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Alam R, Yerrapragada A, Wlajnitz T, Watts E, Pallauf M, Enikeev D, Chang P, Wagner AA, McKiernan JM, Pierorazio PM, Allaf ME, Singla N. Evaluation of Growth Rates for Small Renal Masses in Elderly Patients Undergoing Active Surveillance. EUR UROL SUPPL 2023; 50:78-84. [PMID: 37101773 PMCID: PMC10123410 DOI: 10.1016/j.euros.2023.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 03/05/2023] Open
Abstract
Background As the adoption of active surveillance (AS) for small renal masses (SRMs) grows, the number of elderly patients enrolled for a prolonged period of time will increase. However, our understanding of comparative growth rates (GRs) in aging patients with SRMs remains poor. Objective To examine whether particular age cutoffs are associated with an increased GR for patients undergoing AS for SRMs. Design setting and participants We identified all patients with SRMs enrolled in the multi-institutional, prospective Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry since 2009 who elected for AS. Outcome measurements and statistical analysis Two definitions of GR were examined: GR from the initial image (GRi) and GR from the prior image (GRp). Image measurements were dichotomized based on patient age at the time of imaging. Multiple age cutoffs were examined: 65, 70, 75, and 80 yr. Mixed-effect linear regression examined the associations between age and GR, with controlling to account for multiple measurements from the same individual. Results and limitations We examined 2542 measurements from 571 patients. The median age at enrollment was 70.9 yr (interquartile range [IQR] 63.2-77.4) with a median tumor diameter of 1.8 cm (IQR 1.4-2.5). As a continuous variable, age was not associated with GRi (-0.0001 cm/yr, 95% confidence interval [CI] -0.007 to 0.007, p = 0.97) or GRp (0.008 cm/yr, 95% CI -0.004 to 0.020, p = 0.17) after adjustment. The only age thresholds associated with an increased GR were 65 yr for GRi and 70 yr for GRp. Limitations include the one-dimensional nature of the measurements used. Conclusions Increased age for patients on AS for SRMs is not associated with increased GRs. Patient summary We examined whether patients undergoing active surveillance (AS) exhibited accelerated growth of their small renal masses (SRMs) after a certain age. No demonstrable change was seen, suggesting that AS is a safe and durable management option for aging patients with SRMs.
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Affiliation(s)
- Ridwan Alam
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anirudh Yerrapragada
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tina Wlajnitz
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emelia Watts
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Maximilian Pallauf
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Peter Chang
- Division of Urology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andrew A. Wagner
- Division of Urology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - James M. McKiernan
- Department of Urology, Columbia University Medical Center, New York, NY, USA
| | - Phillip M. Pierorazio
- Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamad E. Allaf
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nirmish Singla
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Urine Molecular Biomarkers for Detection and Follow-Up of Small Renal Masses. Int J Mol Sci 2022; 23:ijms232416110. [PMID: 36555747 PMCID: PMC9785854 DOI: 10.3390/ijms232416110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Active surveillance (AS) is the best strategy for small renal masses (SRMs) management; however, reliable methods for early detection and disease aggressiveness prediction are urgently needed. The aim of the present study was to validate DNA methylation biomarkers for non-invasive SRM detection and prognosis. The levels of methylated genes TFAP2B, TAC1, PCDH8, ZNF677, FLRT2, and FBN2 were evaluated in 165 serial urine samples prospectively collected from 39 patients diagnosed with SRM, specifically renal cell carcinoma (RCC), before and during the AS via quantitative methylation-specific polymerase chain reaction. Voided urine samples from 92 asymptomatic volunteers were used as the control. Significantly higher methylated TFAP2B, TAC1, PCDH8, ZNF677, and FLRT2 levels and/or frequencies were detected in SRM patients' urine samples as compared to the control. The highest diagnostic power (AUC = 0.74) was observed for the four biomarkers panel with 92% sensitivity and 52% specificity. Methylated PCDH8 level positively correlated with SRM size at diagnosis, while TFAP2B had the opposite effect and was related to SRM progression. To sum up, SRMs contribute significantly to the amount of methylated DNA detectable in urine, which might be used for very early RCC detection. Moreover, PCDH8 and TFAP2B methylation have the potential to be prognostic biomarkers for SRMs.
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Bianchi L, Chessa F, Piazza P, Ercolino A, Mottaran A, Recenti D, Serra C, Gaudiano C, Cappelli A, Modestino F, Golfieri R, Bertaccini A, Marcelli E, Porreca A, Celia A, Schiavina R. Percutaneous ablation or minimally invasive partial nephrectomy for cT1a renal masses? A propensity score-matched analysis. Int J Urol 2021; 29:222-228. [PMID: 34894001 DOI: 10.1111/iju.14758] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/03/2021] [Accepted: 11/08/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Local tumor ablation to treat small renal mass is increasing. The aim of the present study was to compare oncologic outcomes among patients with T1 renal mass treated with partial nephrectomy and local tumor ablation. METHODS To reduce the inherent differences between patients undergoing laparoscopic or robot-assisted partial nephrectomy (n = 405) and local tumor ablation (n = 137), we used a 1:1 propensity score-matched analysis. Local tumor ablation consisted of radiofrequency ablation and cryoablation. Disease-free survival, overall survival and other causes mortality-free survival rates were estimated using the Kaplan-Meier method. Multivariable logistic regression and competing-risk regression models were used to identify predictors of complications, recurrence and other causes mortality, respectively. RESULTS Partial nephrectomy had higher disease-free survival estimates, as compared with local tumor ablation (92.8% vs 80.4% at 5 years, P = 0.02), with no significant difference between radiofrequency ablation and cryoablation (P = 0.9). Ablation showed comparable overall survival estimates to partial nephrectomy (91% vs 95.8% at 5 years, P = 0.6). The 5-year recurrence rates were 7.9% versus 23.8% for patients aged ≤70 years, and 2.5% versus 11.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively; the 5-year other causes mortality rates were 0% and 2.2% for patients treated with partial nephrectomy and ablation aged ≤70 years, and 3% versus 10.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively. At multivariable analysis, ablation was associated with fewer complications (odds ratio 0.41; P = 0.01). At competing risks analysis, age (hazard ratio 0.96) and ablation (hazard ratio 4.56) were independent predictors of disease recurrence (all P ≤ 0.008). CONCLUSIONS Local tumor ablation showed a higher risk of recurrence and lower risk of complications compared with partial nephrectomy, with comparable overall survival rates.
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Affiliation(s)
- Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Francesco Chessa
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Pietro Piazza
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Amelio Ercolino
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Angelo Mottaran
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dario Recenti
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carla Serra
- Interventional Ultrasound Unit, Department of Organ Failure and Transplantations, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Gaudiano
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alberta Cappelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Modestino
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Bertaccini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Emanuela Marcelli
- Department of Experimental, Diagnostic and Specialty Medicine, Laboratory of Bioengineering, University of Bologna, Bologna, Italy
| | - Angelo Porreca
- Department of Urology, Veneto Institute of Oncology, Padua, Italy
| | - Antonio Celia
- Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy
| | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
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Bianchi L, Schiavina R, Bortolani B, Cercenelli L, Gaudiano C, Carpani G, Rustici A, Droghetti M, Mottaran A, Boschi S, Salvador M, Chessa F, Cochetti G, Golfieri R, Bertaccini A, Marcelli E. Interpreting nephrometry scores with three-dimensional virtual modelling for better planning of robotic partial nephrectomy and predicting complications. Urol Oncol 2021; 39:836.e1-836.e9. [PMID: 34535356 DOI: 10.1016/j.urolonc.2021.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/08/2021] [Accepted: 07/26/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE 3D models are increasingly used as additional preoperative tools for renal surgery. We aim to evaluate the impact of 3D renal models in the assessment of PADUA, RENAL, Contact Surface Area (CSA) and Arterial Based Complexity (ABC) for the prediction of complications after Robot assisted Partial Nephrectomy (RAPN). METHODS AND MATERIALS Overall, 57 patients with T1 and 1 patient with T2 renal mass referred to RAPN, were prospectively enrolled. 3D virtual modelling was obtained from 2D computed tomography (CT). Two radiologists recorded PADUA2D, RENAL2D, CSA2D and ABC2D by evaluation of 2D images; two bioengineers recorded PADUA3D, RENAL3D, CSA3D and ABC3D by evaluation of the 3D model, using MeshMixer software. To evaluate the concordance between 2D and 3D nephrometry scores, Cohen's j coefficient was calculated. Receiver-operating characteristic (ROC) curves were generated to evaluate the accuracy of 3D and 2D nephrometry scores to predict overall complications. Finally, the impact of 3D model on clamping approach during RAPN was compared to 2D imaging. RESULTS PADUA3D, RENAL3D, CSA3D and ABC3D scores had a significant different distribution compared to PADUA2D, RENAL2D, CSA2D and ABC2D (all p≤0.03). 2D nephrometry scores may be unchanged, reduced or increased after assessment by 3D models: CSA3D, PADUA3D, RENAL3D and ABC3D were reduced in14%, 26%, 29% and 16% and increased in 16%, 36%, 38% and 29% of cases, respectively. At ROC curve analysis, PADUA3D, RENAL3D and ABC3D showed were significantly better accuracy to predict complications compared to PADUA2D, RENAL2D and ABC2D. PADUA3D (OR: 1.66), RENAL3D (OR: 1.69) and ABC3D (OR: 2.44) revealed a significant correlation with postoperative complications (all P ≤0.03). CONCLUSION Nephrometry scores calculated via 3D models predict complications after RAPN with higher accuracy than conventional 2D imaging.
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Affiliation(s)
- Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Università degli Studi di Bologna, Bologna, Italy.
| | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Università degli Studi di Bologna, Bologna, Italy
| | - Barbara Bortolani
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Laura Cercenelli
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Caterina Gaudiano
- Division of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Carpani
- Division of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arianna Rustici
- Division of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Droghetti
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Angelo Mottaran
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sara Boschi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Salvador
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Chessa
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Università degli Studi di Bologna, Bologna, Italy
| | - Giovanni Cochetti
- Department of Surgical and Biomedical Sciences, University of Perugi, Perugia, Italy
| | - Rita Golfieri
- Università degli Studi di Bologna, Bologna, Italy; Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy; Division of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Bertaccini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Emanuela Marcelli
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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Available active surveillance follow-up protocols for small renal mass: a systematic review. World J Urol 2021; 39:2875-2882. [PMID: 33452911 DOI: 10.1007/s00345-020-03581-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To evaluate follow-up strategies for active surveillance of renal masses and to assess contemporary data. METHODS We performed a comprehensive search of electronic databases (Embase, Medline, and Cochrane). A systematic review of the follow-up protocols was carried out. A total of 20 studies were included. RESULT Our analysis highlights that most of the series used different protocols of follow-up without consistent differences in the outcomes. Most common protocol consisted in imaging and clinical evaluation at 3, 6, and 12 months and yearly thereafter. Median length of follow-up was 42 months (range 1-137). Mean age was 74 years (range 67-83). Of 2243 patients 223 (10%) died during the follow-up and 19 patients died of kidney cancer (0.8%). The growth rate was the most used parameter to evaluate disease progression eventually triggering delayed intervention. Maximal axial diameter was the most common method to evaluate growth rate. CT scan is the most used, probably because it is usually more precise than kidney ultrasound and more accessible than MRI. Performing chest X-ray at every check does not seem to alter the clinical outcome during AS. CONCLUSION The minimal cancer-specific mortality does not seem to correlate with the follow-up scheme. Outside of growth rate and initial size, imaging features to predict outcome of RCC during AS are limited. Active surveillance of SRM is a well-established treatment option. However, standardized follow-up protocols are lacking. Prospective, randomized, trials to evaluate the best follow-up strategies are pending.
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Schiavina R, Bianchi L, Chessa F, Barbaresi U, Cercenelli L, Lodi S, Gaudiano C, Bortolani B, Angiolini A, Bianchi FM, Ercolino A, Casablanca C, Molinaroli E, Porreca A, Golfieri R, Diciotti S, Marcelli E, Brunocilla E. Augmented Reality to Guide Selective Clamping and Tumor Dissection During Robot-assisted Partial Nephrectomy: A Preliminary Experience. Clin Genitourin Cancer 2020; 19:e149-e155. [PMID: 33060033 DOI: 10.1016/j.clgc.2020.09.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Riccardo Schiavina
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia; Department of Experimental, Diagnostic, and Specialty Medicine (DIMES), Cardio-Nephro-Thoracic Sciences Doctorate, University of Bologna, Bologna, Italy
| | - Lorenzo Bianchi
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia; Department of Experimental, Diagnostic, and Specialty Medicine (DIMES), Cardio-Nephro-Thoracic Sciences Doctorate, University of Bologna, Bologna, Italy.
| | - Francesco Chessa
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia; Department of Experimental, Diagnostic, and Specialty Medicine (DIMES), Cardio-Nephro-Thoracic Sciences Doctorate, University of Bologna, Bologna, Italy
| | - Umberto Barbaresi
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia
| | - Laura Cercenelli
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Simone Lodi
- Department of Electrical, Electronic, and Information Engineering, "Guglielmo Marconi," University of Bologna, Bologna, Italy
| | - Caterina Gaudiano
- Radiology Unit, Department of Diagnostic Medicine and Prevention, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Barbara Bortolani
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy
| | - Andrea Angiolini
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia
| | - Federico Mineo Bianchi
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia
| | - Amelio Ercolino
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia
| | - Carlo Casablanca
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia
| | - Enrico Molinaroli
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia
| | - Angelo Porreca
- Department of Urology, Abano Terme Hospital, Padua, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Diagnostic Medicine and Prevention, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Stefano Diciotti
- Department of Electrical, Electronic, and Information Engineering, "Guglielmo Marconi," University of Bologna, Bologna, Italy
| | - Emanuela Marcelli
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy
| | - Eugenio Brunocilla
- Department of Urology, University of Bologna, Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italia; Department of Experimental, Diagnostic, and Specialty Medicine (DIMES), Cardio-Nephro-Thoracic Sciences Doctorate, University of Bologna, Bologna, Italy
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Sebastià C, Corominas D, Musquera M, Paño B, Ajami T, Nicolau C. Active surveillance of small renal masses. Insights Imaging 2020; 11:63. [PMID: 32372194 PMCID: PMC7200970 DOI: 10.1186/s13244-020-00853-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/02/2020] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Carmen Sebastià
- Radiology Department, CDIC, Hospital Clínic de Barcelona, C/Villaroel no. 170, 08036, Barcelona, Spain
| | - Daniel Corominas
- Radiology Department, CDIC, Hospital Clínic de Barcelona, C/Villaroel no. 170, 08036, Barcelona, Spain.
| | - Mireia Musquera
- Urology Department, ICNU, Hospital Clínic de Barcelona, C/Villaroel no. 170, 08036, Barcelona, Spain
| | - Blanca Paño
- Radiology Department, CDIC, Hospital Clínic de Barcelona, C/Villaroel no. 170, 08036, Barcelona, Spain
| | - Tarek Ajami
- Urology Department, ICNU, Hospital Clínic de Barcelona, C/Villaroel no. 170, 08036, Barcelona, Spain
| | - Carlos Nicolau
- Radiology Department, CDIC, Hospital Clínic de Barcelona, C/Villaroel no. 170, 08036, Barcelona, Spain
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Dell'Atti L, Borghi C, Galosi AB. Laparoscopic Approach in Management of Renal Cell Carcinoma During Pregnancy: State of the Art. Clin Genitourin Cancer 2019; 17:e822-e830. [PMID: 31227431 DOI: 10.1016/j.clgc.2019.05.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/19/2019] [Accepted: 05/20/2019] [Indexed: 01/13/2023]
Abstract
Renal cell carcinoma (RCC) is extremely rare in pregnant women. However, this is one of the most reported urologic tumors during pregnancy. The aim of this review was to evaluate RCC during pregnancy in terms of epidemiology, risk factors, diagnosis, natural history of disease, and the safety of laparoscopic approach in the management of this tumor. RCC presentation is frequently made incidentally during an ultrasonography performed for other reasons, such as hydronephrosis owing to non-neoplastic causes. The optimal time for surgery during pregnancy and the consequences of surgery on the maternal and fetal well-being are major considerations. Risks for adverse pregnancy outcomes should be explained, and the patient's decision about pregnancy termination should be considered. Ultrasound is good in diagnosing renal masses, with a sensitivity comparable to that of computed tomography only for exophytic masses larger than 3 cm. Magnetic resonance imaging is reproducible and a good, though expensive, alternative to computed tomography scans for the evaluation of renal lesions in pregnant women. Radical nephrectomy or nephron-sparing surgery are essential treatments for management of RCC. Laparoscopic surgery has historically been considered dangerous during pregnancy and avoided whenever possible, because of concerns regarding surgery-related risks, such as uterine injury, miscarriage, teratogenesis, preterm birth, and hypercapnia. The laparoscopic treatment during pregnancy is becoming increasingly accepted where feasible with low morbidity. However, the combination of a multidisciplinary approach, multi-specialty communication, and skilled surgeons can give the best possible outcomes for mother and fetus.
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Affiliation(s)
- Lucio Dell'Atti
- Department of Urology, University Hospital "Ospedali Riuniti" and Polythecnic University of Marche Region, Ancona, Italy.
| | - Chiara Borghi
- Unit of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara and S. Anna Hospital of Ferrara, Ferrara, Italy
| | - Andrea Benedetto Galosi
- Department of Urology, University Hospital "Ospedali Riuniti" and Polythecnic University of Marche Region, Ancona, Italy
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9
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Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project). World J Urol 2019; 38:151-158. [DOI: 10.1007/s00345-019-02665-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/31/2019] [Indexed: 01/20/2023] Open
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10
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Active Surveillance of Small Renal Masses. Urology 2019; 123:157-166. [DOI: 10.1016/j.urology.2018.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/10/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023]
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Bensalah K, Albiges L, Bernhard JC, Bigot P, Bodin T, Boissier R, Correas JM, Gimel P, Hetet JF, Long JA, Nouhaud FX, Ouzaïd I, Rioux-Leclercq N, Méjean A. Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : prise en charge du cancer du rein. Prog Urol 2018; 28 Suppl 1:R5-R33. [DOI: 10.1016/j.purol.2019.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 09/15/2018] [Indexed: 12/15/2022]
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Bensalah K, Albiges L, Bernhard JC, Bigot P, Bodin T, Boissier R, Correas JM, Gimel P, Hetet JF, Long JA, Nouhaud FX, Ouzaïd I, Rioux-Leclercq N, Méjean A. 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. Prog Urol 2018; 28:S3-S31. [PMID: 30473002 DOI: 10.1016/j.purol.2018.09.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 09/15/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- K Bensalah
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35033, Rennes cedex, France.
| | - L Albiges
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Département d'oncologie génito-urinaire, Gustave-Roussy, 94805, Villejuif cedex, France
| | - J-C Bernhard
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie et transplantation rénale, CHU de Bordeaux, place Amélie-Raba-Léon, 33076, Bordeaux, France
| | - P Bigot
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, CHU d'Angers, 4, rue Larrey, 49000, Angers, France
| | - T Bodin
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Centre d'urologie Prado-Louvain, 188, rue du Rouet, 13008, Marseille, France
| | - R Boissier
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie et transplantation rénale, CHU Conception, 147, boulevard Baille, 13005, Marseille, France
| | - J-M Correas
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'imagerie médicale (radiologie), hôpital universitaire Necker-Enfants-malades, 149, rue de Sèvres, 75015, Paris, France
| | - P Gimel
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Centre d'urologie, site Médipôle, 5, avenue Ambroise-Croizat, 66330, Cabestany, France
| | - J-F Hetet
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service de chirurgie urologique, clinique Jules-Verne, 2-4, route de Paris, 44314, Nantes, France
| | - J-A Long
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service de chirurgie urologique et de la transplantation rénale, hôpital Michallon, CHU Grenoble, boulevard de la Chantourne, 38700, La Tronche, France
| | - F-X Nouhaud
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, CHU de Rouen, 1, rue de Germont, 76000, Rouen, France
| | - I Ouzaïd
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Clinique urologique, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018, Paris, France
| | - N Rioux-Leclercq
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'anatomie et cytologie pathologiques, CHU Pontchaillou, 2, rue Henri-le-Guilloux, 35033, Rennes cedex 9, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe rein, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015, Paris, France
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Mir MC, Capitanio U, Bertolo R, Ouzaid I, Salagierski M, Kriegmair M, Volpe A, Jewett MAS, Kutikov A, Pierorazio PM. Role of Active Surveillance for Localized Small Renal Masses. Eur Urol Oncol 2018; 1:177-187. [PMID: 31102618 DOI: 10.1016/j.euo.2018.05.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 11/29/2022]
Abstract
CONTEXT Stage migration of organ-confined renal masses is occurring as a result of incidental diagnosis, especially in the elderly. Active surveillance (AS) is gaining clinical traction as a treatment alternative to surgery and focal therapy. OBJECTIVE To assess contemporary data and evaluate AS risk trade-offs in the treatment of organ-confined kidney cancer. EVIDENCE ACQUISITION A comprehensive search of the Embase, Medline and Cochrane databases was carried out. A systematic review of the role of AS for organ-confined renal masses was performed. A total of 28 studies were included in the systematic review. EVIDENCE SYNTHESIS The median linear tumor growth rate for clinically localized renal masses (CLRMs) was 0.37cm/yr (interquartile range 0.15-0.7), with 0.22cm/yr in the cT1a subgroup and 0.45cm/yr in the cT1b--2 subgroup. The metastatic progression rate was 1-6% and was similar for cT1a (1-6%) and cT1b (0-5%); other-cause mortality for patients with CLRMs was 0-45% (1-25% for cT1a vs 11-13% for cT1b-2); cancer-specific mortality ranged between 0% and 18%. According to the 2011 Oxford scale, AS as a treatment option for CLRMs remains supported by level 3 evidence. CONCLUSIONS Although no randomized clinical data are available, current data support oncologic safety for AS in the management of CLRMs, particularly for small renal masses and among elderly and/or comorbid patients. PATIENT SUMMARY In this review we looked at the outcomes for patients with small kidney masses managed with surveillance. We found that surveillance is a safe initial option for tumors of less than 2cm, especially in elderly and sick patients.
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Affiliation(s)
- Maria Carmen Mir
- Department of Urology, Fundación Instituto Valenciano de Oncologia, Valencia, Spain.
| | - Umberto Capitanio
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy; Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Bertolo
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Turin, Italy
| | - Idir Ouzaid
- Department of Urology, Bichat Hospital, APHP, Paris Diderot University, Paris, France
| | | | | | - Alessandro Volpe
- Department of Urology, University of Novara, Maggiore della Carità Hospital, Novara, Italy
| | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Temple Health System, Philadelphia, PA, USA
| | - Phillip M Pierorazio
- James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sommer CM, Vollherbst DF, Richter GM, Kauczor HU, Pereira PL. [What can/should be treated in kidney tumors and when]. Radiologe 2017; 57:80-89. [PMID: 28130580 DOI: 10.1007/s00117-016-0202-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CLINICAL/METHODICAL ISSUE In the treatment of localized renal cell carcinoma, the lack of randomization in controlled trials on thermal ablation is a major limitation. The latter leads to significant study bias and it ultimately remains unclear whether the improved overall survival in favor of partial nephrectomy can actually be attributed to the treatment method. STANDARD RADIOLOGICAL METHODS For T1a (≤4 cm) renal cell carcinoma without lymph node and distant metastases, excellent technical and clinical results have been described after imaging-guided radiofrequency ablation and cryoablation. METHODICAL INNOVATIONS Low major complication rates, preservation of renal function and three-dimensional confirmation of negative ablation margins (A0 ablation) are the advantages of computed tomography (CT)-guided thermal ablation. PERFORMANCE According to the results of controlled (non-randomized) trials on T1a renal cell cancer, the cancer-specific survival rates are comparable between ablative and surgical techniques. ACHIEVEMENTS It is high time for prospective randomized controlled trials to define the actual value of percutaneous thermal ablation and partial nephrectomy in the treatment of T1a renal cell carcinoma. PRACTICAL RECOMMENDATIONS Apart from localized renal cell carcinoma, angiomyolipoma and oncocytoma can be treated by thermal ablation. Transarterial embolization extends the radiological spectrum for the treatment of renal tumors, either as complementary embolization (e. g. before thermal ablation of T1a and T1b renal cell carcinoma), prophylactic embolization (e. g. angiomyolipoma >6 cm), preoperative embolization (e. g. before laparoscopic partial nephrectomy) or palliative embolization (e. g. in patients with symptomatic macrohematuria due to renal cell carcinoma).
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Affiliation(s)
- C M Sommer
- Klinik für Diagnostische und Interventionelle Radiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland. .,Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Deutschland.
| | - D F Vollherbst
- Abteilung Neuroradiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - G M Richter
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Deutschland
| | - H U Kauczor
- Klinik für Diagnostische und Interventionelle Radiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - P L Pereira
- Klinik für Radiologie, minimal-invasive Therapien und Nuklearmedizin, SLK-Kliniken Heilbronn GmbH, Heilbronn, Deutschland
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Current Role of Active Surveillance in the Management of a Small Renal Mass. Indian J Surg Oncol 2017; 8:403-406. [PMID: 30429637 DOI: 10.1007/s13193-016-0600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/27/2016] [Indexed: 10/19/2022] Open
Abstract
Renal cell carcinoma accounts for 3-4% of adult malignant neoplasms and over 65,000 new cases of kidney cancer were diagnosed in the USA in 2013 [1, 2]. Widespread use of abdominal imaging is leading to an increased incidence in the detection of small renal masses (SRMs) among other causes [1-4]. In light of recent literature on the role of percutaneous renal mass biopsy and retrospective data analysis, surveillance for renal masses ≤4 cm is likely to become more common especially in patients with less aggressive pathology, advanced age and multiple medical comorbidities.
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Prins FM, Kerkmeijer LGW, Pronk AA, Vonken EJPA, Meijer RP, Bex A, Barendrecht MM. Renal Cell Carcinoma: Alternative Nephron-Sparing Treatment Options for Small Renal Masses, a Systematic Review. J Endourol 2017; 31:963-975. [PMID: 28741377 DOI: 10.1089/end.2017.0382] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The standard treatment of T1 renal cell carcinoma (RCC) is (partial) nephrectomy. For patients where surgery is not the treatment of choice, for example in the elderly, in case of severe comorbidity, inoperability, or refusal of surgery, alternative treatment options are available. These treatment options include active surveillance (AS), radiofrequency ablation (RFA), cryoablation (CA), microwave ablation (MWA), or stereotactic body radiotherapy (SBRT). In the present overview, the efficacy, safety, and outcome of these different options are summarized, particularly focusing on recent developments. MATERIALS AND METHODS Databases of MEDLINE (through PubMed), EMBASE, and the Cochrane Library were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The search was performed in December 2016, and included a search period from 2010 to 2016. The terms and synonyms used were renal cell carcinoma, active surveillance, radiofrequency ablation, microwave ablation, cryoablation and stereotactic body radiotherapy. RESULTS The database search identified 2806 records, in total 73 articles were included to assess the rationale and clinical evidence of alternative treatment modalities for small renal masses. The methodological quality of the included articles varied between level 2b and level 4. CONCLUSION Alternative treatment modalities, such as AS, RFA, CA, MWA, and SBRT, are treatment options especially for those patients who are unfit to undergo an invasive treatment. There are no randomized controlled trials available comparing surgery and less invasive modalities, leading to a low quality on the reported articles. A case-controlled registry might be an alternative to compare outcomes of noninvasive treatment modalities in the future.
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Affiliation(s)
- Fieke M Prins
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht, The Netherlands
| | - Linda G W Kerkmeijer
- 1 Department of Radiation Oncology, University Medical Center Utrecht , Utrecht, The Netherlands
| | - Anne A Pronk
- 2 Department of Urology, Tergooi Hospital , Hilversum, The Netherlands
| | - Evert-Jan P A Vonken
- 3 Department of Radiology, University Medical Center Utrecht , Utrecht, The Netherlands
| | - Richard P Meijer
- 4 Department of Urology, University Medical Center Utrecht , Utrecht, The Netherlands
| | - Axel Bex
- 5 Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital , Amsterdam, The Netherlands
| | - Maurits M Barendrecht
- 6 Department of Urology, Tergooi Hospital, Hilversum and University Medical Center Utrecht , Utrecht, The Netherlands
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Ristau BT, Kutikov A, Uzzo RG, Smaldone MC. Active Surveillance for Small Renal Masses: When Less is More. Eur Urol Focus 2017; 2:660-668. [PMID: 28723504 DOI: 10.1016/j.euf.2017.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/05/2017] [Indexed: 12/29/2022]
Abstract
CONTEXT A marked increase in incidentally detected small renal masses (SRMs) has occurred over the past decade. Active surveillance (AS) has emerged as an initial management option for these patients. OBJECTIVE (1) To determine selection criteria, assess appropriate imaging modalities and surveillance frequencies, and define triggers for delayed intervention (DI) for patients on AS. (2) To describe oncologic outcomes for patients on AS protocols. EVIDENCE ACQUISITION The PubMed database was queried for English language articles using the keywords "surveillance" and "renal mass" or "renal cell carcinoma" or "kidney cancer." The level of evidence, sample size, study design, and relevance to the review were considered as inclusion criteria. EVIDENCE SYNTHESIS A total of 69 manuscripts were included in the review. Selection criteria at initial evaluation for patients interested in AS include patient-related factors (eg, age, baseline renal function, other comorbidities), tumor-related factors (size, complexity, history of growth, possible renal mass biopsy), and patient preferences (illness uncertainty, quality of life). Cross-sectional imaging is the preferred initial imaging modality. Surveillance imaging should be performed at frequent intervals (3-4 mo) up front; intervals can be reduced over time if favorable growth kinetics are demonstrated. Delayed intervention (DI) should be considered for rapid tumor growth (eg,>0.5cm/yr), an increase in maximum tumor diameter >3-4cm, malignant renal mass biopsy results, development of symptoms, or patient preferences. Oncologic outcomes in well-controlled studies demonstrate a metastatic rate of 1-2%. Most patients who undergo DI remain eligible for nephron-sparing approaches; oncologic outcomes are not compromised by DI strategies. CONCLUSIONS A period of initial AS is safe for most patients with SRMs. Management decisions should focus on a thorough assessment of risk-benefit trade-offs, judiciously integrating patient-related factors, tumor-related factors, and patient preferences. PATIENT SUMMARY A period of initial active surveillance for kidney masses of ≤4cm in diameter is safe in most patients. Frequent imaging and follow-up are necessary to determine if the tumor grows. If delayed intervention becomes necessary, cancer outcomes are not compromised by the initial choice of active surveillance when patients adhere to close follow-up regimens.
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Affiliation(s)
- Benjamin T Ristau
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Robert G Uzzo
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Marc C Smaldone
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Predictors of growth kinetics and outcomes in small renal masses (SRM ≤4 cm in size): Tayside Active Surveillance Cohort (TASC) Study. Eur J Surg Oncol 2017; 43:1589-1597. [PMID: 28365130 DOI: 10.1016/j.ejso.2017.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/04/2017] [Accepted: 03/09/2017] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine outcomes of small renal masses (≤4 cm) on active surveillance and explore factors which can influence their growth. PATIENTS AND METHODS Two hundred twenty six patients between January 2007 and December 2014 were analysed using cross-linked methodology of healthcare data and independent review. Cancer specific and non-specific survival were the primary outcomes. Growth kinetics, factors influencing growth and need for interventions were secondary outcomes. RESULTS 101 (64.4%) solid and 4 (5.9%) cystic SRMs showed growth. 43 (19.02%) of SRMs required treatment interventions. Seven patients (7/158; 4.4%) died due to renal cancer at a median follow-up of 21.7 (SD 10.6, min 6-42) months, all in solid category. Independent review of serial radiological imaging of these seven cases showed two patients had subtle metastatic disease at the initial presentation, and 5 of the 7 did not adhere to recommended imaging regime. 33 (33/158; 20.8%) died due to other causes including non-renal cancers (14/158; 8.8%). Multivariate analyses showed that lower eGFR at baseline, co-morbidities and tumour location were independently associated with growth in size. CONCLUSIONS A higher cancer-specific mortality was seen in the present study compared to the reported literature. Independent critical review of imaging of cases with poor outcome underscored the importance of adherence to a robust protocol including follow up. Comorbid conditions had a significant impact on growth and overall survival of patients with SRMs.
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Active Surveillance for the Small Renal Mass: Growth Kinetics and Oncologic Outcomes. Urol Clin North Am 2017; 44:213-222. [PMID: 28411913 DOI: 10.1016/j.ucl.2016.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Active surveillance for small renal masses (SRMs) is an accepted management strategy for patients with prohibitive surgical risk. Emerging prospectively collected data support the concept that a period of initial active surveillance in an adherent patient population with well-defined criteria for delayed intervention is safe. This article summarizes the literature describing growth kinetics of SRMs managed initially with observation and oncologic outcomes for patients managed with active surveillance. Existing clinical tools to determine and contextualize competing risks to mortality are explored. Finally, current prospective clinical trials with defined eligibility criteria, surveillance schema, and triggers for delayed intervention are highlighted.
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The role of active surveillance of small renal masses. Int J Surg 2016; 36:518-524. [PMID: 27321381 DOI: 10.1016/j.ijsu.2016.06.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/29/2016] [Accepted: 06/04/2016] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The use of modern abdominal imaging modalities have led in recent years to an increased incidental diagnosis of small renal masses (SRMs), especially in elderly patients. The natural history of SRMs has been historically poorly understood because most have been traditionally surgically removed soon after diagnosis. However, several studies of active surveillance (AS) of SRMs have been published in the last decade. METHODS A review of English-language publications on AS of SRMs was performed from 1995 to 2015 using the Medline, Embase and Web of Science databases. Fifty-six articles were selected based on their scientific relevance and critically analysed. RESULTS When followed conservatively with serial imaging, SRMs have variable growth rates with an average of 0.31 cm/year in the largest multicenter analysis. A significant number of SRMs have a slow growth and some have zero growth under surveillance. The risk of progression to metastatic disease during AS is rare (1-2%). Population-based analyses in older patient populations (>75 years) fail to show a benefit in cancer-specific mortality for surgical treatment of SRMs. DISCUSSION The standard of care for localized renal tumors is surgery. In elderly or unfit patients with decreased life expectancy, it is reasonable to propose an initial period of AS, with delayed intervention for those tumors which exhibit a fast growth during follow-up. At present AS is not recommended in younger and fit patients and for masses >4 cm at diagnosis outside clinical trials. Percutaneous needle biopsies of renal tumors have the potential to characterize histologically SRMs at diagnosis, thereby providing useful information for the selection of the best suited patients for AS. CONCLUSIONS Most SRMs are benign tumors or RCCs with a relatively indolent clinical behaviour. AS can be offered to patients with SRMs and decreased life expectancy. Prospective series of AS of histologically confirmed RCCs are needed to confirm the long term safety of this conservative approach.
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Abstract
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.
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Swaminath A, Chu W. Stereotactic body radiotherapy for the treatment of medically inoperable primary renal cell carcinoma: Current evidence and future directions. Can Urol Assoc J 2015; 9:275-80. [PMID: 26316914 DOI: 10.5489/cuaj.2900] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The incidence of renal cell carcinoma (RCC) is steadily rising due to an aging population and more frequent imaging of the abdomen for other medical conditions. While surgery remains the standard of care treatment for localized disease, many patients are unfit due to their advanced age and medical comorbidities. In these patients, an active surveillance strategy or ablative therapies, including radiofrequency/microwave ablation or cryotherapy, can be offered. Such options have limitations particularly with fast growing, or larger tumors. A promising ablative therapy option to consider is stereo-tactic body radiotherapy (SBRT). SBRT refers to high dose, focally ablative radiation delivered in a short time (3-5 fractions), and is safe and effective in many other cancer sites, including lung, liver and spine. SBRT offers potential advantages in the primary kidney cancer setting due to its ablative dosing (overcoming the notion of "radio-resistance"), short treatment duration (important in an elderly population), low toxicity profile (enabling SBRT to treat larger RCCs than other ablative modalities), and non-invasiveness. To date, there is limited long-term prospective data on the outcomes of SBRT in primary RCC. However, early evidence is intriguing with respect to excellent local control and low toxicity; however, most studies vary in terms of technique and radiation dosing used. Well-designed prospective cohort studies with clearly defined and standardized techniques, dosing, follow-up, and integration of quality of life outcomes will be essential to further establish the role of SBRT in management of inoperable, localized RCC.
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Affiliation(s)
- Anand Swaminath
- Department of Oncology, McMaster University, Hamilton, ON; ; Juravinski Cancer Centre, Hamilton, ON
| | - William Chu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON
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Conti A, Santoni M, Sotte V, Burattini L, Scarpelli M, Cheng L, Lopez-Beltran A, Montironi R, Cascinu S, Muzzonigro G, Lund L. Small renal masses in the era of personalized medicine: Tumor heterogeneity, growth kinetics, and risk of metastasis. Urol Oncol 2015; 33:303-9. [DOI: 10.1016/j.urolonc.2015.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/07/2015] [Accepted: 04/06/2015] [Indexed: 12/26/2022]
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