Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : prise en charge du cancer du rein

Thermoablative Treatment of De Novo Tumor in Kidney Allograft

BACKGROUND

The overall cancer risk increases in transplant patients, including in kidney allografts. This study aimed to analyze the outcome of patients with kidney allograft malignant tumors who underwent percutaneous thermal ablation.

METHODS

We included 26 renal allograft tumors, including 7 clear-cell renal cell carcinoma (RCCs), 16 papillary RCCs, 1 clear-cell papillary RCC, and 2 tubulocystic RCCs, treated in 19 ablation sessions. Outcomes of thermal ablation therapy were assessed, including technical success, adverse events, local tumor progression, development of metastases, survival after thermal ablation, and changes in renal function.

RESULTS

Success rate was achieved in all ablation sessions (primary success rate: 96%; secondary success rate: 100%). No adverse events were observed in grades 3, 4, or 5. The median follow-up period was of 34 mo (15-69 mo). Two patients died during follow-up from a cause independent of renal cancer. The median decrease in estimated glomerular filtration rate 1 y after procedure was -4 (interquartile range, -7 to 0) mL/min/1.73 m 2 . One patient returned to dialysis within the year of the procedure.

CONCLUSIONS

Percutaneous thermal ablation shows convincing results for treating malignant renal graft tumors and should be a useful treatment option. The shorter hospitalization time, the advantage of avoiding a potentially challenging dissection of the transplant, and the excellent preservation of allograft function appear encouraging to extend this indication.

Long-term outcomes after surgical resection of pancreatic metastases from renal Clear-cell carcinoma

BACKGROUND

Clear-cell renal cell carcinoma frequently metastasizes to the pancreas (PMRCC). The management of such metastases remains controversial due to their frequent multifocality and indolent evolution.

METHODS

This study describes the surgical management of these lesions and their long-term oncological outcomes. The study included patients who underwent pancreatic resection of PMRCC at Bordeaux University Hospital between June 2005 and March 2022. Morbidity and mortality were assessed at 90 days. Overall survival (OS) and disease-free (DFS) survival were assessed at 5 years.

RESULTS

Forty-two patients underwent pancreatic resection for PMRCC, including 18 (42.8 %) total pancreatectomies. The median time from nephrectomy to the diagnosis of PMRCC was 121 (range: 6-400) months. Lesions were multiple in 19/42 (45.2 %) patients. Ten (23.8 %) patients suffered a severe complication (Dindo-Clavien classification ≥ IIIA by D90), including one patient who died postoperatively. The median follow-up was 76 months. The R0 rate was 100 %. The OS and DFS rates were 92.8 % and 29.6 %, respectively, at 5 years.

CONCLUSION

Pancreatic resection for PMRCC provides long-term oncological control despite a high recurrence rate.

Selective Arterial Embolization of Pseudoaneurysms and Arteriovenous Fistulas after Partial Nephrectomy: Safety, Efficacy, and Mid-Term Outcomes

The primary objective was to evaluate the clinical success rate after endovascular embolization of iatrogenic vascular lesions caused during partial nephrectomy. The secondary objective was to evaluate the technical success and to assess potential effects on renal function. We retrospectively included consecutive patients from our center who underwent selective embolization to treat iatrogenic renal arterial lesions induced during partial nephrectomy between June 2010 and June 2020. The technical and clinical success rates and renal outcomes were collected. We identified 25 patients with 47 pseudoaneurysms and nine arteriovenous fistulas. Among them, eight were treated by coils only, eight by liquid embolization agents only, and nine by both. The technical success rate was 96% after the first attempt and 100% after the second attempt. The median follow-up was 27.1 ± 24.3 months. Clinical success, defined as no need for further hemostatic surgery during follow-up, was also obtained in 96% and 100% of patients with one and two attempts, respectively. Renal function estimated by the modification of diet in renal disease equation did not change significantly despite a mean 13.8% ± 15.1% decrease in kidney functional volume estimated by angiography. No complications were attributable to the endovascular treatment. No significant difference was found across embolization agents; however, the subgroup sizes were small. Endovascular embolization is safe and effective for treating iatrogenic arterial lesions after partial nephrectomy: success rates are high, complications are infrequent, and renal function is maintained. Recommendations by interventional radiology societies are needed to standardize this treatment.

Management and Health Resource Use of Patients With Metastatic Renal Cell Carcinoma treated With Systemic Therapy Over 2014-2017 in France: A National Real-World Study

BACKGROUND

The introduction of novel systemic therapies for metastatic renal cell carcinoma (mRCC) over the last decade has significantly improved patient outcomes. Little information is available on treatment modalities and outcomes in everyday practice. The objective of this study was to describe patient characteristics, treatment patterns, and healthcare resource use in mRCC patients receiving systemic therapy in France (2014-2017), using the nationwide claims database.

PATIENTS AND METHODS

Patients with a diagnosis of RCC (ICD-10: C64) between 2009 and 2017 and receiving a first systemic treatment for mRCC between 2014 and 2017 were eligible. Patients were divided into two groups at diagnosis, Group A: metastatic RCC and Group B: localized RCC.

RESULTS

4,929 eligible patients were identified (Group A: 2638 patients, 53.5%; Group B: 2,291 patients,46.5%). Median age was 66 years and 73% were men. In patients with incident RCC (N = 3,425), 62.3% underwent nephrectomy (94.4% in Group B). Within the year following mRCC diagnosis, 86.5% were hospitalized at least once; among them 58.1% for RCC. Nearly 31% of patients underwent radiotherapy. First line treatment was sunitinib for 65% of patients and pazopanib for 24%. Twenty five percent and 10% of patients received 2 and 3 lines of systemic treatment, respectively. The 2-year survival rate after mRCC diagnosis was 44%, with median overall survival of 20 [95%CI: 19-21] months (14 and 28 in Group A and B).

CONCLUSION

This study documented patient characteristics, treatment patterns and survival outcomes in mRCC patients receiving systemic therapy in France (2014-2017). Estimated survival rates were consistent with real-world studies from other countries.

Comparison of open and robotic-assisted partial nephrectomy approaches using multicentric data (UroCCR-47 study)

We compared the outcomes of robotic-assisted partial nephrectomy (RPN) and open partial nephrectomy (OPN) using contemporary data to respond to unmet clinical needs. Data from patients included in the registry who underwent partial nephrectomy between January 01, 2014 and June 30, 2017 within 20 centres of the French Network for Research on Kidney Cancer UroCCR were collected (NCT03293563). Statistical methods included adjusted multivariable analyses. Rates of peri- and post-operative transfusion, and of surgical revision, were lower in the RPN (n = 1434) than the OPN (n = 571) group (2.9% vs. 6.0%, p = 0.0012; 3.8% vs. 11.5%, p < 0.0001; 2.4% vs. 6.7%, p < 0.0001, respectively). In multivariable analyses, RPN was independently associated with fewer early post-operative complications than OPN (overall: odds-ratio [95% confidence interval, CI] = 0.48 [0.35-0.66]; severe: 0.29 [0.16-0.54], p < 0.0001 for both) and shorter hospital stays (34% [30%; 37%], p < 0.0001). RPN was also a significantly associated with a decresedrisk of post-operative acute renal failure, and new-onset chronic kidney disease at 3 and 12 months post-surgery. There were no between-group differences in oncological outcomes. In comparison with OPN, RPN was associated with improved peri- and post-operative morbidity, better functional outcomes, and shorter hospital stays. Our results support the use of RPN, even for large and complex tumours.

A pilot study investigating the feasibility of using a fully automatic software to assess the RENAL and PADUA score

PURPOSE

Image-based morphometric scoring systems such as the RENAL and PADUA scores are useful to evaluate the complexity of partial nephrectomy for renal cell carcinoma (RCC). The main aim of this study was to develop a new imaging software to enable an automatic detection and a 3D visualization of RCC from CT angiography (CTA) and to address the feasibility to use it to evaluate the features of the RENAL and the PADUA scores.

METHODS

A training dataset of 210 patients CTA-scans manually segmented was used to train a deep learning algorithm to develop the automatic detection and 3D-visualization of RCC. A trained operator blindly assessed the RENAL and PADUA scores on a testing dataset of 41 CTA from patients with RCC using a commercialized semi-automatic software (ground truth) and the new automatic software. Concordance between the two methods was evaluated.

RESULTS

The median PADUA score was 9 (7-11) and the renal score was 8 (5.5-9). The automatic software enabled to automatically detect the tumoral kidney and provided a 3D-visualization in all cases, with a computational time less than 20 seconds. Concordances for staging the anatomical features of the RENAL scores were respectively: 87.8% for radius, 85.4% for exophytic rate, 82.9% for location to the polar lines and 92.7% for the antero-posterior location. For the PADUA scores, concordances were 90.2% for tumor size, 85.4% for exophytic rate, 87.8% for polar location and 100% for renal rim.

CONCLUSION

By enabling an automatic 3D-visualization of tumoral kidney, this software could help to calculate morphometric scores, save time and improve reproducibility for clinicians.

LEVEL OF EVIDENCE: 4

Impact of blood transfusion on survival after nephrectomy for localized or locally advanced renal cancer

OBJECTIVE

Several studies have reported blood transfusion were associated with a decrease of survival after oncological surgery. For kidney cancer, the effect of blood transfusion is still debated. The objective of this study was to determine the effect of blood transfusion after oncological nephrectomy on overall, specific and recurrence-free survival in a retrospective cohort of localized or locally advanced kidney cancer.

MATERIAL AND METHODS

We performed a monocentric retrospective analysis of all patients managed by surgery for localized or locally advanced renal cancer between January 2000 and December 2016. We compared overall and specific survival and recurrence-free survival between two groups: patients transfused and not transfused. Demographic, surgical and tumor characteristics were compared. Survival analyses were performed using univariate Cox regression and multivariate Cox proportional regression test.

RESULTS

We included 382 patients in this study: 320 (83.8%) were not transfused and 62 (16.2%) were transfused. Transfused patients were significantly older (P=0.001) and had a lower pre-operative hemoglobin level (P=0.008). Operative and oncological characteristics were also different between both groups. In univariate analysis, we showed that blood transfusion was associated with lower overall survival (P<0.001), specific survival (P<0.001), and recurrence-free survival (P<0.001). In multivariate analysis, we found that blood transfusion was not associated with overall survival, or specific survival, but it was associated with lower recurrence-free survival (HR: 1.967, CI95% [1.024-3.780], P=0.042).

CONCLUSIONS

Perioperative blood transfusion is an independent risk factor that increases tumor recurrence among patients treated with nephrectomy for renal cancer.

Magnetic Fields and Cancer: Epidemiology, Cellular Biology, and Theranostics

Humans are exposed to a complex mix of man-made electric and magnetic fields (MFs) at many different frequencies, at home and at work. Epidemiological studies indicate that there is a positive relationship between residential/domestic and occupational exposure to extremely low frequency electromagnetic fields and some types of cancer, although some other studies indicate no relationship. In this review, after an introduction on the MF definition and a description of natural/anthropogenic sources, the epidemiology of residential/domestic and occupational exposure to MFs and cancer is reviewed, with reference to leukemia, brain, and breast cancer. The in vivo and in vitro effects of MFs on cancer are reviewed considering both human and animal cells, with particular reference to the involvement of reactive oxygen species (ROS). MF application on cancer diagnostic and therapy (theranostic) are also reviewed by describing the use of different magnetic resonance imaging (MRI) applications for the detection of several cancers. Finally, the use of magnetic nanoparticles is described in terms of treatment of cancer by nanomedical applications for the precise delivery of anticancer drugs, nanosurgery by magnetomechanic methods, and selective killing of cancer cells by magnetic hyperthermia. The supplementary tables provide quantitative data and methodologies in epidemiological and cell biology studies. Although scientists do not generally agree that there is a cause-effect relationship between exposure to MF and cancer, MFs might not be the direct cause of cancer but may contribute to produce ROS and generate oxidative stress, which could trigger or enhance the expression of oncogenes.

[Renal cell carcinoma of the kidney transplant: The French guidelines from CTAFU]

OBJECTIVE

To propose recommendations for the management of renal cell carcinomas (RCC) of the renal transplant.

METHOD

Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to evaluate prevalence, diagnosis and management of RCC arousing in the renal transplant. References were assessed according to a predefined process to propose recommendations with levels of evidence.

RESULTS

Renal cell carcinomas of the renal transplant affect approximately 0.2% of recipients. Mostly asymptomatic, these tumors are mainly diagnosed on a routine imaging of the renal transplant. Predominant pathology is clear cell carcinomas but papillary carcinomas are more frequent than in general population (up to 40-50%). RCC of the renal transplant is often localized, of low stage and low grade. According to tumor characteristics and renal function, preferred treatment is radical (transplantectomy) or nephron sparing through partial nephrectomy (open or minimally invasive approach) or thermoablation after percutaneous biopsy. Although no robust data support a switch of immunosuppressive regimen, some authors suggest to favor the use of mTOR inhibitors. CTAFU does not recommend a mandatory waiting time after transplantectomy for RCC in candidates for a subsequent renal tranplantation when tumor stage<T3 and low ISUP grade.

CONCLUSION

These French recommendations should contribute to improving the oncological and functional prognosis of renal transplant recipients by improving the management of RCC of the renal transplant.

[Renal cell carcinoma in candidates for renal transplantation and recipients of a kidney transplant: The French guidelines from CTAFU]

OBJECTIVE

To define guidelines for the management of renal cell carcinoma of the native kidney (NKRCC) in kidney transplant (KTx) recipients and renal cell carcinoma (RCC) in end-stage renal disease (ESRD) patients candidates for renal transplantation.

METHOD

A review of the literature following a systematic approach (Medline) was conducted by the CTAFU to report renal cell carcinoma epidemiology, screening, diagnosis and management in KTx candidates and recipients. References were assessed according to a predefined process to propose recommendations with the corresponding levels of evidence.

RESULTS

ESRD patients are at higher risk of RCC with a standardized incidence ratio of approximately 4,5 as compared with general population. NKRCC tumors occur in 1 to 3 % of KTx recipients with a 10 to 15-fold increased risk as compared with general population, especially in patients with acquired multicystic kidney disease. Most authors suggest yearly monitoring of the native kidneys using ultrasound imaging. Radical nephrectomy (either open or laparoscopic approach) is the preferred treatment of NKRCC in KTx recipients and RCC in ESRD. Surveillance in a valid option in small or cystic renal masses. In the localized setting, change in immunosuppressive therapy is not recommended besides perioperative avoidance of mTOR inhibitor to limit morbidity. CTAFU does not recommend a mandatory waiting time after nephrectomy for RCC in ESRD patients candidates for renal tranplantation when tumor stage<T3 and low ISUP grade. Follow-up modalities should follow recommendations in general population.

CONCLUSION

The French recommendations should contribute to improve management of NKRCC in KTx recipients and RCC in ESRD candidates for KTx, integrating oncological objectives in the context of kidney transplantation.

[Influence of age on indications and modalities of radiation therapy: What to keep in mind for adolescents and young adults?]

When using radiation therapy for adolescents and young adults (AYA), paediatricians, adults' oncologists and radiation oncologists need to keep in mind several particularities through the whole therapeutic process. They embrace the indication, target volumes, prescribed dose, treatment techniques and follow-up. Indeed, the young age and the cancer features that characterised this population influence the modalities of irradiation. This article highlights the key points of AYA care with radiation therapy.

[RHESOU (Registry in HErault Specialized in Onco-Urology) : the first French Registry specialized in Onco-Urology. One-year experience]

PURPOSE

In 2016, the Herault tumor registry collected 1961cancers in urology (21.4 % from all Herault cancers this year). RHESOU was created to complete RTH' data with specific parameters in onco-urology. The aim of this study is to describe RHESOU and to give some examples with our first results.

MATERIAL AND METHODS

In November 2018, RHESOU (Registry HErault Specialised in Onco-Urology) was founded with the same registry recommendations. It collects specific oncologic parameters and also complete RTH's data. For each urological cancer, a specific survey with different choices was performed to collect a maximum of data which could be present in patients' file. These surveys were used for urological cancers cases that live in Herault in 2017.

RESULTS

In 2017, we collected 970 prostate cancers, 581 bladder cancers, 212 kidney cancers, 51 upper excretory tract cancers, 28 testicle cancers and 9 penil cancers. Our urological data collection gives many possibilities to create many requests for detailed analysis in urological cancers. In this article, we reported data from kidney, bladder and prostate cancers.

CONCLUSIONS

RHESOU is a new tool opened to the different urologic corporations (urologists, pathologists, oncologists, radiotherapists, radiologists) that permits an overview in urological cancers in Herault. Finally, one important aim is that this tool will be adapted when new treatments or new important parameters appear in the years ahead.

LEVEL OF EVIDENCE

3.

[Results of active surveillance for sporadic renal angiomyolipomas greater than 4cm: A pledge for active surveillance]

INTRODUCTION

Active surveillance (AS) of sporadic renal angiomyolipomas (AML) is under-utilised because of an old dogma fearing a life-threatening retroperitoneal hemorrhage when tumour size exceeds 4cm. The objective of this study was to report the outcome of AS in patients with sporadic AML greater than 4cm.

METHODS

The results of AS in 35 patients managed for sporadic renal AML greater than 4cm were analysed. During AS, tumour growth, occurrence of new symptoms and/or complications, discontinuation of AS protocol, reason for discontinuation as well as subsequent treatment options were reported.

RESULTS

Within a median follow-up of 36 months, 16 (46 %) patients discontinued AS at the end of the study period (mean follow-up 55±66, median 36 months). Patients who discontinued AS were more symptomatic at diagnosis but had similar age, mean tumour size and sex ratio. Active treatment-free survival was 66 % at 5 years. Retroperitoneal hemorrhage was reported in 3 (8.5 %) patients. None of these bleedings required transfusion or monitoring in an intensive care unit. Other reasons for discontinuation were pain (37 %), patient preference (19), changes in the radiological appearance of the tumour (19 %), and hematuria (6 %).

CONCLUSION

This study showed that AS in AML bearing patients was feasible even in the setting of tumours larger than 4cm. More than 50% of the patients were still on AS at 5 years. Discontinuation of AS was not related to bleeding complications in most cases.

LEVEL OF PROOF

3.

Is percutaneous image-guided renal tumour ablation ready for prime time?

In the last few decades, thermal ablation (TA) techniques have been increasingly applied to treat small localised renal cell carcinomas. Despite this trend, there is still an underuse of TA compared to surgery and a substantial lack of high-quality evidence derived from large, prospective, randomised controlled trials comparing the long-term oncologic outcomes of TA and surgery. Therefore, in this narrative review, we assess published guidelines and recent literature concerning the diagnosis and management of kidney-confined renal cell carcinoma to understand whether percutaneous image-guided TA is ready to be proposed as a first-line treatment.