The impact of temporal presentation on clinical and pathological outcomes for patients with sporadic bilateral renal masses

The current evidence on surgical management for synchronous bilateral renal tumors: results from a scoping review

PURPOSE

Synchronous bilateral renal masses (SBRM) account for a low percentage of kidney tumors, and there is no current recommendation for their management. The objective was to review evidence regarding the best surgical approach for SBRM in terms of type and timing of surgery.

METHODS

A broad literature search was performed on 28th January 2023 using Scopus, PubMed, and EMBASE. Only English papers dealing with adults were included. Meeting abstracts were excluded.

RESULTS

Twenty-four papers were accepted and included. SBRM behave less aggressively than metachronous tumors, and partial nephrectomy (PN) is the preferred therapeutic option to preserve renal function. Open, laparoscopic, and robot-assisted approaches were found to be similar in oncological outcomes, though robot-assisted surgery resulted in lower comorbidities. Same-sitting PN was demonstrated to be a safe approach, particularly in the robotic-assisted one. Finally, the same-siting and staged NSS were similar in preserving renal function.

CONCLUSIONS

PN should be the desirable treatment for SBRM whenever feasible and if patients are fit, but surgeon expertise should also be taken into the account.

Robotic Partial Nephrectomy for Bilateral Renal Masses

PURPOSE OF REVIEW

There are very few data on patients undergoing robot-assisted partial nephrectomy (RAPN) for bilateral renal masses. The aim of this review is to update the literature and discuss the controversial points on this topic.

RECENT FINDINGS

Nine papers have been published regarding RAPN for bilateral renal masses. In particular, five papers were case reports while the remaining four reported patient series. Concerning the outcomes, all these papers highlighted the safety, feasibility, and efficacy of bilateral RAPN for bilateral renal masses. The literature confirmed RAPN as an optimal procedure for the treatment of bilateral renal masses. However, these outcomes mainly derived from selected group of patients who underwent complex surgical procedures by expert robotic surgeons at high volume centers and cannot be generalizable to all categories of patients or centers. The simultaneous bilateral approach resulted feasible showing some advantages and without higher complications than a staged procedure in particular when clampless or selective clamping techniques were performed.

Single-cell transcription analysis reveals the tumor origin and heterogeneity of human bilateral renal clear cell carcinoma

Bilateral renal clear cell carcinoma (BRCC) is a rare type of renal cell carcinoma (RCC) that accounts for only 1-5% of RCC cases and has a poor clinical prognosis. The origin, tumor microenvironment, cellular molecular features, and intra-tumoral heterogeneity of BRCC are still unclear. We downloaded BRCC single-cell transcriptome sequencing data from the gene expression omnibus database biochip GSE171306, containing 3,575 cells from left-sided clear cell renal cell carcinoma (ccRCC) and 3,568 cells from right-sided ccRCC, and used a series of R packages for data quality control (QC) and subsequent analysis of BRCC single-cell transcriptome data, including the use of the R packages Seurat and scCancer for cell QC, identification of major cell types, and cell annotation; R package scran for calculation of cell cycle scores; R package infercnv for malignancy scoring of tumor cells; R package ReactomeGSA for functional enrichment analysis; R package Monocle 2 for the analysis of cell differentiation trajectories; and R package CellphoneDB for the analysis of intercellular interactions. In this study, by analyzing the high-quality single-cell transcriptome data of BRCC, we identified 18 cell types and found that left- and right-sided ccRCC were approximately the same in terms of cell type and the number of each cell but differed significantly in terms of tumor cell malignancy score, tumor microenvironment, and cell stemness score. In the cell differentiation trajectory analysis of BRCC, we found that endothelial cells and macrophages play an extremely important role in its tumor progression. Further cell communication analysis was performed, and we found that it may signal through ligand-receptors, such as vascular endothelial growth factor-vascular endothelial growth factor receptor1 (VEGF-VEGFR1), MIF-(CD74-CXCR4), and growth arrest-specific protein 6-AXL, to influence the development of BRCC. The analysis of single-cell transcriptomic data of human BRCC suggests that left- and right-sided ccRCC may be of the same tumor origin, but the left-sided ccRCC is more malignant and has a better immune response.

Surgical Management of Synchronous, Bilateral Renal Masses: A 1-decade Referral Center Experience

BACKGROUND

Management and decision-making in patients with bilateral renal masses are controversial.

OBJECTIVE

To report our experience of surgical management in patients with bilateral renal masses undergoing surgery at a high-volume center.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively collected data from patients treated with partial nephrectomy (PN) or radical nephrectomy for bilateral renal masses at a single referral institution between June 2008 and June 2019. Patient- and tumor-related features, timing (one vs two stage), and surgical approach (open vs robotic) were analyzed.

SURGICAL PROCEDURE

A one- versus two-stage strategy was adopted according to the opportunity to perform at least one PN using a clampless or selective-clamping approach, in order to avoid acute kidney injury.

MEASUREMENTS

Operative time, warm ischemia time, and intra- and postoperative complications were recorded. Histopathological results and tumor histology were assessed.

RESULTS AND LIMITATIONS

Overall, 41 patients were included. The median age was 67 yr and the median preoperative estimated glomerular filtration rate (eGFR) was 84 ml/min/1.73 m². The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 8 (interquartile range [IQR] 7-8) for both sides. In 17 (42%) patients, a simultaneous approach was chosen, with a pure robotic approach in 11/17 cases, while among the 24 (58.6%) patients treated with a two-stage strategy, 15 (62.5%) were treated with a robotic approach on both sides. Intraoperative complications and postoperative major (CDC ≥3) complications were recorded in 7.3% and 4.9% of cases, respectively. The overall positive surgical margins rate was 2.4%. At a median follow-up of 42 (IQR 18-59) mo, the median eGFR was 73 (IQR 64-80) ml/min/1.73 m², while disease-free survival and cancer-specific mortality were 90.2% and 7.3%, respectively.

CONCLUSIONS

Our experience underlines that both simultaneous and staged surgical treatment of patients with bilateral renal masses are feasible and safe if grounded on proper patient selection.

PATIENT SUMMARY

Management of patients with bilateral renal masses is challenging, given the heterogeneity of clinical scenarios and the need to optimize the timing of treatment to achieve maximal functional preservation while ensuring oncological efficacy.

Simultaneous robot-assisted approach in a super-elderly patient with urothelial carcinoma and synchronous contralateral renal cell carcinoma: A case report

BACKGROUND

It is rare for urothelial and renal cell carcinomas to coexist in the same patient, and even rarer for them to be detected simultaneously. Because of this rarity, a standard treatment has not been established and studies about overall survival are scarce. Therefore, physicians must modify treatments according to the individual’s situation and the stage of each disease. In recent years, with advances in the instruments and techniques, minimal invasive robotic surgeries have become available for advanced-stage or high-risk patients.

CASE SUMMARY

An 85-year-old woman with a medical history of hypertension and hyperlipidemia visited our institution. She had visited her local hospital complaining of intermittent, painless, gross hematuria that had started 3 mo earlier. On computed tomography, a right renal mass and left proximal ureteral mass with hydronephrosis were found simultaneously. We decided to perform robot-assisted surgery on both sides during one operation. Considering renal function and kidney loading, right partial nephrectomy was performed first, followed by left nephroureterectomy with bladder cuff excision. At the 6-mo follow-up, no specific symptoms were reported and dialysis was not considered. There were no unusual findings in the imaging study, and regular follow-up and imaging studies are scheduled.

CONCLUSION

This case report assessed the feasibility of simultaneous minimal invasive robotic surgery as an alternative to conventional open or laparoscopic surgery.

Pilot experience of simultaneous robotic-assisted partial nephrectomy for bilateral renal tumors-single center analysis

INTRODUCTION

Bilateral renal tumors accounts for approximately 3% of renal tumors. However, surgical treatment methods for bilateral renal tumors have not yet been established. It is imperative to balance the need for curative surgery with the goal of maximal functional preservation in patients with bilateral synchronous renal tumors. Therefore, partial nephrectomy may be the optimal surgical treatment for bilateral synchronous renal tumors.

METHODS

We conducted a retrospective, observational study to analyze the clinical outcome of simultaneous robotic-assisted partial nephrectomy (RAPN) for bilateral renal tumors at our institution between 2016 and 2019. A total of eight patients were enrolled and the number of renal masses in the 16 kidneys was 18.

RESULTS

There was no positive surgical margin after RAPN in our case series and no local recurrence or metastasis during the follow-up period. The only complication of simultaneous RAPN in the present case series was that one patient experienced acute kidney injury after operation without need for dialysis therapy.

CONCLUSION

Our study suggests that simultaneous RAPN for bilateral renal tumors might be feasible both for the preservation of renal function and for oncological outcome such as negative surgical margin.

Synchronous sporadic bilateral multiple chromophobe renal cell carcinoma accompanied by a clear cell carcinoma and a cyst: A case report

BACKGROUND

Renal cell carcinomas are usually unilateral. However, they are bilateral in 2% to 4% of sporadic cases and is considerably more common in familial cases. Synchronous sporadic bilateral multiple chromophobe renal cell carcinoma (CHRCC) with different subtypes is rare.

CASE SUMMARY

In this case report, we describe a case of synchronous bilateral CHRCC with two histological variants, accompanied by a clear cell carcinoma and a cyst in a 50-year-old male. The patient underwent retroperitoneal laparoscopic bilateral nephron-sparing surgery and there was no serious postoperative renal dysfunction.

CONCLUSION

We report a rare case of synchronous bilateral CHRCC with two histological variants associated with a clear cell carcinoma and a cyst.

Simultaneous versus staged partial nephrectomies for bilateral synchronous solid renal masses

OBJECTIVES

The optimal management approach for synchronous bilateral renal masses is unknown, particularly regarding surgical sequencing of bilateral partial nephrectomy (PN). We evaluated the impact of simultaneous vs. staged bilateral PN on renal functional, perioperative, and oncologic outcomes.

PATIENTS AND METHODS

We reviewed our institutional nephrectomy registry to identify patients who underwent simultaneous or staged (within 6 months) bilateral PN for nonmetastatic bilateral synchronous solid renal masses between 1980 and 2015. Short-term and long-term renal function changes were assessed at 3 and 12 months, respectively. Perioperative outcomes were pooled across staged surgeries by taking the sum of each outcome. Local recurrence-free, distant metastases-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier method. Outcomes were compared by surgical sequencing approach. A sensitivity analysis was performed that grouped approaches by preoperative intent.

RESULTS

Among the 107 patients studied, 77 (72%) underwent simultaneous and 30 (28%) underwent staged PN. The majority of PN were performed by open approach. Clinicopathologic features were similar between groups. Patients who underwent simultaneous PN had lower mean short-term (-6% vs. -24%, P = 0.015) and median long-term (-4% vs. -22%, P < 0.001) reduction in eGFR vs. staged PN, respectively. Furthermore, patients with simultaneous PN had lower pooled length of stay (median 6 vs. 8 days, P < 0.001), rate of urine leak (3% vs. 17%, P = 0.018), and rate of high-grade complications (8% vs. 23%, P = 0.044), relative to staged PN, respectively. However, on sensitivity analysis, only differences in long term reduction in estimated glomerular filtration rate and length of stay remained. There were no significant differences in oncologic outcomes between groups.

CONCLUSIONS

Our results suggest that when technically feasible, simultaneous PN yields comparable outcomes vs. staged PN, offering a reasonable surgical sequencing approach for patients presenting with bilateral synchronous renal masses.

Synchronous Bilateral RCC Is Associated With Poor Recurrence-Free Survival Compared With Unilateral RCC: A Single-Center Study With Propensity Score Matching Analysis

BACKGROUND

Understanding the tumorigenesis of bilateral cancers occurring in paired organs is essential for treatment planning and follow-up strategies. To the best of our knowledge, only a few studies compared the survival outcomes in patients with unilateral and bilateral renal cell carcinoma (RCC). We aimed to evaluate the survival outcomes of these patients after surgery and perform a further comparison of synchronous and metachronous bilateral RCCs.

MATERIALS AND METHODS

We analyzed clinical data from a total of 2169 patients (98.0%) diagnosed with unilateral RCC and 44 patients (2.0%) diagnosed with bilateral RCC including 22 (50.0%) with synchronous (diagnosed concomitantly or within 3 months of the former tumor) and 22 (50.0%) with metachronous RCC at our institution. Comparative analysis of unilateral and bilateral RCC groups was conducted using propensity score matching analysis. Subgroup analysis of bilateral RCC including synchronous and metachronous RCCs was also performed.

RESULTS

Kaplan-Meier survival analysis showed a significantly decreased 5-year recurrence-free survival (RFS; 82.6% vs. 94.3%; log rank test, P = .045) in the bilateral RCC group compared with the unilateral group. In subgroup analysis, the metachronous RCC group showed significantly smaller mean pathologic tumor size (P = .011), and more favorable pathologic T stage (P = .036) compared with the synchronous RCC group. Kaplan-Meier survival analysis showed significantly decreased 5-year RFS in synchronous RCC compared with metachronous RCC (74.7% vs. 92.9%; log rank test, P = .028).

CONCLUSION

The bilateral RCC group showed significantly decreased 5-year RFS compared with the unilateral RCC group. Importantly, the synchronous RCC group manifested more adverse features than the metachronous group.

Synchronous bilateral renal cell carcinomas in "Asynchrony of metabolism"

Here, we present a case of bilateral synchronous renal cell carcinoma in a 52-year-old male patient, who underwent fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan followed by surgical removal of both tumors. On PET scan, left renal mass showed intense FDG uptake while uptake in the right renal mass was minimal. Histopathologically, both tumors were conventional clear cell carcinoma (Fuhrman Grade III). Only the FDG-avid tumor in the left kidney had lymphovascular invasion and necrosis, which are markers of aggressive form of any tumor. FDG PET-CT can act as strong and noninvasive prognostic parameter that could help to identify patients with aggressive disease before treatment.

Risk factors for metachronous bilateral renal cell carcinoma: A surveillance, epidemiology, and end results analysis

BACKGROUND

Patients treated for renal cell carcinoma (RCC) may be diagnosed with a metachronous, contralateral tumor. We evaluated the risks of contralateral tumor development using the Surveillance, Epidemiology, and End Results database.

METHODS

Among RCC patients, we identified those with a metachronous, contralateral RCC diagnosed ≥1 year after primary diagnosis. We performed a competing risks analysis to evaluate associations between clinicopathologic factors and metachronous, bilateral RCC. Cumulative incidence and standardized incidence ratios (SIRs) were calculated.

RESULTS

There were 80,403 cases of RCC identified, with a median follow-up of 8.3 years; of these, 1063 (1.3%) developed metachronous, contralateral RCC (median of 6 years after diagnosis). The cumulative incidence at 10, 20, and 30 years of follow-up was 1.5%, 3.1%, and 4.7%, respectively. An increased risk was observed among men (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.20-1.55), blacks (HR, 2.00; 95% CI, 1.71-2.33), and those with papillary histology (HR, 1.72; 95% CI, 1.41-2.10). Risk of metachronous disease decreased with increasing age at primary diagnosis (HR per 1-year increase, 0.97; 95% CI, 0.96-0.97). The SIRs were highest among those diagnosed at a younger age and remained elevated even after extended follow-up (>10 years).

CONCLUSIONS

Our findings suggest that the cumulative incidence of metachronous, contralateral RCC may be higher than previously reported. Younger age, black race, papillary histology, and male sex increase the risk of metachronous, contralateral RCC development. The high SIRs seen in all demographic groups may support a rationale for lifelong surveillance, especially in high-risk subgroups with early disease onset.

Outcomes of synchronous and metachronous bilateral small renal masses (< 4 cm): a population-based cohort study

OBJECTIVES

To report longitudinal outcomes of a population-based cohort of patients diagnosed with bilateral small renal masses from a period of over 11 years.

PATIENTS AND METHODS

Consecutive patients diagnosed with bilateral small renal masses (synchronous or metachronous) of a defined geographical area were recorded in a large database (TUCAN database) between January 2005 and December 2016. Patients had a unique identifier number and followed during this period using an agreed upon protocol. Clinicopathological characteristics and outcomes of bilateral small renal masses on active surveillance were analysed and compared to propensity score-matched sporadic unilateral small renal masses. Data were analysed for renal mass growth rate, rate of intervention and development of metastatic disease and patient survival.

RESULTS

A total of 1060 patients were diagnosed with renal cancer, of which bilateral small renal masses accounted for 70 (6.6%) cases. Synchronous SRMs were observed in 63 patients, whereas metachronous lesions were found in seven patients during the study period. Metachronous lesion mean time to appearance was 62 ± 41 months (range 9-149 months). While most cases were sporadic, four were found to be hereditary. Growth rate of bilateral small renal masses did not differ from that of unilateral sporadic small renal masses. Similarly, there were no differences between the groups for rate of interventions and survival.

CONCLUSIONS

Progression, rate of metastases and survival for patients diagnosed with bilateral small renal masses are similar to those diagnosed with unilateral disease.

Pathological heterogeneity in sporadic synchronous renal tumors: Is the histological concordance predictable?

OBJECTIVE

To evaluate the pathological concordance rate of multiple synchronous renal masses (MSRM) presumed to be sporadic and to analyze predictive factors of concordance.

MATERIAL AND METHODS

We identified from our institutional database patients with sporadic MSRM treated at our center between January 2000 and December 2015. All tumors were reviewed by a dedicated uropathologist. Pathological concordance rate was analyzed regarding clinical characteristics and preoperative imaging.

RESULTS

We included 112 patients: 50 had unilateral synchronous renal masses and 62 bilateral synchronous renal masses. A total of 291 tumors were analyzed, with an average of 2.6 tumors per patient. Overall, the malignant concordance rate was 91.6%, the pathological concordance rate was 67.3% and the grade concordance rate was 62.5%. In univariate analysis, predictive factors of histological concordance were bilateral synchronous renal masses (odds ratio [OR] = 3.39; 95% CI: 1.06-10.8; P = 0.04), age<60 years (OR = 3.04; 95% CI: 1.2-7.7; P = 0.02) and ≥3 lesions (OR = 2.41; 95% CI: 1.03-5.68; P = 0.04). In multivariate analysis, age<60 remained significantly associated with histological concordance (OR = 3.84; 95% CI: 1.24-11.9; P = 0.02).

CONCLUSIONS

The histological concordance rate of MSRM is low. Age at diagnosis <60 years, bilateral lesions and ≥3 tumors are predictive factors of histological concordance, but the pathological diagnosis remains difficult to predict. This heterogeneity is important to take into account, particularly when choosing the treatment upon the renal biopsy results from a single lesion.

Clinicopathologic Features and Prognosis of Sporadic Bilateral Renal Cell Carcinoma: A Series of 148 Cases

INTRODUCTION

The purpose of this study was to investigate the clinicopathologic features, treatment, and prognosis of sporadic bilateral renal cell carcinoma (RCC).

PATIENTS AND METHODS

A total of 148 patients with sporadic bilateral RCC treated in our center from June 1986 to December 2015 were included in this retrospective study. Their clinicopathologic features and treatments were evaluated. The survival and prognostic factors were assessed based on data from follow-up.

RESULTS

The median age was 54 years (range, 31-78 years). There were 88 patients with synchronous bilateral RCC and 60 with metachronous bilateral RCC. The median interval between bilateral tumors of metachronous bilateral RCC was 75.5 months. There was no significant difference in tumor size, nuclear grade, or T stage between metachronous tumors (P = .385, P = .544, and P = .263, respectively). Of 148 patients, 124 patients underwent bilateral surgery, 16 underwent unilateral surgery, and 8 patients did not undergo surgery. Of the 317 tumors with pathologic results, 297 (93.7%) were clear-cell subtype. A total of 136 (91.9%) patients were followed-up, and the median follow-up period was 77 months (range, 2-398 months). During follow-up, 38 (27.9%) patients died. The 5-year overall survival rate was 85.9%. The median survival time of patients with no surgery was 5 months. Older age (P = .001), bilateral nonoperative treatment (P < .001), higher T stage (P < .001), and multifocality (P = .02) were related to worse prognosis in multivariate analysis.

CONCLUSION

In metachronous bilateral RCC, the latter occurrence does not bear a significantly worse pathologic biology. The prognosis of sporadic bilateral RCC with no surgery is poor. The overall oncologic results of patients with sporadic bilateral RCC are comparable with that of patients with unilateral RCC.

Bilateral renal cancers: oncological and functional outcomes

PURPOSE

The authors assessed the characteristics of bilateral renal cancers.

METHODS

From January 1995 to January 2015, 65 patients underwent surgery for bilateral renal cancers. Thirty-four of the patients had 36 synchronous tumors, while the remaining 29 had metachronous tumors. The mean age of the patients was 60 ± 11 years. There were 22 females and 43 males. In all cases, bilateral partial nephrectomies or unilateral nephrectomy and contralateral nephron-sparing surgery were performed.

RESULTS

The mean sizes of the synchronous tumors were 5.0 ± 2.7 and 4.7 ± 3.0 cm at the first and the second operations, respectively. The average diameters of the metachronous carcinomas were 6.6 ± 3.0 and 3.1 ± 1.6 cm at the initial and the second surgeries, respectively. Histologic concordance was 91.1 % in the synchronous and 96.5 % in the metachronous tumors. The mean postoperative creatinine levels increased by 116 %, while the GFR decreased by 44.8 % in synchronous tumors at the second operation. The mean postoperative creatinine levels increased by 42 %, while the GFR decreased by 30.4 % in metachronous carcinomas at the second operation. The mean follow-up time was 4.8 ± 3.7 years. During this period, distant metastases occurred in two patients with synchronous tumors and in six cases with metachronous tumors. Local recurrences were detected in one case of synchronous tumor and in four patients with metachronous carcinomas. The 5-year overall and tumor-specific survivals were 53 and 80 %, respectively.

CONCLUSIONS

In patients with bilateral renal carcinomas, the histologic concordance was 93.6 %. The bilateral partial nephrectomies or unilateral nephrectomy and contralateral resection provided acceptable oncological and functional outcomes.

Bilateral Synchronous Sporadic Renal Cell Carcinoma: Retroperitoneoscopic Strategies and Intermediate Outcomes of 60 Patients

OBJECTIVE

To evaluate the presentation, management, pathology, and functional and oncological outcomes of patients undergoing retroperitoneoscopic treatment of bilateral synchronous sporadic RCC at our institution.

METHODS

We retrospectively evaluated the records of 60 patients with bilateral synchronous sporadic RCC who underwent retroperitoneoscopic treatment at the General Hospital of People's Liberation Army from 2008 to 2014. The estimated glomerular filtration rate was calculated and compared among different surgical procedures. The overall survival and recurrence free survival were assessed based on information from recent follow-up.

RESULTS

Fifty-six patients underwent bilateral retroperitoneoscopic surgeries in staged procedures, and four patients underwent bilateral retroperitoneoscopic surgeries in simultaneous procedures. Among the former group of patients, 34 underwent bilateral partial nephrectomy, 12 underwent radical nephrectomy followed by partial nephrectomy, and 10 underwent partial nephrectomy followed by radical nephrectomy. Bilateral partial nephrectomy can better preserve renal function (p = 0.040) and the sequence of partial nephrectomy and radical nephrectomy did not affect functional outcomes (p = 0.790). One patient undergoing simultaneous procedures developed acute renal failure and required temporary hemodialysis. At 3 and 5 years, overall survival rates were 93.0% and 89.4%, and recurrence free survival rates were 90.5% and 81.6%. High nuclear grade (p = 0.014) was related to disease recurrence.

CONCLUSIONS

Staged bilateral partial nephrectomy was efficient in preserving renal function. The survival of patients with bilateral synchronous sporadic renal tumors was similar to that of patients with unilateral nonmetastatic tumors. Nuclear grade was an independent prognostic factor of disease recurrence.

Understanding pathologic variants of renal cell carcinoma: distilling therapeutic opportunities from biologic complexity

CONTEXT

Once believed to represent a uniform malignant phenotype, renal cell carcinoma (RCC) is now viewed as a diverse group of cancers that arise from the nephron.

OBJECTIVE

To review the pathologic characteristics, clinical behavior, molecular biology, and systemic therapy options of recognized RCC histologic subtypes.

EVIDENCE ACQUISITION

A systematic review of English-language articles was performed using the Medline and Web of Science databases. Manuscripts were selected with consensus of the coauthors and evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria.

EVIDENCE SYNTHESIS

The major findings of the evaluated manuscripts are discussed with an emphasis on the description of the pathologic features, clinical behavior, prognosis, and therapeutic strategies.

CONCLUSIONS

Classification schemes for kidney cancer have undergone dramatic changes over the past two decades. Improvements in these classification schemes are important, as pathologic variants differ not only in disease biology, but also in clinical behavior, prognosis, and response to systemic therapy. In the era of genomic medicine, further refinements in characterization of RCC subtypes will be critical to the progress of this burgeoning clinical space.

PATIENT SUMMARY

Kidney cancer can be subdivided into related but different cancers that arise from the kidney's tubules. In this article we review current classifications for kidney cancer, discuss their characteristics, and provide an overview of each subtype's clinical behavior and treatment. We stress that each subtype harbors unique biology and thus responds differently to available treatment strategies.

[Infratemporal metastasis from a renal cell carcinoma]

INTRODUCTION

Kidney cancer, particularly clear cell carcinoma, has an unpredictable clinical course with a variable metastatic potential in time. Some metastatic sites are atypical, such as head and neck (6% of cases). We report an extremely rare case of clear cell renal carcinoma with a metastasis in the infratemporal fossa.

OBSERVATION

A 67 year old male patient, operated in 2007 for a Fuhrman grade I clear cell carcinoma of the left kidney (radical nephrectomy), consulted for swelling of the left temporo-zygomatic region. A local biopsy allowed diagnosing clear cell renal carcinoma metastases. The patient was inoperable and was treated by antiangiogenic drugs.

DISCUSSION

The recommended treatment is surgical exeresis when the metastasis is single and can be resected. Antiangiogenic therapy is an alternative in other cases.

Partial nephrectomy in the setting of metastatic renal cell carcinoma

PURPOSE

Cytoreductive nephrectomy remains the standard of care for appropriately selected patients with metastatic renal cell carcinoma. Although the role of partial nephrectomy is well accepted in patients with localized disease, limited data are available on partial nephrectomy in the metastatic setting. We identified the indications for and outcomes of partial nephrectomy in the setting of metastatic renal cell carcinoma with particular attention to partial nephrectomy subgroups.

MATERIALS AND METHODS

We analyzed data on a consecutive cohort of 33 patients with metastatic renal cell carcinoma who underwent partial nephrectomy at a single institution between 1996 and 2011. Nonparametric statistics were used to compare partial nephrectomy subgroups. Overall survival was estimated using the Kaplan-Meier method and survival functions were compared using the log rank test.

RESULTS

At presentation 8 patients had bilateral synchronous renal masses, 20 had a metachronous contralateral renal mass and 5 had a unilateral renal mass. A total of 22 patients (67%) died of disease a median of 27 months postoperatively. Patients who underwent partial nephrectomy for a metachronous contralateral renal mass and a renal mass 4 cm or less had the best overall survival (61 and 42 months, respectively). Median overall survival in patients with vs without metastatic disease at original diagnosis was 27 vs 63 months (p = 0.003).

CONCLUSIONS

Our findings suggest that metastasis at the original diagnosis and the timing of presentation of the partial nephrectomy index lesion have an important role in survival. These factors should be considered when determining which patients would benefit from partial nephrectomy in the setting of metastatic renal cell carcinoma.

Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution

PURPOSE

To review the intermediate term oncologic and functional outcomes after the surgical management of bilateral renal masses (BRM).

MATERIALS AND METHODS

After obtaining Institutional Review Board approval, the Tulane renal surgery database (n = 890 patients) was queried for patients presenting with synchronous bilateral enhancing renal masses (n = 30 renal units). We performed a retrospective chart review evaluating oncologic and functional outcomes, specifically with respect to local recurrence and metastatic disease. We also reviewed changes in glomerular filtration rates.

RESULTS

Of the 30 renal units were operated on for BRM concerning for renal cell carcinoma, 25 kidneys harbored malignancy (83.3 %). The average tumor size was 3.35 cm. Treatment of each kidney was staged; average time period to treatment of contralateral side was 3.5 months. Estimated GFR (eGFR) for these same pre-operative patients was 59 ml/min/1.73 m(2) (range 25-89). The average creatinine after treatment of one kidney was available for all patients and was 1.5 (range 0.7-2.8), with an average eGFR of 51.8 (range 29-87). The average creatinine after the second operation for these same 15 patients was 1.79 (range 0.9-3.7) with an average GFR of 41.9 (range 17-78). No patient had to undergo temporary dialysis. An average change in GFR after the second, contralateral procedure on the kidney was 17.07 mg/dl. Average oncologic follow-up was 608 days. Excluding two patients who presented with metastatic disease, the average recurrence-free survival was 92.8 %.

CONCLUSION

Our data continue to underscore the need for nephron sparing surgery (NSS), especially in the setting of BRM. The average decline in GFR of 28.9 % after treatment of both kidneys and renal cell carcinoma recurrence-free rate of 92.3 % further support the efficacy of NSS in these patients.

Outcomes of patients with surgically treated bilateral renal masses and a minimum of 10 years of followup

PURPOSE

Nephron sparing surgery has been advocated for patients with bilateral renal masses but long-term functional and oncological outcomes are lacking. We report the outcomes of patients with bilateral renal masses and a minimum 10-year followup.

MATERIALS AND METHODS

Patients with bilateral renal masses evaluated at our institution who were treated with initial surgery at least 10 years ago and underwent interventions on each renal unit were included in the analysis. Collected data included demographics, hereditary diagnosis, number of renal interventions, renal function and mortality status. Overall and renal cell carcinoma specific survival was assessed. Comparisons were made of renal function and overall survival between groups with 2 renal units and a surgically solitary kidney.

RESULTS

A total of 128 patients met study inclusion criteria. Median followup in our cohort was 16 years (mean 17, range 10 to 49). The median number of surgical interventions was 3 (range 2 to 10). Of the patients 87 (68%) required repeat interventions on the ipsilateral renal unit at last followup with a median of 6.2 years (range 0.7 to 21) between interventions. Overall and renal cell cancer specific survival was 88% and 97%, respectively. Six patients (4.7%) ultimately underwent bilateral nephrectomy. Although renal function was better preserved in patients with 2 kidneys (70 vs 53 ml/minute/1.73 m(2), p = 0.0002), there was no difference in overall survival between those with bilateral kidneys or a surgically solitary kidney.

CONCLUSIONS

At a minimum 10-year followup after initial surgery, nephron sparing surgery allowed for excellent oncological and functional outcomes. Despite the need for repeat surgical interventions, nephron sparing surgery enabled dialysis to be avoided in more than 95% of patients.

Pathological concordance and surgical outcomes of sporadic synchronous unilateral multifocal renal masses treated with partial nephrectomy

PURPOSE

Patients with unilateral synchronous multifocal renal masses represent a unique population with renal cell carcinoma. While pathological concordance rates have been studied for bilateral cases, limited data exist on unilateral multifocal disease. We characterized pathological concordance rates in this population and evaluated the outcomes of nephron preservation.

MATERIALS AND METHODS

Patients who underwent surgery from 2000 to 2012 for unilateral synchronous multifocal renal masses were identified from a prospectively maintained database. Demographic, surgical and pathological outcomes of this cohort were analyzed. Malignant concordance rates were defined as agreement of all malignant tumor types in a single renal unit. Histological concordance was defined as agreement of all resected mass histologies, eg all clear cell carcinomas. Nuclear grade was considered concordant if all tumors excised were low (Fuhrman 1 or 2, type 1) or high (Fuhrman 3 or 4, type 2) grade.

RESULTS

Using our institutional database of 2,569 patients with renal tumors we identified 97 with unilateral synchronous multifocal renal masses. Malignant and benign concordance rates were 77.2% and 48.6%, and histological and grade concordance rates were 58.8% and 51.5%, respectively. In this cohort we identified 76 patients (76.3% male) with a median age of 62.5 years who had a total of 241 unilateral synchronous multifocal renal masses and underwent nephron sparing surgery. Median mass size was 2.0 cm (IQR 1.1-3.1), there was a median of 3 tumors per patient and median followup was 24 months (IQR 13-40). Identified renal cell carcinoma histologies included clear cell in 49.4% of cases, papillary in 33.5%, mixed in 4.5% and chromophobe in 2.8%.

CONCLUSIONS

In what is to our knowledge the largest published report of unilateral synchronous multifocal renal masses we document low pathological concordance rates. As such, percutaneous biopsy of a single renal mass in these patients may not help inform treatment decisions. Nephron sparing surgery may be performed with acceptable oncological and functional results in patients with unilateral synchronous multifocal renal masses.

Long-term oncologic outcomes after radiofrequency ablation for T1 renal cell carcinoma

BACKGROUND

Radiofrequency ablation (RFA) of renal cell carcinoma (RCC) is used to obtain local control of small renal masses. However, available long-term oncologic outcomes for RFA of RCC are limited by small numbers, short follow-up, and lack of pathologic diagnoses.

OBJECTIVE

To assess the oncologic effectiveness of RFA for the treatment of biopsy-proven RCC.

DESIGN, SETTING, AND PARTICIPANTS

Exclusion criteria included prior RCC or metastatic RCC, familial syndromes, or T2 RCC. We retrospectively reviewed long-term oncologic outcomes for 185 patients with sporadic T1 RCC. Median follow-up was 6.43 yr (interquartile range [IQR]: 5.3-7.7).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The chi-square test and Wilcoxon rank-sum tests were used to compare proportions and medians, respectively. Disease-specific survival and overall survival (OS) were calculated using Kaplan-Meier analysis, then stratified by tumor stage, and comparisons were made using log-rank analysis. The 5-yr disease-free survival (DFS) and OS rates are reported. A p value <0.05 was considered statistically significant.

RESULTS AND LIMITATIONS

Median tumor size was 3 cm (IQR: 2.1-3.9 cm). Tumor stage was T1a: 143 (77.3%) or T1b: 42 (22.7%). Twenty-four patients (13%) were retreated for residual disease. There were 12 local recurrences (6.5%), 6 recurrences in T1a disease (4.2%) and 6 in T1b disease (14.3%) (p=0.0196). Median time to recurrence was 2.5 yr. Local salvage RFA was performed in six patients, of whom five remain disease free at 3.8-yr median follow-up. Tumor stage was the only significant predictor of DFS on multivariate analysis. At last follow-up, 164 patients (88.6%) were disease free (T1a: n=132 [92.3%]; T1b: n=32 [76.2%]; p=0.0038). OS was similar regardless of stage (p=0.06). Five patients developed metachronous renal tumors (2.7%). Four patients developed extrarenal metastases (2.2%), three of whom died of metastatic RCC (1.6%).

CONCLUSIONS

In poor surgical candidates, RFA results in durable local control and low risk of recurrence in T1a RCC. Higher stage correlates with a decreased disease-free survival. Long-term surveillance is necessary following RFA. Patient selection based on tumor characteristics, comorbid disease, and life expectancy is of paramount importance.

Enhancing renal tumors in patients with prior normal abdominal imaging: further insight into the natural history of renal cell carcinoma

PURPOSE

Patients undergoing serial cross-sectional abdominal imaging to evaluate abdominal symptomatology may have a renal tumor develop during followup of an unrelated disease process. Evaluation of such patients provides an opportunity to further define the radiographic inception, natural history and growth patterns of renal tumors.

MATERIALS AND METHODS

Renal tumor databases from 2 institutions were reviewed for patients in whom an enhancing renal tumor developed despite a prior normal cross-sectional radiographic examination of the kidneys. Variables evaluated included age, gender, tumor size at presentation, calculated tumor growth rate from negative scan to radiographic presentation and pathology in patients undergoing definitive treatment.

RESULTS

We identified 36 patients with an average age of 65 years (range 44 to 82). Mean tumor size on presentation was 2.3 cm (range 1.0 to 5.0). The presumed absolute growth rate based on the timing of the initial negative imaging study and tumor diameter at presentation was significantly greater than the observed absolute growth rate after tumor detection (0.71 vs 0.039 cm per year, p = 0.028). No difference was noted between presumed and observed tumor growth based on absolute change in tumor volume (1.44 vs 5.37 cm(3) per year, p = 0.203). Presumed relative growth rates based on tumor diameter (665% vs 23% per year) and volume (1,397% vs 169% per year) were significantly greater than observed relative growth rates (p = 0.005 and p = 0.013, respectively).

CONCLUSIONS

The presumed growth rate of the tumors was significantly greater than the observed growth rate, suggesting that tumor growth rates do not follow a linear pattern throughout their development and progression.

Bilateral synchronous sporadic renal tumors: pathologic concordance and clinical implications

OBJECTIVE

To determine the pathologic concordance rates in patients with bilateral synchronous sporadic renal tumors (BSSRT) and to determine factors predictive of concordance.

METHODS

A retrospective chart review from 1985 to 2008 was completed with search criteria of all patients diagnosed with bilateral renal tumors. We included patients who had image-documented BSSRT or via reported history. We excluded patients with bilateral metachronous renal tumors, cystic renal masses, familial renal cell carcinoma (RCC) syndromes, urothelial cell carcinomas, and other variant histology. Univariate and multivariate analysis were conducted to assess for factors predictive of concordance.

RESULTS

We identified 297 patients eligible for analysis. RCC concordance was exhibited in 222 of 249 (89%) of patients. Benign tumor concordance, specifically oncocytoma, was found in 41 of 59 (71%) of patients. Factors such as age, gender, and tumor size on imaging did not have an association with concordance rates for bilateral RCC or bilateral oncocytoma. On multivariate analysis, multifocal tumors were associated with benign concordance (OR = 6.9, 95% CI = 1.6-29.2, P = .009).

CONCLUSION

Malignant and benign concordance rates are high for patients with BSSRT. Given the high concordance of RCC, the data support a management approach consisting of bilateral nephron-sparing surgery whenever possible. However, given the high concordance rate of oncocytoma in this population as well, less aggressive management (renal mass biopsy and surveillance) of the contralateral kidney may be considered after histologic confirmation of one side.

Prognosis and characteristics of renal cell carcinoma in hemodialysis patients: bilateral occurrence does not influence cancer-specific survival

OBJECTIVES

To compare characteristics and prognosis unilateral and bilateral renal cell carcinoma (RCC) in hemodialysis (HD) patients.

METHODS

Overall 246 HD patients who had undergone a radical nephrectomy for RCC were enrolled in this study. Unilateral RCC occurred in 201 patients, synchronous bilateral RCC in 15 and metachronous bilateral RCC in 30. Cancer-specific survival (CSS) was accessed by the Kaplan-Meier method.

RESULTS

Five-year CSS was not significantly different between the two groups (unilateral, 90%; bilateral, 90%; P=0.9509). In total 17 of the 201 patients (8.5%) with unilateral occurrence and four of the 45 patients (8.9%) with bilateral occurrence died from kidney cancer during the follow-up period. The presence of acquired cystic disease of kidney (unilateral, 73%; bilateral 91%; P=0.00319) and the mean duration of HD before surgery (unilateral: 157±91 months, bilateral: 189±83.5, P = 0.0319) were significantly different between the two groups. There were more multifocal tumors in bilateral than in unilateral occurrence (bilateral: 74%, unilateral: 30%, P<0.0001). There were significant differences in CSS according to HD duration before surgery (5-year CSS >180 months 82%, ≤180 months 95%; P=0.0004), tumor grade (G1 100%, G2 90%, G3 38%; P<0.0001), and tumor size (>4 cm 75%, ≤4 cm 98%; P<0.0001).

CONCLUSIONS

The type of occurrence of RCC, unilateral or bilateral, in HD patients does not appear to influence CSS. Patients with a longer duration of HD have to be followed up rigorously because they tend to have poor cancer prognosis.

Outcomes and clinicopathologic variables associated with late recurrence after nephrectomy for localized renal cell carcinoma

OBJECTIVE

To characterize the incidence and clinicopathologic factors associated with late recurrence after surgical resection for renal cell carcinoma (RCC) because the recurrence patterns >5 years after nephrectomy have been poorly described.

METHODS

We identified 1454 patients treated with nephrectomy for localized RCC from 1970 to 2000 who had remained free of disease for 5 years. Subsequent tumor recurrence was classified as renal recurrence and distant metastasis. The incidence of recurrence >5 years from surgery was estimated using the Kaplan-Meier method. The associations of clinicopathologic variables with late recurrence were analyzed using Cox proportional hazard regression models.

RESULTS

With a median postoperative follow-up of 13.9 years (range 5.1-38.9), 63 patients (4.3%) experienced late renal recurrence at a median of 9.3 years (range 5.1-25.3), and 172 patients (11.8%) developed late distant metastases at a median of 9.6 years (range 5.1-26.6) after surgery. The estimated recurrence-free survival rate at 10 and 15 years was 97.3% and 95.2% for renal recurrence, and 93.1% and 85.9% for distant metastases, respectively. On multivariate analysis, increased tumor size (hazard ratio [HR] 1.12; P < .001) was associated with late renal tumor recurrence, and increased tumor size (HR 1.07; P = .018), clear cell or collecting duct histologic features (HR 3.76; P < .001), and tumor Stage pT1b (HR 2.8; P < .001), pT2a (HR 4.5; P < .001), pT2b (HR 3.4; P = .007), and pT3-pT4 (HR 5.1; P < .001) were associated with distant metastasis.

CONCLUSION

After an initial 5-year postoperative disease-free interval, approximately 5% and 15% of patients will develop renal recurrence and distant metastases, respectively, during the next decade. Therefore, long-term surveillance remains necessary after nephrectomy.

Repeat partial nephrectomy: surgical, functional and oncological outcomes

PURPOSE OF REVIEW

The greater utilization of partial nephrectomy and ablative procedures has increased the incidence of patients presenting with local renal recurrence. The choice to either perform a partial or radical nephrectomy in these situations can be a challenging decision.

RECENT FINDINGS

Repeat and salvage partial nephrectomy, while challenging and potentially associated with increased complications, offers patients the ability to maintain excellent renal functional outcomes and promising oncologic outcomes at intermediate follow-up.

SUMMARY

Surgeons should be familiar with the surgical complications and the functional and oncologic outcomes of reoperative nephron-sparing surgery (NSS). Recent data and outcome analysis support utilization of these procedures in patients presenting with either local recurrence or de-novo lesions in the ipsilateral kidney.

Surgical management of bilateral synchronous kidney tumors: functional and oncological outcomes

PURPOSE

We evaluated renal functional and oncological outcomes after sequential partial nephrectomy and radical nephrectomy in patients with bilateral synchronous kidney tumors.

MATERIALS AND METHODS

A total of 220 patients treated from June 1994 to July 2008 were included in the study. Estimated glomerular filtration rate, and overall, cancer specific and recurrence-free survival were assessed.

RESULTS

Patients underwent sequential partial nephrectomy (134), partial nephrectomy followed by radical nephrectomy (60) or radical nephrectomy followed by partial nephrectomy (26). Final estimated glomerular filtration rate after bilateral surgery was 59, 36 and 35 ml/minute/1.73 m(2) in these 3 groups, respectively (p <0.001). The order in which partial nephrectomy and radical nephrectomy were conducted did not affect functional outcomes. Overall survival of patients with bilateral cancer was 86% at 5 years and 71% at 10 years, cancer specific survival was 96% at 5 and 10 years, and recurrence-free survival was 73% at 5 years and 44% at 10 years. Overall survival was decreased in patients with tumors larger than 7 cm (p = 0.003). Patients with postoperative stage III or greater chronic kidney disease had decreased overall survival due to noncancer causes (p = 0.007).

CONCLUSIONS

Patients treated with sequential surgery for bilateral synchronous kidney tumors have 5 and 10-year oncological outcomes comparable to those of patients with unilateral kidney cancer. Decreased overall survival was significantly associated with tumor size larger than 7 cm and postoperative stage III or greater chronic kidney disease. Nephron sparing surgery should be conducted for all amenable bilateral kidney masses given the negative impact of renal functional decline on overall survival.

Long-term management of bilateral, multifocal, recurrent renal carcinoma

Patients with bilateral multifocal renal cell carcinoma are at increased risk of developing locally recurrent or de novo tumors after nephron-sparing procedures. When dealing with recurrent renal masses the options are limited to observation, total nephrectomy, ablation, or repeat surgical intervention. The main reason for recurrence after nephron-sparing surgery is likely to be the presence of multifocal disease, which is identified in 4.3-25.0% of radical nephrectomy specimen. Bilateral renal involvement is seen in almost 90% of cases of multifocal renal carcinoma, and conversely the majority of patients with bilateral disease will have multifocal tumors. Many patients who are treated for multifocal disease, therefore, require subsequent surgical interventions. The outcome data for repeat renal interventions demonstrate reasonable functional and oncologic outcomes despite higher rates of perioperative complications. Our own results support the use of reoperative renal surgery rather than total nephrectomy and renal replacement therapy.

Management for patients with de novo or recurrent tumors in the residual kidney after surgery for nonfamilial bilateral renal cell carcinoma

The tumor de novo in the residual kidney after surgery for nonfamilial bilateral renal cell carcinoma (RCC) is problematic. We reviewed 5 patients who experienced such a situation. Three patients had had metachronous bilateral RCC, treated with radical nephrectomy in one kidney and nephron-sparing surgery (NSS) in the other. Two patients had had synchronous disease; one patient had received radical nephrectomy and NSS, and the other bilateral NSS. The 5 patients had another solid mass/de novo tumor in the residual kidney 16-88 (mean 46.8) months after surgery. For the tumor de novo in earlier years (1992-1999), one patient underwent surgery and hemodialysis, and the other selected a conservative observation. In recent years (2000-2007), one patient was conservatively observed; the remaining 2 received computerized-tomography-guided radiofrequency ablation, and the local tumors were well controlled postoperatively for 20 and 12 months with their renal function unimpaired. Ablative techniques can potentially strike a balance between oncological and nephrological outcomes in patients with sporadic multiple RCC, successful management of which was difficult previously.

Developments in the surgical management of sporadic synchronous bilateral renal tumours

OBJECTIVE

To examine our experience with managing sporadic bilateral renal masses, focusing on trends in surgical management over time, because as loss of renal function is associated with adverse cardiovascular outcomes, nephron-sparing approaches are increasingly emphasized in the treatment of kidney tumours, creating new challenges for the treatment of bilateral tumours.

PATIENTS AND METHODS

We identified all patients who underwent partial or radical nephrectomy (PN or RN) at Memorial Sloan-Kettering Cancer Center (MSKCC) during 1989-2008. We compared patients presenting with synchronous bilateral renal masses with those with unilateral tumour and evaluated trends in management using logistic regression.

RESULTS

Of the 2777 patients studied, 73 (3%) presented with synchronous bilateral disease. The overall survival and clinical/pathological features between groups were similar. Of those patients receiving bilateral operations for synchronous tumours, three had bilateral RN (all before 2003), 28 (38%) had an RN followed by a PN, 10 (14%) had a PN then an RN, and 32 (44%) had bilateral PN. Over time, the proportion of patients receiving bilateral PN increased (P < 0.001); 13 of 14 patients after 2005 had bilateral PN, compared with only 34% (16 of 45) between 1995 and 2004. Forty-five patients (62%) had the larger tumour removed during the first operation. The concordance rate between tumours in a specific histological subtype was 70% (51/73), and concordance for benign vs malignant disease was 90% (66/73).

CONCLUSION

The use of PN in the management of synchronous bilateral renal masses has increased over time. The contemporary treatment of synchronous bilateral renal masses at MSKCC involves staged PN when feasible, with the more involved kidney (often larger tumour) operated on first.