Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice Guideline

Oncologic and Functional Outcomes of Radical and Partial Nephrectomy in pT3a Pathologically Upstaged Renal Cell Carcinoma: A Multi-institutional Analysis

BACKGROUND

The efficacy of partial nephrectomy (PN) in setting of pT3a pathologic-upstaged renal cell carcinoma (RCC) is controversial. We compared oncologic and functional outcomes of radical nephrectomy (RN) and PN in patients with upstaged pT3a RCC.

PATIENTS AND METHODS

This was a multicenter retrospective analysis of patients with cT1-2N0M0 RCC upstaged to pT3a postoperatively. The primary outcome was recurrence-free survival, with secondary outcomes of overall survival and de novo estimated glomular filtration rate (eGFR) < 60. Multivariable analysis was performed to identify predictive factors for oncologic outcomes. Kaplan-Meier analyses (KMA) were obtained to elucidate survival outcomes.

RESULTS

A total of 929 patients had pT3a upstaging (686 [72.6%] RN; 243 [25.7%] PN; mean follow-up, 48 months). Tumor size was similar (RN 7.7 cm vs. PN 7.3 cm; P = .083). PN had decreased ΔeGFR (6.1 vs. RN 19.4 mL/min/1.73m²; P < .001) and de novo eGFR < 60 (9.5% vs. 21%; P = .008). Multivariable analysis for recurrence showed increasing RENAL score (hazard ratio [HR], 3.8; P < .001), clinical T stage (HR, 1.8; P < .001), positive margin (HR, 1.57; P = .009), and high grade (HR, 1.21; P = .01) to be independent predictors, whereas surgery was not (P = .076). KMA revealed 5-year recurrence-free survival for cT1-upstaged PN, cT1-upstaged RN, cT2-upstaged PN, and cT2-upstaged RN of 79%, 74%, 70%, and 51%, respectively (P < .001). KMA revealed 5-year overall survival for cT1-upstaged PN, cT1-upstaged RN, cT2-upstaged PN, and cT2-upstaged RN of 64%, 65.2%, 56.4%, and 55.2%, respectively (P = .059).

CONCLUSIONS

In pathologically upstaged pT3a RCC, PN did not adversely affect risk of recurrence and provided functional benefit. Surgical decision-making in patients at risk for T3a upstaging should be individualized and driven by tumor as well as functional risks.

Active surveillance of small renal masses

Most renal masses incidentally detected by cross-sectional images are benign, being mainly cysts, and if they are malignant, they are indolent in nature with limited metastatic potential. Enhanced renal masses less than 4 cm in size are known as small renal masses (SRMs), and their growth rate (GR) and the possibility of developing metastasis are extremely low. Delayed intervention of SRMs by closed and routine imaging follow-up known as active surveillance (AS) is now an option according to urological guidelines. Radiologists have a key position in AS management of SRMs even unifocal and multifocal (sporadic or associated with genetic syndromes) and also in the follow-up of complex renal cysts by Bosniak cyst classification system. Radiologists play a key role in the AS of both unifocal and multifocal (sporadic or associated with genetic syndromes) SRMs as well as in the follow-up of complex renal cysts using the Bosniak cyst classification system. Indeed, radiologists must determine which patients with SRMs or complex renal cysts can be included in AS, establish the follow-up radiological test algorithm to be used in different scenarios, perform measurements in follow-up tests, and decide when AS should be discontinued. The purpose of this article is to review the indications and management of AS in SRMs, especially focused on specific scenarios, such as complex renal cysts and multifocal renal tumors (sporadic or hereditary). In this work, the authors aimed to provide a thorough review of imaging in the context of active surveillance of renal masses.

Management of complex renal cysts in Canada: results of a survey study

Background

Bosniak III and IV cysts have a high risk of malignancy and have traditionally been managed surgically. However, growing evidence suggests that many can be managed by active surveillance. The main objective of this study was to characterize the use of surveillance in the management of complex renal cysts.

Methods

A web-based survey was sent to all registered, active members of the Canadian Urological Association (N = 583) in October 2018.

Results

The survey response rate was 24.7%. Management of Bosniak III cysts varied considerably. A large proportion of respondents (33.1%) offered active surveillance in > 50% of cases. Only 13.7% of respondents reported never or rarely (< 5% of cases) offering surveillance. In contrast, for Bosniak IV cysts, 60.1% of urologists never or rarely offered surveillance, while only 10.1% offer it in > 50% of cases. A significantly greater proportion of academic urologists, compared to non-academic urologists, viewed surveillance as a management option for patients with a Bosniak III or IV cyst. The most commonly reported barriers to a greater adoption of surveillance were concerns regarding its oncologic safety, the lack of data to support surveillance in this population, and the lack of triggers for discontinuation of active surveillance and intervention.

Conclusions

Despite active surveillance being included as a management option in guidelines, many Canadian urologists are reluctant to offer surveillance to patients with Bosniak III or IV cysts. Practice patterns are heterogeneous among those offering surveillance. High-quality studies are required to better define the benefits and risks of cystic renal mass surveillance.

Outcomes of Renal Tumors Treated by Image-Guided Percutaneous Cryoablation: Immediate and 3- and 5-Year Outcomes at a Regional Center

OBJECTIVE. The purpose of this study was to evaluate the immediate and 3- and 5-year outcomes of patients with clinical stage T1 (cT1) biopsy-proven renal cell carcinoma (RCC) treated by image-guided percutaneous cryoablation at a regional interventional oncology center. MATERIALS AND METHODS. A prospectively maintained local interventional radiology database identified patients with cT1 RCC lesions that were treated by percutaneous cryoablation. Technical success, procedural complications (graded using the Clavien-Dindo classification system), and the residual unablated tumor rate were collated. Local tumor progression-free survival was estimated using Kaplan-Meier estimates. RESULTS. A total of 180 patients with 185 separate cT1 RCC lesions were identified. Mean patient age was 68.4 years (range, 34.1-88.9 years) and 52 patients (28.9%) were women. There were 168 (90.8%) and 17 (9.2%) cT1a and cT1b lesions, respectively, with a mean lesion size of 28.5 mm (range, 11-58 mm). Technical success was achieved in 183 of 185 (98.9%) patients. The major complication rate (Clavien-Dindo classification ≥ grade III) was 2.2% (four out of 185). Residual unablated tumor on the first follow-up scan was identified in four of 183 tumors (2.2%). Estimated local tumor progression-free survival at 3 and 5 years was 98.3% and 94.9%, respectively. No distant metastases or deaths attributable to RCC occurred. Mean estimated glomerular filtration rate (eGFR) before the procedure was 72.4 ± 18.5 (SD) mL/min/1.73 m² and this was not statistically significantly different after the procedure (69.7 ± 18.8 mL/min/1.73 m²), at 1 year (70.7 ± 16.4 mL/min/1.73 m²), or at 2 years (69.8 ± 18.9 mL/min/1.73 m²) (p > 0.05). CONCLUSION. These data add to the accumulating evidence that image-guided cryoablation is an efficacious treatment for selected cT1 RCC with a low complication rate and ro bust 3- and 5-year outcomes.

Psychological distress associated with active surveillance in patients younger than 70 with a small renal mass

PURPOSE

To compare the psychological distress throughout several predefined disease time points in patients younger than 70 with small renal masses (SRMs) treated with either active surveillance (AS) or ablative/surgical therapy.

METHODS

Using the Edmonton Symptom Assessment System - revised (ESAS-r) questionnaire, we focused on psychological distress symptoms in all consecutive patients with an SRM between 2014 and 2017. We further evaluated the psychological distress sub-score (PDSS) of ESAS-r, consisting of the sum scores of anxiety, depression, and well-being. PDSS of patients treated with AS or ablation/surgery were compared at 4 distinct time points (before and after diagnosis, after a biopsy is performed, and at last follow-up). Multivariable linear regression models were performed to assess factors associated with worse PDSS (1-point score increase).

RESULTS

We examined 477 patients, of whom 217 and 260 were treated with AS and surgery/ablation, respectively. Similar ESAS-r and PDSS scores were shown at all predefined disease time points except following an SRM biopsy and at last, follow-up, where AS-treated patients with a biopsy-proven malignancy had significantly worse PDSS (11.4 vs. 6.1, P = 0.035), and (13.2 vs. 5.4, P = 0.004), respectively. At last follow-up, multivariable linear models demonstrated that a biopsy-proven malignancy (B = 2.630, 95% CI 0.024-5.236, P = 0.048) and AS strategy (B = 6.499, 95% CI 2.340-10.658, P = 0.002) were associated with worse PDSS in all patients, and in those who underwent a biopsy, respectively.

CONCLUSIONS

Offering standardized psychological supportive care may be required for patients younger than 70 years on AS for SRM, especially for those with a biopsy-proven tumor.

Prognostic Value of Histologic Subtype and Treatment Modality for T1a Kidney Cancers

INTRODUCTION

To evaluate overall survival (OS) of T1a kidney cancers stratified by histologic subtype and curative treatment including partial nephrectomy (PN), percutaneous ablation (PA), and radical nephrectomy (RN).

MATERIALS AND METHODS

We queried the National Cancer Data Base (2004-2015) for patients with T1a kidney cancers who were treated surgically. OS was estimated by Kaplan-Meier curves based on histologic subtype and management. Cox proportional regression models were used to determine whether histologic subtypes and management procedure predicted OS.

RESULTS

46,014 T1a kidney cancers met inclusion criteria. Kaplan Meier curves demonstrated differences in OS by treatment for clear cell, papillary, chromophobe, and cystic histologic subtypes (all p < 0.001), but no differences for sarcomatoid (p = 0.110) or collecting duct (p = 0.392) were observed. Adjusted Cox regression showed worse OS for PA than PN among patients with clear cell (HR 1.58, 95%CI [1.44-1.73], papillary RCC (1.53 [1.34-1.75]), and chromophobe RCC (2.19 [1.64-2.91]). OS was worse for RN than PN for clear cell (HR 1.38 [1.28-1.50]) papillary (1.34 [1.16-1.56]) and chromophobe RCC (1.92 [1.43-2.58]). Predictive models using Cox proportional hazards incorporating histology and surgical procedure alone were limited (c-index 0.63) while adding demographics demonstrated fair predictive power for OS (c-index 0.73).

CONCLUSIONS

In patients with pathologic T1a RCC, patterns of OS differed by surgery and histologic subtype. Patients receiving PN appears to have better prognosis than both PA and RN. However, the incorporation of histologic subtype and treatment modality into a risk stratification model to predict OS had limited utility compared with variables representing competing risks.

Current management of small renal masses

One of the consequences of the growing use of diagnostic imaging techniques is the notable growth in the detection of small renal masses presumably corresponding to localized tumors that are potentially curable with surgical treatment. When faced with the finding of a small renal mass, radiologists must determine whether it is benign or malignant, and if it is malignant, what subtype it belong to, and whether it should be managed with surgical treatment, with ablative techniques, or with watchful waiting with active surveillance. Small renal masses are now a clinical entity that require management different from the approaches used for classical renal cell carcinomas. In this scenario, radiologists are key because they are involved in all aspects of the management of these tumors, including in their diagnosis, treatment, and follow-up.

[Geriatric specificities of localized renal cell carcinoma]

PURPOSE

To describe the epidemiology of renal cell carcinoma (RCC) and its natural history in the elderly patient. To propose adaptations of geriatric evaluation specific to RCC. Recall therapeutic options and the treatment options specific to elderly patients.

METHOD

Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific societies of geriatrics, from the National Cancer Institute using the following keywords: elderly, geriatrics, renal cell carcinoma, small renal mass, diagnosis, treatment.

RESULTS

The incidence of RCC increases in France and peaks between 70 and 80 years. This increase in incidence is mainly due to the diagnosis of small renal masses (SMR). The specific mortality of RCC increases with age (at least between 75 and 95 years). Tumor biopsy, especially of SMR, should be considered in the elderly patient. The geriatric assessment of patients with CaR has no specificity apart from specific evaluation of renal function and operative risk. There is no prospective therapeutic trials dedicated to elderly patients with localized RCC. Surgical treatment requires the use of fast track protocol (the modalities of which are being elaborated) in which geriatricians play a key role throughout the process. The role of percutaneous ablative treatment should be better defined in elderly patients. However, given their low specific mortality, surveillance of SRM (at least initially) is probably an interesting option, certainly under-used, although its impact on quality of life remains to be clarified. The overarching goal of geriatric oncology must guide the decisions of care in the older patient with CaR: first, the respect of patient-specific expectations and secondly the search for an overall clinical benefit; objectives that have no reason to be restricted to elderly patients.

CONCLUSION

RCC is becoming a predominantly elderly cancer. It responds to the current general diagnostic and therapeutic guidelines. It is desirable that clinical research help to better define the respective roles of percutaneous biopsy and treatment of localized 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.

Quality assessment of kidney cancer clinical practice guidelines using AGREE II instrument: A critical review

BACKGROUND

Evidence-based guidelines are expected to provide clinicians with explicit recommendations on how to manage health conditions and bridge the gap between research and clinical practice. However, the existing practice guidelines(CPGs) vary in quality. This study aimed to evaluate the quality of CPGs of kidney cancer.

METHODS

We systematically searched PubMed, Embase, China Biology Medicine disc, and relevant guideline websites from their inception to April, 2018. We identified CGPs that provided recommendations on kidney cancer; 4 independent reviewers assessed the eligible CGPs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The consistency of evaluations was calculated using intraclass correlation coefficients (ICC).

RESULTS

A total of 13 kidney cancer CGPs were included. The mean scores for each AGREEII domain were as follows: scope and purpose-76.9%; clarity and presentation-76.4%; stakeholder involvement-62.8%; rigor of development-58.7%; editorial independence-53.7%; and applicability-49.4%. Two CPGs were rated as "recommended"; 8 as "recommended with modifications"; and 3 as "not recommended." Seven grading systems were used by kidney cancer CGPs to rate the level of evidence and the strength of recommendation.

CONCLUSIONS

Overall, the quality of CPGs of kidney cancer is suboptimal. AGREE II assessment results highlight the need to improve CPG development processes, editorial independence, and applicability in this field. It is necessary to develop a standardized grading system to provide clear information about the level of evidence and the strength of recommendation for future kidney cancer CGPs.

Development and validation of CT imaging-based preoperative nomogram in the prediction of unfavorable high-grade small renal masses

PURPOSE

In recent years, there has been an increase in the incidence of small renal masses (SRMs) and nephrectomy was the standard management of this disease in the past. Currently, the use of active surveillance has been recommended as an alternative option in the case of some patients with SRMs due to its heterogenicity. However, limited studies focused on the regarding risk stratification. Therefore, in the current study, we developed a nomogram for the purpose of predicting the presence of high-grade SRMs on the basis of the patient information provided (clinical information, hematological indicators, and CT imaging data).

PATIENTS AND METHODS

A total of 329 patients (consisting of development and validation cohort) who had undergone nephrectomy for SRMs between January 2013 and May 2016 retrospectively were recruited for the present study. All preoperative information, including clinical predictors, hematological indicators, and CT predictors, were obtained. Lasso regression model was used for data dimension reduction and feature selection. Multivariable logistic regression analysis was applied for the establishment of the predicting model. The performance of the nomogram was assessed with respect to its calibration and discrimination properties and externally validated.

RESULTS

The predictors used in the assessment of the nomogram included tumor size, CT tumor contour, CT necrosis, CT tumor exophytic properties, and CT collecting system oppression. Based on these parameters, the nomogram was evaluated to have an effective discrimination and calibration ability, and the C-index was found to be 0.883 after internal validation and 0.887 following external validation.

CONCLUSION

Based on the aforementioned findings, it can be concluded that CT imaging-based preoperative nomogram is an effective predictor of SRMs and hence can be used in the preoperative evaluation of SRMs, due to its calibration and discrimination abilities.

Single-Fiber Laser Ablation in Treating Selected Metastatic Lymph Nodes of Papillary Thyroid Carcinoma and Benign Cold Thyroid Nodules-Preliminary Results

Background and Objectives

To evaluate the feasibility and efficacy of single‐fiber laser ablation (LA) under ultrasound guidance and appropriate ablation modes in the treatment of selected metastatic lymph nodes of papillary thyroid carcinoma (PTC) and benign cold thyroid nodules

Study Design/Materials and Methods

A total of 18 patients (consisting of 8 patients with 18 metastatic lymph nodes of PTC and 10 patients with 10 benign cold thyroid nodules) each underwent one session of single‐fiber LA under ultrasound guidance. On the basis of the sizes of the nodules, the ablation modes were chosen accordingly. The single‐dot ablation mode was used in the nodules with three orthogonal diameters measuring no greater than 10 mm in diameter, with a dot, a level and an insertion. The double‐dots overlapping ablation mode was used in the nodules with the largest diameters measuring greater than 10 mm (in which the nodules measured no more than 15 mm in diameter and with the other two perpendicular diameters measuring no greater than 10 mm in diameter) with two dots, a level and two insertions. The multiple levels and dots overlapping ablation mode was used in the nodules with the three orthogonal diameters all measuring larger than 10 mm, with multiple dots, levels and insertions.

Results

After 12 months of follow‐up in the treated nodules of the metastatic lymph nodes of PTC and benign cold thyroid nodules, the mean baseline volumes decreased from 0.29 ± 0.12  to 0.03 ± 0.03 ml and 3.85 ± 0.64 to 1.1 ± 0.37 ml, respectively, and the mean volume reduction ratios (VRRs), which was calculated as {[(initial volume−final volume) × 100%]/initial volume}, were 90.3 ± 7.6% and 72 ± 5.8%, respectively. There were six ablative zones that completely disappeared, whereas the ablative zones that still existed presented as scar‐like areas or small hyperechoic areas that were compatible with scar tissue among the 18 malignant nodules at the last follow‐up.

Conclusions

Single‐fiber LA under ultrasound guidance, with the appropriate ablation modes, is feasible and effective for the treatment of selected metastatic lymph nodes of PTC and benign cold thyroid nodules. This study suggests that single‐fiber LA may be applied to selected cases with appropriate ablation modes. Lasers Surg. Med. 2019 © 2019 Wiley Periodicals, Inc.

Percutaneous image-guided ablation: From techniques to treatments

Image-guided ablation is performed by percutaneously introducing ablation probes to deliver energy into a tumor to destroy it in a controlled and localized fashion. Ablation modalities can be broadly classified as thermal or non-thermal based on the mechanism of tumor destruction and are performed using different types of image guidance for planning, delivering and follow-up of the treatment. Ablation is performed in a minimally invasive fashion, providing greater residual organ preservation with minimal morbidity to the patient. Image-guided ablation is being used in the clinic for the treatment of primary and metastatic tumors, and this article reviews state of the art for the treatment of malignancies in the liver, lung, kidney and musculoskeletal tissue.

Percutaneous image-guided renal ablations: Current evidences for long-term oncologic efficacy

The rise in incidentally discovered small renal neoplasms has focused attention on nephron-sparing treatment strategies including partial nephrectomy and percutaneous ablation as well as active surveillance. As all treatment modality, renal ablation has matured technically. Radiofrequency ablation, microwave ablation or cryoablation are now performed in many institutions under imaging guidance. The long-term results allow them to be now recommended as a therapeutic option whatever the patients' condition if complete ablation can reliably be achieved.

Systematic Review of Contemporary Evidence for the Management of T1 Renal Cell Carcinoma: What IRs Need to Know for Kidney Cancer Tumor Boards

Renal cell carcinoma is a relatively common malignancy, with 60 to 70 thousand cases a year in the United States alone. Increased utilization of cross-sectional imaging has led to an increase in the number of early renal cell cancers seen by the medical establishment. In addition, certain patient populations have an increased risk of developing kidney cancers which may mandate aggressive screening protocols. This article discusses the epidemiology of renal cell cancers; discusses the current management guidelines from multiple specialty societies; discusses some of the surgical and interventional techniques used in the treatment of such lesions; and provides a review of the literature regarding treatments of early-stage renal cell cancers.

Percutaneous renal biopsy: approach, diagnostic accuracy and risks

PURPOSE OF REVIEW

This article provides a review of recent advances and issues regarding the controversial topic of renal mass biopsy (RMB). The purpose of this review is to provide an update on the current status of renal biopsy based on recently published literature. Here, we particularly focus on articles that have been published within the last 12 months.

RECENT FINDINGS

The main topics covered in this review are the approach, diagnostic accuracy and risks related to RMB.

SUMMARY

Current literature suggests that improvements in both technique and technological advancements of RMB have led to greater diagnostic accuracy and low risks to the patient. Newer technologies are leading toward innovative and harmless ways to diagnose kidney cancer, including liquid and image-based biopsy. However, it appears that the question of whether or not to instate renal biopsy as standard clinical practice has remained a highly debated controversy.

Roles for active surveillance in renal cancer

PURPOSE OF REVIEW

With this review, we describe the most recent advances in active surveillance as well as diagnosis and management of small renal masses (SRMs).

RECENT FINDINGS

We discuss diagnosis, differentiation of solid from cystic lesions, risk prediction and treatment of the SRM. A better understanding of the disease facilitates the use of more conservatory treatments, such as active surveillance. Active surveillance has been increasingly accepted not only for SRM, but also for larger tumors and even metastatic patients. Exiting advances in risk prediction will help us define which patients can be safely managed with active surveillance and which require immediate treatment. Meanwhile, the use of renal tumor biopsies is still an important tool for these cases.

SUMMARY

Active surveillance is an option for many patients with renal masses. Noninvasive methods for diagnosis and risk prediction are being developed, but meanwhile, renal tumor biopsy is a useful tool. A better understanding of the disease increases the number of patients who can undergo active surveillance fully certain of the safety of their management.

Intratumoural renal cell carcinoma haemorrhage following stereotactic radiotherapy: a case report

BACKGROUND

Stereotactic radiotherapy is an emerging treatment option for patients with inoperable renal cell carcinoma (RCC). Haemorrhage has not previously been reported to occur as a result of Stereotactic Body Radiotherapy (SBRT) to the kidney for primary RCC. We report an acute haemorrhage in a patient who received only one of three planned fractions of SBRT as part of a clinical trial.

CASE PRESENTATION

A 74 year old female had a left renal mass under observation for 4 years, during which time she was imaged repeatedly using ultrasound and CT scans. There has been no evidence of metastases, and the lesion has demonstrated a steady pattern of growth over the 4-year period. Fine needle aspiration histologically confirmed RCC. Following a multidisciplinary review, the patient was recommended for SBRT as she was not considered a surgical candidate. Treatment was planned for an ablative 42Gray (Gy) to be delivered in 3 fractions at 14Gy/fraction as part of a clinical trial. Our patient presented to the emergency department (ED) suffering left flank pain, fever and vomiting within 3 h of the first fraction of SBRT. CT showed the mass to have markedly increased in size, measuring 8.7 × 8.1 × 7.0 cm, from 6.5 × 5.4 × 5.6 cm. It was reported as an internal haemorrhage into the malignancy. The patient was admitted for analgesia, anti-pyretics, and transfusion of 2 units of packed red blood cells. The patient recovered without any further intervention but radiotherapy was discontinued. The patient was alive and free from disease progression two years after the aborted treatment.

CONCLUSION

Such events, though rare, are potentially serious, and therefore clinicians should be aware of such treatment related complications.

Management of small renal masses: An interventional radiologist's perspective

Renal cell carcinoma is relatively common malignancy. Its imaging features are often non-specific and can present a diagnostic dilemma for clinicians. Historically, all patients with a renal mass underwent radical nephrectomy. Advances in technology have allowed for an increase in partial nephrectomies and percutaneous ablations. This essay briefly describes some of the imaging findings of renal cell carcinoma and several of its mimics followed by an in-depth review of procedural management with a particular focus on recent advancements.

Oncologic Outcomes Following Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses

BACKGROUND

Long-term data comparing partial nephrectomy (PN) and thermal ablation are lacking.

OBJECTIVE

To update our experience with PN, percutaneous radiofrequency ablation (RFA), and percutaneous cryoablation for cT1 renal masses.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1798 patients with primary cT1N0M0 renal masses treated between 2000 and 2011 at Mayo Clinic were identified.

INTERVENTION

Percutaneous ablation versus PN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Local recurrence, metastases, and death from renal cell carcinoma (RCC) were compared with propensity-score-adjusted Cox models.

RESULTS AND LIMITATIONS

Among 1422 cT1a patients, 1055, 180, and 187 underwent PN, RFA, and cryoablation with median clinical follow-up of 9.4, 7.5, and 6.3yr, respectively. Comparisons of RFA with PN resulted in hazard ratios (HRs) of 1.49 (95% confidence interval [CI] 0.55-4.04, p=0.4), 1.46 (95% CI 0.41-5.19, p=0.6), and 1.99 (95% CI 0.29-13.56, p=0.5) for local recurrence, metastases, and death from RCC. Comparisons of cryoablation to PN resulted in HRs of 1.88 (95% CI 0.76-4.66, p=0.18), 0.23 (95% CI 0.03-1.72, p=0.15), and 0.29 (95% CI 0.01-6.11, p=0.4) for these same outcomes. Five-year CSS was 99%, 96%, and 100% for PN, RFA, and cryoablation, respectively. Among 376 cT1b patients, 324 and 52 underwent PN and cryoablation with median clinical follow-up of 8.7 and 6.0yr, respectively. Comparisons of cryoablation with PN resulted in HRs of 1.22 (95% CI 0.33-4.48, p=0.8), 0.95 (95% CI 0.21-4.38, p>0.9), and 1.94 (95% CI 0.42-8.96, p=0.4) for local recurrence, metastases, and death from RCC, respectively. Five-year CSS was 98% and 91% for PN and cryoablation, respectively. Limitations include retrospective review and selection bias.

CONCLUSIONS

With mature follow-up at a single institution, percutaneous ablation appears to have acceptable results for cT1 renal tumors and is appropriate for patients with a contraindication for surgery. For cT1a patients, clinically relevant differences between PN and ablation are unlikely, and treatment choice should involve shared decision making. For cT1b patients, death from RCC was more common with cryoablation, and large differences in this outcome cannot be ruled out. Further research is needed to confirm the oncologic effectiveness of cryoablation in the cT1b setting.

PATIENT SUMMARY

With appropriate patient triage, partial nephrectomy and percutaneous ablation can be used to treat cT1 renal masses, although additional follow-up and further study are still needed.

Surgical treatment for renal masses in the elderly: analysis of oncological, surgical and functional outcomes

PURPOSE

Radical treatment in elderly patients with renal tumor remains debatable due to uncertainties regarding the risk of surgical complications, risk of end-stage renal disease (ESRD) and survival benefit. The aim of the study was to assess outcomes of radical treatment for renal cancer in elderly patients.

MATERIALS AND METHODS

This retrospective analysis enrolled 507 consecutive patients treated with partial or radical nephrectomy due to renal mass. Patients with upfront metastatic disease (n=46) and patients lost to follow-up (n=110) were excluded from the analysis. Surgical, functional (screen for ESRD development) and survival outcomes were analyzed in patients aged >75 years in comparison to younger individuals.

RESULTS

The analyzed group included 55 elderly patients and 296 younger controls. Within the cohort a total of 148 and 203 patients underwent radical and partial nephrectomies respectively. The rate of surgical complications, including grade >3 Clavien- Dindo complications, did not differ between groups (3.6% vs. 4.4%, p=0.63). Median length of hospital stay was equal in both groups (7 days). During a follow-up (median 51.9 months, no difference between groups), ESRD occurred in 3.4% of controls and was not reported in elderly group (p=0.37). Younger patients demonstrated a statistically significant advantage in both overall survival and cancer-specific survival over elderly patients (OS 94.6% vs. 87% p=0.036, CSS 97.3% vs. 89.1% p=0.0008).

CONCLUSIONS

Surgical treatment in elderly patients with renal tumor is as safe as in younger individuals and does not increase the risk of ESRD. However, cancer specific survival among these patients remains shorter than in younger patients.

Accuracy of renal tumour biopsy for the diagnosis and subtyping of papillary renal cell carcinoma: analysis of paired biopsy and nephrectomy specimens with focus on discordant cases

Aims

Renal tumour biopsy (RTB) is increasingly recognised as a useful diagnostic tool in the management of small renal masses, particularly those that are incidentally found. Intratumoural heterogeneity with respect to morphology, grade and molecular features represents a frequently identified limitation to the use of RTB. While previous studies have evaluated pathological correlation between RTB and nephrectomy, no studies to date have focused specifically on the role of RTB for the diagnosis of papillary renal cell carcinoma (PRCC) and its further subclassification into clinically relevant subtypes.

Methods

This single-institution study evaluated 60 cases of PRCC for concordance between RTB and nephrectomy with respect to diagnosis, grading and subtyping (type 1/type 2).

Results

We observed 93% concordance (55 of 59 evaluable cases) between RTB and nephrectomy for the diagnosis of PRCC, although seven tumours (12%) were undergraded on RTB. Subtyping of PRCC on RTB was concordant with nephrectomy in 89% of cases reported as type 1 PRCC on RTB (31/35), but only 40% of cases reported as type 2 PRCC on RTB (4/10). Morphological misclassification of PRCC on RTB was most likely to occur in tumours showing a solid growth pattern. Discordant PRCC subtyping most often occurred in tumours with eosinophilia/oncocytic change.

Conclusion

There was good concordance between RTB and nephrectomy for the primary diagnosis of PRCC. Although further subtyping of PRCC can aid therapeutic stratification, this can be challenging on RTB and tumours with overlapping or ambiguous features are best reported as PRCC not otherwise specified pending development of more robust methods to facilitate definitive subclassification.

Periprocedural outcome after laparoscopic partial nephrectomy versus radiofrequency ablation for T1 renal tumors: a modified R.E.N.A.L nephrometry score adjusted comparison

BACKGROUND

Comparable oncological outcomes have been seen after surgical nephrectomy and thermal ablation of renal tumors recently. However, periprocedural outcome needs to be assessed for aiding treatment decision.

PURPOSE

To compare efficacy rates and periprocedural outcome (technical success, session time, hospitalization time, and complications) after renal tumor treatment with laparoscopic partial nephrectomy (LPN) or radiofrequency ablation (RFA).

MATERIAL AND METHODS

The initial experience with 49 (treated with LPN) and 84 (treated with RFA) consecutive patients for a single renal tumor (diameter ≤ 5 cm, limited to the kidney) during 2007-2014 was evaluated. Patient and tumor characteristics, efficacy rates, and periprocedural outcome were collected retrospectively. The stratified Mantel Haenzel and Van Elteren tests, adjusted for tumor complexity (with the modified R.E.N.A.L nephrometry score [m-RNS]), were used to assess differences in treatment outcomes.

RESULTS

Primary efficacy rate was 98% for LPN and 85.7% for RFA; secondary efficacy rate was 93.9% for LPN and 95.2% for RFA; and technical success rate was 87.8% for LPN and 100% for RFA. Median session (m-RNS adjusted P < 0.001; LPN 215 min, RFA 137 min) and median hospitalization time were longer after LPN (m-RNS adjusted P < 0.001; LPN 5 days, RFA 2 days). Side effects were uncommon (LPN 2%, RFA 4.8%). Complications were more frequent after LPN (m-RNS adjusted P < 0.001; LPN 42.9%, RFA 10.7%).

CONCLUSION

Both methods achieved equivalent secondary efficacy rates. RFA included several treatment sessions, but session and hospitalization times were shorter, and complications were less frequent than for LPN. The differences remained after adjustment for renal tumor complexity.

Yield of Routine Image-Guided Biopsy of Renal Mass Thermal Ablation Zones: 11-Year Experience

PURPOSE

To determine the yield of routine image-guided core biopsy of renal cell carcinoma (RCC) thermal ablation zones.

METHODS

Institutional review board approval was obtained for this Health Insurance Portability and Accountability Act-compliant quality improvement effort. Routine core biopsy of RCC ablation zones was performed 2 months postablation from July 2003 to December 2014. Routine nicotinamide adenine dinucleotide staining was performed by specialized genitourinary pathologists to assess cell viability. The original purpose of performing routine postablation biopsy was to verify, in addition to imaging, whether the mass was completely treated. Imaging was stratified as negative, indeterminate, or positive for viable malignancy. Histology was stratified as negative, indeterminate, positive, or nondiagnostic for viable malignancy. Histology results were compared to prebiopsy imaging findings.

RESULTS

Routine ablation zone biopsy was performed after 50% (146/292) of index ablations (24 cryoablations, 122 radiofrequency ablations), and postablation imaging was performed more often with multiphasic computed tomography than magnetic resonance imaging (100 vs 46, p < 0.0001). When imaging was negative (n = 117), biopsy added no additional information (92% [n = 108] negative, 0.9% [n = 1] indeterminate, 7% [n = 8] nondiagnostic). When imaging was indeterminate (n = 19), 11% (n = 2) of biopsies had viable RCC and 89% (n = 17) were negative. When imaging was positive, biopsy detected viable neoplasm in only 10% (1/10) of cases; 80% (8/10) were negative and 10% (1/10) were nondiagnostic.

CONCLUSION

Routine biopsy of renal ablation zones to validate postablation imaging results was not value-added and therefore was discontinued at the study institution.

Patient-Reported Outcomes After Percutaneous Renal Ablation: Initial Experience

OBJECTIVE

The purpose of this study is to assess patient-reported outcomes after renal tumor ablation.

MATERIALS AND METHODS

A retrospective review of a pilot quality initiative from February 2016 to April 2016 in our renal ablation practice was performed to assess outcomes after treatment. This included a total of 38 patients (mean age, 63 years; range, 39-83 years) undergoing renal ablation procedures. This pilot included the quantification of recovery, pain, physical well-being, interference with social activities, and physical function as reported by the patient, including measures obtained from the National Institutes of Health's Patient-Reported Outcome Measurement Information System (PROMIS). Such measures were obtained within 24 hours before ablation and days 1-7 and 30 after ablation.

RESULTS

The mean numeric rating (0-10) pain scores at 1 and 2 days after treatment were 1.8 (SD, 2.3) and 2.6 (SD, 2.5). Similarly, mean scores for both overall physical well-being and social activities declined by less than 2 points in the days after ablation. PROMIS scales for physical function and social activities showed very little change from baseline. Nearly 50% of patients thought that they had completely recovered from the ablation on the day after treatment; this perception of recovery declined at days 3-5 and then increased to 89% at 30 days after ablation.

CONCLUSION

This pilot study shows the feasibility of capturing patient-reported outcomes after renal ablation. Such information, particularly when collected from a broader patient population, will be valuable in providing a means to measure quality in the ablation practice and in improving patient education regarding treatment.

Organ-sparing procedures in GU cancer: part 1-organ-sparing procedures in renal and adrenal tumors: a systematic review

PURPOSE

Organ-sparing surgery (OSS) for the kidney and adrenals has emerged as the need for preservation of function is paramount in patients with poor functional reserve. As reports increasingly showed that oncological outcomes were equivalent to radical excision, elective OSS became a viable alternative in patients with otherwise normal reserve. In this review, we summarize the current knowledge of OSS for adrenal and renal tumors.

MATERIALS AND METHODS

PubMed, Web of Science and Cochrane Library Central Search were searched for recently published articles up to December 2017. The following keywords were used; "partial adrenalectomy", "adrenal sparing", "partial nephrectomy", "nephron sparing", "kidney/renal cancer".

RESULTS

Partial adrenalectomy became an attractive alternative to total adrenalectomy avoiding adrenal insufficiency. Both minimally invasive surgery and ablative techniques were increasingly reported for adrenal OSS with adequate residual adrenal function and excellent oncological outcome. Radical nephrectomy remained for many years as the gold standard of treatment for organ-confined renal cell carcinoma. As the need to reduce the impact on renal function, more conservative approaches were utilized. Soon, the non-inferiority of nephron-sparing surgery to that of radical excision became evident and elective partial nephrectomy was gaining ground as the standard of care for small renal masses in patients with normal contralateral kidneys.

CONCLUSIONS

Herein, we present a comprehensive review of the current status of OSS in renal and adrenal tumors.

Current Management of Small Renal Masses, Including Patient Selection, Renal Tumor Biopsy, Active Surveillance, and Thermal Ablation

Renal cancer represents 2% to 3% of all cancers, and its incidence is rising. The increased use of ultrasonography and cross-sectional imaging has resulted in the clinical dilemma of incidentally detected small renal masses (SRMs). SRMs represent a heterogeneous group of tumors that span the full spectrum of metastatic potential, including benign, indolent, and more aggressive tumors. Currently, no composite model or biomarker exists that accurately predicts the diagnosis of kidney cancer before treatment selection, and the use of renal mass biopsy remains controversial. The management of SRMs has changed dramatically over the last two decades as our understanding of tumor biology and competing risks of mortality in this population has improved. In this review, we critically assess published consensus guidelines and recent literature on the diagnosis and management of SRMs, with a focus on patient treatment selection and use of renal mass biopsy, active surveillance, and thermal ablation. Finally, we highlight important opportunities for leveraging recent research discoveries to identify patients with SRMs at high risk for renal cell carcinoma-related mortality and minimize overtreatment and patient morbidity.

Assessment of multiphasic contrast-enhanced MR textures in differentiating small renal mass subtypes

PURPOSE

This study seeks to evaluate the use of quantitative texture parameters extracted from multiphasic contrast-enhanced magnetic resonance (MR) imaging in differentiating between benign and malignant masses (oncocytoma vs. clear cell and papillary RCC) and between common subtypes of renal cell carcinoma (clear cell vs. papillary RCC) in small renal masses (< 4 cm).

METHOD

One-hundred and forty-two renal lesions (90 clear cell and 22 papillary RCCs; 30 oncocytomas) were identified in a cohort of 41 patients (18 men, 23 women: mean age, 52.8 ± 14.4 years) who underwent preoperative multiphasic contrast-enhanced MR with four phases (unenhanced, arterial, venous, and delayed) between 2015 and 2016. In this study, texture features were extracted from entire cross-sectional tumoral region in three consecutive slices containing the largest cross-sectional area from each of the four phases. The change in imaging feature between precontrast imaging and each postcontrast phase was calculated. Data dimension reduction and feature selection were performed by conducting (1) pairwise Wilcoxon rank test followed by modified false discovery rate adjustment, and (2) Lasso regression. Multivariate modeling incorporating the selected features was performed using random forest classification method.

RESULTS

Histogram imaging features were informative variables in differentiating between benign and malignant masses, while textures imaging features were of added value in differentiating between subtypes of RCCs. Papillary RCCs were distinguished from clear cell RCCs (sensitivity 65.5%, specificity 88%, and accuracy 77.9%), oncocytomas from clear cell RCCs (sensitivity 67.3%, specificity 88.9%, and accuracy 79.3%), and oncocytomas from papillary and clear cell RCCs (sensitivity 64.7%, specificity 85.9%, and accuracy 77.9%).

CONCLUSIONS

A combination of histogram and texture imaging features on multiphasic MR can help differentiate histologic cell types in common small renal masses (< 4 cm).

Suture techniques during laparoscopic and robot-assisted partial nephrectomy: a systematic review and quantitative synthesis of peri-operative outcomes

OBJECTIVE

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri-operative outcomes after minimally invasive partial nephrectomy (MIPN).

MATERIALS AND METHODS

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot-assisted partial nephrectomy and comparative studies focused on peri-operative outcomes were included in qualitative and quantitative analyses, respectively.

RESULTS

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon's experience, robot-assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non-barbed suture. The single-layer suture technique was associated with shorter operating and ischaemia time than the double-layer technique. No comparisons were possible concerning renal functional outcomes because of non-homogeneous data reporting.

CONCLUSIONS

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double-layer suture.

Update on the biology and management of renal cell carcinoma

Renal cell cancer (RCC) (epithelial carcinoma of the kidney) represents 2%-4% of newly diagnosed adult tumors. Over the past 2 decades, RCC has been better characterized clinically and molecularly. It is a heterogeneous disease, with multiple subtypes, each with characteristic histology, genetics, molecular profiles, and biologic behavior. Tremendous heterogeneity has been identified with many distinct subtypes characterized. There are clinical questions to be addressed at every stage of this disease, and new targets being identified for therapeutic development. The unique characteristics of the clinical presentations of RCC have led to both questions and opportunities for improvement in management. Advances in targeted drug development and understanding of immunologic control of RCC are leading to a number of new clinical trials and regimens for advanced disease, with the goal of achieving long-term disease-free survival, as has been achieved in a proportion of such patients historically. RCC management is a promising area of ongoing clinical investigation.