[Epidemiology and diagnostic assessment of small renal masses]

Comparison of the Results of Therapy for cT1 Renal Carcinoma with Nephron-Sparing Surgery (NSS) vs. Percutaneous Thermal Ablation (TA)

Implementation of ultrasonography (USG), computed tomography (CT) and magnetic resonance imaging (MRI) into abdominal cavity diagnostics enabled early detection of cT1 graded renal cancers. According to European Association of Urology (EAU) and Polish urological Association (PUA) recommended method of treatment is sparing resection of renal parenchyma with tumour—nephron-sparing surgery (NSS). In selected cases other methods such as thermal ablation (TA) or cryoablation can be introduced /1/. Objectives: To evaluate the results of treatment of cT1 renal tumours with the use of NSS and TA methods. Material and methods: 140 patients with cT1 renal carcinoma were treated in 2nd Department of Urology of Medical University of Lodz between 2014 and 2017. Neuron-sparing surgery was performed in 56 cases (40%), while percutane-ous thermal ablation (TA) in 84 cases (60%). Demographic data, clinical data (lab results, Charlson index), nephrometry data (tumour size, location, R.E.N.A.L. score) post-operative data (Clavien-Dindo classifica-tion) were investigated. Histopathology results, Fuhrman malignancy grading, as total three-year survival of patients were evaluated. The following methods were used for statistical evaluation: Chi2, Fisher, W Shapiro-Wilk, U Mann-Whitney tests, Kaplan-Meier’s curve and Cox model. The results were displayed in a form of median and upper and lower quartile values (25–75%). Results: No statistical differences in gender nor left/right kidney location were observed. Patients, who underwent TA were at average 10 years older and had multiple comorbidities (median age for TA was 79, for NSS 68; median Charlson index for TA was 5 and for NSS was 3). TA patients had lesser haematological values (Hb, Ht). R.E.N.A.L. scoring demonstrated comparable nephrometry in both groups. NSS procedure was open laparotomy without temporary clamping of renal vessels. Surgical margins of resected tumours were negative. TA was performed with Cool-Tip Covidienequipment with the use of Cluster electrode and was ultraso-nography-guided. Post-treatment complications evaluated with the use of Clavien-Dindo classification were slightly more frequent for NSS method. Patients after NSS were discharged at average after 8.5 days and after TA after 3 days. Histopathological type and Fuhrman malignancy grading were comparable in both groups. TA treated patients’ death risk was 9-fold of that observed in NSS treated patients. There was 1 death for each group in perioperative period. Conclusion: 1. NSS was associated with slightly higher side effect rate but resulted in prolonged survival. 2. TA was applied to elderly patients with comorbidities. Despite less invasive treatment this group had poorer/reduced survival. 3. Charlson Comorbidity Index (CCI) and the treatment method were relevant survival factors in patients treated due to cT1 renal cancer tumours.

A Systematic Review and Meta-Analysis of Comparison of Outcomes of Robot-Assisted versus Open Partial Nephrectomy in Clinical T1 Renal Cell Carcinoma Patients

INTRODUCTION

Robot-assisted partial nephrectomy (RAPN) has been increasingly used for renal cell carcinoma in recent years. But the advantages of RARN over open partial nephrectomy (OPN) are still controversial.

METHODS

We searched the articles between 1997 and 2021 in PubMed, Web of Science, Cochrane Library, and EMbase databases. The parameters were perioperative outcomes including operating time (OT), warm ischemic time (WIT), estimated blood loss (EBL), positive surgical margin (PSM), preoperative and postoperative estimated glomerular filtration rate (eGFR), length of stay (LOS), and intraoperative and postoperative complications. Stata 13.0 software was used for the meta-analysis.

RESULTS

Seven studies with 2,646 patients (1,285 in RAPN vs. 1,361 in OPN) were included in the analysis. There were no significant differences in OT (WMD [95% confidence interval (CI)]: 0.14 [-0.33, 0.61], p = 0.570); WIT (WMD [95% CI]:0.28 [-0.13, 0.69], p = 0.187); PSM (odds ratio [OR] [95% CI]: 1.04 [0.37, 2.94], p = 0.944); preoperative eGFR (OR [95% CI]: 0.11 [-0.01, 0.23], p = 0.071); postoperative eGFR (OR [95% CI]: -0.11 [0.27, 0.04], p = 0.159); and intraoperative complications (OR [95% CI]: 0.13 [0.02, 1.04], p = 0.055) between 2 groups. But there were still less EBL (WMD [95% CI]: -0.67 [-1.07, -0.28], p = 0.001), shorter LOS (WMD [95% CI]: -1.09 [-1.86, -0.32], p = 0.005) and fewer postoperative complications (OR [95% CI]: 0.51 [0.38, 0.68], p = 0.000).

CONCLUSIONS

Compared with OPN, RAPN appears to achieve partly similar short-term functional outcomes. Meanwhile, some results are inconsistent with previous studies which seem to show that tumor type is also an important factor in comparison between RAPN and OPN, but the analysis is not carried out due to lack of complete data. Therefore, more high-quality random controlled trials are acquired.

Neutrophil-lymphocyte ratio as a prognostic factor for minute clear cell renal cell carcinoma diagnosed using multi-slice spiral CT

Minute clear cell renal cell carcinoma (MccRCC) has a diameter of <1.5 cm and can be diagnosed using multi-slice spiral CT (MSCT). Recently, the role of the neutrophil-lymphocyte ratio (NLR) in the development of MccRCC has attracted attention. This study aimed to further explore the relationship between the NLR and MccRCC.This was a prospective study of 100 patients who were diagnosed with MccRCC using MSCT at Urumqi Friendship Hospital, China. The study investigated a series of pretreatment factors, including NLR and patients' general clinical data. Statistical methods employed included Pearson's chi-square test, Spearman-rho correlation test, Cox regression analysis, and receiver operator characteristic curve analysis.Based on Pearson's χ2, Spearman-rho test, and univariate/multivariate Cox regression analysis, the overall survival of patients with MccRCC was shown to be significantly related to NLR (P < .001). NLR (hazard ratio = 50.676, 95%CI, 17.543-146.390, P < .001) is a significant independent risk-factor for MccRCC. A receiver operator characteristic curve was plotted to examine specificity and sensitivity between NLR and MccRCC (area under curve = 0.958, P < .001).The level of the NLR plays a crucial role in the survival of patients with MccRCC, as diagnosed with MSCT. The higher the NLR, the worse the prognosis for patients with MccRCC.

Consideration in the management of renal cell carcinoma during the COVID-19 Pandemic

Introduction:

Recently the COVID-19 pandemic became the main global priority; main efforts and health infrastructures have been prioritized in favor of COVID-19 battle and the treatment of benign diseases has been postponed. Renal cell cancer (RCC) patients configure a heterogenous populations: some of them present indolent cases which can safely have postponed their treatments, others present aggressive tumors, deserving immediate care. These scenarios must be properly identified before a tailored therapeutic choice.

Objectives

We propose a risk- based approach for patients with RCC, to be used during this unprecedented viral infection time.

Materials and Methods:

After a literature review focused in COVID-19 and current RCC treatments, we suggest therapeutic strategies of RCC in two sections: surgical approach and systemic therapy, in all stages of this malignance.

Results:

Patients with cT1a tumors (and complex cysts, Bosniak III/IV), must be put under active surveillance and delayed intervention. cT1b-T2a/b cases must be managed by partial or radical nephrectomy, some selected T1b-T2a (≤7cm) cases can have the surgery postponed by 60-90 days). Locally advanced tumors (≥cT3 and or N+) must be promptly resected. As possible, minimally invasive surgery and early hospital discharge are encouraged. Upfront cytoreduction, is not recommendable for low risk oligometastatic patients, which must start systemic treatment or even could be put under surveillance and delayed therapy. Intermediate and poor risk metastatic patients must start target therapy and/or immunotherapy (few good responders intermediate cases can have postponed cytoreduction). The recommendation about hereditary RCC syndromes are lacking, thus we recommend its usual care. Local or loco regional recurrence must have individualized approaches. For all cases, we suggest the application of a specific informed consent and a shared therapeutic choice.

Conclusion:

In the pandemic COVID -19 times, a tailored risk-based approach must be used for a safe management of RCC, aiming to not compromise the oncological outcomes of the patients.

Association of Hypertension and Blood Pressure With Kidney Cancer Risk: A Nationwide Population-Based Cohort Study

Data regarding health behavior-related factors and systolic or diastolic blood pressure to evaluate the association between blood pressure and kidney cancer are lacking. Using nationally representative data from the Korean National Health Insurance System, 9 746 445 participants without kidney cancer between January 1, 2006 and December 31, 2009 were followed up until December 31, 2017 to obtain data regarding cancer incidence. Participants were categorized, according to blood pressure, as normal (<120/80 mm Hg), elevated (120-129/<80 mm Hg), and hypertensive (≥130/80 mm Hg) with or without antihypertensive medication, according to the 2017 American College of Cardiology and American Heart Association blood pressure guidelines. Kidney cancer was noted in 11 083 participants during the 8-year follow-up. Participants with hypertension were at higher risk for kidney cancer than those without hypertension. Participants with hypertension using medication had a higher cancer risk than those not using medication and those with elevated blood pressure. The risk of kidney cancer significantly increased with higher systolic or diastolic blood pressure, in a dose-dependent manner, even after adjusting for antihypertensive medication use. Therefore, hypertension and high systolic or diastolic blood pressure, compared with normal blood pressure, were associated with an increased risk of kidney cancer.

The independent indicators for differentiating renal cell carcinoma from renal angiomyolipoma by contrast-enhanced ultrasound

Background

The value of contrast-enhanced ultrasound (CEUS) in differentiating between renal cell carcinoma (RCC) and angiomyolipoma (AML) was analyzed. The purpose of this study was to identify the independent indicators of CEUS for predicting RCC.

Methods

A total of 172 renal tumors (150 RCCs, 22 AMLs) in 165 patients underwent conventional ultrasound (CUS) and CEUS examinations before radical or partial nephrectomy, and the features on CUS and CEUS were analyzed.

Results

There were significant differences in echogenicity, blood flow signals in color Doppler flow imaging (CDFI), peak intensity, homogeneity of enhancement, wash in, wash out, and perilesional rim-like enhancement between RCC and AML (P < 0.05 for all). Multivariate analysis indicated that perilesional rim-like enhancement (P = 0.035, odds ratio [OR] = 9.907, 95% confidence interval [CI]: 1.169–83.971) and fast wash out (P = 0.001, OR = 9.755, 95%[CI]: 2.497–38.115) were independent indicators for predicting RCC. The area under the receiver operating characteristic (ROC) curve (AUC) for perilesional rim-like enhancement was 0.838 (95% CI: 0.774–0.890) with 76.7% sensitivity and 90.9% specificity, while the AUC of fast wash out was 0.833 (95% CI:0.768–0.885) with 74.7% sensitivity and 81.8% specificity.

Conclusions

This study indicated that CEUS has value in differentiating RCC and AML. Present perilesional rim-like enhancement and fast wash out may be important indicators for predicting RCC.

Does renal mass biopsy influence multidisciplinary treatment recommendations?

Purpose: To examine how a multidisciplinary team approach incorporating renal mass biopsy (RMB) into decision making changes the management strategy.Methods: A multidisciplinary team comprised of a radiology proceduralist, a pathologist and urologists convened monthly for renal mass conference with a structured presentation of patient demographics, co-mborbidities, tumor pathology, laboratory and radiographic features. Biopsy protocol was standardized to an 18-gauge core needle biopsy using a sheathed apparatus under renal ultrasound guidance. Biopsy diagnostic rate, and concordance with nephrectomy specimens were summarized. Descriptive statistics were used to evaluate influence of RMB on management decisions.Results: A total of 83 patients with a ≤4 cm mass were discussed, and 66% of patients underwent RMB. Of those, 87% were diagnostic with 9% of core biopsies showing benign pathology. Active surveillance (AS) was recommended for 34% of patients with biopsy data as compared to 64% of those without biopsy. Ablation was recommended for 38% of the biopsy cohort compared to 7% without biopsy. Partial nephrectomy rates were similar for both cohorts, approximately 17% and 22%, respectively. Our complication rate was 1.5%, with only 1 Clavien-Dindo Grade 2 complication. Histology was concordant in 93% of patients that ultimately underwent partial nephrectomy after biopsy.Conclusions: Over half of our SRM patients underwent a RMB that provided a diagnosis in 85% of cases. RMB aided in shared decision making by providing insight into the biology of renal masses, which helps to guide multidisciplinary management and consideration of nephron sparing options.

Small renal carcinoma: the "when" and "how" of operation, active surveillance, and ablation

Small, locally restricted renal cell carcinoma less than 4 cm in size should ideally be removed operatively by nephron-sparing tumour enucleation (partial kidney resection). In an increasingly elderly population, there is a growing trend toward parallel incidence of renal cell carcinoma and chronic renal insufficiency, with the latter's associated general comorbidities. Thus, for some patients, the risks of the anaesthesia and operation increase, while the advantage in terms of survival decreases. Transcutaneous radio-frequency ablation under local anaesthesia, transcutaneous afterloading high-dose-rate brachytherapy under local anaesthesia, and percutaneous stereotactic ablative radiotherapy may offer a less invasive alternative therapy. Active surveillance is to be regarded as no more than a controlled bridging up to definitive treatment (operation or ablation), while watchful waiting, on account of the lack of prognostic relevance and the symptomatology of renal cell carcinoma, with its comorbidity-related, clearly reduced life expectancy, does not involve any further diagnostic or therapeutic measures.

[Small renal cell carcinoma-active surveillance and ablation]

The incidence of renal cell carcinoma has been rising for years. At the same time there is an increasing prevalence of chronic renal failure with subsequent higher morbidity and shorter life expectancy in those affected. In the last decades the gold standard has thus shifted from radical to partial nephrectomy or tumor enucleation. A treatment alternative can be advantageous for selected patients with high morbidity and an increased risk of complications in anesthesia or surgery. Active surveillance represents a controlled delay in the initiation of treatment with a curative intention. Percutaneous radiofrequency ablation and laparoscopic cryoablation are currently the most commonly used treatment alternatives. Newer ablation procedures, such as high-intensity focused ultrasound, irreversible electroporation, microwave ablation, stereotactic ablative radiotherapy and high-dose brachytherapy have a high potential in some cases but are still considered experimental for the treatment.