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Disease Progression in Older Patients With Renal Tumor Assigned to an Active Surveillance Protocol. Clin Genitourin Cancer 2021; 20:e53-e60. [PMID: 34815184 DOI: 10.1016/j.clgc.2021.09.008] [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: 07/10/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Active surveillance (AS) is a validated option for the treatment of small renal masses (SMRs), especially in older patients. This study investigates the oncologic outcomes and competitive mortality of older patients prospectively assigned to AS. METHODS We conducted a monocentric study on patients ≥75 years treated between 2011 and 2016 for a SMR. Treatment modalities, biopsy data, survivals (overall, specific, cancer progression) and delayed interventions were analyzed. RESULTS Overall, 106 patients (median age 80.5 years) were included, of which 41 were managed by AS during a follow-up of 3.4 years [0-7.1]. Seven patients (17%) had a primary biopsy with 3 confirmed renal cell carcinomas. Fourteen patients (34.1%) presented with progression (29.2% local; 4.9% metastatic), 8 (19.5%) requiring delayed interventions (75% ablative therapy and 25% radical nephrectomy). Overall survival (OS) was 68.3% and cancer specific survival was 95.1% during the study period. Competitive mortality was higher (84.6%) than cancer specific mortality (15.4%), P = .001. CONCLUSION The growth rate of progression including 4.9% metastatic progression underlines the value of AS compared to simple watchful surveillance in the treatment of SMRs in older patients. Of note, the higher competitive mortality confirm that AS should be preferred to active intervention at the beginning of the management.
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2
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Ellis EE, Messing E. Active Surveillance of Small Renal Masses: A Systematic Review. KIDNEY CANCER 2021. [DOI: 10.3233/kca-210114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Our goal is to review current literature regarding active surveillance (AS) of small renal masses (SRMs) and identify trends in survival outcomes, factors that predict the need for further intervention, and quality of life (QOL). METHODS: We performed a comprehensive literature search in PubMed and EMBASE and identified 194 articles. A narrative summary was performed in lieu of a meta-analysis due to the heterogeneity of selected studies. RESULTS: Seventeen articles were chosen to be featured in this review. Growth rate (GR) was not an accurate predictor of malignancy, although it was the characteristic most commonly used to trigger delayed intervention (DI). The mean 5-year overall survival (OS) of all studies was 73.6% ±1.7% for AS groups. The combined cancer specific survival (CSS) for AS is 97.1% ±0.6%, compared to 98.6% ±0.4% for the primary intervention (PI) groups, (p = 0.038). CONCLUSIONS: Short and intermediate-term data demonstrate that AS with the option for DI is a management approach whose efficacy (in terms of CSS) approaches that of PI at 5 years, is cost effective, and prevents overtreatment, especially in patients with significant comorbidities.
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Affiliation(s)
| | - Edward Messing
- University of Rochester Medical Center, Rochester, NY, USA
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3
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Klatte T, Berni A, Serni S, Campi R. Intermediate- and long-term oncological outcomes of active surveillance for localized renal masses: a systematic review and quantitative analysis. BJU Int 2021; 128:131-143. [PMID: 34060192 DOI: 10.1111/bju.15435] [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] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate intermediate- and long-term oncological outcomes of active surveillance (AS) for localized renal masses (LRMs). METHODS This systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered on PROSPERO (CRD42021230416). Studies on AS for LRMs with at least 3 years' follow-up were eligible. Two review authors independently screened the literature, extracted data, and assessed risk of bias. The primary outcomes were metastasis rate, renal cell carcinoma (RCC)-specific mortality (RCC-SM) and all-cause mortality (ACM). Pooled estimates were obtained from random-effects models. Subgroup analyses were performed for small renal masses (SRMs; ≤4 cm) and non-SRMs (>4 cm). RESULTS We analysed 18 unique cohorts comprising 2066 patients. The pooled initial maximum tumour size was 2.8 cm (95% confidence interval [CI] 2.7-3.0) and the percutaneous biopsy rate was 28%. The pooled mean annual growth rate was 2.8 mm (95% CI 2.1-3.4). Within a pooled mean follow-up of 53 months, 2.1% (95% CI 1.0-3.6) of patients developed metastatic disease, 1.0% (95% CI 0.3-2.1) died from RCC and 22.6% (95% CI 15.8-30.2) died from any cause. For patients with SRMs (nine studies, n = 987), the pooled metastasis rate was 1.8% (95% CI 0.5-3.7), RCC-SM was 0.6% (95% CI 0-2.1), and ACM was 28.5% (95% CI 17.4-41.4). Across five studies reporting on outcomes of 239 patients with non-SRMs, the pooled metastasis rate was 5.1% (95% CI 0-17.3), RCC-SM was 2.1% (95% CI 0-8.9) and ACM was 29.1% (95% CI 13.6-47.3). This review is limited by non-standardized inclusion criteria, definitions and follow-up, data heterogeneity, limited patient numbers in sub-analyses and absence of high-quality studies. CONCLUSIONS Active surveillance is a safe intermediate- and long-term management option for well-selected patients with LRMs, especially those with SRMs. Limited data are available for non-SRMs, but current evidence would support further evaluation of this approach in selected patients. It is not possible to draw definitive conclusions until more high-quality data become available.
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Affiliation(s)
- Tobias Klatte
- Department of Urology, Royal Bournemouth Hospital, Dorset University Hospitals NHS Foundation Trust, Bournemouth, UK.,Department of Surgery, University of Cambridge, Cambridge, UK
| | - Alessandro Berni
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Sergio Serni
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Riccardo Campi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,European Association of Urology Young Academic Urologists Renal Cancer Working Group, Arnhem, The Netherlands
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4
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Chan VWS, Tan WS, Leow JJ, Tan WP, Ong WLK, Chiu PKF, Gurung P, Pirola GM, Orecchia L, Liew MPC, Lee HY, Wang Y, Chen IHA, Castellani D, Wroclawski ML, Mayor N, Sathianathen NJ, Braga I, Liu Z, Moon D, Tikkinen K, Kamat A, Meng M, Ficarra V, Giannarini G, Teoh JYC. Delayed surgery for localised and metastatic renal cell carcinoma: a systematic review and meta-analysis for the COVID-19 pandemic. World J Urol 2021; 39:4295-4303. [PMID: 34031748 PMCID: PMC8143063 DOI: 10.1007/s00345-021-03734-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/13/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose The COVID-19 pandemic has led to the cancellation or deferment of many elective cancer surgeries. We performed a systematic review on the oncological effects of delayed surgery for patients with localised or metastatic renal cell carcinoma (RCC) in the targeted therapy (TT) era. Method The protocol of this review is registered on PROSPERO(CRD42020190882). A comprehensive literature search was performed on Medline, Embase and Cochrane CENTRAL using MeSH terms and keywords for randomised controlled trials and observational studies on the topic. Risks of biases were assessed using the Cochrane RoB tool and the Newcastle–Ottawa Scale. For localised RCC, immediate surgery [including partial nephrectomy (PN) and radical nephrectomy (RN)] and delayed surgery [including active surveillance (AS) and delayed intervention (DI)] were compared. For metastatic RCC, upfront versus deferred cytoreductive nephrectomy (CN) were compared. Results Eleven studies were included for quantitative analysis. Delayed surgery was significantly associated with worse cancer-specific survival (HR 1.67, 95% CI 1.23–2.27, p < 0.01) in T1a RCC, but no significant difference was noted for overall survival. For localised ≥ T1b RCC, there were insufficient data for meta-analysis and the results from the individual reports were contradictory. For metastatic RCC, upfront TT followed by deferred CN was associated with better overall survival when compared to upfront CN followed by deferred TT (HR 0.61, 95% CI 0.43–0.86, p < 0.001). Conclusion Noting potential selection bias, there is insufficient evidence to support the notion that delayed surgery is safe in localised RCC. For metastatic RCC, upfront TT followed by deferred CN should be considered. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-021-03734-1.
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Affiliation(s)
- Vinson Wai-Shun Chan
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Division of Surgery and Interventional Science, University College London, London, UK.,S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wei Shen Tan
- Department of Urology, Royal Free Hospital, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore.,Department of Urology, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Wei Phin Tan
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | | | - Peter Ka-Fung Chiu
- S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Pratik Gurung
- Department of Urology, University of Rochester Medical Center, New York, USA
| | | | - Luca Orecchia
- Urology Unit, Policlinico Tor Vergata Foundation, Rome, Italy
| | | | - Hsiang-Ying Lee
- Urology Department, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Yuding Wang
- Division of Urology, Department of Surgery, McMaster University, Hamilton, Canada
| | - I-Hsuan Alan Chen
- Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Daniele Castellani
- Urology Division, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Università Politecnica delle Marche, Ancona, Italy
| | - Marcelo Langer Wroclawski
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil.,BP-A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Nikhil Mayor
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | | | - Isaac Braga
- Department of Urology, Instituto Portugues de Oncologia, Porto, Portugal
| | - Zhenbang Liu
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Dora Moon
- Department of Urology, East Lancashire Hospitals NHS Foundation Trust, Blackburn, UK
| | - Kari Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ashish Kamat
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Max Meng
- Department of Urology, University of California San Francisco, San Francisco, USA
| | - Vincenzo Ficarra
- Department of Human and Pediatric Pathology "Gaetano Barresi", Urologic Section, University of Messina, Messina, Italy
| | - Gianluca Giannarini
- Urology Unit, Santa Maria della Misericordia Academic Medical Centre, Udine, Italy
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
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5
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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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6
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Mongiat-Artus P, Paillaud E, Caillet P, Albrand G, Neuzillet Y. [Geriatric specificities of localized renal cell carcinoma]. Prog Urol 2019; 29:865-873. [PMID: 31771769 DOI: 10.1016/j.purol.2019.08.281] [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: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- P Mongiat-Artus
- Inserm UMR_S1165, service d'urologie et unité de chirurgie et d'anesthésie ambulatoires, hôpital Saint-Louis, université Paris Diderot, université de Paris, Assistance publique-Hôpitaux de Paris, 75010 Paris, France.
| | - E Paillaud
- EA 7376 épidémiologie clinique et vieillissement, service de gériatrie - unité d'onco-gériatrie et UCOG - Paris-Ouest, hôpital européen Georges-Pompidou, université René Descartes, université de Paris, Assistance publique-Hôpitaux de Paris, 75015 Paris, France
| | - P Caillet
- Service de gériatrie, hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, 94000 Créteil, France
| | - G Albrand
- Service de gériatrie et UCOG - IR, AuRA Ouest-Guyane, hospices civils de Lyon, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| | - Y Neuzillet
- Service d'urologie, hôpital Foch, université de Versailles, Saint-Quentin-en-Yvelines, 92150 Suresnes, France
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7
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Abstract
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.
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8
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Guo RQ, Li XG. Comparison of survival benefits of nephron-sparing intervention or active surveillance for patients with localized renal masses: a systematic review and meta-analysis. BMC Urol 2019; 19:74. [PMID: 31382939 PMCID: PMC6683559 DOI: 10.1186/s12894-019-0503-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background Strong evidence comparing effectiveness between nephron-sparing intervention (NSI) and active surveillance (AS) is lacking. Thus, we aim to compare the outcomes of survival, including cancer-specific survival (CSS), overall survival (OS), and cardiovascular-specific survival (CVSS), in patients with renal masses who underwent NSI or AS. Methods A systematic literature search of PubMed, Web of Science, and EMBASE was performed for citations published prior to September 2018 that described NSI, partial nephrectomy and thermal ablation included, and AS for patients with renal masses and a standard meta-analysis on survival outcomes was then conducted. Results The meta-analysis included seven studies containing 5809 patients. The results comparing NSI with AS were as follows: CSS (hazard ratio (HR) = 0.64, 95% confidence interval (CI): 0.46–0.89, P < 0.001), OS (HR = 0.46, 95%CI: 0.39–0.53, P < 0.001), and CVSS (HR = 0.37, 95%CI: 0.24–0.57, P < 0.001). Conclusions This systematic review and meta-analysis indicates that NSI is associated with better OS, CSS and CVSS when compared with AS for patients with renal masses. Further better prospective cohort studies are needed to make definitive statements about these different treatment methods.
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Affiliation(s)
- Run-Qi Guo
- Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, No.1 Dongdan Dahua Street, Beijing, 100370, People's Republic of China
| | - Xiao-Guang Li
- Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, No.1 Dongdan Dahua Street, Beijing, 100370, People's Republic of China.
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9
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Antonelli A, Veccia A, Pavan N, Mir C, Breda A, Takagi T, Rha KH, Maurer T, Zhang C, Long JA, De Nunzio C, Lima E, Ferro M, Micali S, Quarto G, Linares E, Celia A, Schips L, Bove P, Larcher A, Fiori C, Mottrie A, Bindayi A, Trombetta C, Silvestri T, Palou J, Faba OR, Tanabe K, Yang B, Fiard G, Tubaro A, Torres JN, De Cobelli O, Bevilacqua L, Castellucci R, Tracey A, Hampton LJ, Montorsi F, Perdonà S, Simeone C, Palumbo C, Capitanio U, Derweesh I, Porpiglia F, Autorino R. Outcomes of Partial and Radical Nephrectomy in Octogenarians – A Multicenter International Study (Resurge). Urology 2019; 129:139-145. [DOI: 10.1016/j.urology.2019.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/05/2019] [Accepted: 03/12/2019] [Indexed: 01/26/2023]
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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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11
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Miller C, Raza SJ, Davaro F, May A, Siddiqui S, Hamilton ZA. Trends in the treatment of clinical T1 renal cell carcinoma for octogenarians: Analysis of the National Cancer Database. J Geriatr Oncol 2018; 10:285-291. [PMID: 30528544 DOI: 10.1016/j.jgo.2018.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/13/2018] [Accepted: 11/28/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Treatment of renal cell carcinoma has evolved with emphasis on nephron preservation for small renal masses. Our objective was to evaluate the proportions of treatment types for octogenarians with clinical stage 1 renal cell carcinoma. MATERIALS AND METHODS The National Cancer Database was analyzed from 2004 to 2015. Patients with clinical stage 1, tumor size ≤ 7 cm, and age 80-89 years old were compared to a younger control arm of patients ≤ 70 years old. Treatment modality was categorized as radical nephrectomy (RN), partial nephrectomy (PN), percutaneous ablative therapy (PAT), and no treatment (NT). Primary outcome was treatment utilization over time using estimated annual percentage change (EAPC). Secondary outcomes included logistic regression for 30 day readmission after treatment and any definitive tumor treatment choice. RESULTS 18,903 octogenarians were identified and compared to a control of 142,179 patients ≤ 70 years old. Overall, NT (36%) was the most common modality for octogenarians while PN (44.8%) was most common for the control arm. Using EAPC for octogenarians, we found increases for PAT (7.1%), PN (2.8%), and NT (1.6%) but a decrease for RN (-4.6%). EAPC for the younger cohort noted increases for PAT (6.8%), PN (5.4%), and NT (4.4%) but a decrease for RN (-5.5%). CONCLUSION For octogenarians with stage 1 renal cell carcinoma, minimally invasive treatments are increasingly utilized, while RN is decreasing. Compared to a younger cohort, a greater proportion of octogenarians are receiving NT. These findings remain encouraging for appropriate treatment of localized disease in patients with advanced age.
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Affiliation(s)
- Caleb Miller
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Syed J Raza
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Facundo Davaro
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Allison May
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Sameer Siddiqui
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Zachary A Hamilton
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States.
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12
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Heidenreich A. [Limits of surgery in uro-oncology]. Urologe A 2018; 57:1058-1068. [PMID: 30043291 DOI: 10.1007/s00120-018-0735-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: 10/28/2022]
Abstract
The limits of cancer surgery in uro-oncology are characterized by a carefully weighed risk of surgical feasibility and oncological necessity. The limits of uro-oncological cancer surgery do not represent fixed dogmas but ideally these more or less cognitive boundaries move based on new scientific findings, improved imaging modalities, optimized surgical techniques and perioperative care. The limits of cancer surgery are defined by patient-specific parameters, the biological aggressiveness of the tumor itself, the skills and expertise of the surgeon, and adequate perioperative care of the patient. Dependent on the origin of the cancers of the upper and lower urogenital tract, the specific particularities of each individual cancer in terms of prognosis need to be known, taking into consideration the newest molecular insights and modern multimodality treatment regimes. Only the consideration of the above mentioned basics will allow the best decision to be made with the patient concerning the optimal individual treatment. The current article highlights general parameters of the patient, tumor and surgeon which might define the limits of cancer surgery in uro-oncology. In addition, specific clinical scenarios are discussed with regard to surgery limits in cancer of the kidney, the prostate and the testis.
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Affiliation(s)
- A Heidenreich
- Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland. .,Klinik für Urologie, Medizinische Universität Wien, Wien, Österreich.
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13
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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: 79] [Impact Index Per Article: 13.2] [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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14
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Lokeshwar SD, Talukder A, Yates TJ, Hennig MJP, Garcia-Roig M, Lahorewala SS, Mullani NN, Klaassen Z, Kava BR, Manoharan M, Soloway MS, Lokeshwar VB. Molecular Characterization of Renal Cell Carcinoma: A Potential Three-MicroRNA Prognostic Signature. Cancer Epidemiol Biomarkers Prev 2018; 27:464-472. [PMID: 29440068 DOI: 10.1158/1055-9965.epi-17-0700] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/28/2017] [Accepted: 01/09/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Aberrantly expressed miRNAs promote renal cell carcinoma (RCC) growth and metastasis and are potentially useful biomarkers for metastatic disease. However, a consensus clinically significant miRNA signature has not been identified. To identify an miRNA signature for predicting clinical outcome in RCC patients, we used a four-pronged interconnected approach.Methods: Differentially expressed miRNAs were identified and analyzed in 113 specimens (normal kidney: 59; tumor: 54). miRNA profiling was performed in matched normal and tumor specimens from 8 patients and extended to 32 specimens. Seven aberrantly expressed miRNAs were analyzed by qPCR, and their levels were correlated with RCC subtypes and clinical outcome. miRNA signature was confirmed in The Cancer Genome Atlas RCC dataset (n = 241).Results: Discovery phase identified miR-21, miR-142-3p, miR-142-5p, miR-150, and miR-155 as significantly upregulated (2-4-fold) and miR-192 and miR-194 as downregulated (3-60-fold) in RCC; miR-155 distinguished small tumors (<4 cm) from benign oncocytomas. In univariate and multivariate analyses, miRNA combinations (miR-21+194; miR-21+142-5p+194) significantly predicted metastasis and/or disease-specific mortality; miR-21+142-5p+194 (for metastasis): P = 0.0017; OR, 0.53; 95% confidence interval (CI), 0.75-0.33; 86.7% sensitivity; 82% specificity. In the TCGA dataset, combined biomarkers associated with metastasis and overall survival (miR-21+142-5p+194: P < 0.0001; OR, 0.37; 95% CI, 0.58-0.23).Conclusions: The interconnected discovery-validation approach identified a three-miRNA signature as a potential predictor of disease outcome in RCC patients.Impact: With 10% survival at 5 years, metastatic disease presents poor prognosis for RCC patients. The three-miRNA signature discovered and validated may potentially at an early stage detect and predict metastasis, to allow early intervention for improving patient prognosis. Cancer Epidemiol Biomarkers Prev; 27(4); 464-72. ©2018 AACR.
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Affiliation(s)
- Soum D Lokeshwar
- Honors Program in Medical Education, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Biochemistry and Molecular Biology, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Asif Talukder
- Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Travis J Yates
- Sheila and David Fuente Graduate Program in Cancer Biology, Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, Florida
| | - Martin J P Hennig
- Department of Urology, University of Schleswig-Holstein, Lübeck, Germany
| | - Michael Garcia-Roig
- Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Sarrah S Lahorewala
- Honors Program in Medical Education, Miller School of Medicine, University of Miami, Miami, Florida
| | - Naureen N Mullani
- Honors Program in Medical Education, Miller School of Medicine, University of Miami, Miami, Florida
| | - Zachary Klaassen
- Division of Urology, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Bruce R Kava
- Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Murugesan Manoharan
- Division of Urologic Oncology Surgery, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Vinata B Lokeshwar
- Honors Program in Medical Education, Miller School of Medicine, University of Miami, Miami, Florida.
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15
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Active Surveillance in Small Renal Masses in the Elderly: A Literature Review. Eur Urol Focus 2017; 3:340-351. [PMID: 29175368 DOI: 10.1016/j.euf.2017.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/06/2017] [Accepted: 11/14/2017] [Indexed: 12/28/2022]
Abstract
CONTEXT Small renal masses have become increasingly common due to widespread imaging; however, optimal management of these lesions in the elderly can be complex due to the competing risks of intervention, natural history of disease, patient comorbidities, and expectations. In the properly selected elderly patient, active surveillance remains an accepted and attractive treatment approach. OBJECTIVE We completed a literature review of small renal masses (enhancing, <4cm, T1aN0M0 disease) in the elderly, aged ≥70 yr, aimed at identifying the utility of active surveillance in this population. The primary outcomes were conversion to active treatment while on active surveillance and cancer-specific mortality. Secondary outcomes included predictors of treatment, type of treatment performed (partial nephrectomy, radical nephrectomy, and ablation), progression to metastases, all-cause mortality, tumor growth rate, and demographic data including age and Charlson Comorbidity Index. EVIDENCE ACQUISITION A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library) using search terms "small renal mass" OR "SRM", AND "elderly," "senior," "aging," "geriatric," OR "octogenarian" was completed. All randomized controlled trials, nonrandomized comparison studies, and case series were included and screened by the reviewers. All comparison studies included in the systematic review were assessed for methodological quality using the Cochrane Risk of Bias tools. EVIDENCE SYNTHESIS Seventeen primary studies including 36495 patients met the inclusion criteria for the systematic review. All studies were retrospective institutional chart or the Surveillance, Epidemiology, and End Results database reviews. There was a low (4-26%) rate of conversion to active treatment for active surveillance in the identified studies over a follow-up interval of up to 91.5 mo. Overall mortality was substantial in this elderly cohort, with 15-51% of patients being deceased over the course of study follow-up; however, there was minimal cancer-specific mortality due to patients succumbing to alternative comorbid disease. In the future, patient comorbidity and biological age versus the natural history of the individualized tumor biology may play an increasing role in the discussion regarding treatment options and consideration of active surveillance. CONCLUSIONS Active surveillance is an effective management strategy in the elderly population. Few patients required the conversion to active treatment and there was low cancer-specific mortality. The majority of patients who expired over the course of the identified studies succumbed to alternative disease. The goal of treatment strategies should include weighing patient-specific prognosis relative to their competing health risks and treatment goals against the natural history of disease and risks of intervention. PATIENT SUMMARY In this review article, the authors examined the utility of active surveillance in the setting of a small localized renal mass in the elderly population. Despite being on surveillance, we found that cancer-specific outcomes were excellent, and overall mortality was often a result of comorbid disease. However, there is significant heterogeneity among elderly patients, and treatment approaches should be focused around patient-centered goals and prognosis.
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