The role of lymphovascular space invasion in renal cell carcinoma as a prognostic marker of survival after curative resection

Expression analysis of hsa_circ_0020397, hsa_circ_0005986, hsa_circ_0003028, and hsa_circ_0006990 in renal cell carcinoma

Renal cell carcinoma (RCC) is a prevalent heterogeneous kidney cancer. So far, different genes have been reported for RCC development. However, its particular molecular mechanism remains unclear. Circular RNAs (circRNAs), a class of non-coding RNAs, are involved in numerous biological processes in different malignancies such as RCC. This study aims to assess the expression and underlying mechanism of four circRNAs (hsa_circ_0020397, hsa_circ_0005986, hsa_circ_0003028, hsa_circ_0006990) with possible new roles in RCC. In the experimental step, we investigated the expression of these four circRNAs in our RCC samples using quantitative real-time polymerase chain reaction. In the bioinformatics step, the differential expressed mRNAs (DEmRNAs), and miRNAs (DEmiRNAs) were obtained from the GEO datasets using the GEO2R tool. A protein-protein interaction network was constructed using the STRING database, and hub genes were identified by Cytoscape. Molecular pathways associated with hub genes were detected using KEGG pathway enrichment analysis. Then, we utilized the ToppGene database to detect the relationships between DEmiRNAs and hub genes. Furthermore, interactions between circRNAs and DEmiRNAs were predicted by the StarBase and circinteractome databases. Finally, a circRNA-DEmiRNA-hub gene triple network was constructed. Our results revealed that the expression of hsa_circ_0020397, hsa_circ_0005986, and hsa_circ_0006990 was downregulated in RCC tissues. Moreover, these circRNAs had a significantly lower expression in patients with a history of kidney disease. Furthermore, hsa_circ_0003028 and hsa_circ_0006990 showed higher expression in the tumor of participants with Lymphovascular/perineural invasion and oncocytoma type, respectively. Based on bioinformatic results, 15 circRNA-DEmiRNA-hub gene ceRNA regulatory axes were predicted, which included three hub genes, five miRNAs, and four selected circRNAs. In conclusion, the current work is the first to emphasize the expression of the hsa_circ_0020397, hsa_circ_0005986, hsa_circ_0003028, and hsa_circ_0006990 in RCC patients presents a novel perspective on the molecular processes underlying the pathogenic mechanisms of RCC.

Partial nephrectomy and positive surgical margin, oncologic outcomes and predictors: a 15-year single institution experience

Introduction

The aim of this article was to compare oncological outcomes after partial nephrectomy between patients with positive (PSM) and negative (NSM) surgical margins.

Material and methods

In this retrospective study, the data of 733 patients who underwent partial nephrectomy with diagnosis of renal cell carcinoma (RCC) were analyzed. A total of 80 patients from the NSM group were matched to 42 PSM patients. The Kaplan-Meier method was used to estimate freedom from local disease recurrence and metastatic progression and overall survival. Cox proportional hazards models were used to assess the predictors for recurrence/metastasis.

Results

The mean age was 58.4 ±11.4 years (range: 29 to 82). Median follow-up was 24 months (IQ_25-75: 15–36.2). A total of 5 patients from the PSM group (6.2%) developed local recurrence and metastasis was detected in 2 (2.5%) of them while no metastasis or recurrence was observed in the NSM group. In the multivariate analysis, positive surgical margin was the only independent predictor for recurrence/metastasis (HR[CI] = 0.19[0.04–0.75], p = 0.019). Recurrence-free survival was higher in the NSM group (100% for the NSM group vs 88.1%, p = 0.002) and recurrence/metastasis-free survival was also higher in the NSM group (100% for the NSM group vs 85.7%, p = 0.001), but there were no differences in overall survival between the two groups (96.3% for the NSM group vs 97.6% for the PSM group, p = 0.68).

Conclusions

Although tumor recurrence was more prevalent in positive surgical margin patients who underwent partial nephrectomy, there were no differences in overall survival between the two groups. Therefore, active surveillance against further surgery would be a proper option after finding the tumor-involved margins.

[Criteria for an improved prognostic stratification in category pT renal carcinoma]

Asymptomatic renal carcinomas are usually small and localized and thus, for the assessment of pT, precise criteria are required, able to identify the initial phases of a local extension and correlate them with current prognostic prospects. Various studies and consensus meetings have defined precisely how to measure tumoral nodules (solid, cystic and multiple). Furthermore, they have distinguished tumoral extension to the renal sinus, which has a worse prognosis, from that to the perirenal adipose tissue. They have also analyzed the clinical significance of invasion of the sinus vessels, the hilar veins and parenchymal vascular retroinvasion. Our aim is to revise and update the criteria of the different pT subcategories and consider those morphological aspects which could be clinically significant and that are not currently included in the TNM classification.

Synchronous bilateral renal cell carcinomas in "Asynchrony of metabolism"

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

Evaluation of microvascular invasion as a prognostic factor in the progression of non-metastatic renal cancer

Introduction

The aim of this study was to describe the prognostic impact of microvascular invasion (MVI) in patients with non-metastatic renal cell cancer.

Material and methods

We carried out a retrospective, descriptive and analytical study of patients with non-metastatic renal cell carcinoma who had undergone a radical or partial nephrectomy. Patients were divided according to the presence of MVI. In each group, clinical and pathological characteristics were evaluated. Metastasis-free and cancer-specific survival was evaluated by the Kaplan Meier method. The multivariate analysis was performed with Cox proportional method in order to predict risk factors of metastasis and cancer-specific mortality.

Results

A total of 221 patients with a median of 40-month long follow-up were evaluated. Patients with MVI+ were 40 (18%) while those with MVI – were 181 (82%). In the univariate analysis, the presence of MVI had a strong correlation with symptomatic tumors (OR 3.56; p 0.0003), tumor size (OR 12.08; p <0.0001), nuclear grade (OR 6.99; p <0.0001), pathological stage (OR 35.8; p <0.0001), distance metastasis (OR 4.16; p 0.0001), and death by cancer (OR 4.7; p 0.0004). However, in the multivariate analysis it is not presented as an independent predictor of metastasis (HR 0.45; p 0.11) or cancer-specific mortality (HR 0.93; p 0.91).

Conclusions

In our series, MVI is associated with unfavorable tumors characteristics. In spite of this, it does not seem to be an independent predictor for metastasis and death by non-metastatic renal cancer.

Systemic inflammation response index predicts prognosis in patients with clear cell renal cell carcinoma: a propensity score-matched analysis

Purpose

In the present study, we aimed to evaluate the prognostic significance of the systemic inflammation response index (SIRI), which was defined based on peripheral blood counts of neutrophils, lymphocytes, and monocytes, in patients with localized or locally advanced clear cell renal cell carcinoma (CCRCC).

Patients and methods

The prognostic value of SIRI was evaluated in a primary cohort consisting of 414 patients with localized or locally advanced CCRCC and then further validated in an independent cohort composed of 168 patients.

Results

Kaplan-Meier survival analyses of both cohorts revealed that CCRCC patients with high SIRI levels exhibited poorer overall survival (OS) and cancer-specific survival (CSS) compared with those with low SIRI levels. Furthermore, univariate and multivariate analyses identified SIRI as a significant independent predictor for both OS (HR: 4.853; 95% CI: 2.362-9.972; P<0.001) and CSS (HR: 5.913; 95% CI: 2.681-13.040; P<0.001). Following propensity score matching analysis, SIRI remained an excellent predictor for both OS and CSS. The area under the curve for SIRI was larger than that of the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and Memorial Sloan Kettering Cancer Center (MSKCC) prognostic score in both cohorts.

Conclusion

SIRI might be a better prognostic predictor than PLR, NLR, MLR, and MSKCC score in patients with localized or locally advanced CCRCC.

Institutional review board approval number

(2010) Scientific Research Project No. 39.

Prognostic indicators of pulmonary metastasis in patients with renal cell carcinoma who have undergone radical nephrectomy

The aim of the present study was to validate prognostic indicators of pulmonary metastasis in patients with renal cell carcinoma (RCC) that have undergone nephrectomy treatment. The data from 356 patients who underwent nephrectomy were investigated and subsequently divided into 2 groups, according to the pulmonary metastasis status. The risk factors for pulmonary metastasis were examined in all patients. In the subgroup analysis, the risk factors were additionally verified in patients with pulmonary nodules using univariate and multivariate logistic regression analyses. The status of pulmonary nodules and pulmonary metastasis were confirmed through preoperative chest radiography by two radiologists. Pulmonary metastasis was observed in 33 (9.3%) patients with a median follow-up time of 54.4 months (interquartile range, 38.8-71.8). Patients with pulmonary nodules indicated significantly increased rates of pulmonary metastasis, compared with patients without pulmonary nodules (24.2 vs. 6.1%; P<0.001). In multivariate analysis, the presence of pulmonary nodules [hazard ratio (HR)=3.15; P=0.0262], albumin (HR=0.42; P=0.0490) and pTstage (HR=3.63; P=0.0475) were indicated to be independent prognostic markers for pulmonary metastasis. In subgroup analysis, pTstage was the only independent prognostic indicator for pulmonary metastasis in these patients (HR=9.81; P=0.0033). In patients with RCC, the presence of pulmonary nodules was associated with pulmonary metastasis. Furthermore, pTstage is a negative prognostic indicator in patients with pulmonary nodules. Therefore, a chest radiologic short-term follow-up is required for these patients.

Updates in Pathologic Staging and Histologic Grading of Renal Cell Carcinoma

The most important prognostic parameter in renal cell carcinoma is tumor stage. Although pathologic primary tumor (pT) categories are influenced by tumor size (pT1-pT2), critical elements (≥pT3) are dictated by invasion of structures, including renal sinus, perinephric fat, and the renal vein or segmental branches. Because this invasion can be subtle, awareness of the unique characteristics of renal cell carcinoma is critical for the pathologist to aid in clinical decision making. This review addresses challenges in pathologic stage and grade reporting and updates to the World Health Organization and American Joint Commission on Cancer classification schemes.

Preoperative albumin to globulin ratio predicts survival in clear cell renal cell carcinoma patients

In this retrospective analysis, we evaluated associations between albumin to globulin ratio (AGR), clinicopathological characteristics, and survival in 592 patients with localized or locally advanced clear cell renal cell carcinoma (CCRCC) prior to nephrectomy. We found that low AGR was associated with more aggressive tumor behavior; patients with low AGR had poorer overall survival (OS) and cancer-specific survival (CSS) in Kaplan-Meier survival analyses both before and after propensity score matching, which was used to compensate for differences in baseline clinicopathological characteristics. AGR was an independent prognostic factor for both OS (HR: 6.799; 95% CI: 3.215−14.377; P < 0.001) and CSS (HR: 8.806; 95% CI: 3.891−19.928; P < 0.001), and its prognostic value was higher than that of other established inflammation-based prognostic scores. When AGR was incorporated into a prognostic model that included T stage, neutrophil to lymphocyte ratio (NLR), and monocyte to lymphocyte ratio (MLR), the resulting nomogram predicted 3- and 5-year OS in the patients more accurately than when AGR was not included. In conclusion, AGR may be particularly useful for improving clinical outcome predictions for patients with localized or locally advanced CCRCC.

Renal capsular invasion is a prognostic biomarker in localized clear cell renal cell carcinoma

Renal capsular invasion (RCI) and lymphovascular invasion (LVI) are potential prognostic factors of significance in renal cell carcinoma (RCC). We evaluated the independent prognostic implications of RCI and LVI in localized clear cell RCC based on a large multi-institutional cohort. 6, 849 patients who had undergone radical or partial nephrectomy for RCC were included. Associations between recurrence and RCI or LVI were analyzed by constructing statistical models that combined Cox proportional hazard regression and propensity score matching. To analyze RCI, 2, 733 patients including 603 patients with RCI were enrolled. To analyze LVI, 3, 586 patients including 121 patients with LVI were enrolled. Recurrence was observed in 75 (12.4%) patients with RCI and 134 (6.3%) patients without RCI. In all statistical models, RCI was significantly associated with an increased risk of recurrence. Recurrence was observed 29 (24.0%) patients with LVI and 207 (6.0%) patients without LVI. LVI was significantly associated with an increased risk of recurrence only in non-adjusted univariate models, but not in multivariate adjusted analysis or propensity score matching models. In conclusion, these findings suggest that RCI could be a significant risk factor for localized clear cell RCC recurrence. In contrast to RCI, LVI cannot be an independent prognostic variable.

High miR-122 expression promotes malignant phenotypes in ccRCC by targeting occludin

Renal cell carcinoma (RCC) is the most common neoplasm of the adult kidney, and clear cell RCC (ccRCC) represents its most common histological subtype. Although several studies have reported high expression of miR-122 in ccRCC, its physiological role remains unclear. To clarify the role of miR-122 in ccRCC, we compared miR-122 expression levels in non-cancerous tissue and ccRCC. Significant upregulation of miR-122 was observed in ccRCC specimens. Moreover, ccRCC patients with high miR-122 expression showed poor progression-free survival compared to those with low miR-122 expression. Overexpression of miR-122 using an miRNA mimic promoted proliferation, migration, and invasion activities of ccRCC cells. miR-122 directly targets occludin, a known component of tight junctions. Occludin knockdown promoted the cell migration activity but not proliferation or invasion activities of ccRCC cells. In human clinical specimens, miR-122 expression inversely correlated with occludin protein expression. These findings show that miR-122 is an oncomiR in ccRCC.

Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors

PURPOSE

We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy.

MATERIALS AND METHODS

We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan-Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated.

RESULTS

Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease-free survival on Kaplan-Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease-free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five-year disease-free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01).

CONCLUSIONS

High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.

Does chromophobe renal cell carcinoma have better survival than clear cell renal cell carcinoma? A clinical-based cohort study and meta-analysis

BACKGROUND

It is controversial whether chromophobe renal cell carcinoma (chRCC) or clear cell renal cell carcinoma (ccRCC) is associated with better survival. We conducted a clinical-based cohort study and meta-analysis to evaluate the prognostic role of histology between chRCC and ccRCC.

METHODS

A cohort of 1540 patients (166 with chRCC and 1374 with ccRCC) were selected from Sun Yat-sen University and The Cancer Genome Atlas databases. The clinicopathological parameters and overall survival (OS) were compared between patients with chRCC and those with ccRCC. For the meta-analysis, we searched the PubMed, Cochrane Library, and Ovid databases for studies comparing OS or cancer-specific survival (CSS) between chRCC and ccRCC.

RESULTS

The cohort study revealed that patients with chRCC were younger (median 52 vs. 55 years, P < 0.001), were more commonly female (47.0 vs. 33.0%, P < 0.001), and had a larger tumor size (mean 7.1 vs. 5.9 cm, P < 0.001), and they had a lower stage compared with those with ccRCC. Five-year OS rates for chRCC and ccRCC were 90.3 and 75.3%, respectively (P < 0.001). We found significantly better survival for chRCC in stratification analysis by age, sex, tumor size, and stage. Similar results were observed on both univariate [hazard ratio (HR), 0.30; 95% confidence interval (CI) 0.16-0.55, P < 0.001] and multivariate analyses (HR 0.42; 95% CI 0.23-0.79, P = 0.006). Ten studies were included in our meta-analysis. Eight of them provided data on univariate analysis. The pooled HR was statistically significant for OS (pooled HR 0.49; 95% CI 0.30-0.79, P = 0.004) and CSS (pooled HR 0.49; 95% CI 0.37-0.64, P < 0.001). Seven studies reported the HR on multivariate analysis. The pooled HR was also statistically significant for OS (pooled HR 0.63; 95% CI 0.51-0.77, P < 0.001) and CSS (pooled HR 0.72; 95 % CI 0.57-0.90, P = 0.003). These data indicate that patients with chRCC had better outcomes than those with ccRCC.

CONCLUSIONS

Our large cohort study and meta-analysis confirmed that chRCC had better survival than ccRCC.

Impact of preoperative radiological and postoperative pathological findings on survival of patients after radical nephrectomy performed with the indication of renal cell carcinoma

OBJECTIVE

To evaluate the impact of preoperative radiological and postoperative pathological findings on survival of patients after radical nephrectomy because of renal cell carcinoma (RCC).

MATERIAL AND METHODS

We performed 159 consecutive radical nephrectomy between December 2007 and January 2014. We evaluated age, gender, complaints, operation time, comorbidity, computed tomography (CT) and magnetic resonance graphy (MRG) results. Size of the mass, lymph node involvement, renal vein invasion, and presence of metastases were investigated. During histopathological examination, especially, pathological diagnosis, subtypes of RCC, lymph node involvement, lymphovascular, perineural invasion, and capsular, renal pelvis invasion, and renal vein involvement were sought. Follow-up periods of the patients were determined based on dates of death of the patients, and the study period.

RESULTS

RCC was seen in 124 (78%) of patients. Mean estimated suvival of RCC patients was 60 months and 5 year survival was 64%. Tumor size greater than 6.5 cm, lymph node involvement (p=0.006) and metastasis in radiological results (p<0.001), lymphovascular invasion (p=0.015) and stage of disease (p<0.001) found to be significantly affecting the survival. Lymph node involvement in radiological results (p=0.0089; HR: 4.6; CI 95%: 1.4753-14.3523) and stage of the disease (p= 0.0129; HR: 1.6; CI 95%: 1.1087-2.3461) were affecting the survival independently.

CONCLUSION

We found radiological lymph node involvement and stage of the disease as independent factors affecting the survival of RCC patients after radical nephrectomy.

Prognostic value of microvascular invasion in predicting survival in renal cell carcinoma

OBJECTIVE

To assess microvascular tumor invasion and other clinical and histological parameters as potential prognostic factors in surgically treated renal cell carcinoma.

MATERIALS AND METHODS

Surgical specimens from 238 consecutive patients who underwent radical or partial surgery between 1990 and 2006 were retrospectively evaluated. The series included clinically localized or metastatic renal cell carcinoma (pT1-4; N0-1; M0-1). Disease-free and cancer-specific survival assessments were the end points with median follow-up of 75 months (range 1-189 months). Variables studied included: age, sex, tumor size, TNM 2010 classification, Fuhrman grade, histological subtype and microvascular tumor invasion.

RESULTS

Microvascular tumor invasion was observed in 79 patients (33,2%) and was significantly associated with age (P=.010), tumor size (P=.000), Fuhrman grade (P=.000), pT stage 2010 (P=.000),N stage 2010 (P=.000) and M stage 2010 (P=.000). Multivariate analyses determined that sex, Fuhrman grade, pT stage 2010 and histological subtipe were independent prognostic factors of disease-free survival, while sex, Fuhrman grade, pT stage 2010, M stage 2010, histological subtype and microvascular invasion were prognostic factors for cancer-specific survival.

CONCLUSIONS

Our study shows that microvascular tumor invasion is an independent prognostic factor for cancer-specific survival in surgically treated patients with renal cell carcinoma.

Possible role of sonic hedgehog and epithelial-mesenchymal transition in renal cell cancer progression

Purpose

Sonic hedgehog (Shh) signaling and epithelial-mesenchymal transition (EMT) are both known to relate to cancer progression. The purpose of this study was to investigate the role of Shh signaling and EMT in renal cell carcinoma (RCC).

Materials and Methods

Cell proliferation was assayed in RCC cell lines in the presence or absence of a Shh signaling stimulator, recombinant Shh (r-Shh) protein, or a Shh signaling inhibitor, cyclopamine. Real-time reverse transcription-polymerase chain reaction (RT-PCR) was performed to study the expression of EMT markers (E-cadherin, N-cadherin, and vimentin) and osteonectin. The expression of Ki-67, Gli-1, osteonectin, and EMT markers in nephrectomy specimens from RCC patients was also measured by immunohistochemical (IHC) staining.

Results

RCC cells showed enhanced cell proliferation by r-Shh protein, whereas cell proliferation was suppressed by the addition of cyclopamine in RenCa cells. Real-time RT-PCR showed that r-Shh suppressed the expression of E-cadherin and that this suppression was partly blocked by cyclopamine alone in RenCa cells. In the IHC results, osteonectin significantly correlated with vein sinus invasion (p=0.0218), and the expression of vimentin significantly correlated with lymphatic invasion (p=0.0392).

Conclusions

Shh signaling and EMT play roles in RCC progression, and the Shh signaling inhibitor cyclopamine might be a possible molecular targeted therapeutic strategy for RCC.

Association of microvascular and capillary-lymphatic invasion with outcome in patients with renal cell carcinoma

PURPOSE

We evaluated the association of microvascular and capillary-lymphatic invasion with patient outcome after nephrectomy for renal cell carcinoma.

MATERIALS AND METHODS

We identified 1,433 patients surgically treated for sporadic, unilateral renal cell carcinoma between 2001 and 2008. All specimens were reviewed by a single uropathologist for microvascular and capillary-lymphatic invasion. Associations with time to metastasis and death from renal cell carcinoma were evaluated using Cox proportional hazards models, controlling for established clinicopathological prognostic variables.

RESULTS

Microvascular invasion and capillary-lymphatic invasion were identified in 119 (11%) and 17 (2%) of the 1,103 patients with clear cell, 5 (2%) and 1 (less than 1%) of the 219 with papillary, and 1 (1%) and 0 of the 86 with chromophobe renal cell carcinoma, respectively. Median followup in survivors was 6.4 years (range 0 to 11). In clear cell renal cell carcinoma cases microvascular invasion was univariately associated with an increased risk of metastasis and cancer specific death (HR 3.5 and 3.0, respectively, each p <0.001). However, on multivariate analysis these associations were no longer statistically significant (HR 1.2, p = 0.4 and HR 1.3, p = 0.1, respectively). Capillary-lymphatic invasion remained significantly associated with an increased risk of metastasis and death on univariate analysis (HR 15.9 and 11.6) and on multivariate analysis (HR 3.2 and HR 3.1, respectively, each p <0.001).

CONCLUSIONS

Microvascular invasion is associated with an increased risk of metastasis and cancer death in patients with clear cell renal cell carcinoma, although this did not remain significant after controlling for established prognostic variables. Capillary-lymphatic invasion appears to be independently associated with metastasis and cancer death even after controlling for known prognostic risk factors. However, given its rarity, this feature may prove to be of limited clinical significance.

Argument in favor of performing partial nephrectomy for tumors greater than 7 cm: the metastatic prescription has already been written

The acceptance of partial nephrectomy over the past few decades has been gradual with initial utilization of nephron sparing approach for tumors up to 4 cm and more recently up to 7 cm. The arbitrary cutoff values used in the historic recommendations are based on the oncologic outcomes documenting the increase in metastatic potential of renal lesions that is strongly associated with increase in tumor size. Despite these observations, radical nephrectomy has not been found to be protective from development of metastatic disease, and oncologic outcomes of partial nephrectomy for tumors matched for size or stage have not been inferior to radical nephrectomy. The present manuscript argues for avoidance of specific size cutoffs as patients with larger masses may benefit from maximal preservation of nephrons. These are the very patients at higher risk for metastatic disease, who may benefit from preserved renal function to allow for future additional therapies or adjuvant trials.

Surgical management of large renal tumors

The surgical management of patients with renal cell carcinoma has undergone many changes. With equivalent oncologic outcomes and appreciation of the importance of renal functional preservation, the utilization of nephron-sparing partial nephrectomy has increased in recent years. Nevertheless, tumors of larger size continue to be preferentially treated with radical nephrectomy. Here, we present evidence that improvements in techniques and durability of oncologic outcomes has justified the use of nephron sparing to accomplish renal functional preservation even in patients with large renal tumors. In addition, surgical technical considerations when managing such tumors are discussed. Finally, we discuss cytoreductive surgery and the evolving role of systemic targeted therapies in the management of advanced metastatic disease.