Contemporary Age-adjusted Incidence and Mortality Rates of Renal Cell Carcinoma: Analysis According to Gender, Race, Stage, Grade, and Histology

Avoiding "Needless" nephrectomy: What is the role of small renal mass biopsy in 2024?

Current guidelines do not mandate routine preoperative renal mass biopsy (RMB) for small renal masses (SRMs), which results in a considerable rate (18%-26%) of needless nephrectomy/partial nephrectomy for benign renal tumors. In light of this ongoing practice, a narrative review was conducted to examine the role of routine RMB for SRM. First, arguments justifying the current non-biopsy approach to SRM are critically reviewed and contested. Second, as a standalone procedure, RMB is critically assessed; RMB was found to have higher sensitivity, specificity, and an equal or lower complication rate when compared with other commonly preoperatively biopsied solid organ tumors (e.g., breast, prostate, lung, pancreas, thyroid, and liver). Based on the foregoing information, we propose a paradigm shift in SRM management, advocating for an updated policy in which partial nephrectomy or nephrectomy for SRM invariably occurs only after a preoperative biopsy confirms that a SRM is indeed malignant.

Preoperative proteinuria correlates with renal function after partial nephrectomy for renal cell carcinoma

PURPOSE

Preoperative proteinuria is a prognostic factor of chronic kidney disease (CKD). We assessed the association between preoperative proteinuria and postoperative renal function after partial nephrectomy (PN).

METHODS

We retrospectively reviewed our records of patients with a single malignant renal mass who underwent PN between 2000 and 2021. Patients with data on preoperative proteinuria were included. Baseline characteristics and eGFR differences over time between patients with and without proteinuria were evaluated. Univariate and multivariable logistic regression models (LRM) tested for presence of CKDIII or higher at 12-month and at last follow-up.

RESULTS

Two hundred ninety-five patients were included. Twenty-two of them had preoperative proteinuria. No differences of age, smoking status, hypertension or diabetes, tumor size and use of ischemia were observed. Patients with proteinuria had a higher rate of CKD-III at baseline. At a median follow-up of 46.5 months (IQR 19-82), 117 patients developed de novo CKD-III, without differences in the two groups. No differences in decline in eGFR were observed. At univariate LRM, predictors of CKD-III at 12 months after PN were preoperative proteinuria (OR 3.2, 95%CI 1.4-7.8, p = 0.005), age and baseline eGFR, while predictors of CKD-III at last follow-up were age and baseline eGFR. At multivariable LRM, only baseline eGFR predicted CKD-III at 12-month and at last-follow-up.

CONCLUSIONS

Preoperative eGFR is the only independent predictor of long-term renal function after PN. Preoperative proteinuria correlates with renal function at 12 months. Proteinuria should be assessed before PN to identify patients at higher risk of renal functional deterioration in the 12 months following PN.

The causal relationship between smoking, alcohol consumption, and renal clear cell carcinoma: a Mendelian randomization study

Introduction: Observational studies have found a correlation between the consumption of tobacco and alcohol and the likelihood of developing renal cell carcinoma. However, whether these associations indicate causal relationships is unclear. Methods: To establish if these connections indicate causal relationships, we performed a Mendelian Randomization (MR) analysis using a two-sample approach. For the number of daily cigarettes, lifetime smoking index, smoking initiation, and weekly drinking, we employed 44, 108, 174, and 76 single nucleotide polymorphisms (SNPs) as instrumental variables. Outcome data were obtained from the FinnGen Alliance, which included a combined total of 429,290 individuals. The MR analysis was conducted using the inverse-variance weighted (IVW) method to estimate causal effects. To address potential violations of MR assumptions due to directional pleiotropy, we performed MR-Egger regression and MR-PRESSO (Mendelian Randomization Pleiotropy RESidual Sum and Outlier) analysis. Results: Genetically influenced smoking initiation was directly associated with the risk of developing renal cell carcinoma (OR = 1.55, 95% CI: 1.04-2.33; p = 0.03). No causal relationship was found between daily cigarette consumption and lifetime smoking index with the risk of renal cell cancer. Genetic predisposition for weekly alcohol consumption showed a reduced risk of renal cell cancer (OR = 0.45, 95% CI: 0.26-0.81; p = 0.007). Discussion: Our study suggests a potential causal relationship between alcohol consumption and reduced risk of renal cell cancer, while no such association was observed with smoking. Further research is needed to confirm these findings.

Trends in genitourinary cancer mortality in the United States: analysis of the CDC-WONDER database 1999-2020

Introduction

Sociodemographic disparities in genitourinary cancer-related mortality have been insufficiently studied, particularly across multiple cancer types. This study aimed to investigate gender, racial, and geographic disparities in mortality rates for the most common genitourinary cancers in the United States.

Methods

Mortality data for prostate, bladder, kidney, and testicular cancers were obtained from the Centers for Disease Control and Prevention (CDC) WONDER database between 1999 and 2020. Age-adjusted mortality rates (AAMRs) were analyzed by year, gender, race, urban-rural status, and geographic region using a significance level of p < 0.05.

Results

Overall, AAMRs for prostate, bladder, and kidney cancer declined significantly, while testicular cancer-related mortality remained stable. Bladder and kidney cancer AAMRs were 3-4 times higher in males than females. Prostate cancer mortality was highest in black individuals/African Americans and began increasing after 2015. Bladder cancer mortality decreased significantly in White individuals, Black individuals, African Americans, and Asians/Pacific Islanders but remained stable in American Indian/Alaska Natives. Kidney cancer-related mortality was highest in White individuals but declined significantly in other races. Testicular cancer mortality increased significantly in White individuals but remained stable in Black individuals and African Americans. Genitourinary cancer mortality decreased in metropolitan areas but either increased (bladder and testicular cancer) or remained stable (kidney cancer) in non-metropolitan areas. Prostate and kidney cancer mortality was highest in the Midwest, bladder cancer in the South, and testicular cancer in the West.

Discussion

Significant sociodemographic disparities exist in the mortality trends of genitourinary cancers in the United States. These findings highlight the need for targeted interventions and further research to address these disparities and improve outcomes for all populations affected by genitourinary cancers.

Decreased risk of renal cell carcinoma in patients with type 2 diabetes treated with sodium glucose cotransporter-2 inhibitors

Patients with type 2 diabetes (T2D) are at a higher risk of developing renal cell carcinoma (RCC) than the general population. In vitro and in vivo investigations of the effects of sodium glucose cotransporter-2 inhibitors (SGLT2I) have shown a significantly reduced risk of RCC. However, the impact of these drugs on the incidence of RCC in the human population is unclear. This study aimed to examine the association between SGLT2I use and RCC risk in patients with T2D. We undertook a nationwide retrospective cohort study using the Health and Welfare Data Science Center database (2016-2020). The primary outcome was the risk of incident RCC by estimating hazard ratios (HRs) and 95% confidence intervals (CIs). Multiple Cox regression modeling was applied to analyze the association between SGLT2I use and RCC risk in patients with T2D. In a cohort of 241,772 patients with T2D who were using SGLT2Is and 483,544 participants who were not, 220 and 609 RCC cases, respectively, were recorded. The mean follow-up period of the study subjects was 2 years. There was a decreased risk of RCC for SGLT2I users after adjusting for the index year, sex, age, comorbidities, and concurrent medication (adjusted HR 0.68; 95% CI, 0.58-0.81). The sensitivity test for the propensity score 1:1-matched analyses showed similar results (adjusted HR 0.67; 95% CI, 0.55-0.81). The subgroup analysis revealed consistent results for sex, age (<70 years), and comorbidity with chronic kidney disease. The present study indicates that SGLT2I therapy significantly decreases RCC risk in patients with T2D. This finding was also consistent among the sensitivity test and subgroup analysis for those with or without chronic kidney disease/hypertension.

A population-based study on incidence trends of kidney and renal pelvis cancers in the United States over 2000-2020

Cancers of the kidney and renal pelvis are among the most prevalent types of urinary cancers. We aimed to outline the incidence trends of kidney and renal pelvis cancers by age, sex, race/ethnicity, and histology in the United States (US) from 2000 to 2020. The data was obtained from the Surveillance, Epidemiology, and End Results (SEER) 22 database. The identification of patients with kidney and renal pelvis cancers with morphologies of renal cell carcinoma, nephroblastoma, sarcoma, and neuroendocrine tumor was conducted utilizing the International Classification of Diseases for Oncology version 3. The average annual percent change (AAPC) were presented. All estimates were given in the form of counts and delayed age-standardized incidence rates (ASIRs) per 100,000 people. From 2000 to 2019, a total of 490,481 cases of kidney and renal pelvic cancer were recorded across all age groups in the US. The majority of them were among Non-Hispanic Whites (NHWs) (69.75%) and those aged 55-69 years (39.96%). The ASIRs per 100,000 for kidney and pelvis cancers were 22.03 for men and 11.14 for women. Non-Hispanic Black men had the highest ASIR (24.53 [24.24, 24.81]), and increase in ASIR over the 2000-2019 period (AAPC: 2.19% [1.84, 2.84]). There was a noticeable increase in incidence of kidney and renal pelvis cancers. Individuals aged 70-84 years had the highest ASIR for kidney and renal pelvis cancers. The COVID-19 era has resulted in a significant reduction in incidence rates across all demographics.

An epidemiological and clinicopathological study of type 1 vs. type 2 morphological subtypes of papillary renal cell carcinoma- results from a nation-wide study covering 50 years in Iceland

INTRODUCTION

Papillary renal cell carcinoma (pRCC) is the second most common histology of renal cell carcinoma (RCC), accounting for 10-15% of cases. Traditionally, pRCC is divided into type 1 and type 2, although this division is currently debated as a prognostic factor of survival. Our aim was to investigate the epidemiology and survival of the pRCC subtypes in a whole nation cohort of patients during a 50-year period.

MATERIALS AND METHODS

A Population based retrospective study including consecutive cases of RCC in Iceland from 1971-2020. Comparisons were made between histological classifications of RCC, with emphasis on pRCC subtypes (type 1 vs. 2) for outcome estimation. Changes in RCC incidence were analyzed in 5-year intervals after age standardization. The Kaplan-Meier method and Cox regression were used for outcome analysis.

RESULTS

A total of 1.725 cases were identified, with 74.4%, 2.1% and 9.2% having clear cell (ccRCC), chromophobe (chRCC), and pRCC, respectively. The age standardized incidence (ASI) of pRCC was 1.97/100.000 for males and 0.5/100.000 for females, and the proportion of pRCC increased from 3.7% to 11.5% between the first and last intervals of the study (p < 0.001). Age standardized cancer specific mortality (ASCSM) of pRCC was 0.6/100.000 and 0.19/100.000 for males and females, respectively. The annual average increase in ASI was 3.6% for type 1 pRCC, but the ASI for type 2 pRCC and ASCSM for both subtypes did not change significantly. Male to female ratio was 4.4 for type 1 pRCC and 2.3 for type 2. The average tumor size for type 1 and 2 was 58.8 and 73.7 mm, respectively. Metastasis at diagnosis was found in 8.7% in the type 1 pRCC, compared to 30.0% of patients with type 2 pRCC (p < 0.001). Estimated 5-year cancer-specific survival (CSS) were 94.4%, 80.7%, and 69.3% for chRCC, pRCC and ccRCC, respectively (p < 0.001). For the pRCC subtypes, type 1 was associated with better 5-year CSS than type 2 (86.3% vs. 66.0%, p < 0.001), although this difference was not significant after adjusting for cancer stage and grading.

CONCLUSIONS

pRCC histology was slightly less common in Iceland than in other countries. Males are more than three times more likely to be diagnosed with pRCC, compared to other RCC histologies. The subtype of pRCC was not found to be an independent risk factor for worse survival, and as suggested by the most recent WHO Classification of Urinary Tumors, grade and TNM-stage seem to be the most important factors for estimation of survival for pRCC patients.

The influence of age, period, and cohort factors on the incidence of kidney cancer in Spain 1990-2019: Evidence from the global burden of disease study

OBJECTIVE

This study aimed to assess the influence of age, period, and cohort (A-P-C) factors on kidney cancer (KC) incidence trends in Spain from 1990 to 2019.

METHODS

Employing data from the Global Burden of Disease Study 2019, we employed joinpoint analysis to determine long-term patterns and A-P-C modelling to quantify net drift, local drift, longitudinal age curves, and rate ratios (RRs) of period and cohort effects.

RESULTS

Over the period 1990-2019, an estimated 142,811 cases of KC were diagnosed in Spain. A consistent upward trend in KC incidence was observed for both men and women, with the male-to-female ratio remaining stable at 2.6. Joinpoint analysis identified three distinct periods for men: An initial period (1990-1995) characterised by a significant increase in rates, a subsequent period (1995-2016) characterised by a slowdown in the rate of increase, and a final period (2016-2019) in which rates have plateaued. In women, 2 time periods were observed: an initial period (1990-2007) in which rates increased significantly, followed by a period of stabilization (2007-2019). Men born in the early-mid 20th century had a rising KC risk, peaking in the 1960s. Women's risk rose steadily, peaking in the late 1990s.

CONCLUSION

A-P-C analysis reveals steady KC incidence increase in both genders over three decades. This highlights the need for targeted public health policies and effective prevention strategies.

Corosolic acid inhibits metastatic response of human renal cell carcinoma cells by modulating ERK/MMP2 signaling

Corosolic acid (CA), a plant-derived pentacyclic triterpenoid, has potent anti-inflammatory, anti-metabolic, and anti-neoplastic actions against a variety of human cancers. However, the specific mechanism by which CA inhibits the progression of renal cell carcinoma (RCC) is yet unclear. We found that CA (≤8 μM) had no influence on either the growth or viability of RCC cell lines (786-O, ACHN, and Caki-1) or normal HK2 cells. However, in a dose-dependent manner, CA prevented the invasion and migration of RCC cells. Human protease array analysis showed that CA reduced MMP2 expression. At increasing concentrations of CA, the expression of MMP2 was dose-dependently reduced, as shown by western blot and RT-PCR analyses as well as immunofluorescence staining. CA also stimulated ERK1/2 phosphorylation in 786-O and Caki-1 cells. Transfection of CA-treated RCC cells with siRNA-ERK restored MMP2 protein expression and the motility and invasion capabilities of RCC cells. Molecular docking study results showed that CA and MMP2 interact strongly. These findings elucidate the mechanism by which CA prevents RCC cells from migrating and invading, and these findings indicate that CA may be a potential anti-metastatic therapy for RCC.

Neighborhood social vulnerability and disparities in time to kidney cancer surgical treatment and survival in Arizona

BACKGROUND

Hispanics and American Indians (AI) have high kidney cancer incidence and mortality rates in Arizona. This study assessed: (1) whether racial and ethnic minority patients and patients from neighborhoods with high social vulnerability index (SVI) experience a longer time to surgery after clinical diagnosis, and (2) whether time to surgery, race and ethnicity, and SVI are associated with upstaging to pT3/pT4, disease-free survival (DFS), and overall survival (OS).

METHODS

Arizona Cancer Registry (2009-2018) kidney and renal pelvis cases (n = 4592) were analyzed using logistic regression models to assess longer time to surgery and upstaging. Cox-regression hazard models were used to test DFS and OS.

RESULTS

Hispanic and AI patients with T1 tumors had a longer time to surgery than non-Hispanic White patients (median time of 56, 55, and 45 days, respectively). Living in neighborhoods with high (≥75) overall SVI increased odds of a longer time to surgery for cT1a (OR 1.54, 95% CI: 1.02-2.31) and cT2 (OR 2.32, 95% CI: 1.13-4.73). Race and ethnicity were not associated with time to surgery. Among cT1a patients, a longer time to surgery increased odds of upstaging to pT3/pT4 (OR 1.95, 95% CI: 0.99-3.84). A longer time to surgery was associated with PFS (HR 1.52, 95% CI: 1.17-1.99) and OS (HR 1.63, 95% CI: 1.26-2.11). Among patients with cT2 tumor, living in high SVI neighborhoods was associated with worse OS (HR 1.66, 95% CI: 1.07-2.57).

CONCLUSIONS

High social vulnerability was associated with increased time to surgery and poor survival after surgery.

Analysis of clinical characteristics and prognostic factors of elderly patients with renal cell carcinoma based on the SEER database

To study the difference of clinical characteristics and prognostic factors from elderly patients with renal cell carcinoma (RCC), the statistical analysis was carried out based on the surveillance, epidemiology, and end results database. The relevant clinical information of 19,472 RCC patients from 2010 to 2015 were collected, and the differences of clinicopathological characteristics and survival rate was analyzed by log-rank method and Chi square test, respectively. Multivariate Cox regression model was used to explore the independent risk factors affecting the long-term survival of RCC patients. Results showed that the proportion of elderly RCC patients in the 60-64-year group in 2010 was 15.20%, but the value elevated to 18.51% in 2015, and the Chi-square test revealed the significant correlation between elderly RCC patients with gender, race, American Joint Committee on cancer stage, T stage, N stage, and M stage. The difference of survival time between the 60-69 year, 70-79 year, 80-84 year, and 85+ year group was significant, and Kaplan-Meier analysis showed a negative effects of age on survival rate of RCC patients, indicating a worsening trend with increasing age. Cox proportional hazards model analysis further confirmed that age was the important independent prognostic factor. Our study reveals that the onset age of RCC in elderly population is gradually decreasing, and the malignant degree of elderly RCC patients is increasing with age. The female elderly population could be more susceptible to RCC than male elderly population, and 85+ year population could also be cancer susceptible with a higher lymph node metastasis rate, later tumor stage, and poor prognosis, suggesting that these elderly populations should pay more attention to the RCC screening.

Establishing a prognostic model based on five starvation-related long non-coding RNAs for clear cell renal cell carcinoma

BACKGROUND

Starvation-induced tumor microenvironment significantly alters genetic profiles including long non-coding RNAs (lncRNAs), further regulating the malignant biological characteristics (invasion and migration) of clear cell renal cell carcinoma (ccRCC).

METHODS

Transcriptome RNA-sequencing data of 539 ccRCC tumors and 72 normal tissues were acquired from the TCGA and paired clinical samples of 50 ccRCC patients. In vitro experiments, such as qPCR, migration and invasion assays were applied to reveal the clinical relevance of LINC-PINT, AC108449.2 and AC007637.1.

RESULTS

170 lncRNAs were verified as starvation-related lncRNAs (SR-LncRs), of which 25 lncRNAs were associated with overall survival in ccRCC patients. Furthermore, a starvation-related risk score model (SRSM) was built based on the expression levels of LINC-PINT, AC108449.2, AC009120.2, AC008702.2 and AC007637.1. ccRCC patients with high level of LINC-PINT expression were divided into high-risk group and led to higher mortality, but AC108449.2 and AC007637.1 were contrary. Analogously, LINC-PINT was highly expressed in ccRCC cell lines and tumor tissues, especially in patients with advanced stage, T-stage and M-stage, while AC108449.2 and AC007637.1 showed the opposite results. In addition, the increased levels of AC108449.2 and AC007637.1 were significantly correlated with grade. Silencing LINC-PINT reduced the invasion and migration characteristics of ccRCC cells. SiR-AC108449.2 and siR-AC007637.1 enhanced the ability of invasion and migration in ccRCC cells.

CONCLUSIONS

In this study, we find the clinical significance of LINC-PINT, AC108449.2 and AC007637.1 in predicting the prognosis of ccRCC patients and verify their correlation with various clinical parameters. These findings provide an advisable risk score model for ccRCC clinical decision-making.

Cancer-specific mortality free survival rates in non-metastatic non-clear cell renal carcinoma patients at intermediate/high risk of recurrence

BACKGROUND

To date, five trials testing the effect of adjuvant systemic therapy in surgically treated non-metastatic renal cell carcinoma included patients with non-clear cell histology. We tested the effect of papillary vs. chromophobe histological subtype, stage, and grade on 10-year cancer-specific survival, in patients eligible for ≥1 such trial.

METHODS

We identified patients meeting ASSURE, SORCE, EVEREST, PROSPER, or RAMPART trial inclusion criteria in the SEER (2000-2018) database. Kaplan-Meier analyses estimated 10-year survival rates and multivariable Cox regression models tested for the independent predictor status of histological subtype, stage, and grade.

RESULTS

We identified 5465 (68%) papillary and 2562 (32%) chromophobe renal cell carcinoma patients. Cancer-specific survival rates at 10 years were 77% in papillary vs. 90% in chromophobe. In multivariable Cox regression models applied to papillary patients, cancer-specific mortality independent predictor status was reached for T3G3-4 (HR 2.9), T4Gany (HR 3.4), TanyN1G1-2 (HR 3.1), and TanyN1G3-4 (HR 8.0, P<0.001), relative to T1/2Gany. In multivariable Cox regression models applied to chromophobe patients, mortality independent predictor status was reached for T3G3-4 (HR 3.6), T4Gany (HR 14.0), TanyN1G1-2 (HR 5.7), and TanyN1G3-4 (HR 15.0, P<0.001), relative to T1/2Gany.

CONCLUSIONS

In surgically treated non-metastatic intermediate/high-risk renal cell carcinoma patients, papillary histologic subtype exhibited worse cancer-specific survival than chromophobe histologic subtype. Although stage and grade represented independent predictors in both histological subtype groups, the magnitude of their effect was invariably worse in chromophobe than in papillary patients. In consequence, papillary and chromophobe patients should be considered separate entities instead of being combined under the non-clear cell designation.

The Changing Role of Renal Mass Biopsy

The incidence and prevalence of small renal masses (SRMs) continues to rise and with increased detection comes increases in surgical management, although the probability of an SRM being benign is upward of 30%. An extirpative treatment first diagnose-later strategy persists and clinical tools for risk stratification such as renal mass biopsy remain severely underutilized. The overtreatment of SRMs has multiple detrimental effects including surgical complications, psychosocial stress, financial loss, and reduced renal function leading to downstream effects such as the need for dialysis and cardiovascular disease.

A comprehensive assessment of frailty status on surgical, functional and oncologic outcomes in patients treated with partial nephrectomy-A large, retrospective, single-center study

BACKGROUND

Partial nephrectomy (PN) is a challenging procedure, which can be associated with severe complications. In consequence, the search for accurate and independent indicators of unfavorable surgical outcomes appears warranted. We aimed at evaluating the impact of frailty status on surgical, functional and oncologic outcomes in patients undergoing PN for renal cell carcinoma (RCC).

METHODS

A retrospective, single-center study including 1,282 patients treated with PN for clinically localized cT1 RCC was performed. The modified Frailty Index (mFI) was used to assess preoperative frailty. Multivariable logistic, Poisson and linear regression analyses(MVA) tested the effect of frailty on complications, acute kidney injury(AKI), renal function decline after PN. Cumulative incidence and competing-risk analyses investigated survival outcomes.

RESULTS

Of 1,282 patients, 220 (17%) were frail. Overall, 982 (76%) vs. 123 (9.6%) vs. 171 (13%) patients underwent open vs. laparoscopic vs. robot-assisted PN. Median follow-up was 66 (IQR: 35-107) months. At MVA, frailty status predicted increased risk of complications [Odds ratio (OR): 1.46, 95%CI 1.17-1.84; P < 0.001]. Moreover, frail patients were at higher risk of postoperative AKI (OR: 1.95, 95%CI 1.13-3.35; P = 0.01). In frail patients, renal function permanently decreased over time (P = 0.01) without any renal function plateau or improvement during the follow-up, which were instead observed in the nonfrail cohort. At competing-risks analyses, frailty status predicted higher risk of other-cause mortality [Hazard ratio (HR): 1.67, 95%CI 1.05-2.66; P = 0.02], but not of cancer-specific mortality (P = 0.3).

CONCLUSIONS

Frailty status predicts higher risk of adverse surgical outcomes after PN. Moreover, greater renal function decline was observed in frail patients, compared with nonfrail patients. Finally, the risk of OCM significantly overcomes the risk of dying due to RCC in frail patients.

Burden of kidney cancer and attributed risk factors in China from 1990 to 2019

Background

The changing trends and risk-attributed burdens of kidney cancer in China are unknown. Therefore, this study aimed to describe the latest status and trends of kidney cancer burden in China and its associated risk factors.

Methods

The absolute numbers and rates of the incidence, deaths, and disability-adjusted life-years (DALYs) of kidney cancer in China were extracted from the Global Burden of Disease 2019 platform. Overall burden and burden attributed to smoking and high body mass index (BMI) were described. Average annual percent change (AAPC) was calculated to describe trend analyses from 1990 to 2019 using the Joinpoint regression program.

Results

In 2019, 59,827 new cases, 23,954 deaths, and 642,799 DALYs of kidney cancer occurred in China, of which men accounted for 71.1, 70.5, and 72.0%, and the population aged ≥55 years accounted for 58.9, 77.9, and 60.1%, of new cases, deaths, and DALYs, respectively. From 1990 to 2019, the age-standardized incidence rate (per 100,000 person-years) increased from 1.16 in 1990 to 3.21 in 2019, with an AAPC of 3.4% (95% confidence interval [CI]: 3.1-3.8%, p < 0.05); the mortality rate increased from 0.70 to 1.27, with an AAPC of 2.1% (1.5-2.3%, p < 0.05); and the DALY rate increased from 0.70 to 1.27, with an AAPC of 2.1% (1.5-2.3%, p < 0.05). In 2019, the proportions of DALYs attributed to smoking and high BMI were 18.0% and 11.1%, respectively, and the DALY rates attributed to both smoking and high BMI increased from 1990 to 2019, with AAPC of 2.9% (2.6-3.3%, p < 0.05) and 4.8% (4.2-5.4%, p < 0.05), respectively.

Conclusion

The kidney cancer burden in China has continued to grow over the recent three decades, with a severe burden among older adults and men. Therefore, timely preventive interventions for modifiable risk factors are required.

Healthcare Disparities in Interventional Radiology

Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.

Prognostic model for overall survival that includes the combination of platelet count and neutrophil-lymphocyte ratio within the first six weeks of sunitinib treatment for metastatic renal cell carcinoma

BACKGROUND

The association between the combination of platelet count and neutrophil-lymphocyte ratio (COP-NLR) at the time of adverse events during sunitinib treatment and prognosis is unclear, and prognostic models combining the prognostic factors of sunitinib have not been well studied. Thus, we developed a prognostic model that includes the COP-NLR to predict the prognosis of patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib.

METHODS

We performed a retrospective cohort study of 102 patients treated with sunitinib for mRCC between 2008 and 2020 in three hospitals associated with Showa University, Japan. The primary outcome was overall survival (OS). The collected data included baseline patient characteristics, adverse events, laboratory values, and COP-NLR scores within the first 6 weeks of sunitinib treatment. Prognostic factors of OS were analyzed using the Cox proportional hazards model. The integer score was derived from the beta-coefficient (β) of these factors and was divided into three groups. The survival curves were visualized using the Kaplan-Meier method and estimated using a log-rank test.

RESULTS

The median OS was 32.3 months. Multivariable analysis showed that the number of metastatic sites, Memorial Sloan Kettering Cancer Center risk group, number of metastases, non-hypertension, modified Glasgow Prognostic Score, and 6-week COP-NLR were significantly associated with OS. A higher 6-week COP-NLR was significantly associated with a shorter OS (p < 0.001). The β values of the five factors for OS were scored (non-hypertension, mGPS, and 6-week COP-NLR = 1 point; number of metastatic sites = 2 points; MSKCC risk group = 3 points) and patients divided into three groups (≤ 1, 2-3, and ≥ 4). The low-risk (≤ 1) group had significantly longer OS than the high-risk (≥ 4) group (median OS: 99.0 vs. 6.2 months, p < 0.001).

CONCLUSIONS

This study showed that the COP-NLR within the first 6 weeks of sunitinib treatment had a greater impact on OS than the COP-NLR at the start of sunitinib treatment. The developed prognostic model for OS, including the 6-week COP-NLR, will be useful in decision-making to continue sunitinib in the early treatment stage of patients with mRCC.

Diagnostic and Prognostic Biomarkers in Renal Clear Cell Carcinoma

Renal clear cell carcinoma (ccRCC) comprises over 75% of all renal tumors and arises in the epithelial cells of the proximal convoluted tubule. Molecularly ccRCC is characterized by copy number alterations (CNAs) such as the loss of chromosome 3p and VHL inactivation. Additional driver mutations (SETD2, PBRM1, BAP1, and others) promote genomic instability and tumor cell metastasis through the dysregulation of various metabolic and immune-response pathways. Many researchers identified mutation, gene expression, and proteomic signatures for early diagnosis and prognostics for ccRCC. Despite a tremendous influx of data regarding DNA alterations, gene expression, and protein expression, the incorporation of these analyses for diagnosis and prognosis of RCC into the clinical application has not been implemented yet. In this review, we focused on the molecular changes associated with ccRCC development, along with gene expression and protein signatures, to emphasize the utilization of these molecular profiles in clinical practice. These findings, in the context of machine learning and precision medicine, may help to overcome some of the barriers encountered for implementing molecular profiles of tumors into the diagnosis and treatment of ccRCC.

A novel nomogram and risk classification system predicting the overall survival of patients with papillary renal cell carcinoma after nephrectomy: A population-based study

Background

Papillary renal cell carcinoma (pRCC) is the largest histologic subtype of non-clear-cell RCC. To date, there is no reliable nomogram to predict the prognosis of patients with pRCC after nephrectomy. We aimed to first establish an effective nomogram to predict the overall survival (OS) of patients with pRCC after nephrectomy.

Methods

A total of 3,528 eligible patients with pRCC after nephrectomy were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The patients were randomized into the training cohort (n = 2,472) and the validation cohort (n = 1,056) at a 7:3 ratio. In total, 122 real-world samples from our institute (titled the AHMU-pRCC cohort) were used as the external validation cohort. Univariate and subsequent multivariate Cox regression analyses were conducted to identify OS-related prognostic factors, which were further used to establish a prognostic nomogram for predicting 1-, 3-, and 5-year OS probabilities. The performance of the nomogram was evaluated by using the concordance index (C-index), receiver operating characteristic curve (ROC), calibration plot, and decision curve analysis (DCA).

Results

Multivariate Cox analysis showed that age, race, marital status, TNM stage, tumor size, and surgery were significant OS-related prognostic factors. A prognostic model consisting of these clinical parameters was developed and virtualized by a nomogram. High C-index and area under the ROC curve (AUC) values of the nomogram at 1, 3, and 5 years were found in the training, validation, and AHMU-pRCC cohorts. The calibration plot and DCA also showed that the nomogram had a satisfactory clinical application value. A risk classification system was established to risk-stratify patients with pRCC.

Conclusion

Based on a large cohort from the public SEER database, a reliable nomogram predicting the OS of patients with pRCC after nephrectomy was constructed, which could optimize the survival assessment and clinical treatment.

Volumetric Quantitative Contrast-enhanced Ultrasonography Evaluation of Complex Renal Cysts: An Adjunctive Metric to the Bosniak Classification System to Predict Malignancy

BACKGROUND

Management of complex renal cysts is guided by the Bosniak classification system, which may be inadequate for risk stratification of patients for intervention. Fractional tumor vascularity (FV) calculated from volumetric contrast-enhanced ultrasound (CEUS) images may provide additional useful information.

OBJECTIVE

To evaluate CEUS and FV calculation for risk stratification of patients with complex renal cysts.

DESIGN, SETTING, AND PARTICIPANTS

This was a pilot prospective study with institutional review board approval involving patients undergoing surgery for Bosniak IIF-IV complex renal cysts. CEUS was performed preoperatively on the day of surgery with two-dimensional (2D) and three-dimensional (3D) imaging and sulfur hexafluoride lipid-type A microspheres as the ultrasound contrast agent.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A custom MATLAB program was used to select regions of interest on CEUS scans. FV was calculated according to FV = 1 - (total nonenhancing area/total lesion area). We assessed the ability of 2D- and 3D-derived percentage FV (2DFV%, and 3DFV%) and Bosniak classification schemes (pre-2019 [P2019B] and post-2019 [B2019]) to predict malignancy, aggressive histology, and upstaging on surgical pathology. Performance was assessed as area under the receiver operating characteristic curve (AUC).

RESULTS AND LIMITATIONS

Twenty eligible patients were included in final analysis, of whom 85% (n = 17) had Bosniak IV cysts and 85% (n = 17) had malignant disease on final pathology. Four (24%) of the malignant lesions were International Society of Urological Pathology grade 3-4. The AUC for predicting malignancy was 0.980, 0.824, 0.863, and 0.824 with P2019B, B2019, 2DFV%, and 3DFV%, respectively. When the Bosniak classification was combined with FV%, three models had an AUC of 1, while the combined 2DFV% + B2019 model had AUC of 0.980.

CONCLUSIONS

FV is a novel metric for evaluating complex cystic renal masses and enhances the ability of the Bosniak classification system to predict malignancy. This metric may serve as an adjunct in risk stratification for surgical intervention. Further prospective evaluation is warranted.

PATIENT SUMMARY

Cysts in the kidney are currently classified using a scheme called the Bosniak system. We assessed measurement of the percentage of vascular tissue (called fractional vascularity) in cysts on a special type of ultrasound scan. This promising test adds information when combined with the Bosniak system and can help in guiding appropriate treatment.

Coffee and caffeine consumption and risk of renal cell carcinoma: A Mendelian randomization study

Background

The association between coffee and caffeine consumption and the risk of renal cell carcinoma was inconsistent among observational studies, and whether these observed associations were causal remained unclear. Therefore, we performed two-sample Mendelian randomization (MR) study to assess the causal nature of the association.

Materials and methods

In this study, 12 and two independent single nucleotide polymorphisms (SNPs) related to coffee and caffeine consumption at a genome-wide significance level of p < 5 × 10^–8 were used as instrumental variables (IVs), respectively. Summary-level data for renal cell carcinoma were taken from the FinnGen consortium with up to 174,977 individuals, and the International Agency for Research on Cancer (IARC) with 13,230 individuals. We used inverse-variance weighted (IVW) as the main method, followed by the weighted median method, the MR-Egger regression method, and the MR robust adjusted profile score method. Outlier and pleiotropic variants were assessed by the MR Pleiotropy RESidual Sum and Outlier test and MR-Egger regression. We used meta-analysis methods in fixed-effects to combine the estimates from the two sources.

Results

The genetically predicted coffee consumption was not associated with the risk of renal cell carcinoma in the FinnGen consortium, and the relationship was consistent in the IARC consortium. The pooled odds ratio (OR) per 50% increase of coffee consumption was 0.752 [95% confidence interval (CI), 0.512–1.105; p = 0.147]. In addition, complementary analyses that separated the coffee-related SNPs according to their relationship with blood levels of caffeine metabolites (higher, lower, or unrelated) found no relationship with renal cell carcinoma. The results were consistent after excluding eight SNPs due to potential risk factors at genome-wide significance (p < 5 × 10^–8). Moreover, genetically predicted per 80-mg increase in caffeine consumption was not associated with the risk of renal cell carcinoma (pooled OR = 0.872, 95% CI: 0.676–1.125, p = 0.292).

Conclusion

Our MR study provided no convincing evidence for a causal effect between coffee and caffeine consumption and the risk of renal cell carcinoma. The associations for renal cell carcinoma need to be verified in well-powered studies.

Comparative Analysis for the Distinction of Chromophobe Renal Cell Carcinoma from Renal Oncocytoma in Computed Tomography Imaging Using Machine Learning Radiomics Analysis

Background: ChRCC and RO are two types of rarely occurring renal tumors that are difficult to distinguish from one another based on morphological features alone. They differ in prognosis, with ChRCC capable of progressing and metastasizing, but RO is benign. This means discrimination of the two tumors is of crucial importance. Objectives: The purpose of this research was to develop and comprehensively evaluate predictive models that can discriminate between ChRCC and RO tumors using Computed Tomography (CT) scans and ML-Radiomics texture analysis methods. Methods: Data were obtained from 78 pathologically confirmed renal masses, scanned at two institutions. Data from the two institutions were combined to form a third set resulting in three data cohorts, i.e., cohort 1, 2 and combined. Contrast-enhanced scans were used and the axial cross-sectional slices of each tumor were extracted from the 3D data using a semi-automatic segmentation technique for both 2D and 3D scans. Radiomics features were extracted before and after applying filters and the dimensions of the radiomic features reduced using the least absolute shrinkage and selection operator (LASSO) method. Synthetic minority oversampling technique (SMOTE) was applied to avoid class imbalance. Five ML algorithms were used to train models for predictive classification and evaluated using 5-fold cross-validation. Results: The number of selected features with good model performance was 20, 40 and 6 for cohorts 1, 2 and combined, respectively. The best model performance in cohorts 1, 2 and combined had an excellent Area Under the Curve (AUC) of 1.00 ± 0.000, 1.00 ± 0.000 and 0.87 ± 0.073, respectively. Conclusions: ML-based radiomics signatures are potentially useful for distinguishing ChRCC and RO tumors, with a reliable level of performance for both 2D and 3D scanning.

Melatonin combined with sorafenib synergistically inhibit the invasive ability through targeting metastasis-associated protein 2 expression in human renal cancer cells

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Systemic immune-inflammation index is a promising non-invasive biomarker for predicting the survival of urinary system cancers: a systematic review and meta-analysis

OBJECTIVE

Systemic immune-inflammation index (SII) has been reported in numerous studies to effectively predict the survival outcomes of urinary system cancers; however no agreement has been reached. This meta-analysis aimed to explore the prognostic significance of pre-treatment SII in tumours of the urinary system.

METHODS

Relevant published articles were selected from Web of Science, PubMed, Embase, and the Cochrane Library up to 30 August 2020. The hazard ratios (HRs) with 95% confidence intervals (CIs) were computed to estimate the associations of pre-treatment SII with overall survival (OS), progression-free survival (PFS), cancer-specific survival (CSS) in urinary system cancers.

RESULTS

13 papers were included in our meta-analysis. From the combined data, we found that a high pre-treatment SII indicated a markedly worse OS (HR = 1.98; 95% CI: 1.75-2.23; p < .001), PFS (HR: 2.08; 95% CI: 1.32-3.26; p = .002), and CSS (HR: 2.41, 95% CI: 1.73-3.35, p < .001). Additionally, patients with an elevated SII value might have undesirable pathological characteristics, including a large tumour size, a poor differentiation grade, and an advanced tumour stage (all p < .001).

CONCLUSIONS

Pre-treatment SII could be used as a non-invasive and promising biomarker to indicate the prognosis of urinary system cancer patients.KEY MESSAGES:This meta-analysis evaluates the predictive value of systemic immune-inflammation index (SII) for patients with urinary system cancer.A high pre-treatment SII indicates a poor prognosis.SII can serve as a promising non-invasive biomarker to help clinicians assess the prognosis and develop treatment strategies for urinary system cancer patients.

Treatment-free survival after discontinuation of immune checkpoint inhibitors in metastatic renal cell carcinoma: a systematic review and meta-analysis

While immune checkpoint inhibitors (ICI) can lead to sustained responses in metastatic renal cell carcinoma (mRCC), the optimal duration of therapy remains unknown. We aimed to examine treatment-free survival (TFS) in objective responders who discontinued ICI and to explore factors that may impact objective response rate (ORR) and TFS. MEDLINE/PubMed, Embase, and the Cochrane Library were searched for prospective studies reporting individual outcomes after ICI discontinuation in patients with mRCC. Pooled ORR and TFS were estimated using random-effects meta-analyses, and associations between ICI regimen type or treatment line and ORR or TFS were evaluated. Sixteen cohorts comprising 1833 patients treated with ICI were included. The pooled ORR was 43% (95% CI 33% to 53%), and significant differences in summary estimates existed among patients who received ICI monotherapy (22%, 95% CI 18% to 26%), ICI plus a vascular endothelial growth factor (VEGF) pathway inhibitor (57%, 95% CI 48% to 65%), and dual ICI (40%, 95% CI 36% to 44%). Of 572 responders who had available data, 327 stopped ICI, with 86 (26%) continuing to respond off-treatment. Pooled TFS rates at 6 and 12 months were 35% (95% CI 20% to 50%) and 20% (95% CI 8% to 35%), respectively, and were highest for responders treated with dual ICI and lowest for those treated with ICI plus a VEGF pathway inhibitor. Thus, a subset of patients with mRCC who are treated with ICI-based therapy can have durable TFS after therapy discontinuation. Prospective clinical trials and biomarkers are needed to identify patients who can discontinue ICI therapy without compromising clinical outcomes.

Sex and Gender Differences in Kidney Cancer: Clinical and Experimental Evidence

Simple Summary

Kidney cancer is a frequent malignant tumor that accounts for approximately 5% of all cancer incidences. It affects both males and females, but males are twice as likely to develop kidney cancer than females. Evidence shows that this discrepancy takes root in individual differences, such as genetics or pathologies that affect the patient. It is then reflected in the clinical characteristics of the tumors, as males have larger and more aggressive tumors. Understanding the sex- and gender-based differences in kidney cancer is essential to be able to offer patients individualized medicine that would better cover their needs in terms of prevention, diagnosis and treatment.

Abstract

Sex and gender disparities have been reported for different types of non-reproductive cancers. Males are two times more likely to develop kidney cancer than females and have a higher death rate. These differences can be explained by looking at genetics and genomics, as well as other risk factors such as hypertension and obesity, lifestyle, and female sex hormones. Examination of the hormonal signaling pathways bring further insights into sex-related differences. Sex and gender-based disparities can be observed at the diagnostic, histological and treatment levels, leading to significant outcome difference. This review summarizes the current knowledge about sex and gender-related differences in the clinical presentation of patients with kidney cancer and the possible biological mechanisms that could explain these observations. Underlying sex-based differences may contribute to the development of sex-specific prognostic and diagnostic tools and the improvement of personalized therapies.

Alcohol consumption, tobacco smoking, and subsequent risk of renal cell carcinoma: The JPHC study

The effects of alcohol consumption and tobacco smoking on renal cell carcinoma (RCC) incidence have not been well‐investigated in Asian populations. Here, we evaluated these effects in a large Japanese prospective cohort. We collected data on eligible participants in the Japan Public Health Center‐based Prospective Study, and undertook multivariable‐adjusted Cox proportional hazards regression to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of RCC incidence. We identified 340 cases (230 men and 110 women) among the 105 663 eligible participants (50 262 men and 55 741 women), who were followed for an average of 19.1 years, with a cumulative total of 2 020 364 person‐years. A slightly inverse but nonsignificant association was observed between alcohol drinking and RCC incidence. In contrast, the risk of RCC was increased in those with heavy smoking (≥40 pack‐years) when men and women were combined (HR 1.50; 95% CI, 1.01‐2.25). We identified no significant association between alcohol consumption and RCC incidence. In contrast, heavy smoking (≥40 pack‐years) was associated with a significant increase in incidence.

Using a large prospective cohort in Japan, we evaluated the effects of alcohol consumption and tobacco smoking on renal cell carcinoma (RCC). Our analyses showed no significant association between alcohol consumption and RCC incidence. In contrast, heavy smoking (≥40 pack‐years) was associated with a significant increase in incidence.

Kidney cancer mortality disparities among Hispanics in the US

INTRODUCTION

Kidney cancer incidence is increasing among Hispanics but rate differences by distinct group, such as Cuban, Puerto Rican, and Mexican have not been studied. To fill this knowledge gap, we use mortality data, reflecting fatal kidney cancers, to examine patterns by race-ethnicity, including detailed Hispanic groups, and correlate the mortality rates with each group's prevalence of known kidney cancer risk factors: smoking, obesity, hypertension, diabetes, and chronic kidney disease.

METHODS

We used individual-level death data for California, Florida, and New York (2008-2018), and population prevalence data from the National Health Interview Surveys (2008-2018). Age-adjusted mortality rates (AAMRs) and regression-derived mortality rate ratios (MRRs) were computed. Pearson correlation analyses assessed the extent to which group-specific risk factor prevalence explained variability in observed AAMRs.

RESULTS

US-born Mexican Americans and American Indians had the highest rates and MRRs compared to Whites: 1.44 (95 %CI: 1.35-1.53) and 1.51 (1.38-1.64) for Mexican American men and women, respectively, and 1.54 (95 %CI: 1.25-1.89) and 1.53 (95 %CI: 1.15-2.04) for American Indians. In contrast, non-Mexican Hispanics had lower rates than Whites. Among males, positive correlations between AAMRs and smoking, obesity, and chronic kidney disease prevalence by race-ethnicity were found.

CONCLUSION

Mexican Americans and American Indians are high-risk for fatal kidney cancer. Disparities are only partially attributable to higher smoking and obesity prevalence, and more so among men than women. A shared risk factor profile, as well as possible genetic similarities, may explain their disproportionately higher kidney cancer mortality, but further research is warranted.

Race/Ethnicity Determines Life Expectancy in Surgically Treated T1aN0M0 Renal Cell Carcinoma Patients

BACKGROUND

Life expectancy (LE) is an important consideration in the clinical decision-making for T1aN0M0 renal cell cancer (RCC) patients.

OBJECTIVE

To test the effect of race/ethnicity (Caucasian, African American, Hispanic/Latino, and Asian) on LE predictions from Social Security Administration (SSA) life tables in male and female T1aN0M0 RCC patients.

DESIGN, SETTING, AND PARTICIPANTS

We relied on the Surveillance, Epidemiology, and End Results database.

INTERVENTION

Radical nephrectomy (RN) and partial nephrectomy (PN).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Five-year and 10-yr observed overall survival (OS) of pT1aN0M0 RCC patients treated between 2004 and 2006 were compared with the LE predicted from SSA life tables. We repeated the comparison in a more contemporary cohort (2009-2011), with 5-yr follow-up and higher PN rates.

RESULTS AND LIMITATIONS

In the 2004-2006 cohort, PN rate was 40.7%. OS followed the predicted LE in Caucasians, Hispanics/Latinos, and Asians, but not in African Americans, in whom 5-yr OS rates were 5.0% (male) and 8.7% (female) and 10-yr rates were 4.2% (male) and 11.1% (female) lower than predicted. In the 2009-2011 cohort, PN rate was 59.4%. Same observations were made for OS versus predicted LE in Caucasians, Hispanics/Latinos, and Asians. In African Americans, 5-yr OS rates were 1.5% (male) and 4.9% (female) lower than predicted.

CONCLUSIONS

In RN- or PN-treated pT1aN0M0 RCC patients, LE predictions closely approximated OS of Caucasians, Hispanics/Latinos, and Asians. In African-American patients, SSA life tables overestimated LE, more in females than in males. The limitations of our study are its retrospective nature, its validity for US patients only, and the under-representation of racial/ethnic minorities.

PATIENT SUMMARY

Social Security Administration life tables can be used to estimate long-term life expectancy in patients who are surgically treated for renal cancer (≤4 cm). However, while for Caucasians, Hispanics/Latinos, and Asians, the prediction performs well, life expectancy of African Americans is generally overestimated by life table predictions. TAKE  HOME MESSAGE: In the clinical decision-making process for T1aN0M0 renal cell cancer patients eligible for radical or partial nephrectomy, the important influence of patient sex and race/ethnicity on life expectancy should be taken into account, when using Social Security Administration life tables.

Prognostic factors in patients with small renal masses: a comparison between <2 vs. 2.1-4 cm renal cell carcinomas

BACKGROUND

Few data factually support the prognostic distinction between renal cell carcinomas (RCC) < 2 vs. 2.1-4 cm, in terms of cancer-specific mortality (CSM). We investigated CSM rates over time in <2 vs. 2.1-4 cm RCC, according to patient and tumor characteristics.

METHODS

Within the Surveillance, Epidemiology and End Results (SEER) database, we focused on patients with T_1aN₀M₀ RCC who underwent either radical or partial nephrectomy between 2000 and 2015. Temporal trends, Kaplan-Meier plots and multivariable Cox-regression analyses assessed CSM.

RESULTS

Of 43,147 T_1aN₀M₀ patients, 12,238 (28.4%) harbored RCC < 2 cm and 30,909 (71.6%) 2.1-4 cm RCC. The distribution of histological subtypes according to 2 cm cut-off was as follows: a). clear-cell G1/G2: 64.5 vs. 61.8%; b). papillary G1/G2 15.9 vs. 11.1%; c). clear-cell G3/G4: 9.9 vs. 16.1%; d). papillary G3/G4 4.9 vs. 5.4%; and e). chromophobe 4.9 vs. 5.2%. Five-year CSM rates were invariably lower in RCC < 2 cm than in 2.1-4 cm, for all histological subtypes and grade groups (a-e), even after additional multivariable adjustment for age and residual tumor size differences. 5-year CSM rates improved in more contemporary years, in both tumor size groups (< 2 vs. 2.1-4 cm), but to a greater extent in 2.1-4 cm renal masses.

CONCLUSION

Our results validate the presence of prognostically more favorable CSM outcomes in RCC < 2 cm vs. 2.1-4 cm, across all histological subtypes and grades. Moreover, temporal improvements were also recorded in both <2 and 2.1-4 cm RCC groups, with more pronounced improvements in patients with 2.1-4 cm renal masses. However, prospective randomized trials are needed to further confirm our results.