Surgical resection of locally recurrent renal cell carcinoma after nephrectomy: Oncological outcome and predictors of survival

Incidence and Pattern of Recurrence after Surgical Resection in Organ-Confined Renal Cell Carcinoma

PURPOSE

To evaluate the incidence and pattern of recurrence after surgery in patients with organ-confined renal cell carcinoma (RCC) to establish an appropriate follow-up plan.

MATERIALS AND METHODS

In this retrospective study, we evaluated data from 2960 patients who underwent radical or partial nephrectomy for stage 1 or 2 RCC. We investigated the location of first recurrence and recurrence-free survival (RFS) by plotting Kaplan-Meier curves and analyzed the associated variables using Cox regression analysis.

RESULTS

During a median follow-up of 59 months, the 10-year RFS rates were 94.5%, 75.0%, and 57.9%, for T1a, T1b, and T2 RCC, respectively. A total of 211 patients experienced recurrence: 67 after 5 years, and 14 after 10 years. The most common sites of the first recurrence were the lungs, bones, and contralateral kidneys. Male sex, older age, higher pathologic T stage, higher nuclear grade, clear-cell RCC, and presence of differentiation were associated with recurrence. Among patients followed up for more than 60 months, higher pathologic T stage and grade, as well as clear cell RCC were predictors of RFS.

CONCLUSION

Late recurrence after surgery is common in patients with organ-confined RCC, with recurrence occurring even after 10 years. Consequently, long-term follow-up, of perhaps 10 years or more, including imaging studies of the abdomen, lungs, and bone, should be considered for the early detection of recurrence.

Cost-effectiveness analysis of microwave ablation versus robot-assisted partial nephrectomy for patients with small renal masses in Australia

OBJECTIVES

Microwave ablation (MWA) has gained attention as a minimally invasive and safe alternative to surgical intervention for patients with small renal masses; however, its cost-effectiveness in Australia remains unclear. This study conducted a cost-effectiveness analysis to evaluate the relative clinical and economic merits of MWA compared to robotic-assisted partial nephrectomy (RA-PN) in the treatment of small renal masses.

METHODS

A Markov state-transition model was constructed to simulate the progression of Australian patients with small renal masses treated with MWA versus RA-PN over a 10-year horizon. Transition probabilities and utility data were sourced from comprehensive literature reviews, and cost data were estimated from the Australian health system perspective. Life-years, quality-adjusted life-years (QALYs), and lifetime costs were estimated. Modelled uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. A willingness-to-pay (WTP) threshold of $50,000 per QALY was adopted. All costs are expressed in 2022 Australian dollars and discounted at 3% annually. To assess the broader applicability of our findings, a validated cost-adaptation method was employed to extend the analysis to 8 other high-income countries.

RESULTS

Both the base case and cost-adaptation analyses revealed that MWA dominated RA-PN, producing both lower costs and greater effectiveness over 10 years. The cost-effectiveness outcome was robust across all model parameters. Probabilistic sensitivity analyses confirmed that MWA was dominant in 98.3% of simulations at the designated WTP threshold, underscoring the reliability of the model under varying assumptions.

CONCLUSION

For patients with small renal masses in Australia and comparable healthcare settings, MWA is the preferred strategy to maximize health benefits per dollar, making it a highly cost-effective alternative to RA-PN.

Frequent gene mutations and the correlations with clinicopathological features in clear cell renal cell carcinoma: preliminary study based on Chinese population and TCGA database

BACKGROUND

Large-scale sequencing plays important roles in revealing the genomic map of ccRCC and predicting prognosis and therapeutic response to targeted drugs. However, the relevant clinical data is still sparse in Chinese population.

METHODS

Fresh tumor specimens were collected from 66 Chinese ccRCC patients, then the genomic RNAs were subjected to whole transcriptome sequencing (WTS). We comprehensively analyzed the frequently mutated genes from our hospital's cohort as well as TCGA-KIRC cohort.

RESULTS

VHL gene is the most frequently mutated gene in ccRCC. In our cohort, BAP1 and PTEN are significantly associated with a higher tumor grade and DNM2 is significantly associated with a lower tumor grade. The mutant type (MT) groups of BAP1 or PTEN, BAP1 or SETD2, BAP1 or TP53, BAP1 or MTOR, BAP1 or FAT1 and BAP1 or AR had a significantly correlation with higher tumor grade in our cohort. Moreover, we identified HMCN1 was a hub mutant gene which was closely related to worse prognosis and may enhance anti-tumor immune responses.

CONCLUSIONS

In this preliminary research, we comprehensively analyzed the frequently mutated genes in the Chinese population and TCGA database, which may bring new insights to the diagnosis and medical treatment of ccRCC.

Recurrences after nephron-sparing treatments of renal cell carcinoma: a competing risk analysis

PURPOSE

To examine associations between ablative therapy (AT) and partial nephrectomy (PN) and the occurrence of local recurrence (LR), distant metastatic recurrence (DMR) and all-cause mortality in a nation-wide real-world population-based cohort of patients with nonmetastatic renal cell carcinoma (nmRCC).

METHODS

Data on 2751 AT- or PN-treated nmRCC tumours diagnosed during 2005-2018, representing 2701 unique patients, were obtained from the National Swedish Kidney Cancer Register. Time to LR/DMR or death with/without LR/DMR was analysed using Cox regression models.

RESULTS

During a mean of 4.8 years follow-up, LR was observed for 111 (4.0%) tumours, DMR for 108 (3.9%) tumours, and death without LR/DMR for 206 (7.5%) tumours. AT-treated tumours had a 4.31 times higher risk of LR (P < 0.001) and a 1.91 times higher risk of DMR (P = 0.018) than PN-treated, with no significant differences in risk of death without LR/DMR. During a mean of 3.2 and 2.5 years of follow-up after LR/DMR, respectively, 24 (21.6%) of the LR cases and 56 (51.9%) of the DMR cases died, compared to 7.5% in patients without LR/DMR. There were no significant differences between AT- and PN-treated regarding risks of early death after occurrence of LR or DMR.

CONCLUSION

AT treatment of patients with nmRCC implied significantly higher risks of LR and DMR compared with PN treatment. To minimize the risks of LR and DMR, these results suggest that PN is preferred over AT as primary treatment, supporting the EAU guidelines to recommended AT mainly to frail and/or comorbid patients.

Localised non-metastatic sarcomatoid renal cell carcinoma: a 31-year externally verified study

OBJECTIVE

To evaluate post-nephrectomy outcomes and predictors of cancer-specific survival (CSS) between patients with localised sarcomatoid renal cell carcinoma (sRCC) and those with Grade 4 RCC (non-sRCC), as most sRCC research focuses on advanced or metastatic disease with limited studies analysing outcomes of patients with localised non-metastatic sRCC.

PATIENTS AND METHODS

A total of 564 patients with localised RCC underwent partial or radical nephrectomy between June 1988 to March 2019 for sRCC (n = 204) or World Health Organization/International Society of Urological Pathology Grade 4 non-sRCC (n = 360). The CSS at every stage between groups was assessed. Phase III ASSURE clinical trial data were used to externally validate the CSS findings. The Mann-Whitney U-test and chi-squared test compared outcomes and the Kaplan-Meier method evaluated CSS, overall survival (OS) and recurrence-free survival. Clinicopathological features associated with RCC death were evaluated using Cox proportional hazards regression.

RESULTS

The median follow-up was 31.5 months. The median OS and CSS between the sRCC and Grade 4 non-sRCC groups was 45 vs 102 months and 49 vs 152 months, respectively (P < 0.001). At every stage, sRCC had worse CSS compared to Grade 4 non-sRCC. Notably, pT1 sRCC had worse CSS than pT3 Grade 4 non-sRCC. Negative predictors of CSS were sarcomatoid features, non-clear cell histology, positive margins, higher stage (pT3/pT4), and use of minimally invasive surgery (MIS). ASSURE external verification showed worse CSS in patients with sRCC (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.12-2.36; P = 0.01), but not worse outcomes in MIS surgery (HR 1.39, 95% CI 0.75-2.56; P = 0.30).

CONCLUSIONS

Localised sRCC had worse CSS compared to Grade 4 non-sRCC at every stage. Negative survival predictors included positive margins, higher pathological stage, use of MIS, and non-clear cell histology. sRCC is an aggressive variant even at low stages requiring vigilant surveillance and possible inclusion in adjuvant therapy trials.

Exploring the Potential Driver Gene Mutations That Promote Renal Cancer Cell Metastasis and Implantation Based on Circulating Tumor Cells Culture

Studies have shown that the circulating tumor cell (CTC) is a necessary condition for the invasion and distant metastasis of renal cell carcimona (RCC). However, few CTCs-related gene mutations have been developed which could promote the metastasis and implantation of RCC. The objective of this study is to explore the potential driver gene mutations that promote RCC metastasis and implantation based on CTCs culture. Fifteen patients with primary mRCC and three healthy subjects were included, and peripheral blood was obtained. After the preparation of synthetic biological scaffolds, peripheral blood CTCs were cultured. Successful cultured CTCs were applied to construct CTCs-derived xenograft (CDX) models, followed by DNA extraction, whole exome sequencing (WES) and bioinformatics analysis. Synthetic biological scaffolds were constructed based on previously applied techniques, and peripheral blood CTCs culture was successfully performed. We then constructed CDX models and performed WES, and explored the potential driver gene mutations that may promote RCC metastasis and implantation. Bioinformatics analysis showed that KAZN and POU6F2 may be closely related to the prognosis of RCC. We successfully performed the culture of peripheral blood CTCs and, on this basis we initially explored the potential driver mutations for the metastasis and implantation of RCC.

A Survival Model Based on the ASB Genes and Used to Predict the Prognosis of Kidney Renal Clear Cell Carcinoma

Kidney renal clear cell carcinoma (KIRC) is increasing in incidence worldwide, with poor and unpredictable patient prognosis limited by diagnostic and therapeutic approaches. New genes are urgently needed to improve this situation. The ankyrin repeat and suppressor of the cytokine signaling (SOCS) box (ASB) family are a promising class of tumorigenesis-related genes. We examined the expression and mutation of 18 ASB genes in various tumors for this study. The findings revealed that ASB genes exhibit significant copy number variation (CNV) and single nucleotide variation (SNV). There were substantial variations in ASB gene expression in different tumor tissues, and different levels of methylation of ASB genes affected the gene expression and tumor progression. By applying LASSO regression analysis, we established a KIRC survival model based on five ASB genes (ASB6, ASB7, ASB8, ASB13, and ASB17). Additionally, ROC curve analysis was used to assess the survival model’s accuracy. Through univariate and multivariate COX regression analysis, we demonstrated that the model’s risk score might be an independent risk factor for individuals with KIRC. In summary, our KIRC survival model could accurately predict patients’ future survival. Further, we also quantified the survival model through a nomogram. This series of findings confirmed that ASB genes are potential predictive markers and targeted therapies for KIRC. Our KIRC survival model based on five ASB genes can help more clinical practitioners make accurate judgments about the prognosis of KIRC patients.

Percutaneous microwave ablation therapy of renal cancer local relapse after radical nephrectomy: a feasibility and efficacy study

Renal cell carcinoma (RCC) local recurrence after radical nephrectomy is uncommon. When feasible, surgical removal remains the primary treatment strategy; nevertheless, local RCC relapse management is controversial, and less invasive procedures may represent an attractive option to achieve oncologic control. The aim of our study was to assess the feasibility, safety, and clinical outcomes of image-guided percutaneous microwave ablation (MWA) for RCC local recurrence in patients initially treated with nephrectomy with curative intent. 10 consecutive patients underwent CT-guided percutaneous MWA of a total of 10 retroperitoneal nodules. Inclusion criteria were: histologically verified retroperitoneal metastases, previous radical nephrectomy, lesion no larger than 3 cm, no other metastatic site elsewhere. All the procedures were performed under moderate sedation choosing the most favorable patient decubitus. If deemed necessary, pneumodissection was induced before ablation. After the antenna placement inside the target lesion, thermal ablation was achieved by maintenance of a power of 100 W for a total time between 2 and 4 min. All patients were observed overnight and discharged the following day if clinically stable. Technical success was obtained in 100% of patients. One patient was re-treated to complete oncologic response with repeat MWA. No major complications were observed. No patients demonstrated local recurrence at a mean follow-up of 26 months. MWA is a safe and effective treatment strategy for loco-regional relapse of RCC following radical nephrectomy. This technique may represent a valuable approach for patients who are not eligible for surgery.

Very late locally recurrent chromophobe renal cell carcinoma: 15 years following radical nephrectomy for low-stage disease

The majority of patients with renal cell carcinoma develop recurrence within 5 years following radical nephrectomy. Very late sole local recurrence beyond 10 years is rare, and all reported cases had clear cell histology. Surgical resection of local recurrence remains the best option for disease management. This case opens the way for further studying the rare histological variants of renal cancer and to encourage prolonged follow-up and offering surgery as the best option for managing these cases.

Capturing Renal Cell Carcinoma Recurrences When Asymptomatic Improves Patient Survival

INTRODUCTION

The purpose of this study was to explore whether the practice of postoperative renal cell carcinoma (RCC) surveillance affords a survival benefit by investigating whether detection of RCC recurrences in an asymptomatic versus symptomatic manner influences mortality.

PATIENTS AND METHODS

We identified 737 patients who underwent partial or radical nephrectomy for M0 RCC between 1998 and 2016. Overall survival and disease-specific survival stratified by the type of recurrence detection (asymptomatic vs. symptomatic) was estimated using Kaplan-Meier probabilities both from the time of surgery and from the time of recurrence. Cox proportional hazard regression models were used to evaluate the impact of the type of recurrence detection on mortality.

RESULTS

A total of 78 patients (10.6%) experienced recurrence after surgery, of whom 63 (80.8%) were asymptomatic (detected using routine surveillance) and 15 (19.2%) were symptomatic. The median postoperative follow-up was 47.2 months (interquartile range, 26.3-89.4 months). Five- and 10-year overall survival, from time of surgery, among patients with asymptomatic versus symptomatic recurrences was 57% and 39% versus 24% and 8%, respectively (P = .0002). As compared with asymptomatic recurrences, patients with symptomatic recurrences had an increased risk of overall (OD) and disease-specific death (DSD) both when examined from the time of surgery (OD: hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.33-7.49; P = .0091 and DSD: HR, 3.44; 95% CI, 1.38-8.57; P = .0079) and from the time of recurrence (OD: HR, 2.93; 95% CI, 1.24-6.93; P = .0143 and DSD: HR, 3.62; 95% CI, 1.45-9.01; P = .0058).

CONCLUSIONS

Capturing RCC recurrences in an asymptomatic manner during routine surveillance is associated with improved patient survival.