Incidental renal tumors

The platelet-to-lymphocyte ratio as a significant prognostic factor to predict survival outcomes in patients with synchronous metastatic renal cell carcinoma

Purpose

The clinical impact of the platelet-to-lymphocyte ratio (PLR) on the prognosis of patients with metastatic renal cell carcinoma (mRCC) remains controversial. We investigated the associations between elevation of the PLR and disease prognosis in patients with synchronous mRCC.

Materials and Methods

The data of 1,505 patients with synchronous mRCC were retrospectively analyzed. The entire cohort was stratified into two subgroups according to PLR. Kaplan–Meier and Cox proportional analyses were performed to investigate the possible associations between the PLR and disease prognosis.

Results

There were 921 patients with a high PLR and 584 patients with a low PLR by use of the cutoff of 146. The patients with a high PLR had worse clinical characteristics in terms of advanced clinical stage (p<0.001) and rate of lymph node invasion (p=0.036). The Kaplan–Meier analysis showed that patients with a high PLR had significantly shorter overall survival (OS) (p<0.001) and cancer-specific survival (CSS) (p<0.001). The multivariate Cox analysis revealed that the PLR was an independent predictor for shorter OS (hazard ratio [HR], 1.345; 95% confidence interval [CI], 1.183–1.530; p<0.001) and CSS (HR, 1.318; 95% CI, 1.156–1.502; p<0.001). In the subgroup analyses, the PLR showed a significant association with survival outcomes in the subgroup with clear cell type (all p<0.05) but not in the subgroup with the non–clear cell type.

Conclusions

The PLR was an independent prognostic factor for survival outcomes in patients with mRCC. However, the association was statistically significant only in patients with clear cell type mRCC.

The number of metabolic features as a significant prognostic factor in patients with metastatic renal cell carcinoma

The effect of metabolic characteristics on the prognosis of patients with metastatic renal cell carcinoma remains controversial. We investigated the associations between metabolic features of each individual and disease prognosis in patients with metastatic renal cell carcinoma. Data of 1,584 patients with metastatic renal cell carcinoma from a multi-institutional database were retrospectively analyzed. The entire cohort was stratified into three subgroups according to how many patients had abnormal metabolic features (hypertension, diabetes mellitus, and low body mass index). The Kaplan-Meier and Cox proportional analyses were performed to investigate the associations between abnormal metabolic features and disease prognosis. mThere were 465 subjects without any metabolic features, 995 with one or two, and 124 with three. When the survival outcomes were compared according to the number of metabolic features, patients with higher numbers of metabolic features had significantly shorter overall and cancer-specific survival than those with fewer metabolic features (all p values <0.05). The multivariate Cox analysis showed that the number of metabolic features was an independent predictor for shorter cancer-specific and overall survival (all p values < 0.05). When performing subgroup analysis according to the cellular type, significant results were only obtained among the clear cell subtype subgroup, with the association not being significant in the non-clear cell subtype cohort. Patients with more metabolic features had significantly worse survival outcomes than those with fewer metabolic features. However, the association was only statistically significant in patients with clear cell-type metastatic renal cell carcinoma.

Changing the Stage, Grade and Histological Subtypes of Renal Cell Carcinomas during 10 Years Period

Renal cell carcinomas (RCCs) account 80-85% of all primary renal neoplasms and originate from the renal cortex. The patients who underwent radical or partial nephrectomy for renal tumour in our unit between January 2005 and 2015 were evaluated retrospectively. The patients were divided into two groups; group 1 includes patients who were treated between January 2005 and December 2009, group 2 those from January 2010 to 2015. There were 103 patients in group 1. The patients were between 21 and 89 years with mean age of 61.46 year. Renal cell carcinomas account 83.4% of the patients, benign renal tumours were 8.7% and transitional cell carcinomas were 7.7% of the patients in group 1. A total of 32.5% RCCs were classified as pT1a, 24.4% as pT1b, 15.1% as pT2a, 11.6% as pT2b, 15.1% as pT3a and 1.1% as pT4. There were 202 patients in group 2 and the patients were between 27 and 81 years with mean age of 58.5 year. Renal cell carcinomas comprised the main bulk of the tumours with 182 nephrectomy specimens. According to the pathological classification of RCCs, 51 specimens were found as pT1a, 54 were pT1b, 13 were pT2a, 14 were pT2b, 48 were pT3a and 2 were pT4. Although, the incidence of small renal masses has been increasing with widespread use of imaging techniques and recent advancements, the proportion of high grade and advanced stage renal tumours increased during the study period.

Image-guided ablation of renal cell carcinoma

This review article aims to provide an overview of image-guided ablation of renal cell carcinoma (RCC) since it was first introduced in 1998. This will cover the background and rationale behind its development; an overview of the evidence for current thermal technology, such as heat-based, e.g., radiofrequency ablation (RFA), microwave ablation (MWA), and cold-based energies, e.g., cryoablation used; and summarise the published evidence regarding its treatment efficacy and oncological outcome. In addition, it aims to provide an insight into the potential role of the new non-thermal ablative technology, e.g., irreversible electroporation (IRE)/Nanoknife in image-guided ablation of RCC, as well as areas of challenge that will require further research and clinical evaluation to ensure delivery of a quality patient-centred interventional oncology (IO) service in image-guided ablation of RCC.

The establishment of KORCC (KOrean Renal Cell Carcinoma) database

PURPOSE

The purpose of this article is to report establishment of the 1st Web-based database (DB) system to collect renal cell carcinoma (RCC) data in Korea.

MATERIALS AND METHODS

The new Web-based DB system was established to collect basic demographic and clinicopahtological characteristics of a large cohort of patients with RCC in Korea. Data from a total of 6,849 patients were collected from 8 tertiary care hospitals that agreed to participate in organizing the Korean Renal Cell Carcinoma (KORCC) study group as of 1 July 2015. Basic demographic and clinicopathological characteristics were collected. The data of patients who underwent surgical treatments were analyzed to characterize Korean RCC.

RESULTS

We established the 1st Web-based DB of Korean RCC, a database comprising renal mass management cases from multiple centers in Korea. The data of 5,281 patients who underwent surgical management (mean follow-up, 32 months) were analyzed. The most common symptom was incidentally detected renal mass (76.9%). Clinical T1a was the most common (54.3%) stage and mean tumor size was 4.8±4.2 cm. Radical nephrectomy accounted for 62.7% of cases and an open approach was used in 50.7% and 52.2% of radical and partial nephrectomies, respectively. The 5-year overall, cancer-specific and recurrence-free survival rates were 88.1%, 92.2%, and 88.0%, respectively.

CONCLUSIONS

We report the 1st establishment of a Web-based DB system to collect RCC data in Korea. This DB system will provide a solid basis for the characterization of Korean RCC.

Discovery of Renal Tuberculosis in a Partial Nephrectomy Specimen Done for Renal Tumor

The association of renal cancer and renal tuberculosis is uncommon. While the incidental discovery of renal cell carcinoma in a tuberculous kidney is a classical finding, the discovery of tuberculous lesions after nephrectomy for cancer is exceptional. We report the case of a female patient aged 60 who had a partial nephrectomy for a 5 cm exophytic kidney tumor. Pathological examination concluded that renal clear cell carcinoma associated with follicular caseo tuberculosis.

Robotic-assisted partial nephrectomy: experience on 60 cases

INTRODUCTION

Laparoscopic partial nephrectomy is still one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumor. Robotic-assisted partial nephrectomy (RALPN) adds the advantages offered by the "Da Vinci system" to laparoscopy, such as the 3-D vision, and the better degree of freedom of surgical instruments.

OBJECTIVE

The objective of this study is to report our experience with RALPN.

METHODS

From August 2009 to October 2012, 60 patients underwent RALPN for kidney cancer. The average age of the patients (35 female, 25 male) was 63 (range 48-80) years. Average BMI was 25 (range 21.8-29.7) kg/m2. Average tumor size was 3.2 cm (range 2-6.7 cm). All the procedures were performed by a transperitoneal approach. Ilar clamping was used in all cases: in 47 patients by one intracorporeal tourniquet for the artery and one for the vein; in three cases, ilar clamping was "en block" by Satinsky.

RESULTS

Mean operative time was 167.2 min (140-250) with a WIT of 23.8 min (15-28). The mean estimated blood loss was 260 mL (50-300). In one case, nephrectomy was necessary because the tumor involved the renal pedicle. One patient had pulmonary embolism and one urinary leakage conservatively managed.Pathologic examination revealed clear cell renal cell carcinoma in 58 patients, oncocytoma in one patient, and angiomyolipoma in one patient. All resection margins were free from tumor.

CONCLUSIONS

Partial nephrectomy, facilitated by robotic technology, is more and more frequently performed as a safe and effective minimally invasive procedure.

Comparison of Contrast-Enhanced Ultrasound Scan (CEUS) and MRI in the follow-up of cryoablation for small renal tumors. Experience on 25 cases

Introduction

Percutaneous ablation in the kidney is now performed as a standard therapeutic nephron-sparing option in patients who are poor candidates for resection. Its increasing use has been largely prompted by the rising incidental detection of renal cell carcinomas with cross-sectional imaging and the need to preserve renal function in patients with comorbid conditions, multiple renal cell carcinomas, and/or heritable renal cancer syndromes. To date, clinical studies indicate that cryoablation is an effective therapy with acceptable short- to intermediate-term outcomes and with a low risk in the appropriate setting. This article focuses on the efficiency of contrast enhanced ultrasound scan (CEUS) as compared to contrast enhanced magnetic resonance imaging (MRI) during the follow-up after cryoablation of small renal tumors.

Material and Methods

In our Department, percutaneous or laparoscopic assisted cryoablation is offered in the treatment of small renal masses. Between January 2009 and January 2013, 25 patients (pts) were treated with laparoscopic assisted cryoablation or percutaneous cryoablation for renal tumors <3.5 cm in pts unfit for surgery. All pts had severe comorbidities (ASA score 3). Transperitoneal laparoscopic approach was performed in 11 pts, extraperitoneal approach in 3 pts, percutaneous technique was performed in 11 patients. “Tru-cut biopsy” of the renal mass was always performed before cryoablation. The SeedNet system (Galil Medical, Arden Hills, MN) was used in 12/25 pts; the Precise system (Galil Medical, Arden Hills, MN) was used in 13/25 pts. In all cases, IceRod needles were used. Real-time ultrasound guidance was used to localize the tumour and to monitor the progression of “iceball”. A double “freeze-thaw cycle” was used. All pts had MRI and CEUS before cryoablation and the follow-up consisted in CEUS/MRI every 3 months during the first year and every 6 months thereafter.

Results

The mean age of the 25 pts was 67.7 years (range 56–79); 5 pts were females and 20 were males. The mean tumor size was 2.8 cm (range 1.5–3.5). No patient required conversion to open procedure. 19 tumors were located at the lower pole, 4 were interpolar and 2 tumors were located at the upper pole. There were no intraoperative complications. The mean hospital stay was 4 days (range 1–7). Two pts required a blood transfusion; there was no statistically significant difference between preoperative and postoperative serum creatinine levels. The biopsy showed RCC in all cases. In 24/25 patients both CEUS and MRI showed no enhancement. In 1/25 pts, during the follow-up, CEUS and MRI showed a well visible recurrence at the perfusion study. It was histologically confirmed. The final results of CEUS and MRI were concordant in all pts.

Conclusions

CEUS is effective during the follow-up of renal tumor cryoablation. It could be an alternative technique to standard CT and MRI, with some advantages: low cost, short time consuming procedure, no radiation exposure, reduced amount of contrast agent (1–2 mL) and rare adverse reactions.

Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): experience in 200 tumours

Objectives

Patients and Methods

Results

Conclusions

Robotic renal surgery: The future or a passing curiosity?

The development, advancement and clinical integration of robotic technology in surgery continue at a staggering pace. In no other discipline has this rapid evolution occurred to a greater degree than in urology. Although radical prostatectomy has grown to become the prototypical application for the robot, the role of the robot in renal surgery remains controversial. Herein we review the literature on robotic renal surgery. A comprehensive PubMed literature search was performed to identify all published reports relating to robotic renal surgery. All clinically related articles involving human participants were critically appraised in this review. Fifty-one clinical articles were included, encompassing robot-assisted pyeloplasty, nephrectomy, nephroureterectomy, living-donor nephrectomy and partial nephrectomy. Feasibility has been shown for each of these procedures. Robot-assisted techniques have been described for almost all renal-related procedures. However, the intersect between feasibility and necessity as it pertains to robotic renal surgery has yet to be defined. Also, the high cost of surgical robotic technology mandates critical appraisal before adoption, especially in a publicly funded health care system, such as the one present in Canada.

Misdiagnosis of clear cell renal cell carcinoma

Clear cell renal cell carcinoma (RCC) represents the most common histological subtype of malignant kidney tumors. Based on symptoms alone, clear cell RCC is indistinguishable from other histological classes of RCC unless the tumor is present in the context of an RCC syndrome. Histopathological examination is, therefore, important to accurately identify clear cell RCC. Clear cell RCCs have characteristic morphological criteria; these tumors can be easily identified upon typical presentation, but diagnosis can be challenging when tumor cell pattern is unusual or when availability of tissue samples is limited. In this Review, the clinical, radiological and pathological characteristics of clear cell RCCs are described, as well as the potential tumors that can be confused with clear cell RCC and need to be considered in the differential diagnoses. Finally, the importance of an accurate diagnosis is highlighted in the context of the increasing use of preoperative tissue sampling and the prevalence of clear cell tumors associated with hereditary syndromes, which could have different therapeutic and prognostic implications for patients and their families.

Incidental vs symptomatic renal tumours: Survival outcomes

Purpose

Currently there is an increase in the incidental diagnosis of renal cell carcinoma (RCC). Our aim was to assess the survival of patients with incidental and symptomatic renal tumours who had undergone nephrectomy.

Patients and methods

We retrospectively assessed 604 patients who underwent renal surgery for RCC between 1983 and 2005. Patients were divided in two groups; group 1 had incidental and group 2 had symptomatic tumours. The median follow-up was 4 and 3.3 years for groups 1 and 2, respectively. All patients had surgery in the form of radical or partial nephrectomy. Sex, age, tumour size, type of surgery, pathological characteristics and patient survival in both groups were evaluated. The statistical analysis included the log-rank, Kaplan–Meier and Cox regression tests.

Results

There were 85 patients (14%) in group 1 (mean age 49.6 years) and 519 (86%) in group 2 (mean age 50 years). The mean (SEM, range) tumour size was 7.4 (0.4, 1.5–20) cm in group 1 and 9.7 (0.2, 2–38) cm in group 2 (P < 0.001). The most common stage was T1 (52%) and T2 (44%) in groups 1 and 2, respectively, with a predominance of G2 grade and the conventional type histology in both the groups. There was a significant difference in cancer-specific survival (CSS) between the groups (log-rank, P = 0.017). The 5- and 10-year CSS was 94% and 94% for group 1, and 82.5% and 79.5% for group 2. Cox regression analysis showed that in group 1, only the tumour mid-zonal location (P = 0.093), tumour stage pT (P < 0.001), grade 1 (P = 0.03), grade 2 (P = 0.01), grade 4 (P = 0.01) and the papillary histological type (P = 0.019) had significant effects on CSS. In group 2, only tumour size (P = 0.022) and stage pN (P = 0.003) had significant effects on CSS. The tumour recurrence rate was 18% and 29% for groups 1 and 2, respectively.

Conclusions

This large study supports the findings of other smaller studies published previously, confirming that at presentation incidental renal tumours are smaller and their diagnosis provides a better prognosis and longer CSS.

Durable oncologic outcomes after radiofrequency ablation: experience from treating 243 small renal masses over 7.5 years

BACKGROUND

Long-term oncologic outcomes for renal thermal ablation are limited. The authors of this report present their experience with radiofrequency ablation (RFA) therapy for 243 small renal masses (SRMs) over the past 7.5 years.

METHODS

The authors' institutional, prospectively maintained RFA database was reviewed to determine intermediate and long-term oncologic outcomes for patients with SRMs (generally < 4 cm) who underwent RFA. Particular attention was placed on patients who had a minimum 3 years of follow-up. Patients were excluded from the analysis if they had received previous treatment for renal cell carcinoma (RCC) on the ipsilateral kidney or if they did not have at least 1 imaging study available for follow-up.

RESULTS

Two hundred eight patients (with 243 SRMs) who had no evidence of previous ipsilateral renal cancer treatment underwent RFA and had follow-up imaging studies available for review. Overall, tumor size averaged 2.4 cm, and follow-up ranged from 1.5 months to 90 months (mean, 27 months). Of the 227 tumors (93%) that underwent preablation biopsy, RCC was confirmed in 79%. The initial treatment success rate was 97%, and the overall 5-year recurrence-free survival rate was 93% (90% for 160 patients who had biopsy-proven RCC). During follow-up, 3 patients developed metastatic disease, and 1 patient died of RCC, yielding 5-year actuarial metastasis-free and cancer-specific survival rates of 95% and 99%, respectively.

CONCLUSIONS

RFA provided successful treatment of SRMs and produced a low rate of recurrence as well as prolonged metastasis-free and cancer-specific survival rates at 5 years after treatment. Although longer term follow-up of RFA will be required to determine late recurrence rates, the current results indicated a minimal risk of disease recurrence in patients who are >3 years removed from RFA.

Does preoperative symptom classification impact prognosis in patients with clinically localized upper-tract urothelial carcinoma managed by radical nephroureterectomy?

OBJECTIVES

To evaluate if preoperative symptom classification could refine prediction of outcomes for patients with clinically localized upper-tract urothelial carcinoma (UTUC) managed by radical nephroureterectomy (RNU).

METHODS

Data on 654 patients with localized UTUC who underwent RNU were reviewed. Preoperative symptoms were classified as incidental (S1), local (S2), and systemic (S3). Clinical and pathologic data were compared between the cohorts. Kaplan-Meier analyses and Cox proportional hazard modeling were used to determine recurrence-free and cancer-specific survival amongst the symptom cohorts.

RESULTS

Symptom classification was S1 in 213 (33%) patients, S2 in 402 (61%), and S3 in 39 (6%). S3 symptoms were associated with advanced pathology, including higher stage, grade, and lymph node (LN) positivity. Five and 10-year recurrence-free and cancer-specific survival estimates were similar for patients with S1 and S2 symptoms (P = 0.75 and 0.58, respectively), but was worse for patients with S3 symptoms (P < 0.001 for both). On multivariate analysis adjusting for final pathologic stage, grade, and LN status, S3 symptoms were not an independent predictor of recurrence (HR 1.44, P = 0.19) or death due to disease (HR 1.66, P = 0.07). Addition of symptom classification, however, increased the accuracy of a model consisting of stage, grade, and LNs for prediction of recurrence-free and cancer-specific survival by 1.4% and 1.3%, respectively (P < 0.001 for both).

CONCLUSIONS

Local symptoms do not confer worse prognosis compared with patients with incidentally detected UTUC. However, systemic symptoms are associated with worse outcomes despite apparently effective RNU. Patients with systemic symptoms may harbor micrometastatic disease and could potentially benefit from a more rigorous metastatic evaluation or perioperative chemotherapy regimens.

Annexin II represents metastatic potential in clear-cell renal cell carcinoma

BACKGROUND: Annexin II (ANX2) is a multi-functional protein involved in cell proliferation and membrane physiology and is related to cancer progression. The purpose of this study was to assess ANX2 expression in clear-cell (cc) renal cell carcinoma (RCC).

METHODS: The ANX2 expression in 18 primary ccRCCs was examined by real-time reverse transcriptase (RT)–PCR and western blot analyses. Furthermore, immunohistochemical study was performed using paraffin section of 154 primary ccRCCs and 24 metastases. The association between ANX2 expression and the clinicopathological factors and prognosis was analysed.

RESULTS: The ANX2 was upregulated at both mRNA and protein levels in 14 of 18 primary ccRCCs. Immunohistochemical analysis showed that ANX2 was positive in 73 (47.4%) of 154 primary ccRCC and in 21 (87.5%) of 24 metastatic tumours. The ANX2 expression in the primary tumours showed significant associations with a higher stage, a higher nuclear grade. In patients without metastasis, the 5-year metastasis-free rate in patients with ANX2-positive tumour was significantly lower than that in those with ANX2-negative tumour (63.0% vs 90.1%; P<0.0001). Multivariate analysis showed that ANX2 expression is an independent predictor for metastasis.

CONCLUSION: Our findings suggest that ANX2 expression might be a novel predictor of the metastatic potential of ccRCC.

Renal thermal ablative therapy

Energy targeting is greatly enhanced through imaging modalities, which greatly assist needle placement or energy delivery to the optimal location for maximal effectiveness. When vital structures obscure access to the renal lesion, laparoscopic mobilization of these structures with direct visualization of the tumor can increase the likelihood of ablation success and minimize complication risk. Ablative therapies are attractive because of their minimal impact on patient quality of life in addition to their morbidity and cost. Although they show promise of efficacy, they must be evaluated with long-term follow-up before they are considered the standard of oncologic care. Renal masses can be treated with a laparoscopic or percutaneous approach depending on tumor location, size, and the available technology and experience of the center.

Prognostic variables to predict cancer-related death in incidental renal tumours

OBJECTIVE

To identify, in a large multicentre series of incidental renal tumours, the key factors that could predict cancer-related deaths, as such tumours have a better outcome than symptomatic tumours and selected patients are increasingly being included in watchful-waiting protocols.

PATIENTS AND METHODS

Data from 3912 patients were extracted from three international kidney-cancer databases. Age, gender, Eastern Cooperative Oncology Group (ECOG) performance status (PS), Tumour-Node-Metastasis (TNM) stage, tumour size, Fuhrman grade, and final pathology were recorded. Benign tumours and malignant lesions with incomplete information were excluded from final analysis.

RESULTS

The mean (SD) age of the patients was 60.6 (12.2) years and the mean tumour size 5.5 (3.5) cm. Most tumours were malignant (90.2%) and of low stage (T1-T2, 71.7%) and low grade (G1-G2, 72.4%). There were nodal and distant metastases in 5.7% and 13% of the patients. In all, 525 (14.4%) patients died from cancer; in this group, tumours were >4 cm in 88.2% and had nodal or distant metastases in 20.2% and 49.3%, respectively. Multivariable analysis showed that tumour size >4 cm, ECOG PS >or=1, TNM stage and Fuhrman grade were independent predictors of cancer-related death.

CONCLUSION

A significant proportion of incidental renal tumours can lead to the death of the patient. Standard prognostic variables for renal cell carcinoma appear to remain valid for this subset of patients. A watchful-waiting strategy should not be recommended if the tumour diameter is >4 cm, if biopsy confirms high-grade tumours, or if there is an impaired ECOG PS, or computed tomography findings suggest the presence of advanced T stage.

Cryoablation for small renal masses

Advances in imaging techniques (CT and MRI) and widespread use of imaging especially ultrasound scanning have resulted in a dramatic increase in the detection of small renal masses. While open partial nephrectomy is still the reference standard for the management of these small renal masses, its associated morbidity has encouraged clinicians to exploit the advancements in minimally invasive ablative techniques. The last decade has seen the rapid development of laparoscopic partial nephrectomy and novel ablative techniques such as, radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), and cryoablation (CA). In particular, CA for small renal masses has gained popularity as it combines nephron-sparing surgery with a minimally invasive approach. Studies with up to 5-year followup have shown an overall and cancer-specific 5-year survival of 82% and 100%, respectively. This manuscript will focus on the principles and clinical applications of cryoablation of small renal masses, with detailed review of relevant literature.

Genetics and epigenetics of renal cell cancer

Renal cell carcinoma (RCC) is not a single disease, but comprises a group of tumors of renal epithelial origin, each with a different histology, displaying a different clinical course and caused by different genetic alterations. Since cure rates are inversely associated with stage and response to the available treatment regimes is limited to a subgroup of patients, diagnostic methods facilitating early detection and new therapeutic modalities are necessary. Increased knowledge of the underlying pathophysiology of RCC has resulted in the identification of genetic alterations involved in renal cell cancer carcinogenesis. Promising agents to target these pathways, especially the angiogenesis pathway, are being developed, some of which are already standard of care. In addition to genetics, knowledge on epigenetics in the process of renal tumorigenesis has been significantly increased in the last decades. Epigenetics will play an increasing role in the development of new therapeutic modalities and may deliver new prognostic and early diagnostic markers. In this review we discuss the background of RCC and the clinical applications of RCC genetics and epigenetics.

Diagnosis of Renal Lymphoma by Percutaneous Image Guided Biopsy: Experience With 11 Cases

PURPOSE

We reviewed an institutional experience with image guided percutaneous biopsy of focal renal masses that yielded a diagnosis of lymphoma.

MATERIALS AND METHODS

We retrospectively reviewed the hospital records of patients undergoing percutaneous renal biopsy between September 1997 and February 2005.

RESULTS

A total of 407 image guided focal renal lesion biopsies were identified. A diagnosis of lymphoma was made in 11 patients (3%). Biopsies were performed under computerized tomography guidance in 9 cases (82%) and under ultrasound guidance in 2 (18%). Core biopsies were performed in 11 cases, while fine needle aspiration was done in 10 (91%). Fine needle aspirations underwent cytological analysis in 10 cases and flow cytometry analysis in 9. The final combined pathological diagnoses were B-cell lymphoma in 10 cases and lymphomatoid granulomatosis in 1. Analysis of core biopsies yielded a diagnosis of B-cell lymphoma in 10 cases (91%) and lymphomatoid granulomatosis in 1. Analysis of fine needle aspirations yielded a diagnosis of B-cell lymphoma in 3 cases (30%), lymphoma in 4 (40%), suspicion of lymphoma in 1 (10%), atypical cells in 1 (10%) and a nondiagnostic sample in 1 (10%). Flow cytometry concurred with cytology in the diagnosis of B-cell lymphoma in 2 cases, allowed the identification of lymphoma subtype, which was not made on cytology, in 4, was insufficient in 2 and identified no abnormality in 1. No patients underwent surgery or an ablative procedure.

CONCLUSIONS

Core biopsy has a higher diagnostic yield than fine needle aspiration for diagnosing renal lymphoma. Flow cytometry analysis adds additional diagnostic information to cytological examination of fine needle aspiration samples. Accurate diagnosis of lymphoma in these cases allowed proper treatment without unnecessary surgery or other procedures.

Clinical symptoms in localized renal cell carcinoma reflect its invasive potential: comparative study between incidentally detected and symptomatic diseases

The objectives of this study were to analyze the association of clinical symptoms with several parameters in patients with organ-confined renal cell carcinoma (RCC), and investigate the difference in biologic characteristics between incidentally detected and symptomatic RCCs. This study included 132 patients who were pathologically diagnosed with organ-confined RCC after radical surgery, and their clinicopathologic features were compared to those in patients with incidentally detected and symptomatic diseases. In this series, 91 patients were incidentally diagnosed with RCC, while the remaining 41 had some clinical symptoms. The cause-specific survival in patients with incidental RCC was significantly higher than that in patients with symptomatic RCC, and the presence of clinical symptoms could be an independent predictor of cause-specific survival in these patients. Immunohistochemical staining of resected specimens from these patients were then performed with Ki-67, Bcl-2, matrix metalloproteinase (MMP)-2, MMP-9, and vascular endothelial growth factor antibodies. Despite the lack of differences in Ki-67, Bcl-2, and vascular endothelial growth factor expression between these 2 groups, significantly increased expressions of MMP-2 and MMP-9 in symptomatic RCCs were observed compared with those in incidental RCCs. Moreover, the presence of clinical symptoms in organ-confined RCC was significantly correlated with immunoreactivities of MMP-2 and MMP-9. These findings suggest that clinical symptoms have a significant impact on the prognosis of patients with organ-confined RCC and that the appearance of clinical symptoms may reflect the increased invasive potentials characterized by overexpression of MMPs.

Results of computerized tomography guided percutaneous ablation of renal masses with nondiagnostic pre-ablation pathological findings

PURPOSE

Ablative therapy for renal masses has been criticized because the entire tumor cannot be evaluated pathologically after the procedure. Diagnosis depends on imaging findings and the results of percutaneous needle biopsies, which may be nondiagnostic in up to 21% of cases. We determined outcomes in patients undergoing ablation who had nondiagnostic biopsies at the time of the procedure.

MATERIALS AND METHODS

A total of 79 patients (88 renal masses) underwent percutaneous computerized tomography guided biopsy and ablation of a renal mass under conscious sedation. Patients with nondiagnostic biopsies were identified and the medical records were reviewed retrospectively. All patients had an enhancing renal mass on preoperative computerized tomography or magnetic resonance imaging and all underwent postoperative contrast imaging to evaluate persistent viable tumor.

RESULTS

A total of 19 patients (20 tumors) with nondiagnostic percutaneous biopsy (22.7% or 20 of 88) were included in the study. No serious complications occurred. Tumors were treated with frequency ablation (12) or cryoablation (7). In 17 patients (89.5%) post-procedure imaging confirmed the absence of contrast enhancement at a median followup of 27.3 months (range 3 weeks to 56 months). In 2 cases (10.5%) post-procedure imaging showed a residual renal mass or recurrence with enhancement, suggesting that the original percutaneous biopsy result was false negative. In 1 patient residual tumor was identified on initial post-ablation imaging and the patient underwent laparoscopic partial nephrectomy. In another patient recurrence was diagnosed 30 months after ablation and the patient underwent laparoscopic radical nephrectomy. Although there was a nondiagnostic percutaneous biopsy in each case, pathological findings in the subsequent surgical specimen confirmed renal cell carcinoma.

CONCLUSIONS

Nondiagnostic percutaneous biopsy at renal tumor ablation does not obviate the need for standard post-procedure imaging followup. Of patients with nondiagnostic biopsies in this series 10.5% still harbored viable renal cell carcinoma after percutaneous ablation.

Incidencia creciente en el carcinoma de células renales

OBJECTIVES

To analyze the change in the behavior of renal cell carcinoma for its presentation, treatment, histology and mortality during a 17 year period.

MATERIAL AND METHOD

Retrospective study on 212 patients diagnosed with renal cell carcinoma in our Department from the year 1988 up to 2004, analyzing the clinical and demographic data and comparing them to each other according to two periods: 1988-1996 and 1997-2004.

RESULTS

An increase has been appreciated in the incidence of renal tumors in the second period and in a same way an increase in the incidental diagnosis and in the practice of nephron sparing surgery. Clear cell type was the most frequent in both periods and tumoral size was higher in the first period than in second. TNM stage I was the most frequent, although in first period it was higher percentage of stage IV. Cause-specific mortality has increased in the last years.

CONCLUSION

An increase is appreciated in the incidence of renal cell tumors. Although the diagnosis is in earlier stages, a descent in the mortality has not been found.

Intraperitoneal drop metastasis after radiofrequency ablation of pararenal tumor recurrences

We report the case of a 66-year-old woman who developed intraperitoneal drop metastasis after radiofrequency ablation of recurrent renal cell carcinoma. This patient had undergone multiple nephron-sparing procedures, including radiofrequency ablation to treat local recurrences. At routine follow-up, she was noted to have two intraperitoneal drop metastases, one in the right paracolic gutter and the other in the cul-de-sac of Douglas. The metastases were treated with complete surgical resection. To our knowledge, this is the first reported case of drop metastasis after radiofrequency ablation, drawing attention to the potential complications of this new treatment modality.

Technique for ensuring negative surgical margins during laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE

Obtaining a negative surgical margin during laparoscopic partial nephrectomy (LPN) is paramount to optimizing the oncologic efficacy of the procedure. Limitations of laparoscopy hinder the ability to extrapolate the intraparenchymal tumor extension from the exophytic portion. We developed a technique wherein ultrasound-confirmed needle localization of the deep tumor margin prior to tumor extirpation ensured negative surgical margins.

MATERIALS AND METHODS

Our technique was developed and initially tested using an agar-based ultrasound phantom designed to mimic 2-cm exophytic renal tumors. Needle placement was imaged with ultrasonography and subsequently correlated with findings on sectioning of the tumor mimic. Laparoscopic extirpation of the tumor mimic following needle placement was carried out in a pelvic trainer. The technique has subsequently been incorporated into our LPN technique in four patients.

RESULTS

Ultrasound-confirmed needle localization of intraparenchymal tumor extension was feasible and reproducible in an ultrasound phantom. Ultrasound findings correlated with gross findings. Needle placement prior to tumor resection helped to ensure negative surgical margins when applied in the pelvic trainer and when used in three patients. In the remaining patient, improper needle placement resulted in a grossly positive deep margin.

CONCLUSION

Ultrasound-confirmed needle placement effectively and reproducibly marks the deep margin of small renal tumors in a mimic as well as in vivo. Our needle technique eliminates the guesswork and unreliability associated with mental visualization and extrapolation of tumor extent during LPN.

The natural history of small renal masses

The incidence of renal cell carcinoma is increasing, in part due to the growing use of cross-sectional imaging. Most renal tumors are now incidentally detected as small masses in asymptomatic patients. A minority of small renal masses, presumed to be renal cell carcinoma, grow significantly over time if managed conservatively, but the growth rate of the majority is slow or undetectable. In the absence of other prognostic factors, measurement of tumor growth rate can be helpful for initial conservative management of selected patients with small renal tumors. To date, there have been no reports of progression to metastatic disease occurring during active surveillance, but longer follow-up is needed to confirm this observation. The standard of care for small localized renal neoplasms is partial or radical nephrectomy. At the present time, active surveillance of small renal masses, with delayed therapy for patients whose disease progresses, is an experimental approach that can be considered for the elderly or patients with significant comorbidity. Renal core biopsy and fine-needle aspiration can provide essential information for treatment decision-making and should therefore be considered in the diagnostic work-up of all small renal masses. In future, the identification of prognostic indicators, with the use of new techniques including functional imaging and molecular or genomic characterization of tissue from needle biopsies, are expected to help clinicians differentiate between indolent and potentially aggressive small renal tumors.

Long-term followup of patients with renal cell carcinoma treated with radio frequency ablation with curative intent

PURPOSE

We defined the role of radio frequency ablation in the treatment of renal cell carcinoma.

MATERIALS AND METHODS

A total of 16 patients with biopsy proven renal cell carcinoma were treated with radio frequency ablation in an outpatient setting and followed for a minimum of 4 years.

RESULTS

Of the 16 patients 5 died before 4 years of followup of unrelated causes. All except 1 tumor was successfully treated. All patients with exophytic tumors were successfully treated.

CONCLUSIONS

Radio frequency ablation of exophytic renal cell carcinomas less than 5 cm in diameter is effective in eradicating the tumor and comparable to surgical extirpation at 4 years.

[Incidentally detected renal cancer. Prognostic factors]

OBJECTIVE

To study the clinical and pathological characteristics of incidental renal tumors treated in our center.

MATERIAL AND METHODS

A retrospective review is conducted of 318 nephrectomies comparing the clinico-pathological variables of renal tumors diagnosed incidentally with those of symptomatic renal tumors. The factors influencing disease-free survival are analyzed in both groups.

RESULTS

In our experience, although incidental renal tumors presented better survival than symptomatic ones owing to their better pathological state and tumor grade, incidental diagnosis was not an independent influencing factor in the multivariate study. Only when patients were studied who did not present metastases on diagnosis did incidental diagnosis become an influencing factor very close to statistical significance.

CONCLUSIONS

Incidental diagnosis is not an independent prognostic factor.

Quantitative detection of promoter hypermethylation of multiple genes in the tumor, urine, and serum DNA of patients with renal cancer

Aberrant promoter hypermethylation of several known or putative tumor suppressor genes occurs frequently during the pathogenesis of human cancers and is a promising marker for cancer detection. We investigated the feasibility of detecting aberrant DNA methylation in the urine and serum samples of renal cancer patients. We examined the tumor and the matched urine and serum DNA for aberrant methylation of nine gene promoters (CDH1, APC, MGMT, RASSF1A, GSTP1, p16, RAR-beta2, and ARF) from 17 patients with primary kidney cancer by quantitative fluorogenic real-time PCR. An additional 9 urine samples (total, 26) and 1 serum sample (total, 18) also were tested from renal cancer patients. Urine from 91 patients without genitourinary cancer and serum from 30 age-matched noncancer individuals were used as controls. Promoter hypermethylation of at least two of the genes studied was detected in 16 (94%) of 17 primary tumors. Aberrant methylation in urine and serum DNA generally was accompanied by methylation in the matched tumor samples. Urine samples from 91 control subjects without evidence of genitourinary cancer revealed no methylation of the MGMT, GSTP1, p16, and ARF genes, whereas methylation of RAR-beta2, RASSF1A, CDH1, APC, and TIMP3 was detected at low levels in a few control subjects. Overall, 23 (88%) of 26 urine samples and 12 (67%) of 18 serum samples from cancer patients were methylation positive for at least one of the genes tested. By combination of urine or serum analysis of renal cancer patients, hypermethylation was detected in 16 of 17 patients (94% sensitivity) with high specificity. Our findings suggest that promoter hypermethylation in urine or serum can be detected in the majority of renal cancer patients. This noninvasive high-throughput approach needs to be evaluated in large studies to assess its value in the early detection and surveillance of renal cancer.

Multi-institutional validation of a symptom based classification for renal cell carcinoma

PURPOSE

We validate the prognostic value of a symptom based classification (S classification) in a multi-institutional study.

MATERIALS AND METHODS

A total of 2,242 patients from 5 European centers were included in this study. Based on symptoms at diagnosis, patients were stratified into 3 groups of S1-asymptomatic tumors, S2-tumors with local symptoms and S3-tumors with systemic symptoms. Variables such as age, gender, tumor size, TNM stage, Fuhrman grade, Eastern Cooperative Oncology Group (ECOG) performance status, perinephric fat, renal vein and adrenal invasion were also considered for prognostic value. The end point of the study was cancer specific survival. Survival assessment was made with univariate and multivariate analyses using the Kaplan-Meier method and Cox regression analysis.

RESULTS

Of the patients 1,018 (45.4%) were classified as S1, 865 (38.6%) S2 and 339 (16.0%) S3. The S classification correlated to tumor stage, grade and ECOG (p <0.001). On univariate analysis ECOG performance status, S classification, tumor size, TNM stage, Fuhrman grade, and adrenal, perinephric fat or vein invasion were significant prognostic factors (p <0.001). The S classification provided a significant prognostic stratification in the aggregate as well at each of the 5 centers. On multivariate analysis the S classification, TNM stage, Fuhrman grade, and perinephric fat and renal vein invasion remained independent prognostic factors (p <0.001).

CONCLUSIONS

This study confirms that it is possible to graduate symptoms for a prognostic purpose. The proposed symptom score should be evaluated for its integration in prognostic algorithms.

The Changing Evolution of Renal Tumours: A Single Center Experience over a Two-Decade Period

OBJECTIVES

To study the evolution of renal tumours treated in a single institution over a 2-decade period.

MATERIAL AND METHODS

729 patients surgically treated due to a renal tumour were included in this study. Age at diagnosis, gender, tumour size, TNM stage, percentage (%) of benign tumours, type of treatment, histologic subtype and mode of presentation were compared over 3 periods (1984-1992, 1993-1997, and 1998-2003).

RESULTS

During the period of the study, the median tumour size decreased from 7.5 to 6 cm while the rate of nephron-sparing surgery (NSS) increased from 1.6 to 19.6% and from 3.1 to 46.9% in all tumours and in tumours measuring less than 4 cm respectively. In this former group, the percentage of benign tumours increased from 6.3 to 15.2% while the percentage of radical nephrectomies decreased from 100% to 54.2%.

CONCLUSION

We are treating today a great amount of small good prognosis renal tumors as well as an increasing percentage of benign tumours. In both cases, expanding the role of NSS will significantly reduce the rate of useless radical nephrectomies.

The natural history of incidentally detected small renal masses

BACKGROUND

The incidence of renal cell carcinoma (RCC) is increasing, largely due to the widespread use of cross-sectional imaging. Most renal tumors are detected incidentally as small, asymptomatic masses. To study their natural history, the authors prospectively followed a series of patients with this type of lesion who were unsuited for or refused surgery.

METHODS

Twenty-nine patients with 32 masses that measured < 4 cm in greatest dimension (25 solid masses and 7 complex cystic masses) were studied. The primary outcome was tumor size, which was calculated as volume over time. All patients were followed with serial abdominal imaging, and each mass had at least three follow-up measurements. The median follow-up was 27.9 months (range, 5.3-143.0 months).

RESULTS

Overall, the average growth rate did not differ statistically from zero growth (P = 0.09; 95% confidence interval, - 0.005-0.2 cm per year) and was not associated with either initial size (P = 0.28) or mass type (P = 0.41). Seven masses (22%) reached 4 cm in greatest dimension after 12-85 months of follow-up. Eight masses (25%) doubled their volumes within 12 months. Overall, 11 masses (34%) fulfilled 1 of these 2 criteria of rapid growth. Nine tumors were removed surgically after an average of 3.1 years of follow-up because it was believed that they were growing fast. No patient had disease progression.

CONCLUSIONS

Approximately one-third of small renal masses that are presumed RCCs grow if they are managed conservatively and are followed with serial imaging. The growth rate is slow or undetectable in the majority of patients. These observations raise the possibility of a period of initial observation in selected patients, particularly the elderly or infirm.