1
|
Hou Q, Yu X, Cheng Z, Han Z, Liu F, Dou J, Yu J, Liang P. Survival benefits analyses of T1a renal cell carcinoma patients treated with microwave ablation. Eur J Radiol 2021; 144:109951. [PMID: 34607288 DOI: 10.1016/j.ejrad.2021.109951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/26/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The individual decision-making reference of Microwave ablation (MWA) for T1a RCC treatment is not clear, and it may not benefit all the patients equally. Therefore, we quantitatively evaluated the distinct survival benefits of patients with T1a RCC stratified by survival predictors. MATERIALS AND METHODS A total of 237 patients with T1a RCC who underwent MWA over the last 16 years were retrospectively reviewed for survival benefit analysis. Cox proportional hazard models were used to control for the prognostic variables of OS, CSS, and PFS. Survival rates were calculated using the Kaplan-Meier method and compared by log-rank analysis. Linear extrapolation was used to compute median survival periods. RESULTS The OS benefit was significantly dependent on age (HR:2.499, 95% CI: 1.245-5.016, p = 0.010) and age-adjusted Charlson comorbidity index (CCI) score (HR:3.956, 95% CI, 1.409-11.110, p = 0.009). OS in patients aged <75 years or with an age-adjusted CCI score <7 was significantly prolonged (44.68, 65.55 months) compared to OS in patients aged ≥75 years or with CCI score ≥7 (p < 0.001 for both). PFS benefit was significantly dependent on age-adjusted CCI (HR:3.325, 95% CI, 1.390-7.956, p = 0.007), patient type (HR:0.4, 95% CI, 0.214-0.745, p = 0.004), and tumour growth pattern (HR:12.562, 95% CI, 1.552-101.696, p = 0.018). PFS in incipient patients was significantly prolonged (33.75 months) compared to that in the relapsed patients (p = 0.037). Patients with an age-adjusted CCI score <7 or without tumour protruding into the renal pelvis, lived free from recurrence or metastasis (55.69 or 101.61 months) longer than that in patients with an age-adjusted CCI score ≥7 or with tumour protruding into the renal pelvis (p < 0.01 for both). None of the variables was associated with CSS benefit. CONCLUSIONS The OS and PFS benefits from MWA were not equal for all T1a RCC patients. Age ≥75 years and age-adjusted CCI ≥ 7 significantly shortened OS. Age-adjusted CCI ≥ 7, relapsed RCC, and RCC protruding into the renal pelvis significantly shortened the PFS period. For a better survival prognosis, appropriate patient triage is still needed.
Collapse
Affiliation(s)
- Qidi Hou
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China; Department of Clinical Laboratory, Institute of Laboratory Medicine, Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, School of Medical Technology, Guangdong Medical University, Dongguan 523808, China
| | - Xiaoling Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China.
| | - Zhigang Cheng
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhiyu Han
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Fangyi Liu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Jianping Dou
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China.
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China.
| |
Collapse
|
2
|
Dai JC, Morgan TN, Moody D, McLaughlin J, Cadeddu JA. Radiofrequency Ablation of Small Renal Masses. J Endourol 2021; 35:S38-S45. [PMID: 34499555 DOI: 10.1089/end.2020.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although the incidence of localized renal cell carcinoma has increased in recent decades due to greater use of imaging, the treatment has shifted to less invasive, nephron-sparing approaches. Radiofrequency ablation (RFA) is one accepted treatment modality for patients with small renal masses, and it has the advantage of being minimally invasive and highly nephron sparing, with the additional benefits of reduced blood loss and complication rates. We describe our experience with RFA with an accompanying instructional video outlining the procedure's key components.
Collapse
Affiliation(s)
- Jessica C Dai
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tara Nikonow Morgan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Devan Moody
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joseph McLaughlin
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeffrey A Cadeddu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
3
|
Li Z, Zhang J, Zhang L, Yao L, Zhang C, He Z, Li X, Zhou L. Natural history and growth kinetics of clear cell renal cell carcinoma in sporadic and von Hippel-Lindau disease. Transl Androl Urol 2021; 10:1064-1070. [PMID: 33850741 PMCID: PMC8039623 DOI: 10.21037/tau-20-1271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background To evaluate and compare the natural history and growth kinetics of sporadic clear cell renal cell carcinoma (ccRCC) with those of ccRCC in von Hippel-Lindau disease (VHL). Methods Sixty patients in the sporadic group with 61 tumors and 15 patients in the VHL group with 30 tumors whom all underwent delayed surgery after at least 12 months of active surveillance (AS) were enrolled to conduct a retrospective cohort study. The growth rate was calculated, and the growth kinetics between the sporadic and VHL groups were compared. The patient and tumor characteristics were reviewed, and their correlation with growth rate was analyzed. Results The mean growth rate of sporadic ccRCC was 0.91 cm/year (ranging from 0–4.74 cm/year) and that of VHL ccRCC was 0.47 cm/year (ranging from 0.04–1.89 cm/year). The growth rate of sporadic ccRCC showed a tendency of being faster than that of VHL ccRCC but did not reach statistical significance (P=0.07). The factors affecting the growth rate were different between the two groups. For VHL ccRCC, the only factor that correlated with growth rate was initial tumor diameter (P<0.001), but for sporadic ccRCC, the only factor was pathological nuclear grade (P<0.001). Conclusions The growth rate of VHL-associated ccRCC might be slower than that of sporadic ccRCC. Furthermore, we identified a disparity in growth kinetics between sporadic and VHL-associated ccRCC.
Collapse
Affiliation(s)
- Ziao Li
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| | - Jin Zhang
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Lei Zhang
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| | - Lin Yao
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| | - Cuijian Zhang
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| | - Zhisong He
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Beijing, China; Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, Beijing, China
| |
Collapse
|
4
|
Gantsev SK, Khmelevskiy AA, Gantsev KS, Khrizman YN. Asymptomatic Kidney Tumors in Elderly Patients: Review of Treatment Approaches in Russia and Western Countries. ADVANCES IN GERONTOLOGY 2020. [DOI: 10.1134/s2079057020010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
5
|
Mongiat-Artus P, Paillaud E, Caillet P, Albrand G, Neuzillet Y. [Geriatric specificities of localized renal cell carcinoma]. Prog Urol 2019; 29:865-873. [PMID: 31771769 DOI: 10.1016/j.purol.2019.08.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe the epidemiology of renal cell carcinoma (RCC) and its natural history in the elderly patient. To propose adaptations of geriatric evaluation specific to RCC. Recall therapeutic options and the treatment options specific to elderly patients. METHOD Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific societies of geriatrics, from the National Cancer Institute using the following keywords: elderly, geriatrics, renal cell carcinoma, small renal mass, diagnosis, treatment. RESULTS The incidence of RCC increases in France and peaks between 70 and 80 years. This increase in incidence is mainly due to the diagnosis of small renal masses (SMR). The specific mortality of RCC increases with age (at least between 75 and 95 years). Tumor biopsy, especially of SMR, should be considered in the elderly patient. The geriatric assessment of patients with CaR has no specificity apart from specific evaluation of renal function and operative risk. There is no prospective therapeutic trials dedicated to elderly patients with localized RCC. Surgical treatment requires the use of fast track protocol (the modalities of which are being elaborated) in which geriatricians play a key role throughout the process. The role of percutaneous ablative treatment should be better defined in elderly patients. However, given their low specific mortality, surveillance of SRM (at least initially) is probably an interesting option, certainly under-used, although its impact on quality of life remains to be clarified. The overarching goal of geriatric oncology must guide the decisions of care in the older patient with CaR: first, the respect of patient-specific expectations and secondly the search for an overall clinical benefit; objectives that have no reason to be restricted to elderly patients. CONCLUSION RCC is becoming a predominantly elderly cancer. It responds to the current general diagnostic and therapeutic guidelines. It is desirable that clinical research help to better define the respective roles of percutaneous biopsy and treatment of localized RCC.
Collapse
Affiliation(s)
- P Mongiat-Artus
- Inserm UMR_S1165, service d'urologie et unité de chirurgie et d'anesthésie ambulatoires, hôpital Saint-Louis, université Paris Diderot, université de Paris, Assistance publique-Hôpitaux de Paris, 75010 Paris, France.
| | - E Paillaud
- EA 7376 épidémiologie clinique et vieillissement, service de gériatrie - unité d'onco-gériatrie et UCOG - Paris-Ouest, hôpital européen Georges-Pompidou, université René Descartes, université de Paris, Assistance publique-Hôpitaux de Paris, 75015 Paris, France
| | - P Caillet
- Service de gériatrie, hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, 94000 Créteil, France
| | - G Albrand
- Service de gériatrie et UCOG - IR, AuRA Ouest-Guyane, hospices civils de Lyon, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| | - Y Neuzillet
- Service d'urologie, hôpital Foch, université de Versailles, Saint-Quentin-en-Yvelines, 92150 Suresnes, France
| |
Collapse
|
6
|
Gupta M, Alam R, Patel HD, Semerjian A, Gorin MA, Johnson MH, Chang P, Wagner AA, McKiernan JM, Allaf ME, Pierorazio PM. Use of delayed intervention for small renal masses initially managed with active surveillance. Urol Oncol 2019; 37:18-25. [DOI: 10.1016/j.urolonc.2018.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/11/2018] [Accepted: 10/01/2018] [Indexed: 01/20/2023]
|
7
|
Active Surveillance for Localized Renal Masses: Tumor Growth, Delayed Intervention Rates, and >5-yr Clinical Outcomes. Eur Urol 2018; 74:157-164. [PMID: 29625756 DOI: 10.1016/j.eururo.2018.03.011] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/14/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Active surveillance (AS) has gained acceptance as a management strategy for localized renal masses. OBJECTIVE To review our large single-center experience with AS. DESIGN, SETTING, AND PARTICIPANTS From 2000 to 2016, we identified 457 patients with 544 lesions managed with AS from our prospectively maintained kidney cancer database. A subset analysis was performed for patients with ≥5-yr follow-up without delayed intervention (DI). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Linear growth rates (LGRs) were estimated using linear regression for the initial LGR (iLGR) AS interval and the entire AS period. Overall survival (OS) and cumulative incidence of DI were estimated with Kaplan-Meier methods utilizing iLGR groups, adjusting for covariates. DI was evaluated for association with OS in Cox models. RESULTS AND LIMITATIONS Median follow-up was 67 mo (interquartile range [IQR] 41-94 mo) for surviving patients. Cumulative incidence of DI (n=153) after 1, 2, 3, 4, and 5 yr was 9%, 22%, 29%, 35%, and 42%, respectively. Median initial maximum tumor dimension was 2.1cm (IQR 1.5-3.1cm). Median iLGR and overall LGR were 1.9 (IQR 0-7) and 1.9 (IQR 0.3-4.2) mm/yr, respectively. Compared with the no growth group, low iLGR (hazard ratio [HR] 1.25, 95% cumulative incidence [CI] 0.82-1.91), moderate iLGR (HR 2.1, 95% CI 1.31-3.36), and high iLGR (HR 1.87, 95% CI 1.23-2.84) were associated with DI (p=0.003). The iLGR was not associated with OS (p=0.8). DI was not associated with OS (HR 1.34, 95% CI 0.79-2.29, p=0.3). Five-year cancer-specific mortality (CSM) was 1.2% (95% CI 0.4-2.8%). Of 99 patients on AS without DI for >5 yr, one patient metastasized. CONCLUSIONS At >5 yr, AS±DI is a successful strategy in carefully managed patients. DI often occurs in the first 2-3 yr, becoming less likely over time. Rare metastasis and low CSM rates should reassure physicians that AS is safe in the intermediate to long term. PATIENT SUMMARY In this report, we looked at the outcomes of patients with kidney masses who elected to enroll in active surveillance rather than immediate surgery. We found that patients who need surgery are often identified early and those who remain on active surveillance become less likely to need surgery over time. We concluded that active surveillance with or without delayed surgery is a safe practice and that, when properly managed and followed, patients are unlikely to metastasize or die from kidney cancer.
Collapse
|
8
|
Alsharm A, Bazarbashi S, Alghamdi A, Alkhateeb S, Aljubran A, Abusamra A, Alharbi H, Alotaibi M, Almansour M, Alkushi H, Ahmed I, Murshid E, Eltijani A, Rabah D. Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017. Urol Ann 2018; 10:123-132. [PMID: 29719321 PMCID: PMC5907318 DOI: 10.4103/ua.ua_175_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.
Collapse
Affiliation(s)
- Abdullah Alsharm
- Department of Medical Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shouki Bazarbashi
- Oncology Center, Section of Medical Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah Alghamdi
- Department of Urology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sultan Alkhateeb
- Department of Surgery, Division of Urology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Aljubran
- Oncology Center, Section of Medical Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ashraf Abusamra
- Department of Surgery, Urology Section, King Khalid Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Hulayel Alharbi
- Department of Medical Oncology, King Fahed Specialist Hospital, Dammam, Saudi Arabia
| | - Mohammed Alotaibi
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mubarak Almansour
- Department of Oncology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Hussein Alkushi
- Department of Pathology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Imran Ahmed
- Department of Oncology, Section of Medical Oncology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Esam Murshid
- Department of Oncology, Oncology Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Amin Eltijani
- Department of Oncology, Division of Medical Oncology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Danny Rabah
- Department of Surgery, College of Medicine and Uro-Oncology Research Chair, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
9
|
Alsharm A, Bazarbashi S, Alghamdi A, Alkhateeb S, Aljubran A, Abusamra A, Alharbi H, Alotaibi M, Almansour M, Alkushi H, Ahmed I, Murshid E, Eltijani A, Rabah D. Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017. Urol Ann 2018. [PMID: 29719321 DOI: 10.4103/ua.ua-175-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.
Collapse
Affiliation(s)
- Abdullah Alsharm
- Department of Medical Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shouki Bazarbashi
- Oncology Center, Section of Medical Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah Alghamdi
- Department of Urology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sultan Alkhateeb
- Department of Surgery, Division of Urology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Aljubran
- Oncology Center, Section of Medical Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ashraf Abusamra
- Department of Surgery, Urology Section, King Khalid Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Hulayel Alharbi
- Department of Medical Oncology, King Fahed Specialist Hospital, Dammam, Saudi Arabia
| | - Mohammed Alotaibi
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mubarak Almansour
- Department of Oncology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Hussein Alkushi
- Department of Pathology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Imran Ahmed
- Department of Oncology, Section of Medical Oncology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Esam Murshid
- Department of Oncology, Oncology Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Amin Eltijani
- Department of Oncology, Division of Medical Oncology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Danny Rabah
- Department of Surgery, College of Medicine and Uro-Oncology Research Chair, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
10
|
Welch HG, Skinner JS, Schroeck FR, Zhou W, Black WC. Regional Variation of Computed Tomographic Imaging in the United States and the Risk of Nephrectomy. JAMA Intern Med 2018; 178:221-227. [PMID: 29279887 PMCID: PMC5838611 DOI: 10.1001/jamainternmed.2017.7508] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE While computed tomography (CT) represents a tremendous advance in diagnostic imaging, it also creates the problem of incidental detection-the identification of tumors unrelated to the clinical symptoms that initiate the test. OBJECTIVE To determine the geographic variation in the United States in CT imaging and the corresponding association with one of the most consequential sequelae of incidental detection: nephrectomy. DESIGN, SETTING, AND PARTICIPANTS This study is a cross-sectional analysis of age-, sex-, and race-adjusted Medicare data (January 2010-December 2014) from 306 hospital referral regions (HRRs) in the United States and includes information from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years. EXPOSURES Regional CT risk (ie, the proportion of the population receiving either a chest or abdominal CT over 5 years). MAIN OUTCOMES AND MEASURES Five-year risk of nephrectomy (partial or total). RESULTS Data from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years were gathered and illustrate that 43% of Medicare beneficiaries age 65 to 85 years received either a chest or abdominal CT from January 2010 to December 2014. This risk varied across the HRRs, ranging from 31% in Santa Cruz, California, to 52% in Sun City, Arizona. Increased regional CT risk was associated with a higher nephrectomy risk (r = 0.38; 95% CI, 0.28-0.47), particularly among HRRs with more than 50 000 beneficiaries (r = 0.47; 95% CI, 0.31-0.61). After controlling for HRR adult smoking rates, imaging an additional 1000 beneficiaries was associated with 4 additional nephrectomies (95% CI, 3-5). Case-fatality rates for those who underwent nephrectomy were 2.1% at 30 days and 4.3% at 90 days. CONCLUSIONS AND RELEVANCE Fee-for-service Medicare beneficiaries are commonly exposed to CT imaging. Those residing in high-scanning regions face a higher risk of nephrectomy, presumably reflecting the incidental detection of renal masses. Additional surgery should be considered one of the risks of excessive CT imaging.
Collapse
Affiliation(s)
- H Gilbert Welch
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Jonathan S Skinner
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Department of Economics, Dartmouth College, Hanover, New Hampshire
| | - Florian R Schroeck
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont.,Department of Surgery, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Urology Service, Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Weiping Zhou
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire
| | - William C Black
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire.,Department of Radiology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| |
Collapse
|
11
|
Abstract
With the ubiquitous use of cross-sectional abdominal imaging in recent years, the incidence of small renal masses (SRMs) has increased, and the evaluation and management of SRMs have become important clinical issues. Diagnosing a mass in the early stages theoretically allows for high rates of cure but simultaneously risks overtreatment. In the past 20 years, surgical treatment of SRMs has transitioned from radical nephrectomy for all renal tumors, regardless of size, to elective partial nephrectomy whenever technically feasible. Additionally, newer approaches, including renal mass biopsy, active surveillance for select patients, and renal mass ablation, have been increasingly used. In this chapter, we review the current evidence-based papers covering aspects of the diagnosis and management of SRMs.
Collapse
Affiliation(s)
- Avinash Chenam
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Rd, MOB L002H, Duarte, CA, 91010, USA
| | - Clayton Lau
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Rd, MOB L002H, Duarte, CA, 91010, USA.
| |
Collapse
|
12
|
Active Surveillance in Small Renal Masses in the Elderly: A Literature Review. Eur Urol Focus 2017; 3:340-351. [PMID: 29175368 DOI: 10.1016/j.euf.2017.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/06/2017] [Accepted: 11/14/2017] [Indexed: 12/28/2022]
Abstract
CONTEXT Small renal masses have become increasingly common due to widespread imaging; however, optimal management of these lesions in the elderly can be complex due to the competing risks of intervention, natural history of disease, patient comorbidities, and expectations. In the properly selected elderly patient, active surveillance remains an accepted and attractive treatment approach. OBJECTIVE We completed a literature review of small renal masses (enhancing, <4cm, T1aN0M0 disease) in the elderly, aged ≥70 yr, aimed at identifying the utility of active surveillance in this population. The primary outcomes were conversion to active treatment while on active surveillance and cancer-specific mortality. Secondary outcomes included predictors of treatment, type of treatment performed (partial nephrectomy, radical nephrectomy, and ablation), progression to metastases, all-cause mortality, tumor growth rate, and demographic data including age and Charlson Comorbidity Index. EVIDENCE ACQUISITION A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library) using search terms "small renal mass" OR "SRM", AND "elderly," "senior," "aging," "geriatric," OR "octogenarian" was completed. All randomized controlled trials, nonrandomized comparison studies, and case series were included and screened by the reviewers. All comparison studies included in the systematic review were assessed for methodological quality using the Cochrane Risk of Bias tools. EVIDENCE SYNTHESIS Seventeen primary studies including 36495 patients met the inclusion criteria for the systematic review. All studies were retrospective institutional chart or the Surveillance, Epidemiology, and End Results database reviews. There was a low (4-26%) rate of conversion to active treatment for active surveillance in the identified studies over a follow-up interval of up to 91.5 mo. Overall mortality was substantial in this elderly cohort, with 15-51% of patients being deceased over the course of study follow-up; however, there was minimal cancer-specific mortality due to patients succumbing to alternative comorbid disease. In the future, patient comorbidity and biological age versus the natural history of the individualized tumor biology may play an increasing role in the discussion regarding treatment options and consideration of active surveillance. CONCLUSIONS Active surveillance is an effective management strategy in the elderly population. Few patients required the conversion to active treatment and there was low cancer-specific mortality. The majority of patients who expired over the course of the identified studies succumbed to alternative disease. The goal of treatment strategies should include weighing patient-specific prognosis relative to their competing health risks and treatment goals against the natural history of disease and risks of intervention. PATIENT SUMMARY In this review article, the authors examined the utility of active surveillance in the setting of a small localized renal mass in the elderly population. Despite being on surveillance, we found that cancer-specific outcomes were excellent, and overall mortality was often a result of comorbid disease. However, there is significant heterogeneity among elderly patients, and treatment approaches should be focused around patient-centered goals and prognosis.
Collapse
|
13
|
Tricard T, Tsoumakidou G, Lindner V, Garnon J, Albrand G, Cathelineau X, Gangi A, Lang H. Thérapies ablatives dans le cancer du rein : indications. Prog Urol 2017; 27:926-951. [DOI: 10.1016/j.purol.2017.07.245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/22/2017] [Indexed: 12/19/2022]
|
14
|
Focal ablation therapy for renal cancer in the era of active surveillance and minimally invasive partial nephrectomy. Nat Rev Urol 2017; 14:669-682. [PMID: 28895562 DOI: 10.1038/nrurol.2017.143] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Partial nephrectomy is the optimal surgical approach in the management of small renal masses (SRMs). Focal ablation therapy has an established role in the modern management of SRMs, especially in elderly patients and those with comorbidities. Percutaneous ablation avoids general anaesthesia and laparoscopic ablation can avoid excessive dissection; hence, these techniques can be suitable for patients who are not ideal surgical candidates. Several ablation modalities exist, of which radiofrequency ablation and cryoablation are most widely applied and for which safety and oncological efficacy approach equivalency to partial nephrectomy. Data supporting efficacy and safety of ablation techniques continue to mature, but they originate in institutional case series that are confounded by cohort heterogeneity, selection bias, and lack of long-term follow-up periods. Image guidance and surveillance protocols after ablation vary and no consensus has been established. The importance of SRM biopsy, its optimal timing, the type of biopsy used, and its role in treatment selection continue to be debated. As safety data for active surveillance and experience with minimally invasive partial nephrectomy are expanding, the role of focal ablation therapy in the treatment of patients with SRMs requires continued evaluation.
Collapse
|
15
|
Current Role of Active Surveillance in the Management of a Small Renal Mass. Indian J Surg Oncol 2017; 8:403-406. [PMID: 30429637 DOI: 10.1007/s13193-016-0600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/27/2016] [Indexed: 10/19/2022] Open
Abstract
Renal cell carcinoma accounts for 3-4% of adult malignant neoplasms and over 65,000 new cases of kidney cancer were diagnosed in the USA in 2013 [1, 2]. Widespread use of abdominal imaging is leading to an increased incidence in the detection of small renal masses (SRMs) among other causes [1-4]. In light of recent literature on the role of percutaneous renal mass biopsy and retrospective data analysis, surveillance for renal masses ≤4 cm is likely to become more common especially in patients with less aggressive pathology, advanced age and multiple medical comorbidities.
Collapse
|
16
|
Delayed Intervention of Small Renal Masses on Active Surveillance. J Kidney Cancer VHL 2017; 4:24-30. [PMID: 28725541 PMCID: PMC5515897 DOI: 10.15586/jkcvhl.2017.75] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 05/10/2017] [Indexed: 01/17/2023] Open
Abstract
Although surgical excision is the standard of therapy for small renal masses (SRMs), there is a growing recognition of active surveillance as an option in select patients who are poor surgical candidates or who have shorter life expectancy. A number of patients on expectant management, however, subsequently advance to definitive therapy. In this study, we systematically reviewed the literature and performed a pooled analysis of active surveillance series to evaluate the rate and indications for definitive treatment after initiating a period of active surveillance. Fourteen clinical series (1245 patients; 1364 lesions) met our selection criteria. Mean lesion size at presentation was 2.30 ± 0.40 cm with a mean follow-up of 33.6 ± 16.9 months. Collectively, 34.0% of patients underwent delayed intervention, which ranged in individual series from 3.6% to 70.3%. Of patients undergoing delayed intervention, the average time on active surveillance prior to definitive treatment was 27.8 ± 10.6 months. A pooled analysis revealed that 41.0% of patients underwent therapy secondary to tumor growth rate and 51.9% secondary to patient or physician preference in the absence of clinical progression. Overall, 1.1% of all patients progressed to metastatic disease during the average follow-up period. Thus, active surveillance may be an appropriate option for carefully selected patients with SRMs. However, delayed treatment is pursued in a significant percentage of patients within 3 years. Prospective registries and clinical trials with standardized indications for delayed intervention are needed to establish true rates of disease progressions and recommendations for delayed intervention.
Collapse
|
17
|
Wah TM. Image-guided ablation of renal cell carcinoma. Clin Radiol 2017; 72:636-644. [PMID: 28527529 DOI: 10.1016/j.crad.2017.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/07/2017] [Accepted: 03/14/2017] [Indexed: 02/07/2023]
Abstract
This review article aims to provide an overview of image-guided ablation of renal cell carcinoma (RCC) since it was first introduced in 1998. This will cover the background and rationale behind its development; an overview of the evidence for current thermal technology, such as heat-based, e.g., radiofrequency ablation (RFA), microwave ablation (MWA), and cold-based energies, e.g., cryoablation used; and summarise the published evidence regarding its treatment efficacy and oncological outcome. In addition, it aims to provide an insight into the potential role of the new non-thermal ablative technology, e.g., irreversible electroporation (IRE)/Nanoknife in image-guided ablation of RCC, as well as areas of challenge that will require further research and clinical evaluation to ensure delivery of a quality patient-centred interventional oncology (IO) service in image-guided ablation of RCC.
Collapse
Affiliation(s)
- T M Wah
- Institute of Oncology, St. James's University Hospital, Diagnostic and Interventional Radiology, Leeds, UK.
| |
Collapse
|
18
|
Ristau BT, Kutikov A, Uzzo RG, Smaldone MC. Active Surveillance for Small Renal Masses: When Less is More. Eur Urol Focus 2017; 2:660-668. [PMID: 28723504 DOI: 10.1016/j.euf.2017.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/05/2017] [Indexed: 12/29/2022]
Abstract
CONTEXT A marked increase in incidentally detected small renal masses (SRMs) has occurred over the past decade. Active surveillance (AS) has emerged as an initial management option for these patients. OBJECTIVE (1) To determine selection criteria, assess appropriate imaging modalities and surveillance frequencies, and define triggers for delayed intervention (DI) for patients on AS. (2) To describe oncologic outcomes for patients on AS protocols. EVIDENCE ACQUISITION The PubMed database was queried for English language articles using the keywords "surveillance" and "renal mass" or "renal cell carcinoma" or "kidney cancer." The level of evidence, sample size, study design, and relevance to the review were considered as inclusion criteria. EVIDENCE SYNTHESIS A total of 69 manuscripts were included in the review. Selection criteria at initial evaluation for patients interested in AS include patient-related factors (eg, age, baseline renal function, other comorbidities), tumor-related factors (size, complexity, history of growth, possible renal mass biopsy), and patient preferences (illness uncertainty, quality of life). Cross-sectional imaging is the preferred initial imaging modality. Surveillance imaging should be performed at frequent intervals (3-4 mo) up front; intervals can be reduced over time if favorable growth kinetics are demonstrated. Delayed intervention (DI) should be considered for rapid tumor growth (eg,>0.5cm/yr), an increase in maximum tumor diameter >3-4cm, malignant renal mass biopsy results, development of symptoms, or patient preferences. Oncologic outcomes in well-controlled studies demonstrate a metastatic rate of 1-2%. Most patients who undergo DI remain eligible for nephron-sparing approaches; oncologic outcomes are not compromised by DI strategies. CONCLUSIONS A period of initial AS is safe for most patients with SRMs. Management decisions should focus on a thorough assessment of risk-benefit trade-offs, judiciously integrating patient-related factors, tumor-related factors, and patient preferences. PATIENT SUMMARY A period of initial active surveillance for kidney masses of ≤4cm in diameter is safe in most patients. Frequent imaging and follow-up are necessary to determine if the tumor grows. If delayed intervention becomes necessary, cancer outcomes are not compromised by the initial choice of active surveillance when patients adhere to close follow-up regimens.
Collapse
Affiliation(s)
- Benjamin T Ristau
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Robert G Uzzo
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Marc C Smaldone
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| |
Collapse
|
19
|
Daugherty M, Sedaghatpour D, Shapiro O, Vourganti S, Kutikov A, Bratslavsky G. The metastatic potential of renal tumors: Influence of histologic subtypes on definition of small renal masses, risk stratification, and future active surveillance protocols. Urol Oncol 2017; 35:153.e15-153.e20. [DOI: 10.1016/j.urolonc.2016.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 11/06/2016] [Accepted: 11/13/2016] [Indexed: 12/25/2022]
|
20
|
Abstract
Objective: To review hot issues and future direction of renal tumor biopsy (RTB) technique. Data Sources: The literature concerning or including RTB technique in English was collected from PubMed published from 1990 to 2015. Study Selection: We included all the relevant articles on RTB technique in English, with no limitation of study design. Results: Computed tomography and ultrasound were usually used for guiding RTB with respective advantages. Core biopsy is more preferred over fine needle aspiration because of superior accuracy. A minimum of two good-quality cores for a single renal tumor is generally accepted. The use of coaxial guide is recommended. For biopsy location, sampling different regions including central and peripheral biopsies are recommended. Conclusion: In spite of some limitations, RTB technique is relatively mature to help optimize the treatment of renal tumors.
Collapse
Affiliation(s)
- Lei Zhang
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Xue-Song Li
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Li-Qun Zhou
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| |
Collapse
|
21
|
Re: Population-Based Assessment of Cancer-Specific Mortality after Local Tumour Ablation or Observation for Kidney Cancer: A Competing Risks Analysis. J Urol 2017; 197:314-315. [DOI: 10.1016/j.juro.2016.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 11/20/2022]
|
22
|
Correas JM, Delavaud C, Gregory J, Le Guilchet T, Lamhaut L, Timsit MO, Méjean A, Hélénon O. Ablative Therapies for Renal Tumors: Patient Selection, Treatment Planning, and Follow-Up. Semin Ultrasound CT MR 2017; 38:78-95. [DOI: 10.1053/j.sult.2016.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
23
|
Kim SP, Gross CP, Meropol N, Kutikov A, Smaldone MC, Shah ND, Yu JB, Psutka S, Kiechle J, Abouassaly R. National treatment trends among older patients with T1-localized renal cell carcinoma. Urol Oncol 2016; 35:113.e15-113.e21. [PMID: 27839926 DOI: 10.1016/j.urolonc.2016.10.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 09/30/2016] [Accepted: 10/07/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the national trends in treatment of localized renal tumors among older patients with limited life expectancy. MATERIALS AND METHODS Using the National Cancer Database, we identified older patients (≥70y) diagnosed with T1 renal cell carcinoma from 2002 to 2011. Primary outcome was the initial treatment-partial nephrectomy (PN), radical nephrectomy, EM, and ablation. Multivariable logistic regression analysis stratified by tumor size (<2, 2-3.9, or 4-7cm) and age groups (70-79 and ≥80y) was used to identify covariates associated with different treatments. RESULTS Among 41,518 older patients with T1 renal cell carcinoma renal tumors, most were treated with radical nephrectomy (59.0%) followed by PN (20.0%) and ablation (8.4%). Only 12.6% were managed by EM. Among older patients aged 70 to 79 years with renal tumors 2 to 3.9cm, PN was used more frequently in 2008 to 2009 (odds ratio [OR] = 1.32; P = 0.001) and 2010 to 2011 (OR = 1.87; P<0.001) compared to 2002 to 2003 and at academic hospitals (OR = 1.91; P<0.001) compared to community hospitals. Similar trends were observed for patients aged 70 to 79 years with 4 to 7cm tumors and for patients aged≥80 years across renal tumor sizes. CONCLUSIONS Among older patients with localized renal tumors and limited life expectancy, most are treated surgically with a growing use of PN. A smaller proportion of older patients are managed by EM in the United States.
Collapse
Affiliation(s)
- Simon P Kim
- Urology Institute, Center of Outcomes and Health Care Quality, University Hospitals Cleveland Medical Center, Cleveland, OH; Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Cancer Outcomes Public Policy and Effectiveness Research (COPPER), Yale University, New Haven, CT.
| | - Cary P Gross
- Cancer Outcomes Public Policy and Effectiveness Research (COPPER), Yale University, New Haven, CT; Department of Medicine, Yale University, New Haven, CT
| | - Neal Meropol
- Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | | | | | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - James B Yu
- Department of Radiation Oncology, Yale University, New Haven, CT
| | - Sarah Psutka
- Division of Urologic Surgery, Cook County Health and Hospitals Systems, Chicago, IL
| | - Jonathon Kiechle
- Urology Institute, Center of Outcomes and Health Care Quality, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Robert Abouassaly
- Urology Institute, Center of Outcomes and Health Care Quality, University Hospitals Cleveland Medical Center, Cleveland, OH
| |
Collapse
|
24
|
Active surveillance for incidental renal mass in the octogenarian. World J Urol 2016; 35:1089-1094. [DOI: 10.1007/s00345-016-1961-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022] Open
|
25
|
Erman M, Benekli M, Basaran M, Bavbek S, Buyukberber S, Coskun U, Demir G, Karabulut B, Oksuzoglu B, Ozkan M, Sevinc A, Yalcin S. Renal cell cancer: overview of the current therapeutic landscape. Expert Rev Anticancer Ther 2016; 16:955-68. [DOI: 10.1080/14737140.2016.1222908] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
26
|
Ambani SN, Morgan TM, Montgomery JS, Gadzinski AJ, Jacobs BL, Hawken S, Krishnan N, Caoili EM, Ellis JH, Kunju LP, Hafez KS, Miller DC, Palapattu GS, Weizer AZ, Wolf JS. Predictors of Delayed Intervention for Patients on Active Surveillance for Small Renal Masses: Does Renal Mass Biopsy Influence Our Decision? Urology 2016; 98:88-96. [PMID: 27450936 DOI: 10.1016/j.urology.2016.04.067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To review our clinical T1a renal mass active surveillance (AS) cohort to determine whether renal mass biopsy was associated with maintenance of AS. MATERIALS AND METHODS From our prospectively maintained database we identified patients starting AS from June 2009 to December 2011 who had at least 5 months of radiologic follow-up, unless limited by unexpected death or delayed intervention. The primary outcome was delayed intervention. Clinical, radiologic, and pathologic variables were compared. We constructed Kaplan-Meier survival curves for maintenance of AS. Cox multivariable regression analysis was performed to assess predictors of delayed intervention. RESULTS We identified 118 patients who met criteria for inclusion with a median radiologic follow-up of 29.5 months. The delayed intervention group had greater initial mass size and faster growth rate compared to those who continued AS. Rate of renal mass biopsy was similar between the 2 groups. In the multivariable analysis, size >2 cm (hazard ratio [HR] 3.65, 95% confidence interval [CI] 1.28-10.38, P = .015), growth rate (continuous by mm/year: HR 1.26, 95% CI 1.12-1.41, P < .001), but not renal biopsy (HR 1.52, 95% CI 0.70-3.30, P = .29), were associated with increased risk of delayed intervention. Time-to-event curves also showed that size was closely associated with delayed intervention whereas renal mass biopsy was not. CONCLUSION At our institution, growth rate and initial tumor size appear to be more influential than renal mass biopsy results in determining delayed intervention after a period of AS. Further analysis is required to determine the role of renal biopsy in the management of patients being considered for AS.
Collapse
Affiliation(s)
- Sapan N Ambani
- Department of Urology, University of Michigan Health System, Ann Arbor, MI.
| | - Todd M Morgan
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | | | - Adam J Gadzinski
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Scott Hawken
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Elaine M Caoili
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - James H Ellis
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Lakshmi P Kunju
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI
| | - Khaled S Hafez
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - David C Miller
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Ganesh S Palapattu
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Alon Z Weizer
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - J Stuart Wolf
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| |
Collapse
|
27
|
Ahmad AE, Finelli A, Jewett MAS. Surveillance of Small Renal Masses. Urology 2016; 98:8-13. [PMID: 27397098 DOI: 10.1016/j.urology.2016.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/21/2016] [Accepted: 06/03/2016] [Indexed: 12/21/2022]
Abstract
The widespread utilization of imaging has led to an increasing incidence of small renal masses (SRMs). However, at least 20% are benign. Nevertheless, nephron-sparing surgery is the standard treatment for SRMs without pretreatment characterization with biopsy. Elderly patients and patients with multiple comorbidities and limited life expectancy may safely be managed with active surveillance with low risk of disease progression and mortality. An initial period of observation to determine tumor growth kinetics is safe and appropriate in select candidates. Renal tumor biopsy is accurate, safe and should be considered for SRMs prior to finalizing treatment plans.
Collapse
Affiliation(s)
- Ardalan E Ahmad
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Canada
| | - Antonio Finelli
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Canada
| | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Canada.
| |
Collapse
|
28
|
Quiroga Matamoros W, Fernandez F, Citarella Otero D, Rangel J, Estrada Guerrero A, Patiño ID. Guía de manejo del carcinoma de células renales. Rev Urol 2016. [DOI: 10.1016/j.uroco.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
29
|
Alghamdi A, Alkhateeb S, Alghamdi K, Bazarbashi S, Murshid E, Alotaibi M, Abusamra A, Rabah D, Ahmad I, Al-Mansour M, Saadeddin A, Alsharm A. Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma. Urol Ann 2016; 8:136-40. [PMID: 27141180 PMCID: PMC4839227 DOI: 10.4103/0974-7796.179239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This is an update to the previously published Saudi guidelines for the evaluation, medical, and surgical management of patients diagnosed with renal cell carcinoma (RCC). It is categorized according to the stage of the disease using the tumor node metastasis staging system 7(th) edition. The guidelines are presented with supporting evidence level, they are based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and healthcare policy makers in the management of patients diagnosed with RCC.
Collapse
Affiliation(s)
- Abdullah Alghamdi
- Department of Urology, Prince Sultan Military Medical City, Jeddah, Saudi Arabia
| | - Sultan Alkhateeb
- Department of Surgery, Division of Urology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Address for correspondence: Dr. Sultan Alkhateeb, Department of Surgery, Division of Urology, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 22490 (1446), Riyadh 11426, Saudi Arabia. E-mail:
| | - Khalid Alghamdi
- Department of Surgery, Division of Urology, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Shouki Bazarbashi
- Department of Oncology, Section of Medical Oncology, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Esam Murshid
- Department of Oncology, Oncology Center, Prince Sultan Military Medical City, Jeddah, Saudi Arabia
| | - Mohammed Alotaibi
- Department of Urology, King Faisal Specialist Hospital and Research Center, RIyadh, Saudi Arabia
| | - Ashraf Abusamra
- Department of Surgery, Urology Section, King Khalid Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Danny Rabah
- Department of Surgery, College of Medicine and Uro-Oncology Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Imran Ahmad
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mubarak Al-Mansour
- Department of Oncology, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ahmad Saadeddin
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alsharm
- Department of Medical Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
30
|
|
31
|
Larcher A, Trudeau V, Sun M, Boehm K, Meskawi M, Tian Z, Fossati N, Dell'Oglio P, Capitanio U, Briganti A, Shariat SF, Montorsi F, Karakiewicz PI. Population-based assessment of cancer-specific mortality after local tumour ablation or observation for kidney cancer: a competing risks analysis. BJU Int 2015; 118:541-6. [PMID: 26384713 DOI: 10.1111/bju.13326] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To examine, using competing risks regression, differences in cancer-specific mortality (CSM) that might distinguish between local tumour ablation (LTA) and observation (OBS) for patients with kidney cancer. PATIENTS AND METHODS The study focused on 1 860 patients with cT1a kidney cancer treated with either LTA or OBS between 2000 and 2009 in the Surveillance Epidemiology and End Results-Medicare database. Propensity-score matching was used. The study outcome was CSM. Multivariable competing risks regression analyses, adjusting for other-cause mortality as well as patient (including comorbidities) and tumour characteristics, were fitted. RESULTS Overall, fewer patients underwent LTA than OBS (30 vs 70%; n = 553 vs n = 1 307). Compared with patients in the OBS group, those in the LTA group were younger (median age 77 vs 78 years; P < 0.001), more likely to be white (84 vs 78%; P = 0.005), more frequently married (59 vs 52%; P = 0.02) and more frequently of high socio-economic status (54 vs 45%; P = 0.001). After propensity-score matching, 553 patients who underwent LTA and 553 who underwent OBS remained for subsequent analyses. The mean standardized differences of patient characteristics between the two groups were <10%, indicating a high degree of similarity. After LTA or OBS, the 5-year CSM estimates from Poisson regression-derived smoothed plots were 3.5 and 9.1%, respectively. In multivariable competing risks regression analyses, LTA use was found to have a protective effect on CSM (hazard ratio 0.47 [95% confidence interval 0.25-0.89]; P = 0.02). CONCLUSIONS After adjustment for comorbidity and tumour characteristics in elderly patients with kidney cancer, LTA was associated with a clinically and statistically significant protective effect on CSM, compared with OBS. This advantage of LTA deserves consideration when obtaining informed consent.
Collapse
Affiliation(s)
- Alessandro Larcher
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada. .,Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Vincent Trudeau
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.,Department of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - Katharina Boehm
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.,Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malek Meskawi
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.,Department of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Nicola Fossati
- Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Paolo Dell'Oglio
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.,Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Umberto Capitanio
- Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Briganti
- Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Francesco Montorsi
- Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.,Department of Urology, University of Montreal Health Center, Montreal, QC, Canada
| |
Collapse
|
32
|
The growth rate of "clinically significant" renal cancer. SPRINGERPLUS 2015; 4:580. [PMID: 26543715 PMCID: PMC4628034 DOI: 10.1186/s40064-015-1385-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/27/2015] [Indexed: 12/27/2022]
Abstract
Surveillance studies of enhancing renal masses report on a mean tumor growth rate of about 0.3 cm/year. In most of these studies however, only small tumors in elderly patients were followed. In the current report, we attempt to evaluate the growth rate of “clinically significant” renal carcinomas defined as tumors that were treated immediately upon diagnosis. 46 patients (mean age 64 years SD 11 years) were treated for renal carcinoma. All had a cross-sectional imaging studies performed 6–60 months prior to diagnosis of kidney cancer demonstrating no tumor. Tumor growth rate was calculated by dividing tumor’s largest diameter by the time interval between the normal kidney imaging and diagnosis of renal cancer. Mean tumor diameter was 4.5 cm (SD 2.4 cm). Mean time period from the normal imaging to diagnosis of renal cancer was 33.6 months (SD 18 months). According to the proposed model, the average growth rate of “clinically significant” renal carcinomas was 2.13 cm/year (SD 1.45, range 0.2–6.5 cm/year). Tumor growth rate correlated inversely with patient’s age (p = 0.007). Patient gender or Fuhrman’s grade did not correlate however. The growth rate of “clinically significant” renal cancer appears to be higher than the rate reported in surveillance trials. Renal tumors tend to grow faster in young patients. As such, variable growth rate should be taken into account when considering active surveillance in young patients and when designing trials for evaluation of anti-cancer agents.
Collapse
|
33
|
The Past, Present, and Future in Management of Small Renal Masses. JOURNAL OF ONCOLOGY 2015; 2015:364807. [PMID: 26491445 PMCID: PMC4605375 DOI: 10.1155/2015/364807] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/06/2015] [Accepted: 09/13/2015] [Indexed: 12/20/2022]
Abstract
Management of small renal masses (SRMs) is currently evolving due to the increased incidence given the ubiquity of cross-sectional imaging. Diagnosing a mass in the early stages theoretically allows for high rates of cure but simultaneously risks overtreatment. New consensus guidelines and treatment modalities are changing frequently. The multitude of information currently available shall be summarized in this review. This summary will detail the historic surgical treatment of renal cell carcinoma with current innovations, the feasibility and utility of biopsy, the efficacy of ablative techniques, active surveillance, and use of biomarkers. We evaluate how technology may be used in approaching the small renal mass in order to decrease morbidity, while keeping rates of overtreatment to a minimum.
Collapse
|
34
|
The management of small renal masses: what is likely to change? Urologia 2015. [PMID: 26219473 DOI: 10.5301/uro.5000127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The diffusion of imaging has determined an increased discovery of small renal masses (SRMs). Recent publications have been reviewed to present the state of the art in the management of SRMs and to try to foresee the next steps in this challenging condition. The role of percutaneous biopsies is expanding, since management algorithms include also active surveillance and ablative therapies. However up to 30% of biopsies fail to provide histological diagnosis and there is the risk of under-evaluating high-grade tumors. Active surveillance has been proposed in patients with reduced life expectancy and numerous comorbidities. The average growth of SRMs is slow, and metastatic progression has been observed in about 1%. Ablative therapies (cryotherapy and radiofrequency ablation) are used in patients with relevant comorbidities or advanced age and unfit for surgery, but who desire active treatment. Compared to conservative surgical treatment both techniques have increased local progression rates, while metastatic progression is relatively low.Partial nephrectomy (PN) is the recommended curative treatment for SRMs and can be performed open, laparoscopically or robotically. Open PN represents the benchmark, with similar cancer specific survival and better preservation of renal function compared to nephrectomy. Laparoscopy is comparable to open surgery in terms of oncologic results, but a long learning curve is necessary. Perioperative outcomes of robot-assisted PN appear superior to laparoscopy and the learning curve is shorter, but data for oncological results are still immature. With the increasing diffusion of robotic technology it is likely more SRMs will be managed with this approach.
Collapse
|
35
|
Les traitements ablatifs dans le cancer du rein localisé : revue de la littérature en 2014. Prog Urol 2015; 25:499-509. [DOI: 10.1016/j.purol.2015.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 04/27/2015] [Accepted: 04/29/2015] [Indexed: 01/25/2023]
|
36
|
Tsili AC, Argyropoulou MI. Advances of multidetector computed tomography in the characterization and staging of renal cell carcinoma. World J Radiol 2015; 7:110-127. [PMID: 26120380 PMCID: PMC4473304 DOI: 10.4329/wjr.v7.i6.110] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/18/2015] [Accepted: 04/29/2015] [Indexed: 02/06/2023] Open
Abstract
Renal cell carcinoma (RCC) accounts for approximately 90%-95% of kidney tumors. With the widespread use of cross-sectional imaging modalities, more than half of RCCs are detected incidentally, often diagnosed at an early stage. This may allow the planning of more conservative treatment strategies. Computed tomography (CT) is considered the examination of choice for the detection and staging of RCC. Multidetector CT (MDCT) with the improvement of spatial resolution and the ability to obtain multiphase imaging, multiplanar and three-dimensional reconstructions in any desired plane brought about further improvement in the evaluation of RCC. Differentiation of RCC from benign renal tumors based on MDCT features is improved. Tumor enhancement characteristics on MDCT have been found closely to correlate with the histologic subtype of RCC, the nuclear grade and the cytogenetic characteristics of clear cell RCC. Important information, including tumor size, localization, and organ involvement, presence and extent of venous thrombus, possible invasion of adjacent organs or lymph nodes, and presence of distant metastases are provided by MDCT examination. The preoperative evaluation of patients with RCC was improved by depicting the presence or absence of renal pseudocapsule and by assessing the possible neoplastic infiltration of the perirenal fat tissue and/or renal sinus fat compartment.
Collapse
|
37
|
Mehrazin R, Smaldone MC, Egleston B, Tomaszewski JJ, Concodora CW, Ito TK, Abbosh PH, Chen DYT, Kutikov A, Uzzo RG. Is anatomic complexity associated with renal tumor growth kinetics under active surveillance? Urol Oncol 2015; 33:167.e7-12. [PMID: 25778696 PMCID: PMC4417444 DOI: 10.1016/j.urolonc.2015.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/05/2015] [Accepted: 01/18/2015] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Linear growth rate (LGR) is the most commonly employed trigger for definitive intervention in patients with renal masses managed with an initial period of active surveillance (AS). Using our institutional cohort, we explored the association between tumor anatomic complexity at presentation and LGR in patients managed with AS. METHODS AND MATERIALS Enhancing renal masses managed expectantly for at least 6 months were included for analysis. The association between Nephrometry Score and LGR was assessed using generalized estimating equations, adjusting for the age, Charlson score, race, sex, and initial tumor size. RESULTS Overall, 346 patients (401 masses) met the inclusion criteria (18% ≥ cT1b), with a median follow-up of 37 months (range: 6-169). Of these, 44% patients showed progression to definitive intervention with a median duration of 27 months (range: 6-130). On comparing patients managed expectantly to those requiring intervention, no difference was seen in median tumor size at presentation (2.2 vs. 2.2 cm), whereas significant differences in median age (74 vs. 65 y, P < 0.001), Charlson comorbidity score (3 vs. 2, P<0.001), and average LGR (0.23 vs. 0.49 cm/y, P < 0.001) were observed between groups. Following adjustment, for each 1-point increase in Nephrometry Score sum, the average tumor LGR increased by 0.037 cm/y (P = 0.002). Of the entire cohort, 6 patients (1.7%) showed progression to metastatic disease. CONCLUSIONS The demonstrated association between anatomic tumor complexity at presentation and renal masses of LGR of clinical stage 1 under AS may afford a clinically useful cue to tailor individual patient radiographic surveillance schedules and warrants further evaluation.
Collapse
Affiliation(s)
- Reza Mehrazin
- Department of Urology & Oncological Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marc C Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - Brian Egleston
- Biostatistics & Bioinformatics Facility, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - Jeffrey J Tomaszewski
- Department of Surgery, MD Anderson Cancer Center at Cooper, Rowan, University School of Medicine, Camden, NJ
| | - Charles W Concodora
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - Timothy K Ito
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - Philip H Abbosh
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - David Y T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - Alexander Kutikov
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA
| | - Robert G Uzzo
- Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA.
| |
Collapse
|
38
|
Borghesi M, Brunocilla E, Volpe A, Dababneh H, Pultrone CV, Vagnoni V, La Manna G, Porreca A, Martorana G, Schiavina R. Active surveillance for clinically localized renal tumors: An updated review of current indications and clinical outcomes. Int J Urol 2015; 22:432-8. [DOI: 10.1111/iju.12734] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/30/2014] [Accepted: 01/16/2015] [Indexed: 01/14/2023]
Affiliation(s)
- Marco Borghesi
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
- Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Eugenio Brunocilla
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Alessandro Volpe
- Department of Urology; University of Eastern Piedmont, Maggiore della Carità Hospital; Novara Italy
| | - Hussam Dababneh
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Cristian Vincenzo Pultrone
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
- Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Valerio Vagnoni
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Gaetano La Manna
- Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
- Department of Nephrology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Angelo Porreca
- Department of Urology; Abano Terme Hospital; Abano Terme Italy
| | - Giuseppe Martorana
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
- Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Riccardo Schiavina
- Department of Urology; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
- Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| |
Collapse
|
39
|
McKibben MJ, Smith AB. Evaluation and Management of the Geriatric Urologic Oncology Patient. CURRENT GERIATRICS REPORTS 2015; 4:7-15. [PMID: 25678987 PMCID: PMC4321682 DOI: 10.1007/s13670-014-0106-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The geriatric population presents a unique set of challenges in urologic oncology. In addition to the known natural history of disease, providers must also consider patient factors such as functional and nutritional status, comorbidities and social support when determining the treatment plan. The development of frailty measures and biomarkers to estimate surgical risk shows promise, with several assessment tools predictive of surgical complications. Decreased dependence on chronologic age is important when assessing surgical fitness, as age cutoffs prevent appropriate treatment of many elderly patients who would benefit from surgery. Within bladder, kidney and prostate cancers, continued refinement of surgical techniques offers a broader array of options for the geriatric patient than previously available.
Collapse
Affiliation(s)
- Maxim J McKibben
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Angela B Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
40
|
Bickel H, Pinker-Domenig K, Bogner W, Spick C, Bagó-Horváth Z, Weber M, Helbich T, Baltzer P. Quantitative Apparent Diffusion Coefficient as a Noninvasive Imaging Biomarker for the Differentiation of Invasive Breast Cancer and Ductal Carcinoma In Situ. Invest Radiol 2015; 50:95-100. [DOI: 10.1097/rli.0000000000000104] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
41
|
Castañeda CV, Danzig MR, Finkelstein JB, RoyChoudhury A, Wagner AA, Chang P, Pierorazio PM, Allaf ME, McKiernan JM. The natural history of renal functional decline in patients undergoing surveillance in the DISSRM registry. Urol Oncol 2015; 33:166.e17-20. [PMID: 25601768 DOI: 10.1016/j.urolonc.2014.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/31/2014] [Accepted: 11/25/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the natural history of renal function in patients on active surveillance (AS) for small renal masses (SRM) in the Delayed Intervention and Surveillance for Small Renal Masses Registry. METHODS Delayed Intervention and Surveillance for Small Renal Masses is a prospective, multi-institutional registry of patients with SRM (≤ 4 cm) who choose intervention or AS. Of these, 64 patients on AS had longitudinal serum creatinine (sCr) values and underwent analysis of estimated glomerular filtration rate (eGFR). eGFR was calculated using the Modification of Diet in Renal Disease formula. The Kidney Disease Outcomes Quality Initiative chronic kidney disease (CKD) classification was used to categorize patients' eGFR values. RESULTS Median age was 74 (range: 34-88) years at onset of AS. Overall, 9% (6/64) of patients had CKD at baseline. Median initial tumor size was 2.1cm (range: 0.8-4.0). Median Charlson comorbidity index score was 4 (range: 0-8). Median baseline sCr was 1.0mg/dl (range: 0.4-2.1) and median baseline eGFR was 70.25 (range: 24.07-165.52). After a median follow-up of 17 (range: 2-46) months, 64% of patients experienced a decrease in eGFR, with average yearly decrease in eGFR of 1.82 ml/min/1.73 m(2) (P = 0.092) and average yearly increase in sCr of 0.046 (P = 0.012). A total of 15 (24%) patients experienced an upstaging in classification of CKD. DISCUSSION Nearly two-thirds of patients on AS experienced a decrease in eGFR and nearly one-fourth had upstaging of CKD classification. The annual eGFR decline experienced by patients on AS minimally exceeded the annual decline of 1.49 ± 0.3 ml/min/1.73 m(2) that an individual who was 70 to 79 years of age can expect from aging alone. Further follow-up is necessary to assess this in a more definitive manner, but this trend should be considered when evaluating AS as an alternative to interventional therapies for SRM.
Collapse
Affiliation(s)
- Crystal V Castañeda
- Department of Urology, Herbert Irving Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Matthew R Danzig
- Department of Urology, Herbert Irving Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Julia B Finkelstein
- Department of Urology, Herbert Irving Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Arindam RoyChoudhury
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | - Andrew A Wagner
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter Chang
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Phillip M Pierorazio
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohamad E Allaf
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - James M McKiernan
- Department of Urology, Herbert Irving Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY.
| |
Collapse
|
42
|
Wah TM. Locoregional therapy of renal cancer. Cancer Imaging 2014. [PMCID: PMC4242729 DOI: 10.1186/1470-7330-14-s1-o20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
43
|
Bazarbashi S, Alkhateeb S, Abusamra A, Rabah D, Alotaibi M, Almansour M, Murshid E, Alsharm A, Alolayan A, Ahmad I, Alghamdi K, Alghamdi A. Saudi oncology society and Saudi urology association combined clinical management guidelines for renal cell carcinoma. Urol Ann 2014; 6:286-9. [PMID: 25371602 PMCID: PMC4216531 DOI: 10.4103/0974-7796.140974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 04/15/2014] [Indexed: 02/05/2023] Open
Abstract
In this report, updated guidelines for the evaluation, medical and surgical management of renal cell carcinoma are presented. They are categorized according the stage of the disease using the tumor node metastasis staging system 7(th) edition. The recommendations are presented with supporting evidence level.
Collapse
Affiliation(s)
| | - Sultan Alkhateeb
- Department of Surgery, Division of Urology, Riyadh, Saudi Arabia
| | - Ashraf Abusamra
- Section of Urology, Department of Surgery, King Khaled Hospital, Riyadh, Saudi Arabia
| | - Danny Rabah
- Department of Surgery, Division of Urology, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Princess Al-Johora Al-Ibrahim Centre for Cancer Research (Uro-Oncology Research Chair), King Saud University, Riyadh, Saudi Arabia
- Address for correspondence: Dr. Danny Rabah, Department of Surgery, Division of Urology, College of Medicine, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, Princess Al-Johora Al-Ibrahim Centre for Cancer Research (Uro-Oncology Research Chair), King Saud University, Riyadh, Saudi Arabia. E-mail:
| | - Mohammed Alotaibi
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mubarak Almansour
- Oncology Department, Princess Noura Oncology Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Esam Murshid
- Department of Oncology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alsharm
- Department of Oncology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ashwaq Alolayan
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Imran Ahmad
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Khalid Alghamdi
- Department of Surgery, Division of Urology, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Abdullah Alghamdi
- Department of Urology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
44
|
Diagnosis of complex renal cystic masses and solid renal lesions using PET imaging: comparison of 11C-acetate and 18F-FDG PET imaging. Clin Nucl Med 2014; 39:e208-14. [PMID: 24217534 DOI: 10.1097/rlu.0000000000000287] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The study aims to assess the usefulness of PET with C-acetate and F-FDG to differentiate renal cell carcinoma (RCC) from complicated renal cysts. METHODS Thirty-one patients were enrolled, 14 patients with complicated renal cysts (12 with Bosniak III and 2 with Bosniak IV) and 17 patients with 19 solid renal tumors. The patients underwent both C-acetate PET and FDG PET. Nephrectomy or partial nephrectomy was performed after the PET scans. RESULTS In 29 patients, 32 renal lesions were diagnosed as RCC. Twenty-three of the 32 RCCs (72%) had positive C-acetate PET findings, whereas only 7 FDG PET studies were positive (22%). Considering the relationship between tumor size measured by macroscopic appearance of resected tumors and PET results, 22 of 25 (88%) tumors more than 1.5 cm showed positive C-acetate PET findings. In 12 patients with Bosniak III renal cysts, 10 renal lesions were diagnosed as RCC. In this subgroup, 5 of the 10 RCCs (50%) had positive C-acetate PET findings, whereas 2 RCCs (20%) had positive FDG PET findings. None of the cases with benign findings had positive C-acetate PET or FDG PET scans. CONCLUSIONS C-acetate PET demonstrates a pronounced increase in tracer uptake in RCC, especially in renal tumors more than 1.5 cm, and displays a higher sensitivity than FDG PET. These preliminary data show that C-acetate may be a useful PET tracer to exclude RCC in complex renal cysts.
Collapse
|
45
|
Low Enhancement on Multiphase Contrast-Enhanced CT Images: An Independent Predictor of the Presence of High Tumor Grade of Clear Cell Renal Cell Carcinoma. AJR Am J Roentgenol 2014; 203:W295-300. [PMID: 25148187 DOI: 10.2214/ajr.13.12297] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
46
|
Laguna MP. Re: management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical management. J Urol 2014; 191:1262-3. [PMID: 24745480 DOI: 10.1016/j.juro.2014.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2014] [Indexed: 11/17/2022]
|
47
|
Abstract
Renal cell carcinoma (RCC) is most commonly diagnosed as an incidental finding on cross-sectional imaging and represents a significant clinical challenge. Although most patients have a surgically curable lesion at the time of diagnosis, the variability in the biologic behavior of the different histologic subtypes and tumor grade of RCC, together with the increasing array of management options, creates uncertainty for the optimal clinical approach to individual patients. State-of-the-art magnetic resonance imaging (MRI) provides a comprehensive assessment of renal lesions that includes multiple forms of tissue contrast as well as functional parameters, which in turn provides information that helps to address this dilemma. In this article, we review this evolving and increasingly comprehensive role of MRI in the detection, characterization, perioperative evaluation, and assessment of the treatment response of renal neoplasms. We emphasize the ability of the imaging "phenotype" of renal masses on MRI to help predict the histologic subtype, grade, and clinical behavior of RCC.
Collapse
Affiliation(s)
- Naomi Campbell
- Department of Radiology, Center for Biomedical Imaging, NYU Langone Medical Center, New York, NY
| | - Andrew B. Rosenkrantz
- Department of Radiology, Center for Biomedical Imaging, NYU Langone Medical Center, New York, NY
| | - Ivan Pedrosa
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX
| |
Collapse
|
48
|
Mehrazin R, Smaldone MC, Kutikov A, Li T, Tomaszewski JJ, Canter DJ, Viterbo R, Greenberg RE, Chen DYT, Uzzo RG. Growth kinetics and short-term outcomes of cT1b and cT2 renal masses under active surveillance. J Urol 2014; 192:659-64. [PMID: 24641909 DOI: 10.1016/j.juro.2014.03.038] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2014] [Indexed: 01/08/2023]
Abstract
PURPOSE Compared to T1a lesions the natural history of untreated renal masses larger than 4 cm is poorly understood. We assessed the growth kinetics and outcomes of cT1b/T2 cortical renal tumors managed by an initial period of active surveillance. We compared these cases to those treated with definitive delayed intervention. MATERIALS AND METHODS We reviewed our institutional, prospectively maintained renal tumor database to identify enhancing solid and cystic masses managed expectantly. Included in analysis were clinically localized tumors greater than 4.0 cm (T1b or greater) that were radiographically followed for more than 6 months. Tumor size at presentation, annual linear tumor growth rate, Charlson comorbidity index, followup and clinical outcomes were compared in patients who remained on active surveillance and those who underwent delayed surgical intervention. RESULTS We identified 72 tumors 4 cm or greater in diameter in a total of 68 patients. Active surveillance was the only treatment in 45 patients (66%) while 23 (34%) progressed to intervention. Median tumor size at presentation was 4.9 cm and the mean linear growth rate was 0.44 cm per year. Of the masses 14.7% demonstrated no growth with time. Comparing patients treated exclusively with active surveillance and those who progressed to definitive intervention revealed no difference in median tumor size at presentation (4.9 vs 4.6 cm, p = 0.79) or the median Charlson comorbidity index (3 vs 2, p = 0.6) but significant differences were seen in median age at presentation (77 vs 60 years, p = 0.0002) and the mean linear growth rate (0.37 vs 0.73 cm per year, p = 0.02). After adjustment younger patients (OR 0.91, 95% CI 0.86-0.97) and tumors with a faster linear growth rate (OR 9.1, 95% CI 1.7-47.8) were more likely to be treated with delayed surgical intervention. At a mean ± SD 38.9 ± 24.0 months of followup (median 32, range 6 to 105) 9 patients (13%) had died of another cause and none had progressed to metastatic disease. CONCLUSIONS Localized cT1b or larger renal masses show growth rates comparable to those of small tumors managed expectantly with a low rate of progression to metastatic disease at short-term followup. An initial period of active surveillance to determine tumor growth kinetics is a reasonable option in select patients with significant competing risks and limited life expectancy.
Collapse
Affiliation(s)
- Reza Mehrazin
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania.
| | - Marc C Smaldone
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Tianyu Li
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Jeffrey J Tomaszewski
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Daniel J Canter
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Rosalia Viterbo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Richard E Greenberg
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - David Y T Chen
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| | - Robert G Uzzo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania
| |
Collapse
|
49
|
Becker A, Roghmann F, Ravi P, Tian Z, Kluth LA, Gandaglia G, Noldus J, Dahlem R, Schlomm T, Graefen M, Karakiewicz PI, Trinh QD, Sun M. Delay in Nephrectomy and Cancer Control Outcomes in Elderly Patients with Small Renal Masses. Urol Int 2014; 92:455-61. [DOI: 10.1159/000356175] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 10/04/2013] [Indexed: 11/19/2022]
|
50
|
Buethe DD, Spiess PE. Current management considerations for the incidentally detected small renal mass. Cancer Control 2014; 20:211-21. [PMID: 23811705 DOI: 10.1177/107327481302000309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Nephron-sparing treatments remain underutilized for the management of small renal masses despite a rise in incidentally detected renal cell carcinoma and a downward stage migration. METHODS Historical publications representative of currently accepted paradigms were reviewed, and the results of a contemporary scientific literature search conducted in PubMed focusing on studies involving humans, published in English, and inclusive of clinical trials, meta-analyses, randomized controlled trials, and practice guidelines are included. Results from contemporary retrospective trials augment the data when level I or II evidence is absent. RESULTS Phase III clinical trial results substantiate the long-held tenet that partial nephrectomy is equivalent to radical nephrectomy with respect to safety and oncologic efficacy. Further, minimally invasive techniques using laparoscopy and robotic assistance to achieve partial nephrectomy appear equally effective to traditional open techniques. Although no prospective randomized studies are available, large retrospective studies support the notion that active surveillance and thermal ablative techniques are viable options for carefully selected patients. CONCLUSIONS The management of small renal masses encompasses a host of therapeutic options, all of which must be considered and discussed with the individual patient.
Collapse
Affiliation(s)
- David D Buethe
- Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL 33612, USA
| | | |
Collapse
|