Contemporary imaging modalities for the surveillance of patients with renal cell carcinoma

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : prise en charge du cancer du reinFrench ccAFU guidelines – Update 2018–2020: Management of kidney cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article.

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.

The value of "liver windows" settings in the detection of small renal cell carcinomas on unenhanced computed tomography

OBJECTIVE

To assess if "liver window" settings improve the conspicuity of small renal cell carcinomas (RCC).

METHODS

Patients were analysed from our institution's pathology-confirmed RCC database that included the following: (1) stage T1a RCCs, (2) an unenhanced computed tomography (CT) abdomen performed ≤ 6 months before histologic diagnosis, and (3) age ≥ 17 years. Patients with multiple tumours, prior nephrectomy, von Hippel-Lindau disease, and polycystic kidney disease were excluded. The unenhanced CT was analysed, and the tumour locations were confirmed by using corresponding contrast-enhanced CT or magnetic resonance imaging studies. Representative single-slice axial, coronal, and sagittal unenhanced CT images were acquired in "soft tissue windows" (width, 400 Hounsfield unit (HU); level, 40 HU) and liver windows (width, 150 HU; level, 88 HU). In addition, single-slice axial, coronal, and sagittal unenhanced CT images of nontumourous renal tissue (obtained from the same cases) were acquired in soft tissue windows and liver windows. These data sets were randomized, unpaired, and were presented independently to 3 blinded radiologists for analysis. The presence or absence of suspicious findings for tumour was scored on a 5-point confidence scale.

RESULTS

Eighty-three of 415 patients met the study criteria. Receiver operating characteristics (ROC) analysis, t test analysis, and kappa analysis were used. ROC analysis showed statistically superior diagnostic performance for liver windows compared with soft tissue windows (area under the curve of 0.923 vs 0.879; P = .0002). Kappa statistics showed "good" vs "moderate" agreement between readers for liver windows compared with soft tissue windows.

CONCLUSION

Use of liver windows settings improves the detection of small RCCs on the unenhanced CT.

Metastatic renal clear-cell carcinoma to the gallbladder: A radiologist's perspective

Renal-cell carcinoma is the most lethal of all urologic malignancies, with a high metastatic potential. Approximately 25% of patients present with stage IV disease, and up to 40% of patients have disease recurrence after nephrectomy. Computed tomography (CT) is an important imaging modality for initial diagnosis and restaging of this patient population. Although extremely rare, clear-cell renal carcinoma has been reported to metastasize to the gallbladder. We present the case of a 50-year-old man who developed clear-cell renal carcinoma metastases to the contralateral adrenal gland and the gallbladder that were detected at initial restaging with CT scan.

Significance of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography for the postoperative surveillance of advanced renal cell carcinoma

OBJECTIVES

To evaluate the role of (18)F-fluorodeoxyglucose (FDG) positron-emission tomography (PET)/computed tomography (CT) for the surveillance of patients with renal cell carcinoma (RCC) who have a high risk of local recurrence or distant metastasis, by comparing the results with those of conventional imaging methods.

PATIENTS AND METHODS

Sixty-three patients with RCC had conventional imaging studies and FDG PET/CT during the follow-up after surgical treatment. Their pathological stages were T2 in 28 patients, T3a in 14, T3b in 19 and T4 in two; lymph-node or distant metastases were present in 12 patients. Suspicious recurrent or metastatic lesions were confirmed by histopathology or by clinical follow-up. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of conventional surveillance methods and FDG PET/CT were analysed. The difference in the accuracy of FDG PET/CT by nuclear grade and histological subtype of tumours was also assessed.

RESULTS

The FDG PET/CT accurately classified the presence of a recurrence or metastasis in 56 (89%) patients. FDG PET/CT had an 89.5% sensitivity, 83.3% specificity, 77.3% positive predictive value, 92.6% negative predictive value, and 85.7% accuracy in detecting recurrence or metastasis, which was not significantly different from the results with conventional methods. Moreover, the accuracy of the FDG PET/CT by nuclear grade and histological subtypes was not significantly different.

CONCLUSION

For the surveillance of high-risk RCC, FDG PET/CT had results that were as good as conventional methods and were not influenced by the nuclear grades of cancer cells. In addition, it was possible to examine all organ systems in one procedure, and there was no need for contrast agents, that can damage renal function. Therefore, FDG PET/CT might replace conventional methods.

Achados da tomografia computadorizada em metástases pancreáticas do carcinoma de células renais

OBJETIVO: Apresentar os achados da tomografia computadorizada observados em quatro pacientes submetidos a nefrectomia radical por carcinoma de células renais e que apresentaram metástases pancreáticas. MATERIAIS E MÉTODOS: Os quatro pacientes foram submetidos a nefrectomia radical por carcinoma de células renais, estádios T1 (n=2) e T3a (n=2). O intervalo médio entre a nefrectomia e a detecção das metástases foi de oito anos. Dois pacientes apresentaram metástase pancreática solitária (confinada ao pâncreas) e dois apresentaram metástases pancreáticas única e múltiplas, respectivamente, ambos com recorrência tumoral no rim contralateral. RESULTADOS: As metástases pancreáticas foram visualizadas, na tomografia computadorizada, como lesões hipervascularizadas, solitária (n=2), única (n=1) ou múltiplas (n=1). Foi realizada pancreatectomia parcial em dois pacientes com metástase solitária. Estes pacientes estão livres da doença quatro e dois anos após a cirurgia, respectivamente. CONCLUSÃO: Metástases pancreáticas de carcinoma de células renais são raras, podendo ocorrer muitos anos após a apresentação inicial. Metástases pancreáticas múltiplas e metástases pancreáticas associadas a recorrência tumoral no rim contralateral são incomuns. À tomografia computadorizada, as metástases pancreáticas aparecem como lesões hipervascularizadas e solitárias, simulando tumores das ilhotas celulares. O tratamento cirúrgico das lesões solitárias deve ser considerado.

Ki-67 and coagulative tumor necrosis are independent predictors of poor outcome for patients with clear cell renal cell carcinoma and not surrogates for each other

BACKGROUND

Ki-67 is a cell proliferation protein associated with aggressive clear cell renal cell carcinoma (ccRCC). A recent report suggests that Ki-67 may represent a surrogate marker for coagulative tumor necrosis. Thus, the goal was to directly test whether Ki-67 and necrosis convey similar or distinct information for the prognostic assessment of ccRCC.

METHODS

Tumor specimens from 741 consecutively treated patients who underwent surgery for ccRCC between 1990 and 1999 were evaluated. Tumor specimens were assessed for various clinicopathologic features, including levels of tumor cell Ki-67 expression. Associations of these features with death from RCC were evaluated using Cox proportional hazards regression models.

RESULTS

At last follow-up, 396 patients had died, including 238 who died from ccRCC at a median of 2.1 years after surgery. Although tumor cell Ki-67 expression and coagulative tumor necrosis were highly correlated, the prognostic information conveyed by these 2 markers failed to overlap. For the subset of patients with necrotic tumors, high levels of Ki-67 more than doubled the risk of death from RCC (risk ratio, 2.18; 95% confidence interval [CI], 1.52-3.11; P < .001). For patients with tumors lacking necrosis, high levels of Ki-67 expression were similarly correlated with an increased risk of death from RCC (risk ratio, 2.50; 95% CI, 1.66-3.77; P < .001).

CONCLUSIONS

Prognostic information conveyed by Ki-67 and coagulative tumor necrosis are not interchangeable. Thus, Ki-67 and coagulative tumor necrosis should not be treated as surrogates for one another and both of these features should be evaluated when generating outcome predictions for patients with ccRCC.