates and durable complete responses are rare. Surgery remains the main treatment modality, especially for organ-confined disease, with a selective role in advanced and metastatic disease. Smaller tumours are increasingly managed with biopsy, minimally invasive interventions and surveillance. The future promises multimodal, integrated and personalized care, with further understanding of the disease leading to new treatment options.

Preoperatively misclassified, surgically removed benign renal masses: a systematic review of surgical series and United States population level burden estimate

PURPOSE

A significant proportion of renal masses removed for suspected malignancy are histologically benign with the probability inversely proportional to lesion size. To our knowledge the number of preoperatively misclassified benign renal masses treated with nephrectomy is currently unknown. Given the increasing incidence and decreasing average size of renal cell carcinoma, this burden is likely increasing. We estimated the population level burden of surgically removed, preoperatively misclassified benign renal masses in the United States.

MATERIALS AND METHODS

We systematically reviewed the literature for studies of pathological findings of renal masses removed for suspected renal cell carcinoma based on preoperative imaging through July 1, 2014. We excluded studies that did not describe benign pathology and with masses not stratified by size, and in which pathology results were based on biopsy. SEER data were queried for the incidence of surgically removed renal cell carcinomas in 2000 to 2009.

RESULTS

A total of 19 studies of tumor pathology based on size met criteria for review. Pooled estimates of the proportion of benign histology in our primary analysis (American studies only and 1 cm increments) were 40.4%, 20.9%, 19.6%, 17.2%, 9.2% and 6.4% for tumors less than 1, 1 to less than 2, 2 to less than 3, 3 to less than 4, 4 to 7 and greater than 7, respectively. The estimated number of surgically resected benign renal masses in the United States from 2000 to 2009 increased by 82% from 3,098 to 5,624.

CONCLUSIONS

These estimates suggest that the population level burden of preoperatively misclassified benign renal masses is substantial and increasing rapidly, paralleling increases in surgically resected small renal cell carcinoma. This study illustrates an important and to our knowledge previously unstudied dimension of overtreatment that is not directly quantified in contemporary surveillance data.

Pathological characteristics and radiographic correlates of complex renal cysts

OBJECTIVES

To characterize pathological and cancer-specific outcomes of surgically resected cystic renal tumors and to identify clinical or radiographic features associated with these outcomes.

METHODS AND MATERIALS

All patients at our institution who underwent radical or partial nephrectomy for complex renal cystic masses between 2004 and 2011 with available computed tomographic imaging were included. The Bosniak score was determined, as were 10 specific radiographic characteristics of renal cysts in patients with preoperative imaging available for review. These characteristics were correlated with cystic mass histopathology. Recurrence-free survival after surgery was determined.

RESULTS

Overall, 133 patients underwent renal surgery for complex cystic lesions, 89 (67%) of whom had malignant lesions. Malignancy risk increased with Bosniak score (P≤0.01) and presence of mural nodules (P = 0.01). Most (63%) malignancies demonstrated clear cell histology. The papillary renal cell carcinomas (25%) exhibited lower enhancement levels (P = 0.04) and were less often septated (P<0.01). Of the malignancies, 79% were low stage (pT1), and 73% were Fuhrman grade 1 or 2. Large cyst size was associated with advanced tumor stage (P = 0.05). Neither Bosniak score nor any other radiographic parameter was associated with Fuhrman grade. In 70 patients with a median follow-up of 43 months, only 1 (1.4%) developed disease recurrence.

CONCLUSIONS

Most cystic renal malignancies are low-stage, low-grade lesions. Papillary renal cell carcinomas account for nearly a quarter of cystic renal malignancies and have unique radiographic characteristics. Disease recurrence after surgical resection is rare. These findings suggest an indolent behavior for cystic renal tumors, and these lesions may be amenable to active surveillance.

Patients with anatomically "simple" renal masses are more likely to be placed on active surveillance than those with anatomically "complex" lesions

OBJECTIVE

To determine if radiographically less complex renal lesions are deemed clinically less "worrisome" and therefore are more likely to be considered for active surveillance (AS).

METHODS

We examined our prospective institutional database to identify and compare patients with localized renal cell carcinoma undergoing an initial period of AS or immediate surgery. Multivariate logistic regression was used to examine covariates associated with receipt of AS.

RESULTS

Of 1,059 patients with available anatomic complexity data, 195 underwent an initial period of AS (median duration of AS 25.6 mo [interquartile range: 11.8-52.8 mo]). Compared with patients undergoing immediate surgical treatment, patients selected for AS had lower overall nephrometry scores (NS) with tumors that were smaller, further from the sinus or urothelium, more often polar, and less often hilar (P<0.0015 all comparisons). After adjustment for age, largest tumor size, individual components of NS, total NS, and Charlson comorbidity index, total NS (odds ratio [OR] = 1.9 [CI: 1.4-2.5]), "R" score of 1 (OR = 5.2 [CI: 1.8-15.2]), "N" score of 1 (OR = 2.3 [CI: 1.5-3.6]), "L" score of 1 (OR = 1.4 [CI: 0.84-2.2]), and nonhilar tumor location (OR = 2.7 [CI: 1.2-5.8]) increased the probability of being selected for AS compared with immediate surgery. Findings remained significant in a subanalysis of T1a renal masses.

CONCLUSIONS

Lower tumor anatomic complexity was strongly associated with the decision to proceed with AS in patients with stage I renal mass. Not only may these data afford new insights into renal mass treatment trends, but the findings may also prove useful in the development of objective protocols to most appropriately select patients for AS.

MRI phenotype in renal cancer: is it clinically relevant?

Renal cell carcinoma (RCC) is most commonly diagnosed as an incidental finding on cross-sectional imaging and represents a significant clinical challenge. Although most patients have a surgically curable lesion at the time of diagnosis, the variability in the biologic behavior of the different histologic subtypes and tumor grade of RCC, together with the increasing array of management options, creates uncertainty for the optimal clinical approach to individual patients. State-of-the-art magnetic resonance imaging (MRI) provides a comprehensive assessment of renal lesions that includes multiple forms of tissue contrast as well as functional parameters, which in turn provides information that helps to address this dilemma. In this article, we review this evolving and increasingly comprehensive role of MRI in the detection, characterization, perioperative evaluation, and assessment of the treatment response of renal neoplasms. We emphasize the ability of the imaging "phenotype" of renal masses on MRI to help predict the histologic subtype, grade, and clinical behavior of RCC.

Current patterns of presentation and treatment of renal masses: a clinical research office of the endourological society prospective study

PURPOSE

To assess epidemiologic characteristics, clinical and pathologic patterns of presentation, and treatment strategies in a contemporary population with renal masses (RMs).

METHODS

The Clinical Research Office of the Endourological Society collected prospective epidemiologic, clinical, and pathologic data on consecutive patients with RMs who were treated during a 1-year period in 98 centers worldwide. Preoperative assessment and treatment were performed according to local clinical practice guidelines.

RESULTS

From January 2010 to February 2012, 4288 patients (4355 cases, 4815 tumors) were treated for a RM. The mean age of the cohort was 61.5 years, and the ratio male:female 1.8:1. Caucasians represented 75% of the population, and the median body mass index was 27. The cohort exhibited a high rate of comorbidity (65.6%), including a 48.5% rate of hypertension; one-third of patients had a combination of two or more comorbidities. One-third of patients (36%) had risk factors for renal-cell carcinoma (RCC), of which smoking and obesity were the most common. Diagnosis was incidental in 67% of cases, and 22.2% of cases had chronic kidney disease stage ≥III at presentation. Median radiologic size was 44 mm (range 2-300 mm) and 68% were cT1. Radical nephrectomy and nephron-sparing surgery (NSS) including ablation were performed in 52% and 46% of cases, respectively, while 3.6% of cases were actively surveyed. Median pathologic size was 43 mm (range 2-300 mm) and 63% of the RCCs were pT1.

CONCLUSIONS

Current patterns of presentation of RMs are consistent with the decreasing trends in age and clinical or pathologic size and increasing incidental diagnosis. Patients exhibit a considerable basal comorbidity and presence of risk factors for RCC. Half of the cases are treated by a nephron-sparing modality with an increase in the penetration of NSS techniques in the contemporary urologic practice.

Recombinant interleukin-21 plus sorafenib for metastatic renal cell carcinoma: a phase 1/2 study

Background

Despite the positive impact of targeted therapies on metastatic renal cell carcinoma (mRCC), durable responses are infrequent and an unmet need exists for novel therapies with distinct mechanisms of action. We investigated the combination of recombinant Interleukin 21 (IL-21), a cytokine with unique immunostimulatory properties, plus sorafenib, a VEGFR tyrosine kinase inhibitor.

Methods

In this phase 1/2 study, 52 mRCC patients received outpatient treatment with oral sorafenib 400 mg twice daily plus intravenous IL-21 (10–50 mcg/kg) on days 1–5 and 15–19 of each 7-week treatment course. The safety, antitumor activity, pharmacokinetic and pharmacodynamic effects of the combination were evaluated.

Results

In phase 1 (n = 19), the maximum tolerated dose for IL-21 with the standard dose of sorafenib was determined to be 30 mcg/kg/day; grade 3 skin rash was the only dose-limiting toxicity. In phase 2, 33 previously-treated patients tolerated the combination therapy well with appropriate dose reductions; toxicities were mostly grade 1 or 2. The objective response rate was 21% and disease control rate was 82%. Two patients have durable responses that are ongoing, despite cessation of both IL-21 and sorafenib, at 41+ and 30+ months, respectively. The median progression-free survival in phase 2 was 5.6 months. The pharmacokinetic and pharmacodynamic properties of IL-21 appeared to be preserved in the presence of sorafenib.

Conclusion

IL-21 plus sorafenib has antitumor activity and acceptable safety in previously treated mRCC patients. IL-21 may represent a suitable immunotherapy in further exploration of combination strategies in mRCC.

Trial registration

ClinicalTrials.gov Identifier: NCT00389285

Patterns of recurrence and surveillance strategies for renal cell carcinoma following surgical resection

Renal cell carcinoma (RCC) remains one of the most lethal urologic malignancies, with up to 40% of patients eventually dying of cancer progression. Despite advances in the diagnosis, staging and treatment of patients with RCC, approximately a third of patients who undergo surgery for clinically localized RCC will suffer a recurrence. Timely identification of recurrences following surgical extirpation is imperative in the treatment of these patients. RCC is known to metastasize through hematogenous routes of spread to distant organ sites and via lymphatic channels to regional lymph nodes. The path of tumor escape is associated with diverse clinical outcomes and a unique tumor biology. A consensus on surveillance regimens for patients following surgical resection of localized disease is lacking. The most extensively used system for providing prognostic information regarding survival and recurrence of disease has historically been the tumor-node-metastasis (TNM) classification system. As a result, most contemporary surveillance protocols have tailored follow-up regimens according to stage-based stratifications. Numerous studies have recently demonstrated that certain clinical and histopathological factors can improve the prediction of tumor recurrence. The incorporation of these prognostic factors into stage-based stratification models should be better than stage alone in attempting to provide a rational approach to identifying treatable recurrences while minimizing unnecessary exams and tests, as well as patient anxiety. Advances in the understanding of the pathogenesis, behavior and molecular biology of RCC have paved the way for developments that may enhance early diagnosis and prognostication, and improve survival for patients. Lastly, molecular markers should, in the future, revolutionize surveillance protocols for RCC by tailoring follow-up to specific molecular classifications.

RENAL nephrometry score is a predictive factor for the annual growth rate of renal mass

OBJECTIVE

To evaluate the association between the RENAL nephrometry score and annual growth rates of renal masses presumed to be renal cell carcinoma.

METHODS

The current study included 47 renal tumors followed up for at least 12 months, of which 26 tumors were found to be pathologically proven renal cell carcinomas. Annual tumor growth rates were calculated from changes in the maximal diameter on computed tomography, and RENAL nephrometry scores were recorded on initial imaging by two senior urologists. The associations between clinical characteristics including the RENAL nephrometry score and annual growth rates were analyzed using a linear regression model.

RESULTS

The median tumor size at diagnosis was 1.7 cm (range 0.6-5.8). The median nephrometry score at diagnosis was 7 (range 4-10). Overall, the median tumor growth rate was 0.34 cm per year (range -0.19-2.0). Linear regression analysis showed that the annual tumor growth rate was associated with the RENAL nephrometry score (P < 0.0001), but it was independent of the age at diagnosis, sex and initial tumor size. In addition, the correlation between the RENAL nephrometry score and annual growth rate remained significant in the 26 pathologically proven renal cell carcinomas.

CONCLUSIONS

The RENAL nephrometry score is associated with the annual growth rate of renal masses. Our findings further support the association between the RENAL nephrometry score and tumor biology.

Restored kidney graft from urologist referrals for renal transplantation

BACKGROUND

A new transplantation program using kidneys after a small tumor excision was initiated in Western Australia in February 2007. The aim of this study was to report the outcomes over 5 years.

METHODS

Local urologists were encouraged to refer the kidney to the transplantation service when considering a radical nephrectomy. Recipients are selected according to strict criteria. Between February 2007 and February 2012 24 of 30 referred kidneys were restored for transplantation. Average donor age was 53.4 (range, 32-75) years while the recipients were 66.3 (range, 57-80) years. Twenty-one kidneys were restored after excision of a small tumor (<3.3 cm) and 3 kidneys were restored after being obtained from patients who had experienced complicated ureteric injuries secondary to laparotomy and colectomy.

RESULTS

Nineteen of 24 grafts displayed immediate function, 4 had delayed function, and 1 had nonfunction. The first 3 patients developed urinary leakages, which all resolved by subsequent management. One graft showed a pseudoaneurysm on the day 1 Doppler ultrasound, requiring interventional embolization. All patients but 1 have been off dialysis with satisfactory graft function; creatinine (Cr) levels ranged from 70 μmol/L to 330 μmol/L. There was no tumor recurrence on close follow-up from 6 to 55 months (median, 26). Three patients died due to other medical issues.

CONCLUSION

Kidneys could be restored from urologic disease for transplantation after excision of a small tumor with satisfactory outcomes at an average follow-up of 26 months. Frozen section is necessary to ensure the clearance of the tumor prior to transplantation. A modification of the surgical technique has minimized urine leakage and pseudoaneurysm formation after tumor resection.