Limitations of Available Studies Prevent Reliable Comparison Between Tumour Ablation and Partial Nephrectomy for Patients with Localised Renal Masses: A Systematic Review from the European Association of Urology Renal Cell Cancer Guideline Panel

[Nephron sparing in the management of localized solid renal mass]

Managing a malignant renal tumor requires, first of all, a reflection on the necessity of its treatment. It must consider the renal function, altered at the time of diagnosis in 50% of cases. The treatment method chosen depends on many factors, in particular, the predicted residual renal function, the risk of chronic kidney disease, the need for temporary or long-term dialysis, and overall long-term survival. Other factors include the size, position, and number of tumors and a hereditary tumor background. When a renal-sparing management alternative is available, total nephrectomy should no longer be performed in patients with small malignant renal masses (cT1a). This may consist of surgery (partial nephrectomy or lumpectomy), percutaneous thermo-ablation (by radiofrequency, microwave, or cryotherapy). In patients with limited life expectancy, imaging-based surveillance may be proposed to suggest treatment in case of local progression. Good coordination between urologist, radiologist, nephrologist, and sometimes radiotherapist should allow optimal management of patients with a malignant renal tumor with or without underlying renal failure.

Stereotactic body radiation therapy for primary renal cell carcinoma: A review on behalf of the CC-AFU

INTRODUCTION

The incidence of localized renal cell carcinoma (RCC) is on the rise among individuals aged 70 and older. While the gold standard for treatment remains surgical resection, some elderly and frail patients with comorbidities are not eligible for this procedure. In selected cases, percutaneous thermal ablation, such as cryotherapy, microwave and radiofrequency, offers less invasive options. General anesthesia is sometimes necessary for such treatments, but most of the procedures can be conducted using mild or deep conscious sedation. This approach is preferably recommended for small cT1a tumors situated at a distance from the renal hilum and/or ureter. Active surveillance remains an alternative in the case of small low grade RCC although it may induce anxiety in certain patients. Recent research has highlighted the potentials of stereotactic ablative body radiotherapy (SABR) as a noninvasive, well-tolerated, and effective treatment for small renal tumors. This narrative review aims to explore recent advances in SABR for localized RCC, including appropriate patient selection, treatment modalities and administration, as well as efficacy and tolerance assessment.

MATERIAL AND METHODS

We conducted a literature review using the terms [kidney cancer], [renal cell carcinoma], [stereotactic radiotherapy], [SBRT], and [SABR] in the Medline, PubMed, and Embase databases, focusing on prospective and relevant retrospective studies published in English.

RESULTS

Studies report local control rates ranging from 70% to 100% with SABR, highlighting its efficacy in treating RCC. The decline in glomerular filtration rate (GFR) is approximately -5 to -17mL/min over the years following SABR. Common toxicities are rare, primarily CTCAE grade 1, include fatigue, nausea, chest or back pain, diarrhea, or gastritis.

CONCLUSION

Stereotactic ablative body radiotherapy (SABR) may be considered as a viable option for patients with localized RCC who are not suitable candidates for surgery with a high local control rate and a favorable safety profile. This approach should be discussed in a multidisciplinary meeting and results from ongoing clinical trials are awaited.

LEVEL OF EVIDENCE: 5

Perioperative and Oncological Outcomes of Percutaneous Radiofrequency Ablation versus Partial Nephrectomy for cT1a Renal Cancers: A Retrospective Study on Groups with Similar Clinical Characteristics

Over the recent years, progress in imaging techniques has led to an increased detection of kidney tumours, including small renal masses. While surgery is still the standard of care, there is a growing interest in minimally invasive methods. Ultrasound (US)-guided percutaneous ablation is particularly attractive because it is a safe and relatively simple procedure. In this study, we investigated the results of US-guided percutaneous radiofrequency ablation (RFA) and partial nephrectomy (PN) in the treatment of cT1a renal cancers. Between August 2016 and February 2022, 271 patients with renal tumours underwent percutaneous RFA as initial treatment in our institution. In the same period, 396 patients with renal tumours underwent surgical tumour excision. For the purpose of this study, only patients with confirmed renal cancer with matched age and tumour characteristics (size, location) were selected for both groups. Thus, a group of 44 PN patients and 41 RFA patients were formed with the same qualification criteria for both groups. Parameters such as procedure length, blood loss, hospital stay, analgesics used, and pre- and post-procedural serum creatinine were compared between these groups. Patients followed up with contrast-enhanced CT. There was no significant difference in age, tumour size, tumour location, and creatinine levels between these groups. All procedures were generally well tolerated. During a median follow-up of 28 months, two cases of recurrence/residual disease were found in each group. The overall survival was 100% in both groups, and all patients were disease-free at the end of observation. Percutaneous RFA was associated with a significantly shorter procedure length and hospital stay, lower blood loss, and lower analgesics used than PN. In the selected group of renal cancer patients, US-guided percutaneous RFA was associated with a shorter hospital stay, less analgesics used, and a shorter procedure length than PN, without differences in the oncological results or kidney function.

Perioperative and Survival Outcomes of Patients Treated With Robot-Assisted Partial Nephrectomy and Percutaneous Microwave Ablation for Small Renal Masses: A Single Center Experience

BACKGROUND

Robot assisted partial nephrectomy (RAPN) and microwave ablation (MWA) are 2 of the most advanced techniques for the management of localized small renal masses.

PURPOSE

To compare the perioperative, functional and oncological results of RAPN and MWA.

MATERIALS AND METHODS

Data from 171 consecutive patients undergoing either RAPN or MWA for a localized small renal mass at a single academic center was retrospectively collected. Baseline features included patients' demographics and masses' characteristics. Procedures were compared in terms of perioperative outcomes and renal function variation Progression of a persistent lesion or local recurrence after a complete treatment defined local tumor progression. Descriptive statistics and survival analysis tested the association between predictors and local tumor progression.

RESULTS

Of all, 109 and 62 patients underwent RAPN and MWA. Patients in the MWA group were older (P = .002) had higher Charlson Comorbidity Index (CCI) (P < .001) and higher frequency of preoperative chronic kidney disease (P < .001). MWA led to a shorter postoperative hospitalization time (P < .001) and lower incidence of medical complications (6.5% vs. 22.9%, P = .02) than RAPN. GFR decline was similar between groups both at discharge (P = .39) and at the time of last follow up (P = 1.00). A lower rate of secondary interventions (11.7% vs. 2.8%, P = .037) and a better disease-free survival (83.2% vs. 96.5%, P = .027) were reported after RAPN. Conversely, cancer specific and overall survival were comparable (P > .05). At univariate regression analysis, MWA was associated with local tumor progression (HR 3.46, P = .040).

CONCLUSION

MWA displayed a lower perioperative impact, while functional outcomes were similar after each intervention. RAPN resulted superior in terms of tumor eradication, but no difference was noted regarding cancer specific survival. Thus, MWA represents a valid alternative in frail patients, though less radical than RAPN.

Ablative or Surgical Treatment for Small Renal Masses (T1a): A Single-Center Comparison of Perioperative Morbidity and Complications

The purpose of this study is to evaluate the treatment safety of thermal ablation compared to surgical treatment of T1a tumors (small renal masses) at a high-volume center. We conducted an observational single-center study based on data collected form the National Swedish Kidney Cancer Register (NSKCR) between 2015 and 2021. In total, 444 treatments of T1a tumors were included. Patients underwent surgery (partial or total nephrectomy) or ablative treatment-radiofrequency ablation (RFA) or microwave ablation (MWA). Patient characteristics were retrieved from patient records, and tumor complexity was estimated from pre-interventional CT scans. The odds ratio (OR) of suffering from a severe surgical complication following ablative treatment was estimated using a logistic regression model adjusted for age, BMI, ASA physical status classification, smoking status and RENAL nephrometry score. The frequency of severe surgical complications was 6.3% (16/256 treatments) after surgical intervention and 2.1% (4/188 treatments) following ablative treatment. Our primary hypothesis that ablative treatment is associated with a lower risk of severe surgical complications is supported by the results (OR 0.39; 0.19-0.79; p = 0.013). When adjusting for age, smoking status, ASA score, BMI score and RENAL nephrometry score, we see an even greater difference between the two groups (OR 0.34; 0.17-0.68; p = 0.002). Our study was limited by the differences in patient and tumor characteristics between the two compared groups and the study design. If oncological outcomes are found to be comparable, ablative treatment should be considered as a first-line treatment for all small renal masses.

Perioperative, functional, and oncological outcomes after cryoablation or partial nephrectomy for small renal masses in solitary kidneys: a systematic review and meta-analysis

AIM

This study aims to compare the perioperative, functional, and oncological outcomes of cryoablation (CA) and partial nephrectomy (PN) for managing small renal masses in patients with solitary kidneys. The study seeks to assess the efficacy and safety of both interventions, evaluating their impact on kidney function and their ability to mitigate cancer recurrence.

METHODS

Searches were systematically conducted on PubMed, Scopus, EMBASE, SinoMed, and Google Scholar, identifying seven observational studies. Statistical analysis was performed using Stata v.12.0 and Review Manager version 5.2. Results for dichotomous variables are expressed using odds ratios, and weighted mean differences are used for continuous variables.

RESULTS

Our findings revealed that patients undergoing CA experienced significantly shorter operative time (p < 0.0001), reduced estimated blood loss (p < 0.00001), a shorter length of stay (p = 0.0001), and fewer postoperative complications (p = 0.02) compared to those undergoing PN. Although the CA group exhibited a lower transfusion rate (p = 0.69) compared with the PN group, the difference was not statistically significant. The combined data analysis demonstrated a significantly lower increase in serum creatinine levels after surgery in the CA group compared with the PN group (p = 0.003). Similarly, there was a noteworthy decrease in the estimated glomerular filtration rate after surgery in the PN group compared with the CA group (p < 0.0001). While not statistically significant, the CA group showed a lower postoperative dialysis rate (p = 0.11). Regarding oncological outcomes, the analysis revealed no significant differences between CA and PN concerning local recurrence (p = 0.2) and distant metastasis (p = 0.12), respectively.

CONCLUSIONS

Our analysis indicates comparable efficacy between PN and CA in controlling tumour recurrence and metastasis. However, CA is associated with superior preservation of renal function, significantly enhanced perioperative outcomes, and fewer postoperative complications. Based on our data, it can be inferred that the scope for applying CA might be expanded to encompass more patients seeking a less invasive treatment option.

Percutaneous ablation of renal tumors: Long-term outcomes

OBJECTIVE

To evaluate the long-term outcomes of renal tumor ablation, analyzing efficacy, long-term survival, and factors associated with complications and therapeutic success.

MATERIAL AND METHODS

We retrospectively reviewed 305 ablations (generally done with expandable electrodes) of 273 renal tumors between May 2005 and April 2019. We analyzed survival, primary and secondary efficacy, and complications according to various patient factors and tumor characteristics.

RESULTS

Mean blood creatinine was 1.14 mg/dL before treatment and 1.30 mg/dL after treatment (p < 0.0001). Complications were observed in 13.25% of the ablations, including major complications in in 4.97%. Complications were associated with age (p = 0.013) and tumor diameter (p < 0.0001). Primary efficacy was 96.28%. Incomplete ablation was more common in lesions measuring > 4 cm in diameter (p = 0.002). Secondary efficacy was 95.28%. The only factor associated with the risk of recurrence was the size of the tumor (p = 0.02). Overall survival was 95.26% at 1 year, 77.01% at 5 years, and 51.78% at 10 years, with no differences between patients with malignant and benign lesions. Mortality was higher in patients with creatinine >1 (p = 0.05) or ASA > 2 (p = 0.0001).

CONCLUSIONS

Percutaneous ablation is extremely efficacious for renal tumors; it improves the prognosis of renal carcinoma to the point where it does not differ from that of benign lesions. Complications are rare. Like survival, complications are associated with age and overall health status.

Efficacy and safety of cryoablation for localized renal tumor as an alternative approach to partial nephrectomy

Introduction

Renal cryoablation displays a profile of high tolerance, including in a frail population. Cryoablation appears as a validated alternative treatment to surgery for renal tumors smaller than 4 cm. However, evidence is lacking for larger tumors, despite encouraging data for tumors up to 7 cm.

Material and methods

This retrospective descriptive study of a population with a stage T1b renal tumor treated by cryoablation was conducted at the Nantes University Hospital between January 2009 and July 2021. Primary endpoint was 3-year rate of local recurrence. Secondary endpoints included technical efficacy, overall and cancer-specific survivals, and safety assessment.

Results

A total of 63 patients were analyzed. Three-year rate of local recurrence was 11.1%. Primary and secondary technical efficacies were achieved in 88.9% and 96.8% of patients, respectively, and 3-year overall and cancer-specific survival were 87.3% and 95.2%, respectively. Most patients (73%) experienced no complications, 13% of patients had minor (CIRSE grades 1 or 2) adverse effects, and 13% had severe but non-lethal (CIRSE grade 3) adverse effects. One patient died following cryoablation due to colic perforation. The most common AE (all grades) was hemorrhage (9.5%).

Discussion

This study showed a good efficacy and safety of cryoablation for renal tumors up to 7 cm (T1b). Our results were consistent with a rather sparse literature and contributed to guide future recommendations about cryoablation as an alternative to surgery for T1b renal tumors.

The Judicious Use of Stereotactic Ablative Radiotherapy in the Primary Management of Localized Renal Cell Carcinoma

Localized renal cell carcinoma is primarily managed surgically, but this disease commonly presents in highly comorbid patients who are poor operative candidates. Less invasive techniques, such as cryoablation and radiofrequency ablation, are effective, but require percutaneous or laparoscopic access, while generally being limited to cT1a tumors without proximity to the renal pelvis or ureter. Active surveillance is another management option for small renal masses, but many patients desire treatment or are poor candidates for active surveillance. For poor surgical candidates, a growing body of evidence supports stereotactic ablative radiotherapy (SABR) as a safe and effective non-invasive treatment modality. For example, a recent multi-institution individual patient data meta-analysis of 190 patients managed with SABR estimated a 5.5% five-year cumulative incidence of local failure with one patient experiencing grade 4 toxicity, and no other grade ≥3 toxic events. Here, we discuss the recent developments in SABR for the management of localized renal cell carcinoma, highlighting key concepts of appropriate patient selection, treatment design, treatment delivery, and response assessment.

The PRO-RCC study: a long-term PROspective Renal Cell Carcinoma cohort in the Netherlands, providing an infrastructure for 'Trial within Cohorts' study designs

BACKGROUND

Ongoing research in the field of both localized, locally advanced and metastatic renal cell carcinoma has resulted in the availability of multiple treatment options. Hence, many questions are still unanswered and await further research. A nationwide collaborative registry allows to collect corresponding data. For this purpose, the Dutch PROspective Renal Cell Carcinoma cohort (PRO-RCC) has been founded, for the prospective collection of long-term clinical data, patient reported outcome measures (PROMs) and patient reported experience measures (PREMs).

METHODS

PRO-RCC is designed as a multicenter cohort for all Dutch patients with renal cell carcinoma (RCC). Recruitment will start in the Netherlands in 2023. Importantly, participants may also consent to participation in a 'Trial within cohorts' studies (TwiCs). The TwiCs design provides a method to perform (randomized) interventional studies within the registry. The clinical data collection is embedded in the Netherlands Cancer Registry (NCR). Next to the standardly available data on RCC, additional clinical data will be collected. PROMS entail Health-Related Quality of Life (HRQoL), symptom monitoring with optional ecological momentary assessment (EMA) of pain and fatigue, and optional return to work- and/or nutrition questionnaires. PREMS entail satisfaction with care. Both PROMS and PREMS are collected through the PROFILES registry and are accessible for the patient and the treating physician.

TRIAL REGISTRATION

Ethical board approval has been obtained (2021_218) and the study has been registered at ClinicalTrials.gov (NCT05326620).

DISCUSSION

PRO-RCC is a nationwide long-term cohort for the collection of real-world clinical data, PROMS and PREMS. By facilitating an infrastructure for the collection of prospective data on RCC, PRO-RCC will contribute to observational research in a real-world study population and prove effectiveness in daily clinical practice. The infrastructure of this cohort also enables that interventional studies can be conducted with the TwiCs design, without the disadvantages of classic RCTs such as slow patient accrual and risk of dropping out after randomization.

Percutaneous Ablation vs Robot-Assisted Partial Nephrectomy for Completely Endophytic Renal Masses: A Multicenter Trifecta Analysis with a Minimum 3-Year Follow-Up

Purpose: To compare outcomes of robot-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses. Methods: Data of patients who underwent RAPN or PTA for treatment of completely endophytic (three points for "E" domain of R.E.N.A.L. score) were collected from seven high-volume U.S. and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Meier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment "quality." Multivariable logistic regression model assessed predictors of trifecta failure. Results: One hundred fifty-two patients (RAPN, n = 60; PTA, n = 92) were included in the analysis. RAPN group was younger (p < 0.001), had lower American Society of Anesthesiologists score (p = 0.002), and higher baseline estimated glomerular filtration rate (p < 0.001). There was no difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (p < 0.001) and minor (p < 0.001) complications. ΔeGFR at 1 year was statistically higher for RAPN (-15.5 mL/min vs -3.1 mL/min; p = 0.005), no difference in ΔeGFR at last follow-up (p = 0.22) was observed. No difference in recurrences (RAPN, n = 2; PTA, n = 6) and RFS was found (p = 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3% vs 58.8%; p = 0.477). R.E.N.A.L. Nephrometry Score resulted predictive of trifecta failure (odds ratio = 1.47; confidence interval = 1.13-1.90; p = 0.004). Conclusions: PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications and good mid-term functional and oncologic outcomes. These outcomes compare favorably with those of RAPN, which seem to be the preferred option for younger and less comorbid patients.

Percutaneous cryoablation versus partial nephrectomy for cT1b renal tumors: An inverse probability weight analysis

PURPOSE

To investigate differential clinical outcomes in patients treated with partial nephrectomy (PN) vs. percutaneous cryoablation (PCA) for cT1b renal tumors.

MATERIALS AND METHODS

We retrospectively analyzed the records of 119 patients who had undergone PN (n = 90) or PCA (n = 29) for cT1b renal tumors. Inverse probability weighting (IPW) was used for balancing patient demographics, including renal function and tumor complexity. Perioperative complications, renal function preservation rates, and oncological outcomes such as local recurrence-free, metastasis-free, cancer-specific, and overall survival were compared using IPW-adjusted restricted mean survival times (RMSTs).

RESULTS

PCA was more likely to be selected for octogenarians (odds ratio: 11.4, 95% confidence interval [CI]: 3.33-45.1). During the median follow-up of 43 months in the PCA group and 36.5 months in the PN group, unablated local residue or local recurrence was noted in 6 patients in the PCA group and local recurrence was noted in 4 patients in the PN groups. Of the 6 patients in the PCA group, 4 underwent salvage PCA, and local control had been achieved at the last visit. In the IPW-adjusted population, PCA had significantly worse local recurrence-free survival compared with PN (IPW-adjusted RMST difference: -22.7 months, 95% CI: -45.3 to -0.4, P = 0.046). IPW-adjusted RMST for metastasis-free survival (P = 0.23), cancer-specific survival (P = 0.77), and overall survival (P = 0.11) did not differ between PCA and PN. In addition, PN was not a predictor for local control failure at the last visit (odds ratio: 0.30, 95%CI: 0.05-1.29). There were no statistically significant differences between PN and PCA in renal function preservation or overall/severe complication rates.

CONCLUSIONS

In patients with cT1b renal tumor, although the local recurrence rate is higher for PCA than for PN, PCA provides comparable distant oncologic outcomes. PCA can be an alternative treatment option for elderly, comorbid patients, even those with cT1b renal tumors.

Predictive characteristics for disease recurrence and overall survival in non-metastatic clinical T1 renal cell carcinoma - results from the National Swedish Kidney Cancer Register

OBJECTIVE

Patients with clinical T1 renal cell carcinoma (cT1RCC) have risks for recurrence and reduced overall survival despite being in the best prognostic group. This study aimed to evaluate the association of different treatments on disease recurrence and overall survival using clinical and pathological characteristics in a nation-wide cT1RCC cohort.

MATERIALS AND METHODS

A total of 4,965 patients, registered in the National Swedish Kidney Cancer Register (NSKCR) between 2005 and 2014, with ≥ 5-years follow-up were identified: 3,040 males and 1,925 females, mean age 65 years. Times to recurrence and overall survival were analyzed with Kaplan-Meier curves, log-rank test, and Cox regression models.

RESULTS

Age, TNM-stage, tumor size, RCC-type, and performed treatment were all associated with disease recurrence. Patients selected for ablative treatments had increased risk for recurrent disease: hazard ratio (HR) = 3.79 [95% confidence interval (CI) = 2.69-5.32]. In multivariate analyses, age, gender, tumor size, RCC-type, N-stage, recurrence and performed treatment were all independently associated with overall survival. Patients with chRCC had a 41% better overall survival (HR = 0.59, 95% CI = 0.44-0.78; p < 0.001) than ccRCC. Patients treated with partial nephrectomy (PN) had an 18% better overall survival (HR = 0.83, 95% CI = 0.71-0.95, p < 0.001) than patients treated with radical nephrectomy.

CONCLUSIONS

Age, gender, T-stage, tumor size, RCC type and treatment modality are all associated with risk of recurrence. Furthermore, age, male gender, tumor size, N-stage and recurrence are associated with reduced overall survival. Patients with chRCC, compared with ccRCC and pRCC patients, and PN compared with RN treated patients, had an advantageous overall survival, indicating a possible survival advantage of nephron sparing treatment.

Percutaneous thermal ablation for cT1 renal mass in solitary kidney: A multicenter trifecta comparative analysis versus robot-assisted partial nephrectomy

INTRODUCTION

Renal cell carcinoma (RCC) in solitary kidney (SK) represents a challenging scenario. We sought to compare outcomes of robot-assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation (PTA) in SK patients with renal tumors cT1.

MATERIALS AND METHODS

We performed a multicenter retrospective analysis of SK patients treated for RCC. The PTA group included cryoablation or radiofrequency ablation. We collected baseline characteristics, intraoperative, pathological, and post-operative data. We applied an arbitrary composite "trifecta" to assess surgical, functional, and oncological outcomes, only for malignant histology. RFS analysis was performed using the Kaplan-Meier method. Multivariable regression analysis was performed to determine independent predictors of "trifecta" achievement.

RESULTS

We included 198 SK patients (RAPN, n = 50; PTA n = 119). Mean clinical tumor size was not significantly different while R.E.N.A.L. score was higher for RAPN (p < 0.001). No differences in intra and major post-procedural complications. Recurrence rate was higher in PTA group but not statistically significant (p < 0.328). No difference in metastasis rate was found (p = 0.435). RFS was 96.1% in RAPN and 86.8% in PTA cohort (p = 0.003) while no difference in PFS was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 77.3% of PTA (p = 0.481). Multivariable analysis has not detected predictors for Trifecta achievement.

CONCLUSION

PTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence; on the other hand, re-treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting RCC. In general, it should be preferred in more frail patients to minimize the risk of complications.

Ultrasound-Guided Percutaneous Thermal Ablation of Renal Cancers-In Search for the Ideal Tumour

Over the recent years, the progress in imaging techniques has led to an increased detection of kidney tumours, including small renal masses. While surgery is still the standard of care, there is a growing interest in minimally invasive methods. Ultrasound (US)-guided percutaneous ablation is particularly attractive because it is a safe and relatively simple procedure. In this study, we investigated the success of percutaneous radiofrequency ablation (RFA) in relation to kidney tumour diameter and location. Between August 2016 and September 2021, 253 patients with 259 renal tumours underwent US-guided RFA as a primary treatment in our institution. A total of 67 patients were excluded from this study. Abdominal computed tomography (CT) and tumour biopsy were performed before the procedure. Patients were followed with contrast-enhanced CT, the average follow-up time was 28 months. The studied group was composed of 186 patients with 191 renal tumours-only biopsy-confirmed renal cancers were included. During the follow-up, 46 cases of residual disease and 4 cases of local progression were found. There was a significant correlation between tumour size and the ablation success rate. The success rate was 73.5% and 87.6% for lesions ≤25 mm, 94.6% for lesions ≤25 mm and exophytic, 79.1% for lesions 26-30 mm and 84.4% for lesions 26-30 mm and exophytic, respectively. Four Clavien-Dindo grade ≥2 complications were observed. US-guided percutaneous RFA of T1a renal cancers is safe and well-tolerated. Its effectiveness depends on tumour size, with best results for exophytic lesions smaller than 3 cm. Most of the recurrent or residual tumours can be successfully re-treated with US-guided percutaneous RFA.

Cancer-specific Mortality in T1a Renal Cell Carcinoma Treated with Local Tumor Destruction Versus Partial Nephrectomy

BACKGROUND

Large-scale analyses addressing cancer-specific mortality (CSM) in T1a renal cell carcinoma (RCC) patients treated with local tumor destruction (LTD), relative to partial nephrectomy (PN), are scarce.

OBJECTIVE

To compare CSM after LTD versus PN.

DESIGN, SETTING, AND PARTICIPANTS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2018), we identified patients with clinical T1a stage RCC treated with LTD or PN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

After 1:1 ratio propensity score matching (PSM) between patients treated with LTD versus PN, competing risks regression (CRR) models addressed CSM, after adjustment for other-cause mortality (OCM) and other covariates (age, tumor size, tumor grade, and histological subtype).

RESULTS AND LIMITATIONS

Relative to the 35 984 PN patients, 5936 LTD patients were older and more frequently harbored unknown RCC histological subtype or unknown grade. After 1:1 PSM that resulted in 5352 LTD versus 5352 PN patients, the 10-yr CSM rate was 8.7% versus 5.5%. In multivariable CRR models, LTD was associated with higher CSM, relative to PN (hazard ratio [HR]: 1.58, p < 0.001). Subgroup analyses revealed invariably higher CSM after LTD versus PN in patients with tumor size ≤3 cm (10-yr CSM 7.2% vs 5.3%, multivariable HR: 1.47, p < 0.001) and in patients with tumor size 3.1-4 cm (10-yr CSM 11.4% vs 6.1%, multivariable HR: 1.72, p < 0.001). Lack of information regarding earlier cancer controls, retreatment, tumor location within the kidney, and type of surgery represented limitations.

CONCLUSIONS

In T1a RCC patients, LTD is invariably associated with higher CSM relative to PN, even after adjustment for OCM and all available patient and tumor characteristics, and regardless of tumor size considerations. However, the magnitude of CSM disadvantage was more pronounced in LTD patients with tumor size 3.1-4 cm than in those with tumor size ≤3 cm.

PATIENT SUMMARY

In patients with small renal masses, we observed higher cancer-specific death rates for local tumor destruction (LTD) than for partial nephrectomy. The LTD disadvantage was more pronounced for patients with tumor size 3.1-4 cm, but was also present in those with tumor size ≤3 cm.

Targeting hyaluronic acid synthase-3 (HAS3) for the treatment of advanced renal cell carcinoma

BACKGROUND

Hyaluronic acid (HA) promotes cancer metastasis; however, the currently approved treatments do not target HA. Metastatic renal carcinoma (mRCC) is an incurable disease. Sorafenib (SF) is a modestly effective antiangiogenic drug for mRCC. Although only endothelial cells express known SF targets, SF is cytotoxic to RCC cells at concentrations higher than the pharmacological-dose (5-µM). Using patient cohorts, mRCC models, and SF combination with 4-methylumbelliferone (MU), we discovered an SF target in RCC cells and targeted it for treatment.

METHODS

We analyzed HA-synthase (HAS1, HAS2, HAS3) expression in RCC cells and clinical (n = 129), TCGA-KIRC (n = 542), and TCGA-KIRP (n = 291) cohorts. We evaluated the efficacy of SF and SF plus MU combination in RCC cells, HAS3-transfectants, endothelial-RCC co-cultures, and xenografts.

RESULTS

RCC cells showed increased HAS3 expression. In the clinical and TCGA-KIRC/TCGA-KIRP cohorts, higher HAS3 levels predicted metastasis and shorter survival. At > 10-µM dose, SF inhibited HAS3/HA-synthesis and RCC cell growth. However, at ≤ 5-µM dose SF in combination with MU inhibited HAS3/HA synthesis, growth of RCC cells and endothelial-RCC co-cultures, and induced apoptosis. The combination inhibited motility/invasion and an HA-signaling-related invasive-signature. We previously showed that MU inhibits SF inactivation in RCC cells. While HAS3-knockdown transfectants were sensitive to SF, ectopic-HAS3-expression induced resistance to the combination. In RCC models, the combination inhibited tumor growth and metastasis with little toxicity; however, ectopic-HAS3-expressing tumors were resistant.

CONCLUSION

HAS3 is the first known target of SF in RCC cells. In combination with MU (human equivalent-dose, 0.6-1.1-g/day), SF targets HAS3 and effectively abrogates mRCC.

5-year outcomes after stereotactic ablative body radiotherapy for primary renal cell carcinoma: an individual patient data meta-analysis from IROCK (the International Radiosurgery Consortium of the Kidney)

BACKGROUND

Stereotactic ablative body radiotherapy (SABR) is a non-invasive treatment option for primary renal cell carcinoma, for which long-term data are awaited. The primary aim of this study was to report on long-term efficacy and safety of SABR for localised renal cell carcinoma.

METHODS

This study was an individual patient data meta-analysis, for which patients undergoing SABR for primary renal cell carcinoma across 12 institutions in five countries (Australia, Canada, Germany, Japan, and the USA) were eligible. Eligible patients had at least 2 years of follow-up, were aged 18 years or older, had any performance status, and had no previous local therapy. Patients with metastatic renal cell carcinoma or upper-tract urothelial carcinoma were excluded. SABR was delivered as a single or multiple fractions of greater than 5 Gy. The primary endpoint was investigator-assessed local failure per the Response Evaluation Criteria in Solid Tumours version 1.1, and was evaluated using cumulative incidence functions.

FINDINGS

190 patients received SABR between March 23, 2007, and Sept 20, 2018. Single-fraction SABR was delivered in 81 (43%) patients and multifraction SABR was delivered in 109 (57%) patients. Median follow-up was 5·0 years (IQR 3·4-6·8). 139 (73%) patients were men, and 51 (27%) were women. Median age was 73·6 years (IQR 66·2-82·0). Median tumour diameter was 4·0 cm (IQR 2·8-4·9). 96 (75%) of 128 patients with available operability details were deemed inoperable by the referring urologist. 56 (29%) of 190 patients had a solitary kidney. Median baseline estimated glomerular filtration rate (eGFR) was 60·0 mL/min per 1·73 m2 (IQR 42·0-76·0) and decreased by 14·2 mL/min per 1·73 m2 (IQR 5·4-22·5) by 5 years post-SABR. Seven (4%) patients required dialysis post-SABR. The cumulative incidence of local failure at 5 years was 5·5% (95% CI 2·8-9·5) overall, with single-fraction SABR yielding fewer local failures than multifraction (Gray's p=0·020). There were no grade 3 toxic effects or treatment-related deaths. One (1%) patient developed an acute grade 4 duodenal ulcer and late grade 4 gastritis.

INTERPRETATION

SABR is effective and safe in the long term for patients with primary renal cell carcinoma. Single-fraction SABR might yield less local failure than multifraction, but further evidence from randomised trials is needed to elucidate optimal treatment schedules. These mature data lend further support for renal SABR as a treatment option for patients unwilling or unfit to undergo surgery.

FUNDING

None.

Cryoablation for the Treatment of Kidney Cancer: Comparison With Other Treatment Modalities and Review of Current Treatment

With cancer among the leading causes of death worldwide and kidney cancer among the more common cancers in the United States, it has become increasingly important to ensure that first-line treatments remain validated and supported in recent literature. Surgical intervention has long remained the gold standard for intervention but with newer techniques and technology on the horizon, there must be a constant review of other options that may provide improved outcomes and reduction of associated risks. Ablative techniques have gained traction and are becoming a valuable intervention for multiple different types of cancers, kidney cancer included. Cryoablation, a newer ablative technique taking advantage of extreme cold to freeze and destroy abnormal tissue, provides a promising option for treatment. Currently, no review article, to our knowledge, compares all the different treatment options for kidney cancer. Additionally, while some literature has addressed cryoablation in comparison to other methods of management, there has not been an extensive review to combine our current understanding of these comparisons. In this review article, we provide an overview of each of the commonly used treatments for kidney cancer and summarize the current literature regarding the advantages and disadvantages of each intervention. Finally, we seek to compare cryoablation, a newer option for treatment, to each of the approaches with the goal of evaluating the best methods for management and determining cryoablation's role alongside these current interventions.

Partial Nephrectomy versus Percutaneous Cryoablation of Small Renal Cell Carcinomas: A Comparison of Adverse Events in a Prospective Multicenter Cohort Study

PURPOSE

To assess and compare complications and readmissions after partial nephrectomy and percutaneous cryoablation of cT1 renal cell carcinoma (RCC).

MATERIALS AND METHODS

Patients treated for cT1 RCC between 2019 and 2021 were prospectively and consecutively enrolled. Complications recorded within 30 and 90 days were graded according to the Clavien-Dindo classification, and percutaneous cryoablation was graded according to the Society of Interventional Radiology classification of adverse events. Major complications were defined as complications with a grade of ≥3 based on the Clavien-Dindo classification. Readmission within 30 days was recorded.

RESULTS

The cohort included 86 partial nephrectomies and 104 cryoablations. The complication rate within 90 days was 23% after partial nephrectomy and cryoablation (P = .98), with major complication rates of 3% after partial nephrectomy and 10% after cryoablation (P = .15). The readmission rates were 14% and 11% after partial nephrectomy and cryoablation, respectively (P = .48). Double-J stents were associated with overall complications (odds ratio [OR], 9.88; 95% confidence interval [CI], 2.18-44.68; P = .003) and readmissions (OR, 5.39; 95% CI, 1.37-21.06; P = .015) after cryoablation. A high versus low radius-endophytic-nearness-anterior-location score (OR, 5.86; 95% CI, 1.08-31.81; P = .040) and endophytic location (OR, 7.70; 95% CI, 1.72-34.50; P = .008) were associated with a higher complication rate after cryoablation. The Charlson Comorbidity Index (CCI) was associated with major complications after partial nephrectomy (OR, 2.12; 95% CI, 1.05-4.30; P = .036).

CONCLUSIONS

Partial nephrectomy and cryoablation are comparable regarding complications within 90 days after treatment. Tumor complexity and double-J stents were associated with complications after cryoablation, and a high CCI was associated with complications after partial nephrectomy.

The multispeciality approach to the management of localised kidney cancer

Historically, kidney cancer was approached in a siloed single-speciality way, with urological surgeons managing the localised stages of the disease and medical oncologists caring for patients if metastases developed. However, improvements in the management of localised kidney cancer have occurred rapidly over the past two decades with greater understanding of the disease biology, diagnostic options, and innovations in curative treatments. These developments are favourable for patients but provide a substantially more complex landscape for patients and clinicians to navigate, with associated challenging decisions about who to treat, how, and when. As such, the skill sets needed to manage the various aspects of the disease and guide patients appropriately outstrips the capabilities of one particular specialist, and the evolution of a multispeciality approach to the management of kidney cancer is now essential. In this Review, we summarise the current best multispeciality practice for the management of localised kidney cancer and the areas in need of further research and development.

Differential efficacy of ablation therapy versus partial nephrectomy between clinical T1a and T1b renal tumors: A systematic review and meta-analysis

PURPOSE

To assess the differential clinical outcomes of patients treated with partial nephrectomy (PN) vs. those treated with ablation therapy (AT) such as radiofrequency ablation, cryoablation and microwave ablation for cT1b compared to cT1a renal tumors.

MATERIALS AND METHODS

Multiple databases were searched for articles published before August 2021. Studies were deemed eligible if they compared clinical outcomes in patients who underwent PN with those who underwent AT for cT1a and/or cT1b renal tumors.

RESULTS

Overall, 27 studies comprising 13,996 patients were eligible for this meta-analysis. In both cT1a and cT1b renal tumors, there was no significant difference in the percent decline of estimated glomerular filtration rates or in the overall/severe complication rates between PN and AT. Compared to AT, PN was associated with a lower risk of local recurrence in both patients with cT1a and cT1b tumors (cT1a: pooled risk ratio [RR]; 0.43, 95% confidence intervals [CI]; 0.28-0.66, cT1b: pooled RR; 0.41, 95%CI; 0.23-0.75). Subgroup analyses regarding the technical approach revealed no statistical difference in local recurrence rates between percutaneous AT and PN in patients with cT1a tumors (pooled RR; 0.61, 95%CI; 0.32-1.15). In cT1b, however, PN was associated with a lower risk of local recurrence (pooled RR; 0.45, 95%CI; 0.23-0.88). There was no difference in distant metastasis or cancer mortality rates between PN and AT in patients with cT1a, or cT1b tumors.

CONCLUSIONS

AT has a substantially relevant disadvantage with regards to local recurrence compared to PN, particularly in cT1b renal tumors. Despite the limitations inherent to the nature of retrospective and unmatched primary cohorts, percutaneous AT could be used as a reasonable alternative treatment for well-selected patients with cT1a renal tumors.

A Systematic Review and Meta-Analysis of Minimally Invasive Partial Nephrectomy Versus Focal Therapy for Small Renal Masses

Background

Minimally invasive partial nephrectomy (MIPN) and focal therapy (FT) are popular trends for small renal masses (SRMs). However, there is currently no systematic comparison between MIPN and FT of SRMs. Therefore, we systematically study the perioperative, renal functional, and oncologic outcomes of MIPN and FT in SRMs.

Methods

We have searched the Embase, Cochrane Library, and PubMed for articles between MIPN (robot-assisted partial nephrectomy and laparoscopic partial nephrectomy) and FT {radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (CA), irreversible electroporation, non-thermal [irreversible electroporation (IRE)] ablation, and stereotactic body radiation therapy (SBRT)}. We calculated pooled mean difference (MD), odds ratios (ORs), and 95% confidence intervals (CIs) (CRD42021260787).

Results

A total of 26 articles (n = 4,420) were included in the study. Compared with MIPN, the operating time (OP) of FT had significantly lower (SMD, −1.20; CI, −1.77 to −0.63; I2 = 97.6%, P &lt; 0.0001), estimated blood loss (EBL) of FT had significantly less (SMD, −1.20; CI, −1.77 to −0.63; I2 = 97.6%, P &lt; 0.0001), length of stay (LOS) had shorter (SMD, −0.90; CI, −1.26 to −0.53; I2 = 92.2%, P &lt; 0.0001), and estimated glomerular filtration rate (eGFR) of FT was significantly lower decrease (SMD, −0.90; CI, −1.26 to −0.53; I2 = 92.2%, P &lt; 0.0001). However, FT possessed lower risk in minor complications (Clavien 1–2) (OR, 0.69; CI, 0.45 to 1.07; I2 = 47%, P = 0.023) and overall complications (OR, 0.71; CI, 0.51 to 0.99; I2 = 49.2%, P = 0.008). Finally, there are no obvious difference between FT and MIPN in local recurrence, distant metastasis, and major complications (P &gt; 0.05).

Conclusion

FT has more advantages in protecting kidney function, reducing bleeding, shortening operating time, and shortening the length of stay. There is no difference in local recurrence, distant metastasis, and major complications. For the minimally invasive era, we need to weigh the advantages and disadvantages of all aspects to make comprehensive choices.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier PROSPERO (CRD42021260787).

Cone-beam CT-guided tagging of endophytic renal tumors with indocyanine green via trans-arterial selective delivery in patients undergoing robot-assisted partial nephrectomy with near infrared fluorescence imaging

PURPOSE

To evaluate the safety, efficacy, and clinical impact of pre-operative cone-beam CT (CBCT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and lipiodol in patients undergoing robot-assisted partial nephrectomy (RAPN) using near infrared fluorescent imaging (NIFI).

MATERIALS AND METHODS

Patients with renal endophytic tumors eligible for RAPN and trans-arterial embolization with ICG and lipiodol were prospectively included. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as the lipiodol accumulation into the nodule, was classified as poor, moderate, good, and optimal based on post-embolization CBCT. Surgical visibility of the tumors during RAPN with the use of NIFI was classified as: not visible, visible with poorly defined margins, and visible with well-defined margins.

RESULTS

Forty-one patients underwent pre-operative selective embolization. Technical success was 100%. Lipiodol accumulation at CBCT was poor in 2/41 (4.9%), moderate in 6/41 (14.6%), good in 25/41 (61.0%), and optimal in 8/41 patients (19.5%). During RAPN with NIFI, tumors were visible with well-defined margins in 26/41 (63.4%), visible with blurred margins in 14/41 (34.1%) and not visible in 1/41 (2.4%) of cases. There were no adverse events following endovascular embolization.

CONCLUSION

Pre-operative trans-arterial super-selective embolization of endophytic renal tumors with ICG and lipiodol in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Overview of clinical management for older patients with renal cell carcinoma

The rapidly increasing pool of older patients being diagnosed with and surviving their cancer is creating many challenges. Regarding localized renal cell carcinoma, surgery is considered as gold standard treatment options even in older men, whereas active surveillance and ablation therapy are alternative options for a proportion of these patients. With regard to advanced disease, anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) and immune check point inhibitor are standard treatment modalities, although treatment choice from multiple regimens and prevention of adverse events need to be considered. Better assessment techniques, such as comprehensive geriatric assessment to meet the unique needs of older patients, are a central focus in the delivery of high-quality geriatric oncology care. Through this process, shared decision-making should be adopted in clinical care to achieve optimal goals of care that reflect patient and caregiver hopes, needs and preferences. It is necessary to continue investigating oncological outcomes and complications associated with treatment in this population to ensure appropriate cancer care. In this narrative review, we completed a literature review of the various treatments for renal cell carcinoma in older patients that aimed to identify the current evidence related to the full range of the treatments including active surveillance, surgery, ablation therapy and systemic therapy. Prospectively designed studies and studies regarding geriatric assessment were preferentially added as references. Our goals were to summarize the real-world evidence and provide a decision framework that guides better cancer practices for older patients with renal cell carcinoma.

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

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

Quality of life and complications after nephron-sparing treatment of renal cell carcinoma stage T1-a systematic review

BACKGROUND

Despite the fact that nephron-sparing treatment is considered preferable from a surgical perspective patients' quality of life (QoL) following different types of nephron-sparing treatments remains unclear.

PURPOSE

To investigate the quality of life and complications after nephron-sparing treatment of renal cell carcinomas of stage T1.

MATERIALS AND METHODS

A systematic search of six databases was carried out. We included studies that reported the quality of life and complications in patients aged 18 years or older following nephron-sparing treatment of renal cell carcinoma stage T1. The quality assessment was performed using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies and the CASP Randomized Controlled Trial Checklist. Data were analyzed using a narrative approach.

RESULTS

Eight studies were included, six of which investigated QoL after partial nephrectomy and two after ablation therapies. Seven studies reported complications. Three studies reported higher QoL scores after partial nephrectomy compared to radical nephrectomy. Two studies showed that QoL increased or returned to baseline levels up to 12 months following partial nephrectomy. One study reported a gradual increase in QoL after radiofrequency ablation, and one study reported that all patients recovered to baseline QoL following cryoablation. Across studies, we found a complication rate up to 20% after partial nephrectomy and up to 12.5% after ablation therapy.

CONCLUSIONS

The results of this systematic review suggest that nephron-sparing treatment appears to be superior or comparable to other treatment alternatives with regard to QoL outcomes. Additionally, based on the studies included in this review, partial nephrectomy appears to have a higher complication rate compared with ablation therapies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020155594.

Ablative therapies versus partial nephrectomy for small renal masses - A systematic review and meta-analysis

BACKGROUND

High quality studies and reviews on the management of small renal masses (SRM) are lacking. This review aims to compare oncological outcomes in patients undergoing ablative therapies (AT) or partial nephrectomy (PN) for T1a or T1b SRM.

MATERIAL AND METHODS

Medline, EMBASE, Cochrane CENTRAL and conference proceedings were searched on the 15th July 2020 for comparative studies respective to our research question. The ROBINS-I tool and the GRADE approach were used to assess any risk of biases and certainty of evidence in the included studies. The review is registered on PROSPERO.

RESULTS

1,748 records were retrieved. 32 observational studies and 1 RCT integrating 74,946 patients were included. Patients undergoing AT patients are significantly older than PN patients (MD 5.70, 95%CI 3.83-7.58). In T1a patients, AT patients have significantly worse overall survival (HR 1.64, 95%CI 1.39-1.95). Local recurrence-free survival is similar with PN in patients with longer than five-years follow up (HR 1.54, 95%CI 0.88-2.71). AT patients also have similar cancer-specific survival (CSS), metastasis-free survival, disease-free survival, significantly fewer post-operative complications (RR 0.72, 95%CI 0.55-0.94), and a smaller decline in estimated glomerular filtration rate post-operatively (MD: -7.42, 95%CI -13.1 to -1.70) compared to those undergoing PN. Evidence contradicts in T1b patients for oncological outcomes.

CONCLUSIONS

AT have similar long-term oncological durability; lower rates of complications and superior kidney function preservation compared to PN. Given the low quality of evidence, AT is a reasonable alternative to PN in frail and co-morbid patients. Long-term high-quality studies are needed to confirm the potential benefits of AT, especially in T1b patients.

PROSPERO REGISTRATION

CRD42020199099.

Long-term outcomes of image-guided ablation and laparoscopic partial nephrectomy for T1 renal cell carcinoma

OBJECTIVE

To compare long-term outcomes and peri-operative outcomes of image-guided ablation (IGA) and laparoscopic partial nephrectomy (LPN).

MATERIAL AND METHODS

This is a retrospective cohort study of localised RCC (T1a/bN0M0) patients undergoing cryoablation (CRYO), radio-frequency ablation (RFA), or LPN at our institution from 2003 to 2016. Oncological outcomes were compared using Cox regression and log-rank analysis. eGFR changes were compared using Kruskal-Wallis and Wilcoxon-rank tests.

RESULTS

A total of 296 (238 T1a, 58 T1b) consecutive patients were identified; 103, 100, and 93 patients underwent CRYO, RFA, and LPN, respectively. Median follow-up time was 75, 98, and 71 months, respectively. On univariate analysis, all oncological outcomes were comparable amongst CRYO, RFA, and LPN (p > 0.05). On multivariate analysis, T1a patients undergoing RFA had improved local recurrence-free survival (LRFS) (HR 0.002, 95% CI 0.00-0.11, p = 0.003) and metastasis-free survival (HR 0.002, 95% CI 0.00-0.52, p = 0.029) compared to LPN. In T1a and T1b patients combined, both CRYO (HR 0.07, 95% CI 0.01-0.73, p = 0.026) and RFA (HR 0.04, 95% CI 0.03-0.48, p = 0.011) had improved LRFS rates. Patients undergoing CRYO and RFA had a significantly smaller median decrease in eGFR post-operatively compared to LPN (T1a: p < 0.001; T1b: p = 0.047). Limitations include retrospective design and limited statistical power.

CONCLUSIONS

IGA is potentially as good as LPN in oncological durability. IGA preserves kidney function significantly better than LPN. More studies with larger sample size should be performed to establish IGA as a first-line treatment alongside LPN.

KEY POINTS

• Ablative therapies are alternatives to partial nephrectomy for managing small renal cell carcinomas. • This study reports long-term outcomes of image-guided ablation versus partial nephrectomy. • Ablative therapies have comparable oncological durability and better renal function preservation compared to partial nephrectomy.

Delayed surgery for localised and metastatic renal cell carcinoma: a systematic review and meta-analysis for the COVID-19 pandemic

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.