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Wang Y, Butaney M, Wilder S, Ghani K, Rogers CG, Lane BR. The evolving management of small renal masses. Nat Rev Urol 2024; 21:406-421. [PMID: 38365895 DOI: 10.1038/s41585-023-00848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/18/2024]
Abstract
Small renal masses (SRMs) are a heterogeneous group of tumours with varying metastatic potential. The increasing use and improving quality of abdominal imaging have led to increasingly early diagnosis of incidental SRMs that are asymptomatic and organ confined. Despite improvements in imaging and the growing use of renal mass biopsy, diagnosis of malignancy before treatment remains challenging. Management of SRMs has shifted away from radical nephrectomy, with active surveillance and nephron-sparing surgery taking over as the primary modalities of treatment. The optimal treatment strategy for SRMs continues to evolve as factors affecting short-term and long-term outcomes in this patient cohort are elucidated through studies from prospective data registries. Evidence from rapidly evolving research in biomarkers, imaging modalities, and machine learning shows promise in improving understanding of the biology and management of this patient cohort.
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Affiliation(s)
- Yuzhi Wang
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Mohit Butaney
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Samantha Wilder
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Khurshid Ghani
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Craig G Rogers
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Brian R Lane
- Division of Urology, Corewell Health West, Grand Rapids, MI, USA.
- Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
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2
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Sharma G, Shah M, Ahluwalia P, Dasgupta P, Challacombe BJ, Bhandari M, Ahlawat R, Rawal S, Buffi NM, Sivaraman A, Porter JR, Rogers C, Mottrie A, Abaza R, Rha KH, Moon D, Yuvaraja TB, Parekh DJ, Capitanio U, Maes KK, Porpiglia F, Turkeri L, Gautam G. Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy. Eur Urol Focus 2022; 9:345-351. [PMID: 36153228 DOI: 10.1016/j.euf.2022.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/27/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ability to predict the risk of intraoperative adverse events (IOAEs) for patients undergoing partial nephrectomy (PN) can be of great clinical significance. OBJECTIVE To develop and internally validate a preoperative nomogram predicting IOAEs for robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS In this observational study, data for demographic, preoperative, and postoperative variables for patients who underwent RAPN were extracted from the Vattikuti Collective Quality Initiative (VCQI) database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS IOAEs were defined as the occurrence of intraoperative surgical complications, blood transfusion, or conversion to open surgery/radical nephrectomy. Backward stepwise logistic regression analysis was used to identify predictors of IOAEs. The nomogram was validated using bootstrapping, the area under the receiver operating characteristic curve (AUC), and the goodness of fit. Decision curve analysis (DCA) was used to determine the clinical utility of the model. RESULTS AND LIMITATIONS Among the 2114 patients in the study cohort, IOAEs were noted in 158 (7.5%). Multivariable analysis identified five variables as independent predictors of IOAEs: RENAL nephrometry score (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25); clinical tumor size (OR 1.01, 95% CI 1.001-1.024); PN indication as absolute versus elective (OR 3.9, 95% CI 2.6-5.7) and relative versus elective (OR 4.2, 95% CI 2.2-8); Charlson comorbidity index (OR 1.17, 95% CI 1.05-1.30); and multifocal tumors (OR 8.8, 95% CI 5.4-14.1). A nomogram was developed using these five variables. The model was internally valid on bootstrapping and goodness of fit. The AUC estimated was 0.76 (95% CI 0.72-0.80). DCA revealed that the model was clinically useful at threshold probabilities >5%. Limitations include the lack of external validation and selection bias. CONCLUSIONS We developed and internally validated a nomogram predicting IOAEs during RAPN. PATIENT SUMMARY We developed a preoperative model than can predict complications that might occur during robotic surgery for partial removal of a kidney. Tests showed that our model is fairly accurate and it could be useful in identifying patients with kidney cancer for whom this type of surgery is suitable.
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Affiliation(s)
- Gopal Sharma
- Department of Urologic Oncology, Max Institute of Cancer Care, New Delhi, India
| | - Milap Shah
- Department of Urologic Oncology, Max Institute of Cancer Care, New Delhi, India
| | - Puneet Ahluwalia
- Department of Urologic Oncology, Max Institute of Cancer Care, New Delhi, India
| | - Prokar Dasgupta
- Faculty of Life Sciences and Medicine, King's Health Partners, King's College, London, UK
| | | | | | | | - Sudhir Rawal
- Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | | | | | | | | | | | - Ronney Abaza
- Central Ohio Urology Group and Mount Carmel Health System Prostate Cancer Program, Columbus, OH, USA
| | - Khoon Ho Rha
- Yonsei University Health System, Seoul, South Korea
| | - Daniel Moon
- Peter MacCallum Cancer Centre, Royal Melbourne Clinical School, University of Melbourne, Melbourne, Australia
| | | | | | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Kris K Maes
- Center for Robotic and Minimally Invasive Surgery, Hospital Da Luz, Lisbon, Portugal
| | | | - Levent Turkeri
- Department of Urology, Acıbadem M.A, Aydınlar University, Altuzinade Hospital, Istanbul, Turkey
| | - Gagan Gautam
- Department of Urologic Oncology, Max Institute of Cancer Care, New Delhi, India.
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3
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Cruz A, Dickerson F, Pulling KR, Garcia K, Gachupin FC, Hsu CH, Chipollini J, Lee BR, Batai K. Impacts of Neighborhood Characteristics and Surgical Treatment Disparities on Overall Mortality in Stage I Renal Cell Carcinoma Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:2050. [PMID: 35206240 PMCID: PMC8872003 DOI: 10.3390/ijerph19042050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/15/2022] [Accepted: 02/09/2022] [Indexed: 12/20/2022]
Abstract
Racial/ethnic minority groups in the United States have high renal cell carcinoma (RCC) mortality rates. This study assessed surgical treatment disparities across racial/ethnic groups and impacts of neighborhood socioeconomic characteristics on surgical treatments and overall mortality. Stage I RCC patients diagnosed between 2004 and 2016 from National Cancer Database were included (n = 238,141). We assessed differences in associations between race/ethnicity and treatment patterns using logistic regression and between race/ethnicity and overall mortality using Cox regression with and without neighborhood characteristics in the regression models. When compared to non-Hispanic Whites (NHWs), American Indians/Alaska Natives and non-Hispanic Blacks (NHBs) were more likely not to receive surgical care and all racial/ethnic minority groups had significantly increased odds of undergoing radical rather than partial nephrectomy, even after adjusting for neighborhood characteristics. Including surgical treatment and neighborhood factors in the models slightly attenuated the association, but NHBs had a significantly increased risk of overall mortality. NHBs who underwent radical nephrectomy had an increased risk of mortality (HR 1.15, 95% CI: 1.08-1.23), but not for NHBs who underwent partial nephrectomy (HR 0.92, 95% CI: 0.84-1.02). Neighborhood factors were associated with surgical treatment patterns and overall mortality in both NHBs and NHWs. Neighborhood socioeconomic factors may only partly explain RCC disparities.
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Affiliation(s)
- Alejandro Cruz
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
| | - Faith Dickerson
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
| | - Kathryn R. Pulling
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
| | - Kyle Garcia
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
| | - Francine C. Gachupin
- Department of Family and Community Medicine, University of Arizona, Tucson, AZ 85711, USA;
| | - Chiu-Hsieh Hsu
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ 85724, USA;
| | - Juan Chipollini
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
| | - Benjamin R. Lee
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
| | - Ken Batai
- Department of Urology, University of Arizona, Tucson, AZ 85724, USA; (A.C.); (F.D.); (K.R.P.); (K.G.); (J.C.); (B.R.L.)
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Postoperative outcomes of elderly patients undergoing partial nephrectomy. Sci Rep 2021; 11:17201. [PMID: 34433877 PMCID: PMC8387350 DOI: 10.1038/s41598-021-96676-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/23/2021] [Indexed: 01/20/2023] Open
Abstract
To describe clinical outcomes of patients aged 75 years and above after partial nephrectomy (PN), and to assess independent factors of postoperative complications. We retrospectively reviewed information from our multi-institutional database. Every patient over 75 years old who underwent a PN between 2003 and 2016 was included. Peri-operative and follow up data were collected. Multivariate logistic regression was performed to determine independent predictive factors of postoperative complications. We reviewed 191 procedures including 69 (40%) open-surgery, and 122 (60%) laparoscopic procedures, of which 105 were robot-assisted. Median follow-up was 25 months. The mean age was 78 [75–88]. The American Society of Anesthesiologist’s score was 1, 2, 3 and 4 in 10.5%, 60%, 29% and 0.5% of patients respectively. The mean tumor size was 4.6 cm. Indication of PN was elective in 122 (65%) patients and imperative in 52 patients (28%). The median length of surgery was 150(± 60) minutes, and the median estimated blood loss 200 ml. The mean glomerular filtration rate was 71.5 ml/minute preoperatively, and 62 ml/min three months after surgery. The severe complications (Clavien III-V) rate was 6.2%. On multivariate analysis, the robotic-assisted procedure was an independent protective factor of medical postoperative complications (Odds Ration (OR) = 0.31 [0.12–0.80], p = 0.01). It was adjusted for age and RENAL score, robotic-assisted surgery (OR = 0.22 [0.06–0.79], p = 0.02), and tumor size (OR = 1.13 [1.02–1.26], p = 0.01), but the patients age did not forecast surgical complications. Partial nephrectomy can be performed safely in elderly patients with an acceptable morbidity, and should be considered as a viable treatment option. Robotic assistance is an independent protective factor of postoperative complications.
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Cui HW, Sullivan ME. Surveillance for low-risk kidney cancer: a narrative review of contemporary worldwide practices. Transl Androl Urol 2021; 10:2762-2786. [PMID: 34295761 PMCID: PMC8261444 DOI: 10.21037/tau-20-1295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/04/2021] [Indexed: 11/09/2022] Open
Abstract
The management trend of low-risk kidney cancer over the last decade has been from treatment with radical nephrectomy, to use of nephron sparing procedures of partial nephrectomy and ablation, as well as the option of active surveillance (AS). This narrative review aims to summarise the available guidelines related to AS and review the published descriptions of regional practices on the management of low-risk kidney cancer worldwide. A search of PubMed, Google Scholar and Cochrane Library databases for studies published 2010 to June 2020 identified 15 studies, performed between 2000 and 2019, which investigated 13 different cohorts of low-risk kidney cancer patients on AS. Although international guidelines show a level of agreement in their recommendation on how AS is conducted, in terms of patient selection, surveillance strategy and triggers for intervention, cohort studies show distinct differences in worldwide practice of AS. Prospective studies showed general agreement in their predefined selection criteria for entry into AS. Retrospective studies showed that patients who were older, with greater comorbidities, worse performance status and smaller tumours were more likely to be managed with AS. The rate of percutaneous renal mass biopsy varied between studies from 2% to 56%. The surveillance protocol was different across all studies in terms of recommended modality and frequency of imaging. Of the 6 studies which had set indications for intervention, these were broadly in agreement. Despite clear criteria for intervention, patient or surgeon preference was still the reason in 11–71% of cases of delayed intervention across 5 studies. This review shows that AS is being applied in a variety of centres worldwide and that key areas of patient selection criteria and surveillance strategy have large similarities. However, the rate of renal mass biopsy and of delayed intervention varies significantly between studies, suggesting the process of diagnosing malignant SRM and decision making whilst on AS are varying in practice. Further research is needed on the diagnosis and characterisation of incidentally found small renal masses (SRM), using imaging and histology, and the natural history of these SRM in order to develop evidence-based active surveillance protocols.
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Affiliation(s)
- Helen Wei Cui
- Urology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Edward Sullivan
- Urology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Patel AK, Rogers CG, Johnson A, Noyes SL, Qi J, Miller D, Shervish E, Stockton B, Lane BR. Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative. EUR UROL SUPPL 2021; 23:13-19. [PMID: 34337485 PMCID: PMC8317780 DOI: 10.1016/j.euros.2020.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%. OBJECTIVE To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative. DESIGN SETTING AND PARTICIPANTS The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test. RESULTS AND LIMITATIONS Out of 965 patients, observation was employed in 48% (n = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p < 0.0001) and had smaller tumors (2.3 vs 3.4 cm, p < 0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III-IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III-IV vs solid, p = 0.017), tumor stage (cT1a vs cT1b, p < 0.001), and higher age (p < 0.001). A short duration of follow-up limits the assessment of longer-term patient management. CONCLUSIONS Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study. PATIENT SUMMARY The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic tumor type.
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Affiliation(s)
| | | | - Anna Johnson
- Department of Urology, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Ji Qi
- Department of Urology, Michigan Medicine, Ann Arbor, MI, USA
| | - David Miller
- Department of Urology, Michigan Medicine, Ann Arbor, MI, USA
| | | | | | - Brian R. Lane
- Spectrum Health Hospital System, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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7
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Morkos J, Porosnicu Rodriguez KA, Zhou A, Kolarich AR, Frangakis C, Rodriguez R, Georgiades CS. Percutaneous Cryoablation for Stage 1 Renal Cell Carcinoma: Outcomes from a 10-year Prospective Study and Comparison with Matched Cohorts from the National Cancer Database. Radiology 2020; 296:452-459. [PMID: 32515677 DOI: 10.1148/radiol.2020192325] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Percutaneous cryoablation (PCA) is an increasingly utilized treatment for stage I renal cell carcinoma (RCC), albeit without supportive level I evidence. Purpose Primary objective was to determine the 10-year oncologic outcomes of PCA for stage I RCC in a prospective manner. Secondary objectives were to compare outcomes after partial nephrectomy (PN) and radical nephrectomy (RN) from the National Cancer Database (NCDB), to determine long-term renal function, and to determine the risk of metachronous disease. Materials and Methods In this institutional review board-approved prospective observational study (2006-2013), study participants with single, sporadic, biopsy-proven RCC were included to calculate the 10-year overall survival, recurrence-free survival, and disease-specific survival after PCA. Results were compared with matched PN and RN NCDB cohorts. Overall and recurrence-free survival probabilities were estimated by using nonparametric maximum likelihood estimator. Disease-specific survival was estimated by using the redistribution-to-right method. Age at diagnosis was stratified as a risk for survival. The effect on estimated glomerular filtration rate, serum creatinine level, and the risk for hemodialysis and metachronous disease were calculated. Results One hundred thirty-four patients (46% men) with single, sporadic, biopsy-proven RCC (median size ± standard deviation, 2.8 cm ± 1.4) were included. Overall survival was 86% (95% confidence interval [CI]: 80%, 93%) and 72% (95% CI: 62%, 83%), recurrence-free survival was 85% (95% CI: 79%, 91%) and 69% (95% CI: 59%, 79%) (improved over surgery), and disease-specific survival was 94% (95% CI: 90%, 98%) at both 5 years and 10 years (similar to surgery), respectively. The 10-year risk of hemodialysis was 2.3%. Risk of metachronous RCC was 6%. Charlson/Deyo Combined Comorbidity score analysis showed decreasing overall survival with increasing comorbidity index. The PCA cohort outperformed both RN- and PN-matched subgroups in all Charlson/Deyo Combined Comorbidity score categories. Conclusion Percutaneous cryoablation yielded a 10-year disease-specific survival of 94%, equivalent to that reported after radical or partial nephrectomy. Overall survival probability after percutaneous cryoablation at 5 years and 10 years was longer than for radical or partial nephrectomy, especially for patients at higher risk (Charlson/Deyo Combined Comorbidity score ≥2). © RSNA, 2020.
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Affiliation(s)
- John Morkos
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
| | - Kori A Porosnicu Rodriguez
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
| | - Alice Zhou
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
| | - Andrew R Kolarich
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
| | - Constantine Frangakis
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
| | - Ronald Rodriguez
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
| | - Christos S Georgiades
- From the Department of Radiology (J.M., K.A.P.R., A.Z., A.R.K.), Department of Biostatistics (C.F.), and Department of Vascular and Interventional Radiology (C.S.G.), Johns Hopkins University, 1800 Orleans St, Zayed 7203, Baltimore, MD 21231; and Department of Urology, University of Texas Health Sciences Center, San Antonio, TX (R.R.)
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8
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The association of anxiety and depression with perioperative and oncologic outcomes among patients with clear cell renal cell carcinoma undergoing nephrectomy. Urol Oncol 2020; 38:41.e19-41.e27. [DOI: 10.1016/j.urolonc.2019.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/25/2019] [Accepted: 10/29/2019] [Indexed: 12/29/2022]
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9
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Shahait M, Jackman S, Landman J, Lechevallier E, Billiet I, Fossion L, Aslan Y, Laguna MP. Utilization and Operative Influence of Renal Mass Biopsy in the Small Renal Mass: Analysis from the Clinical Research Office of the Endourological Society Small Renal Mass registry. J Endourol 2019; 34:99-106. [PMID: 31559847 DOI: 10.1089/end.2019.0297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Introduction and Objective: Definitive inclusion of renal mass biopsy (RMB) in small renal mass (SRM) diagnostic algorithm remains controversial. We assessed incidence and accuracy of RMB in SRMs in the CROES Renal Mass registry and the influence of preoperative RMB on perioperative complications after SRM nephron-sparing surgery (NSS). Materials and Methods: "ad hoc" description of incidence of preoperative RMB and characteristics of SRM cases with and without RMB. Accuracy of RMB was calculated in the SRM subcohort that received extirpative treatment and complication rate after NSS compared to between the two groups. Continuous variables were compared using t-test; categorical variables were compared using the chi-square test. K-statistics was used to analyze agreement between the biopsy histology and surgical pathology. Logistic regression was used to assess the association between RMB and NSS complications. All tests were two sided, and p-values <0.05 were considered statistically significant. Results: The rate of preoperative RMB in SRMs was 11.6% (175/1597) in Europe and the United States. RMB patients were more likely to have hypertension (p < 0.04), be on dialysis (p < 0.024), or smokers (p = 0.005), with multiple/bilateral tumors (0.008 and 0.010) and previous other malignancy (p = 0.021). They underwent radical nephrectomy more frequently than non-RMB group (p = 0.034). RMB was nondiagnostic in 16 cases (9%). Accuracy of RMB in distinguishing malignant from benign was 89.5%. Agreement between biopsy and final surgical pathology was 93% for malignant vs benign tumors (kappa = 0.655). Upstaging to pT3a occurred more frequently in the RMB group (12.6% vs 6.25% [p = 0.022]). Complication rate in renal mass-NSS subcohort was 15.8%, not statistically different between RMB and non-RMB groups. On logistic regression analysis, RMB was not associated with increased risk of postoperative complication after NSS (OR: 0.9, 95% CI: 0.43-1.89). Conclusion: The practice of RMB in SRM is still scarce despite high accuracy and concordance with final pathology. RMB does not seem to increase complication rate after NSS.
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Affiliation(s)
- Mohammed Shahait
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen Jackman
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jaime Landman
- Department of Urology, University of California Irvine, Orange, California
| | | | | | - Laurent Fossion
- Department of Urology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Yilmaz Aslan
- Clinic of Urology, Ankara Numune Training and Research Hospital, Hacettepe, Ankara, Turkey
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10
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Doolittle J, Piotrowski J, Zuk K, Jacobsohn K, Langenstroer P, See W, Johnson S. Evolving Trends for Selected Treatments of T1a Renal Cell Carcinoma. Urology 2019; 132:136-142. [PMID: 31279691 DOI: 10.1016/j.urology.2019.06.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate contemporary trends in the management of small renal masses and how patient age has impacted practice patterns. METHODS Using the NCDB Participant User File (PUF) from 2002 to 2015, we identified patients with T1a renal masses. The initial treatment was categorized as radical nephrectomy (RN), partial nephrectomy (PN), ablation, or active surveillance (AS). A multinominal logistic regression model was used to identify significant factors impacting treatment. RESULTS We identified 75,691 patients for analysis. RN, PN, and ablation accounted for 28%, 52%, and 12%, respectively, while 8% were managed with AS. In the past decade the likelihood of undergoing PN, ablation, or surveillance compared to RN has consistently increased, independent of age, sex, race, comorbidity, tumor size, or institution. As age increased, patients were independently less likely to undergo PN and more likely to be managed with ablation or AS. Compared to patients under 40 years of age, patients between 70 and 79 were far less likely to undergo PN (RR 0.58, P< .01), and far more likely to undergo either ablation (RR 5.53, P< .01) or AS (RR 3.7, P< .01). CONCLUSION Trends in small renal mass management continue to evolve, with PN supplanting RN over the past decade as the predominant surgical treatment. Age significantly impacts treatment selection, particularly in older cohorts whom are much more likely to undergo ablation or AS. While the use of minimally invasive therapies has increased over the past decade, AS lags behind despite quality data supporting its use. When controlling for multiple clinical factors, PN, ablation and surveillance have consistently increased in utilization compared to RN.
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Affiliation(s)
| | | | - Keegan Zuk
- Medical College of Wisconsin, Milwaukee, WI
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Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project). World J Urol 2019; 38:151-158. [DOI: 10.1007/s00345-019-02665-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/31/2019] [Indexed: 01/20/2023] Open
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12
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Vartolomei MD, Matei DV, Renne G, Tringali VM, Crișan N, Musi G, Mistretta FA, Russo A, Conti A, Cozzi G, Luzzago S, Catellani M, Cioffi A, Cordima G, Bianchi R, Di Trapani E, Serino A, Delor M, Bianco R, Bottero D, Ferro M, De Cobelli O. Long-term oncologic and functional outcomes after robot-assisted partial nephrectomy in elderly patients. MINERVA UROL NEFROL 2019; 71:31-37. [DOI: 10.23736/s0393-2249.18.03006-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Determinants of Active Surveillance in Patients With Small Renal Masses. Urology 2019; 123:167-173. [DOI: 10.1016/j.urology.2018.07.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 01/20/2023]
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14
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Autorino R, Mayer Grob B, Guruli G, Hampton LJ. Partial Versus Total Nephrectomy: Indications, Limitations, and Advantages. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Active Surveillance of Small Renal Masses. Urology 2019; 123:157-166. [DOI: 10.1016/j.urology.2018.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/10/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023]
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Sanchez A, Feldman AS, Hakimi AA. Current Management of Small Renal Masses, Including Patient Selection, Renal Tumor Biopsy, Active Surveillance, and Thermal Ablation. J Clin Oncol 2018; 36:3591-3600. [PMID: 30372390 PMCID: PMC6804853 DOI: 10.1200/jco.2018.79.2341] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Renal cancer represents 2% to 3% of all cancers, and its incidence is rising. The increased use of ultrasonography and cross-sectional imaging has resulted in the clinical dilemma of incidentally detected small renal masses (SRMs). SRMs represent a heterogeneous group of tumors that span the full spectrum of metastatic potential, including benign, indolent, and more aggressive tumors. Currently, no composite model or biomarker exists that accurately predicts the diagnosis of kidney cancer before treatment selection, and the use of renal mass biopsy remains controversial. The management of SRMs has changed dramatically over the last two decades as our understanding of tumor biology and competing risks of mortality in this population has improved. In this review, we critically assess published consensus guidelines and recent literature on the diagnosis and management of SRMs, with a focus on patient treatment selection and use of renal mass biopsy, active surveillance, and thermal ablation. Finally, we highlight important opportunities for leveraging recent research discoveries to identify patients with SRMs at high risk for renal cell carcinoma-related mortality and minimize overtreatment and patient morbidity.
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Affiliation(s)
- Alejandro Sanchez
- Alejandro Sanchez and A. Ari Hakimi, Memorial Sloan Kettering Cancer Center, New York, NY; and Adam S. Feldman, Massachusetts General Hospital, Boston, MA
| | - Adam S. Feldman
- Alejandro Sanchez and A. Ari Hakimi, Memorial Sloan Kettering Cancer Center, New York, NY; and Adam S. Feldman, Massachusetts General Hospital, Boston, MA
| | - A. Ari Hakimi
- Alejandro Sanchez and A. Ari Hakimi, Memorial Sloan Kettering Cancer Center, New York, NY; and Adam S. Feldman, Massachusetts General Hospital, Boston, MA
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Miller C, Raza SJ, Davaro F, May A, Siddiqui S, Hamilton ZA. Trends in the treatment of clinical T1 renal cell carcinoma for octogenarians: Analysis of the National Cancer Database. J Geriatr Oncol 2018; 10:285-291. [PMID: 30528544 DOI: 10.1016/j.jgo.2018.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/13/2018] [Accepted: 11/28/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Treatment of renal cell carcinoma has evolved with emphasis on nephron preservation for small renal masses. Our objective was to evaluate the proportions of treatment types for octogenarians with clinical stage 1 renal cell carcinoma. MATERIALS AND METHODS The National Cancer Database was analyzed from 2004 to 2015. Patients with clinical stage 1, tumor size ≤ 7 cm, and age 80-89 years old were compared to a younger control arm of patients ≤ 70 years old. Treatment modality was categorized as radical nephrectomy (RN), partial nephrectomy (PN), percutaneous ablative therapy (PAT), and no treatment (NT). Primary outcome was treatment utilization over time using estimated annual percentage change (EAPC). Secondary outcomes included logistic regression for 30 day readmission after treatment and any definitive tumor treatment choice. RESULTS 18,903 octogenarians were identified and compared to a control of 142,179 patients ≤ 70 years old. Overall, NT (36%) was the most common modality for octogenarians while PN (44.8%) was most common for the control arm. Using EAPC for octogenarians, we found increases for PAT (7.1%), PN (2.8%), and NT (1.6%) but a decrease for RN (-4.6%). EAPC for the younger cohort noted increases for PAT (6.8%), PN (5.4%), and NT (4.4%) but a decrease for RN (-5.5%). CONCLUSION For octogenarians with stage 1 renal cell carcinoma, minimally invasive treatments are increasingly utilized, while RN is decreasing. Compared to a younger cohort, a greater proportion of octogenarians are receiving NT. These findings remain encouraging for appropriate treatment of localized disease in patients with advanced age.
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Affiliation(s)
- Caleb Miller
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Syed J Raza
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Facundo Davaro
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Allison May
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Sameer Siddiqui
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States
| | - Zachary A Hamilton
- Division of Urology, Department of Surgery, Saint Louis University, St Louis, MO, United States.
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Sandbergen L, Guven S, Laguna MP. Can ablation win against partial nephrectomy and become first line therapy in cT1a renal tumours? Curr Opin Urol 2018; 29:70-77. [PMID: 30308573 DOI: 10.1097/mou.0000000000000559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Currently, small renal masses account for the largest proportion of renal tumour and small renal cell carcinomas (RCC). Although partial nephrectomy, whenever possible, is recognized as the gold standard for treatment, thermal ablation has gained increasing attention as optional treatment in a population sector harbouring small renal masses/small RCCs. The purpose of this review is to update comparative outcomes between these two options of treatment. RECENT FINDINGS Recent observational case-control and population-based cohorts applying propensity score or inverse probability treatment weighted methodology adjusting for baseline patient and tumour characteristics, compare outcomes between partial nephrectomy and thermal ablation (both cryotherapy and radiofrequency), radical nephrectomy and thermal ablation and between thermal ablation and nonsurgical management. Most of them focus on T1aRCC. SUMMARY Comparative outcomes' evidence is limited to population-based or institutional series adjusted for baseline differences and systematic reviews. With exception of special clinical situations, thermal ablation provides similar estimated 5-year cancer and overall survival with a clear benefit in postoperative outcomes when compared to partial nephrectomy in cT1a older patients. The trade-off is more evident when thermal ablation is compared to radical nephrectomy. The advantages in terms of adverse events persist up to 1 year after treatment. Benefits are less apparent in solitary kidneys and when synchronous bilateral approaches are performed.
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Affiliation(s)
- Laura Sandbergen
- UMC Amsterdam, AMC University of Amsterdam, Amsterdam, The Netherlands
| | - Selcuk Guven
- Department of Urology, Istanbul Medipol University, Istanbul, Turkey
| | - Maria Pilar Laguna
- UMC Amsterdam, AMC University of Amsterdam, Amsterdam, The Netherlands.,Department of Urology, Istanbul Medipol University, Istanbul, Turkey
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Calaway AC, Monn MF, Bahler CD, Cary C, Boris RS. A novel preoperative model to predict 90-day surgical mortality in patients considered for renal cell carcinoma surgery. Urol Oncol 2018; 36:470.e11-470.e17. [PMID: 30274725 DOI: 10.1016/j.urolonc.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/01/2018] [Accepted: 07/14/2018] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Surgical benefits for renal cell carcinoma must be weighed against competing causes of mortality, especially in the elderly patient population. We used a large cancer registry to evaluate the impact of patient and cancer-specific factors on 90-day mortality (90DM). A nomogram to predict the odds of short-term mortality was created. MATERIALS AND METHODS The National Cancer Database was queried to identify all patients with clinically localized, nonmetastatic disease treated with partial or radical nephrectomy. Using a random sample of 60%, multiple logistic regression with 90DM outcomes were performed to identify preoperative variables associated with mortality. Variables included age, sex, race, co-morbidity score, tumor size, and presence of a thrombus. A nomogram was created and tested on the remaining 40% of patients to predict 90DM. RESULTS 183,407 patients met inclusion criteria. Overall 90DM for the cohort was 1.9%. All preoperative variables significantly influenced the risk of 90DM. Patient age was by far the strongest predictor. Nomogram scores ranged from 0 to 12. Compared to patients with 0 to 1 points, those with 2 to 3 (odds ratio [OR] 2.89, 2.42-3.46; P < 0.001), 4 to 5 (OR 6.25, 5.26-7.43; P < 0.001), and >6 (OR 12.86, 10.83-15.27; P < 0.001) were at incrementally significantly higher odds of 90DM. Being >80 years of age alone placed patients into the highest risk of surgical mortality. CONCLUSIONS Management of localized kidney cancer must consider competing causes of mortality, especially in elderly patients with multiple co-morbidities. We present a preoperative tool to calculate risk of surgical short-term mortality to aid surgeon-patient counseling.
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Affiliation(s)
- Adam C Calaway
- Indiana University School of Medicine, Department of Urology, Indianapolis, IN.
| | - M Francesca Monn
- Indiana University School of Medicine, Department of Urology, Indianapolis, IN.
| | - Clinton D Bahler
- Indiana University School of Medicine, Department of Urology, Indianapolis, IN.
| | - Clint Cary
- Indiana University School of Medicine, Department of Urology, Indianapolis, IN.
| | - Ronald S Boris
- Indiana University School of Medicine, Department of Urology, Indianapolis, IN.
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Penn DC, Baker M, Geiger AM, Harlan LC. Treatment and Survival Disparities in the National Cancer Institute's Patterns of Care Study (1987-2017). Cancer Invest 2018; 36:319-329. [PMID: 30136865 PMCID: PMC6295665 DOI: 10.1080/07357907.2018.1474894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/06/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cancer health services research is a primary tool for analyzing the association between various factors, cancer health care delivery, and the resultant outcomes. To address disparities strategies must be developed to target factors that are related to differences in care; however, to date, most disparities studies have been descriptive. The primary objective was to describe cancer treatment and survival disparities in community oncology practice patterns found in the National Cancer Institute's population-based Patterns of Care (POC) Study (1987-2017). Secondarily, we compared POC findings to peer-reviewed literature. In POC data, older age was consistently associated with decreased odds of treatment and increased mortality. Interestingly, in contrast to current literature, few POC studies found race/ethnicity significantly predicted disparities. Cancer health disparities are complex; they are multifactorial, differ by cancer site and may wax and wane. The complexity supports the need for deeper understanding and targeted interventions to ensure equitable cancer care and outcomes.
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Affiliation(s)
- Dolly C. Penn
- National Cancer Institute/Division of Cancer Control and Population Sciences/Healthcare Delivery Research Program, 9609 Medical Center Drive Bethesda, Maryland 20892
| | - Melanie Baker
- National Cancer Institute/Division of Cancer Control and Population Sciences/Healthcare Delivery Research Program, 9609 Medical Center Drive Bethesda, Maryland 20892
| | - Ann M. Geiger
- National Cancer Institute/Division of Cancer Control and Population Sciences/Healthcare Delivery Research Program, 9609 Medical Center Drive Bethesda, Maryland 20892
| | - Linda C. Harlan
- National Cancer Institute/Division of Cancer Control and Population Sciences/Healthcare Delivery Research Program, 9609 Medical Center Drive Bethesda, Maryland 20892
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Tang DH, Nawlo J, Chipollini J, Gilbert SM, Poch M, Pow-Sang JM, Sexton WJ, Spiess PE. Management of Renal Masses in an Octogenarian Cohort: Is There a Right Approach? Clin Genitourin Cancer 2017; 15:696-703. [DOI: 10.1016/j.clgc.2017.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/26/2017] [Accepted: 05/01/2017] [Indexed: 11/29/2022]
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Withington J, Neves JB, Barod R. Surgical and Minimally Invasive Therapies for the Management of the Small Renal Mass. Curr Urol Rep 2017; 18:61. [DOI: 10.1007/s11934-017-0705-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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23
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Partial Versus Total Nephrectomy: Indications, Limitations, and Advantages. Urol Oncol 2017. [DOI: 10.1007/978-3-319-42603-7_62-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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