Long-term follow-up of bilateral sporadic renal tumors

Impact of tumor multiplicity on the prognosis of patients with primary renal cell carcinoma: a SEER database analysis

To compare clinical characteristics and survival outcomes of patients with multiple renal cell carcinoma versus single renal cell carcinoma. Develop a prognostic model for predicting prognosis in patients with multiple tumors and analyze prognostic factors. Patients with primary multiple renal cell carcinoma were selected from the Surveillance, Epidemiology, and End Results database (2004-2015). They were divided into single-tumor and multiple-tumor groups. Survival analysis was conducted using the Kaplan-Meier method and log-rank test. A Cox regression model was used to identify potential prognostic factors. A total of 19,489 renal cell carcinoma cases were included, with 947 in the multiple-tumor group and 18,542 in the single-tumor group. The multiple-tumor group had lower cancer-specific survival (P = 0.03, HR = 1.431). Cox regression identified risk factors for the multiple-tumor group including number of tumors, gender, combined summary stage, T stage, N stage, tumor size, and type of surgery. The predicted probabilities showed acceptable agreement with the actual observations at 3-, 5-, and 8-years area under the curve values in both the training and validation cohorts (0.831 vs. 0.605; 0.775 vs. 0.672; and 0.797 vs. 0.699, respectively). Compared with single renal cell carcinoma, multiple renal cell carcinoma is associated with decreased cancer-specific survival. Additionally, we identified several prognostic factors including the number of tumors, T stage, tumor size, and type of surgery. These findings offer valuable insights for selecting appropriate treatment strategies for patients diagnosed with multiple renal cell carcinomas.

Surgical Management of Synchronous, Bilateral Renal Masses: A 1-decade Referral Center Experience

BACKGROUND

Management and decision-making in patients with bilateral renal masses are controversial.

OBJECTIVE

To report our experience of surgical management in patients with bilateral renal masses undergoing surgery at a high-volume center.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively collected data from patients treated with partial nephrectomy (PN) or radical nephrectomy for bilateral renal masses at a single referral institution between June 2008 and June 2019. Patient- and tumor-related features, timing (one vs two stage), and surgical approach (open vs robotic) were analyzed.

SURGICAL PROCEDURE

A one- versus two-stage strategy was adopted according to the opportunity to perform at least one PN using a clampless or selective-clamping approach, in order to avoid acute kidney injury.

MEASUREMENTS

Operative time, warm ischemia time, and intra- and postoperative complications were recorded. Histopathological results and tumor histology were assessed.

RESULTS AND LIMITATIONS

Overall, 41 patients were included. The median age was 67 yr and the median preoperative estimated glomerular filtration rate (eGFR) was 84 ml/min/1.73 m². The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 8 (interquartile range [IQR] 7-8) for both sides. In 17 (42%) patients, a simultaneous approach was chosen, with a pure robotic approach in 11/17 cases, while among the 24 (58.6%) patients treated with a two-stage strategy, 15 (62.5%) were treated with a robotic approach on both sides. Intraoperative complications and postoperative major (CDC ≥3) complications were recorded in 7.3% and 4.9% of cases, respectively. The overall positive surgical margins rate was 2.4%. At a median follow-up of 42 (IQR 18-59) mo, the median eGFR was 73 (IQR 64-80) ml/min/1.73 m², while disease-free survival and cancer-specific mortality were 90.2% and 7.3%, respectively.

CONCLUSIONS

Our experience underlines that both simultaneous and staged surgical treatment of patients with bilateral renal masses are feasible and safe if grounded on proper patient selection.

PATIENT SUMMARY

Management of patients with bilateral renal masses is challenging, given the heterogeneity of clinical scenarios and the need to optimize the timing of treatment to achieve maximal functional preservation while ensuring oncological efficacy.

Simultaneous robot-assisted approach in a super-elderly patient with urothelial carcinoma and synchronous contralateral renal cell carcinoma: A case report

BACKGROUND

It is rare for urothelial and renal cell carcinomas to coexist in the same patient, and even rarer for them to be detected simultaneously. Because of this rarity, a standard treatment has not been established and studies about overall survival are scarce. Therefore, physicians must modify treatments according to the individual’s situation and the stage of each disease. In recent years, with advances in the instruments and techniques, minimal invasive robotic surgeries have become available for advanced-stage or high-risk patients.

CASE SUMMARY

An 85-year-old woman with a medical history of hypertension and hyperlipidemia visited our institution. She had visited her local hospital complaining of intermittent, painless, gross hematuria that had started 3 mo earlier. On computed tomography, a right renal mass and left proximal ureteral mass with hydronephrosis were found simultaneously. We decided to perform robot-assisted surgery on both sides during one operation. Considering renal function and kidney loading, right partial nephrectomy was performed first, followed by left nephroureterectomy with bladder cuff excision. At the 6-mo follow-up, no specific symptoms were reported and dialysis was not considered. There were no unusual findings in the imaging study, and regular follow-up and imaging studies are scheduled.

CONCLUSION

This case report assessed the feasibility of simultaneous minimal invasive robotic surgery as an alternative to conventional open or laparoscopic surgery.

Unilateral synchronous papillary renal neoplasm with reverse polarity and clear cell renal cell carcinoma: a case report with KRAS and PIK3CA mutations

Background

The presence of histologically different neoplasms in the same organ is rare in pathologic practice. We report the first case of synchronous clear cell renal cell carcinoma (clear cell RCC) and papillary renal neoplasm with reverse polarity (PRNRP) with comprehensive immunohistochemical and molecular characterization using next-generation sequencing (NGS).

Case presentation

A 61-year-old man was incidentally found to have a left renal mass on imaging studies performed for workup of left back pain and urine color change for 1 week. A laparoscopic left radical nephrectomy was performed. Gross examination showed lobulated masses measuring 5.6 × 4.0 × 3.3 cm in the upper to mid pole and 1.1 × 1.0 × 1.0 cm in the lower pole. Microscopic findings revealed these to be two different separate masses of clear cell renal cell carcinoma and papillary renal neoplasm with reverse polarity. NGS analyses revealed KRAS gene mutation (c.35G > T/p.G12V in exon 2) in the papillary renal neoplasm with reverse polarity, with PIK3CA gene mutation restricted to the clear cell renal cell carcinoma (c.1624G > A/p.E542K in exon 10).

Conclusions

We report here an extraordinarily rare case of synchronous renal tumors of papillary renal neoplasm with reverse polarity and clear cell renal cell carcinoma. We identified simultaneous KRAS and PIK3CA mutations in two different renal masses in the same kidney for the first time. New pathologic assessment with comparative molecular analysis of mutational profiles may be helpful for tumor studies.

Simultaneous versus staged partial nephrectomies for bilateral synchronous solid renal masses

OBJECTIVES

The optimal management approach for synchronous bilateral renal masses is unknown, particularly regarding surgical sequencing of bilateral partial nephrectomy (PN). We evaluated the impact of simultaneous vs. staged bilateral PN on renal functional, perioperative, and oncologic outcomes.

PATIENTS AND METHODS

We reviewed our institutional nephrectomy registry to identify patients who underwent simultaneous or staged (within 6 months) bilateral PN for nonmetastatic bilateral synchronous solid renal masses between 1980 and 2015. Short-term and long-term renal function changes were assessed at 3 and 12 months, respectively. Perioperative outcomes were pooled across staged surgeries by taking the sum of each outcome. Local recurrence-free, distant metastases-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier method. Outcomes were compared by surgical sequencing approach. A sensitivity analysis was performed that grouped approaches by preoperative intent.

RESULTS

Among the 107 patients studied, 77 (72%) underwent simultaneous and 30 (28%) underwent staged PN. The majority of PN were performed by open approach. Clinicopathologic features were similar between groups. Patients who underwent simultaneous PN had lower mean short-term (-6% vs. -24%, P = 0.015) and median long-term (-4% vs. -22%, P < 0.001) reduction in eGFR vs. staged PN, respectively. Furthermore, patients with simultaneous PN had lower pooled length of stay (median 6 vs. 8 days, P < 0.001), rate of urine leak (3% vs. 17%, P = 0.018), and rate of high-grade complications (8% vs. 23%, P = 0.044), relative to staged PN, respectively. However, on sensitivity analysis, only differences in long term reduction in estimated glomerular filtration rate and length of stay remained. There were no significant differences in oncologic outcomes between groups.

CONCLUSIONS

Our results suggest that when technically feasible, simultaneous PN yields comparable outcomes vs. staged PN, offering a reasonable surgical sequencing approach for patients presenting with bilateral synchronous renal masses.

Pathological heterogeneity in sporadic synchronous renal tumors: Is the histological concordance predictable?

OBJECTIVE

To evaluate the pathological concordance rate of multiple synchronous renal masses (MSRM) presumed to be sporadic and to analyze predictive factors of concordance.

MATERIAL AND METHODS

We identified from our institutional database patients with sporadic MSRM treated at our center between January 2000 and December 2015. All tumors were reviewed by a dedicated uropathologist. Pathological concordance rate was analyzed regarding clinical characteristics and preoperative imaging.

RESULTS

We included 112 patients: 50 had unilateral synchronous renal masses and 62 bilateral synchronous renal masses. A total of 291 tumors were analyzed, with an average of 2.6 tumors per patient. Overall, the malignant concordance rate was 91.6%, the pathological concordance rate was 67.3% and the grade concordance rate was 62.5%. In univariate analysis, predictive factors of histological concordance were bilateral synchronous renal masses (odds ratio [OR] = 3.39; 95% CI: 1.06-10.8; P = 0.04), age<60 years (OR = 3.04; 95% CI: 1.2-7.7; P = 0.02) and ≥3 lesions (OR = 2.41; 95% CI: 1.03-5.68; P = 0.04). In multivariate analysis, age<60 remained significantly associated with histological concordance (OR = 3.84; 95% CI: 1.24-11.9; P = 0.02).

CONCLUSIONS

The histological concordance rate of MSRM is low. Age at diagnosis <60 years, bilateral lesions and ≥3 tumors are predictive factors of histological concordance, but the pathological diagnosis remains difficult to predict. This heterogeneity is important to take into account, particularly when choosing the treatment upon the renal biopsy results from a single lesion.

Bilateral renal cancers: oncological and functional outcomes

PURPOSE

The authors assessed the characteristics of bilateral renal cancers.

METHODS

From January 1995 to January 2015, 65 patients underwent surgery for bilateral renal cancers. Thirty-four of the patients had 36 synchronous tumors, while the remaining 29 had metachronous tumors. The mean age of the patients was 60 ± 11 years. There were 22 females and 43 males. In all cases, bilateral partial nephrectomies or unilateral nephrectomy and contralateral nephron-sparing surgery were performed.

RESULTS

The mean sizes of the synchronous tumors were 5.0 ± 2.7 and 4.7 ± 3.0 cm at the first and the second operations, respectively. The average diameters of the metachronous carcinomas were 6.6 ± 3.0 and 3.1 ± 1.6 cm at the initial and the second surgeries, respectively. Histologic concordance was 91.1 % in the synchronous and 96.5 % in the metachronous tumors. The mean postoperative creatinine levels increased by 116 %, while the GFR decreased by 44.8 % in synchronous tumors at the second operation. The mean postoperative creatinine levels increased by 42 %, while the GFR decreased by 30.4 % in metachronous carcinomas at the second operation. The mean follow-up time was 4.8 ± 3.7 years. During this period, distant metastases occurred in two patients with synchronous tumors and in six cases with metachronous tumors. Local recurrences were detected in one case of synchronous tumor and in four patients with metachronous carcinomas. The 5-year overall and tumor-specific survivals were 53 and 80 %, respectively.

CONCLUSIONS

In patients with bilateral renal carcinomas, the histologic concordance was 93.6 %. The bilateral partial nephrectomies or unilateral nephrectomy and contralateral resection provided acceptable oncological and functional outcomes.

Bilateral Synchronous Sporadic Renal Cell Carcinoma: Retroperitoneoscopic Strategies and Intermediate Outcomes of 60 Patients

OBJECTIVE

To evaluate the presentation, management, pathology, and functional and oncological outcomes of patients undergoing retroperitoneoscopic treatment of bilateral synchronous sporadic RCC at our institution.

METHODS

We retrospectively evaluated the records of 60 patients with bilateral synchronous sporadic RCC who underwent retroperitoneoscopic treatment at the General Hospital of People's Liberation Army from 2008 to 2014. The estimated glomerular filtration rate was calculated and compared among different surgical procedures. The overall survival and recurrence free survival were assessed based on information from recent follow-up.

RESULTS

Fifty-six patients underwent bilateral retroperitoneoscopic surgeries in staged procedures, and four patients underwent bilateral retroperitoneoscopic surgeries in simultaneous procedures. Among the former group of patients, 34 underwent bilateral partial nephrectomy, 12 underwent radical nephrectomy followed by partial nephrectomy, and 10 underwent partial nephrectomy followed by radical nephrectomy. Bilateral partial nephrectomy can better preserve renal function (p = 0.040) and the sequence of partial nephrectomy and radical nephrectomy did not affect functional outcomes (p = 0.790). One patient undergoing simultaneous procedures developed acute renal failure and required temporary hemodialysis. At 3 and 5 years, overall survival rates were 93.0% and 89.4%, and recurrence free survival rates were 90.5% and 81.6%. High nuclear grade (p = 0.014) was related to disease recurrence.

CONCLUSIONS

Staged bilateral partial nephrectomy was efficient in preserving renal function. The survival of patients with bilateral synchronous sporadic renal tumors was similar to that of patients with unilateral nonmetastatic tumors. Nuclear grade was an independent prognostic factor of disease recurrence.

Open mini-flank partial nephrectomy: an essential contemporary operation

Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.

Coexisting papillary and clear renal cell carcinoma in the same kidney

Renal cell carcinoma (RCC) is the most common solid lesion of the kidney. Bilateral synchronous benign and malignant renal tumors have been defined in some reports. However, unilateral concordance of malignant renal tumors is very rare and there are only a few cases that had synchronous different subtypes of malignant renal tumors arising within the same kidney. Herein, we describe a 67-year-old male patient who had clear cell RCC and papillary RCC in his right kidney that were successfully treated with radical nephrectomy. We also reviewed the pertinent literature.

Partial nephrectomy achieves local tumor control and prevents chronic kidney disease

Over the last 10 years, a rapidly changing clinical landscape has created an optimal environment to expand the use of partial nephrectomy for the treatment of renal cortical tumors. The main factors responsible for the increasing use of partial nephrectomy relate to the appreciation of the diversity of renal cortical tumor histology, the tumor stage and size migration associated with their incidental detection, and the oncological efficacy of partial nephrectomy for tumors of 7 cm or smaller. Evidence has now emerged that radical nephrectomy performed during the treatment of a small renal mass may further reduce an already impaired baseline renal function and place the patient in the realm of chronic kidney disease. Important new information concerning chronic kidney disease, a condition far more prevalent in the aging US population than previously appreciated, and its associated cardiovascular morbidity and mortality, now places maximal renal functional preservation on a par with local tumor control as surgical plans are formulated for the resection of a small renal cortical tumor.

Pathological concordance and surgical outcomes of sporadic synchronous unilateral multifocal renal masses treated with partial nephrectomy

PURPOSE

Patients with unilateral synchronous multifocal renal masses represent a unique population with renal cell carcinoma. While pathological concordance rates have been studied for bilateral cases, limited data exist on unilateral multifocal disease. We characterized pathological concordance rates in this population and evaluated the outcomes of nephron preservation.

MATERIALS AND METHODS

Patients who underwent surgery from 2000 to 2012 for unilateral synchronous multifocal renal masses were identified from a prospectively maintained database. Demographic, surgical and pathological outcomes of this cohort were analyzed. Malignant concordance rates were defined as agreement of all malignant tumor types in a single renal unit. Histological concordance was defined as agreement of all resected mass histologies, eg all clear cell carcinomas. Nuclear grade was considered concordant if all tumors excised were low (Fuhrman 1 or 2, type 1) or high (Fuhrman 3 or 4, type 2) grade.

RESULTS

Using our institutional database of 2,569 patients with renal tumors we identified 97 with unilateral synchronous multifocal renal masses. Malignant and benign concordance rates were 77.2% and 48.6%, and histological and grade concordance rates were 58.8% and 51.5%, respectively. In this cohort we identified 76 patients (76.3% male) with a median age of 62.5 years who had a total of 241 unilateral synchronous multifocal renal masses and underwent nephron sparing surgery. Median mass size was 2.0 cm (IQR 1.1-3.1), there was a median of 3 tumors per patient and median followup was 24 months (IQR 13-40). Identified renal cell carcinoma histologies included clear cell in 49.4% of cases, papillary in 33.5%, mixed in 4.5% and chromophobe in 2.8%.

CONCLUSIONS

In what is to our knowledge the largest published report of unilateral synchronous multifocal renal masses we document low pathological concordance rates. As such, percutaneous biopsy of a single renal mass in these patients may not help inform treatment decisions. Nephron sparing surgery may be performed with acceptable oncological and functional results in patients with unilateral synchronous multifocal renal masses.

Use of tyrosine kinase inhibitors in patients with metastatic kidney cancer receiving haemodialysis: a retrospective Italian survey

What's known on the subject? and What does the study add? Sunitinib and sorafenib are orally administered multikinase inhibitors approved for the treatment of advanced RCC. The limited pharmacokinetics data on sunitinib and sorafenib suggest that haemodialysis does not significantly alter plasma concentrations. In this retrospective study we define the safety and efficacy of tyrosine kinase inhibitors in patients with metastatic RCC (mRCC) and end-stage renal disease requiring haemodialysis. Even though the retrospective nature of this survey and the relatively small sample size represent major limitations, these data indicate that treatment with sunitinib and sorafenib in this cohort of patients is feasible with no unexpected toxicity and good efficacy, results similar to those in the general population of patients with mRCC.

OBJECTIVE

To investigate the safety and efficacy of tyrosine kinase inhibitors (TKIs) in patients with metastatic renal cell carcinoma (mRCC) and end-stage renal disease requiring haemodialysis (HD).

PATIENTS AND METHODS

Between July 2006 and December 2010, 24 patients undergoing HD were treated with sunitinib and/or sorafenib for mRCC in 14 Italian institutions. We retrospectively reviewed the medical records of these patients to evaluate the administered doses of TKIs, treatment-related toxicities and the clinical response to therapy.

RESULTS

Sunitinib was administered at 50 mg daily for 4-6 weeks in six patients, 37.5 mg daily for 4-6 weeks in seven patients (one patient subsequently increased the dose to 50 mg daily), 25 mg daily for 4-6 weeks in two patients and 12.5 mg daily for 4-6 weeks in one patient. Among the eight patients treated with sorafenib, four patients received 800 mg daily (400 mg every 12 h), three patients 400 mg daily and one patient 200 mg daily with a continuous schedule. The estimated median progression-free and overall survival periods of this cohort of patients were 10.3 months and 22.6 months, respectively. With regard to tolerability and safety, no unexpected adverse events were registered and no grade 4 haematological or non-haematological toxicities were reported.

CONCLUSIONS

Sunitinib and sorafenib treatment is not contraindicated in patients with mRCC undergoing HD. The outcome of this patient population is similar to that observed in patients with normal renal function treated with TKIs. These results merit further confirmation by a larger prospective trial.

Simultaneous bilateral single-port radical nephrectomies

The management of bilateral enhancing renal masses can be technically challenging. Simultaneous bilateral laparoscopic nephrectomies in postrenal transplant patients have been previously described, but these typically require multiple port placements in addition to a hand port. Herein, we describe simultaneous bilateral single-port laparoscopic radical nephrectomies in a postrenal transplant patient.

Bilateral synchronous sporadic renal tumors: pathologic concordance and clinical implications

OBJECTIVE

To determine the pathologic concordance rates in patients with bilateral synchronous sporadic renal tumors (BSSRT) and to determine factors predictive of concordance.

METHODS

A retrospective chart review from 1985 to 2008 was completed with search criteria of all patients diagnosed with bilateral renal tumors. We included patients who had image-documented BSSRT or via reported history. We excluded patients with bilateral metachronous renal tumors, cystic renal masses, familial renal cell carcinoma (RCC) syndromes, urothelial cell carcinomas, and other variant histology. Univariate and multivariate analysis were conducted to assess for factors predictive of concordance.

RESULTS

We identified 297 patients eligible for analysis. RCC concordance was exhibited in 222 of 249 (89%) of patients. Benign tumor concordance, specifically oncocytoma, was found in 41 of 59 (71%) of patients. Factors such as age, gender, and tumor size on imaging did not have an association with concordance rates for bilateral RCC or bilateral oncocytoma. On multivariate analysis, multifocal tumors were associated with benign concordance (OR = 6.9, 95% CI = 1.6-29.2, P = .009).

CONCLUSION

Malignant and benign concordance rates are high for patients with BSSRT. Given the high concordance of RCC, the data support a management approach consisting of bilateral nephron-sparing surgery whenever possible. However, given the high concordance rate of oncocytoma in this population as well, less aggressive management (renal mass biopsy and surveillance) of the contralateral kidney may be considered after histologic confirmation of one side.

The role of surgery in the management of early-stage renal cancer

There were an estimated 58,240 new cases and 13,040 deaths from kidney cancer in the United States in 2010. The increased treatment and cure of small, incidentally discovered renal tumors, most of which are nonlethal in nature, has not offset the increased mortality caused by advanced and metastatic tumors. In this article, the optimum approach to the surgical management of localized renal tumors and its impact on renal function are discussed.

The impact of germline BHD mutation on histological concordance and clinical treatment of patients with bilateral renal masses and known unilateral oncocytoma

PURPOSE

Managing oncocytoma in the setting of bilateral renal masses is a challenging scenario. Nevertheless, to our knowledge the pathological concordance of an oncocytic neoplasm in 1 kidney with tumors in the contralateral kidney is not known. We evaluated the influence of germline Birt-Hogg-Dubé mutation on concordance rates to assist in managing these cases.

MATERIALS AND METHODS

We reviewed the records of patients at the National Institutes of Health between 1983 and 2009 who had bilateral renal masses, known pathology bilaterally and oncocytoma or an oncocytic neoplasm in at least 1 kidney. Oncocytoma or an oncocytic neoplasm in 2 renal units was considered concordant. Demographic, pathological and clinical data were collected.

RESULTS

The population consisted of 40 patients, including 23 with and 17 without a diagnosis of Birt-Hogg-Dubé syndrome. Patients with the syndrome were younger (p <0.01) but there were no other differences between the 2 groups. However, patients with the syndrome had statistically lower histological concordance between bilateral masses than patients without the diagnosis (Fisher's exact test p <0.01). Also, the 8 patients without Birt-Hogg-Dubé syndrome who had multifocal renal masses showed 100% oncocytoma concordance between renal units.

CONCLUSIONS

Of patients with bilateral renal masses those with Birt-Hogg-Dubé syndrome have significantly lower histological concordance than those without the syndrome. Patients with Birt-Hogg-Dubé syndrome should be monitored and treated differently than those without detected genetic mutations, especially patients with multifocal oncocytomas. Genetic testing for Birt-Hogg-Dubé should be considered in the treatment algorithm of patients with bilateral renal masses and known oncocytoma.

Long-term management of bilateral, multifocal, recurrent renal carcinoma

Patients with bilateral multifocal renal cell carcinoma are at increased risk of developing locally recurrent or de novo tumors after nephron-sparing procedures. When dealing with recurrent renal masses the options are limited to observation, total nephrectomy, ablation, or repeat surgical intervention. The main reason for recurrence after nephron-sparing surgery is likely to be the presence of multifocal disease, which is identified in 4.3-25.0% of radical nephrectomy specimen. Bilateral renal involvement is seen in almost 90% of cases of multifocal renal carcinoma, and conversely the majority of patients with bilateral disease will have multifocal tumors. Many patients who are treated for multifocal disease, therefore, require subsequent surgical interventions. The outcome data for repeat renal interventions demonstrate reasonable functional and oncologic outcomes despite higher rates of perioperative complications. Our own results support the use of reoperative renal surgery rather than total nephrectomy and renal replacement therapy.

[Surgical treatment for renal cancer metastases]

Complete removal of metastatic lesions can contribute to improve clinical prognosis of renal cancer. Nowadays, it is accepted that surgical extirpation of solitary metastases for patients with renal cancer is the only potential for long-term survival. Provided that the metastases could be technical and functionally resected. This review addresses the current evidence about resecable renal cancer metastases at lung, liver, bone, kidney and other organs. The criteria to consider a patient as candidate for resection of metastases are: control of primary tumor, surgical extirpation feasibility and lack of systemic disease. In patients with synchronous metastases, the surgical extirpation should be performed at the same time than nephrectomy. The clinical prognosis is worse when metastases are asynchronous. After the introduction of novel anti-angiogenic agents, surgery is also justified in patients with good responses. Although, this approach remains in the field of investigation.

The contemporary role of surgery in kidney cancer

The diagnosis and treatment of renal cell carcinoma (RCC) has been the subject of major changes since the late 1980s. Initially, surgery was the only treatment available, but more recently, systemic therapies have been developed, and their introduction has modified some of the surgical indications for rcc. In addition, refinements in surgical technique and the introduction of minimally invasive approaches have revolutionized patient care and bear the promise of even more improvements to come. This paper provides an up-to-date overview of recent developments in the surgical treatment of RCC.

Radiologic evaluation of small renal masses (II): posttreatment management

The increase in the detection of small renal masses (SRMs) and their best knowledge leads to a change in the therapeutic management of these lesions. The use of a less aggressive surgical technique or even an expectant attitude is the current tendency, in order to preserve as much renal function as possible. Imaging techniques are essential in the followup of these lesions. It allows us to know the postsurgical changes and possible complications due to treatment and the presence of local recurrence and metastases. Furthermore, a close radiological followup of SRM related to ablative treatments is mandatory. The purpose of this article is to reveal the imaging features of complications due to surgical or ablative treatments, local recurrence and metastasis, as well as their followup.

[Prognostic factors in localised and regionally advanced renal cell carcinoma]

In the last 10 years, several factors have been identified to confer a prognostic effect on renal cancer outcome. Pathologic stage, nuclear and histologic grade are the most frecuent studied and the most important at this moment. We evaluated those factors and introduced some others, looking for new parameters that could be useful. 96 cases of non methastatic renal cell cancer were included in our study. We found that as was mentioned by other authors pathologic and Furhman stage are the stronger prognostic factors but the presence of palpable tumor, pain and weight lost had significance too.

The impact of temporal presentation on clinical and pathological outcomes for patients with sporadic bilateral renal masses

BACKGROUND

The origin of bilateral renal masses has not been definitively established to date. As limited studies on the genetics of bilateral tumors exist, defining the clinical behavior of these lesions remains important.

OBJECTIVE

To evaluate the impact of synchronous versus metachronous presentation on clinicopathological outcomes of patients with bilateral renal masses.

DESIGN, SETTING, AND PARTICIPANTS

We identified 310 patients who were treated at the Mayo Clinic for sporadic bilateral renal masses between 1970-2003, including 148 (47.7%) with synchronous tumors and 162 (52.3%) with metachronous lesions.

INTERVENTION

Patients underwent surgical resection of bilateral renal tumors.

MEASUREMENTS

Clinicopathological features of synchronous and metachronous tumors were compared. Survival rates for patients with synchronous (n=92) and metachronous (n=100) renal cell carcinoma (RCC) were estimated using the Kaplan-Meier method and compared with the log rank test.

RESULTS AND LIMITATIONS

Metachronous tumors had a greater degree of pathological concordance than synchronous lesions, with 87.7% of metachronous tumors representing bilateral RCC, compared to 69.2% of synchronous masses (p=0.002). Patients with synchronous RCC tended to have an increased incidence of papillary RCC compared to patients with metachronous RCC, who were more likely to have bilateral clear-cell RCC (p=0.076). A longer interval between tumors was inversely associated with the risk of cancer death for patients with metachronous RCC (HR 0.90, 95% CI 0.81-0.99, p=0.039). Compared to patients with metachronous RCC, patients with synchronous bilateral RCC had similar 10-yr CSS (70.5% vs. 69.4%, p=0.51) and OS (47.5% vs. 51.2%, p=0.58). We nevertheless recognize that these findings may be limited by the study's retrospective, single-institution design.

CONCLUSIONS

Metachronous bilateral solid renal masses have a greater degree of pathological concordance and were more likely to represent malignancy. Surgical resection may provide durable cancer control for patients with bilateral RCC, with no difference in survival noted between synchronous and metachronous cancers.

Pathologic concordance of sporadic synchronous bilateral renal masses

OBJECTIVES

To review the collective experience evaluating pathologic concordance rates of sporadic bilateral synchronous renal tumors reported in the Surveillance, Epidemiology, and End Results (SEER) database and the published English literature and treated at Fox Chase Cancer Center; specifically, to analyze concordance rates of malignant versus benign disease, histologic type, tumor stage, and nuclear grade.

METHODS

We reviewed the SEER database, the published English language literature, and our own institutional tumor registry to identify all cases of sporadic, synchronous localized (cT1-3N0M0) bilateral renal masses. Malignant and benign concordance rates were defined as agreement of any benign or malignant tumor type bilaterally. Histologic concordance was defined as bilateral histologic agreement. Tumors with mixed histologies were discordant unless all patterns were identical bilaterally. Nuclear grades were concordant if bilateral tumors were either "high" grade or "low" grade.

RESULTS

The malignant concordance rate in the SEER data was 99% (273 of 274), and benign concordance was 0 (0 of 1). In the published literature and Fox Chase Cancer Center series, malignant concordance rates ranged from 84% to 95%, whereas benign concordance ranged from 39% to 67%. The SEER data revealed a histologic concordance rate of 93% (256 of 274), and nuclear grade concordance was 85% (88 of 103).

CONCLUSIONS

These data demonstrate that in cases of bilateral sporadic localized synchronous renal masses, a diagnosis of ipsilateral renal cell carcinoma is associated with contralateral renal cell carcinoma in the vast majority of patients, whereas ipsilateral benign pathology is associated with contralateral benign disease at a substantially lower rate. Histologic concordance is similarly high, meaning most cases of clear cell or papillary tumors ipsilaterally are concordant in the contralateral kidney. Concordance rates of nuclear grade were slightly lower. These data are important when counseling and managing patients with bilateral synchronous sporadic renal tumors.

Contemporary strategies for treating nonhereditary synchronous bilateral renal tumors and the impact of minimally invasive, nephron-sparing techniques

OBJECTIVES

As surgical technology and expertise advance, treatment strategies for patients with bilateral renal tumors will continue to shift toward methods that maximize preservation of renal function and maintain optimal oncologic outcomes while minimizing morbidity. Reports about such strategies are limited. We report the outcome of a contemporary cohort of patients treated for nonhereditary synchronous bilateral renal tumors at our institution to evaluate surgical strategies and newer techniques used during patient treatment.

METHODS

From a surgical database, we identified 43 patients who met the criteria for nonhereditary, synchronous, bilateral renal tumors. Demographic characteristics, tumor pathology, renal function, surgical data, and outcomes were extracted from each patient's medical record. Computerized literature searches were performed to identify related articles for comparative purposes.

RESULTS

Of the 43 patients, 36 (82%) were treated with staged procedures a median of 54 days apart. A total of 23 patients (53.3%) received bilateral nephron-sparing therapy, of whom 11 underwent a minimally invasive nephron-sparing approach. There was a median 28.0 ml/min decrease in creatinine clearance between initial preoperative levels and at last follow-up, with a median follow-up duration of 16 months, and no patient required dialysis. Of the 43 patients, 2 (4.7%) had local recurrences, and 1 (2.3%) had metastatic disease.

CONCLUSION

These findings show a contemporary standard of care for treating patients with bilateral renal tumors, with more than half the patients undergoing bilateral nephron-sparing and nearly one third of patients receiving a minimally invasive nephron-sparing approach.

The Prevalence of Malignancy in Satellite Renal Lesions and its Surgical Implication During Nephron Sparing Surgery

PURPOSE

We examined the prevalence of malignancy in a synchronous ipsilateral renal lesion identified during partial nephrectomy and evaluated its clinical significance.

MATERIALS AND METHODS

We retrospectively reviewed the records of 112 patients (114 renal units) who underwent nephron sparing surgery for a clinically localized sporadic renal mass between May 1995 and September 2005.

RESULTS

In 37 patients (32%) an additional lesion was diagnosed and excised intraoperatively, while in 67% these lesions were known before the operation and believed to be simple cysts. During surgery the additional mass was suspicious in 8 cases and in the remainder the mass was described as simple cysts that were excised. The mean size of the primary mass was 3.1 cm (SD 1.4). In 29 (78%) cases the primary mass was malignant, in 23 (79%) of these the second mass was benign and in the remainder renal cell carcinoma was diagnosed. In 8 cases (22%) the primary mass was benign and in 2 (25%) the secondary mass was malignant. Overall 22% of all second masses were malignant, and all were low grade and low stage. We found that 7% of second ipsilateral masses could be expected to harbor malignancy.

CONCLUSIONS

Based on our data it is questionable whether total nephrectomy is mandatory as an immediate response to an ipsilateral synchronous second renal mass. The present findings may represent an increased appreciation of ipsilateral multicentricity compared to historical data.

Open partial nephrectomy: an essential operation with an expanding role

PURPOSE OF REVIEW

To describe the rationale for expanding the role of partial nephrectomy in the treatment of renal cortical tumors.

RECENT FINDINGS

Renal tumors are a family of neoplasms ranging from the benign oncocytoma, to the indolent papillary and chromophobe carcinomas, to the more potentially malignant clear cell carcinomas that account for 54% of the lesions resected, but 90% of those that metastasize. Due to a contemporary stage migration, 70% of the tumors are detected incidentally with a median tumor size of below 4.0 cm. Partial nephrectomy for tumors of 7 cm or less provides equivalent oncological tumor control to radical nephrectomy with maximum preservation of long-term renal function. Twenty-six percent of patients prior to operation already have stage 3 chronic kidney disease with an estimated glomerular filtration rate of less than 60 ml/min/1.73 m. Chronic kidney disease is an independent risk factor for the development of cardiovascular disease, hospitalization and death. The likelihood of freedom from a glomerular filtration rate of less than 45 was 95% after partial nephrectomy, but only 64% following radical nephrectomy.

SUMMARY

Partial nephrectomy is an essential surgical approach to the small kidney tumor and provides equivalent local tumor control while preventing the new onset or worsening of chronic kidney disease.

Imaging of kidney cancer

Advances in molecular genetics have expanded the understanding of renal cell tumors. Now it is understood that renal cortical tumors are a family of neoplasms with distinct cytogenetics and molecular defects, unique histopathologic features, and different malignant potentials. Imaging contributes to clinical management of patients with renal tumors in providing diagnostic information for tumor detection, characterization, staging, treatment planning, and follow-up.

Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm

OBJECTIVE

To compare the outcomes of patients who had a elective partial nephrectomy (PN) or radical nephrectomy (RN) for clear cell renal cell carcinoma (RCC) of 4-7 cm.

PATIENTS AND METHODS

From March 1998 to July 2004, 45 and 151 patients underwent PN and RN, respectively, for clear cell RCC. A multivariate Cox model was constructed for disease-free survival with adjustment for markers of disease severity, and a propensity-score approach used as a confirmatory analysis.

RESULTS

In the PN and RN cohorts the treatment failed in one and 20 patients, respectively; the median follow-up was 21 months. The hazard ratio (95% confidence interval) for PN after adjusting for disease severity was 0.36 (0.05-2.82; P = 0.3). Using planned PN as a predictor (intent-to-treat analysis) the hazard ratio was 1.06 (0.32-3.53; P = 0.9). In the propensity-score model, planned PN was associated with a hazard ratio of 1.75 (0.50-6.14; P = 0.4). The serum creatinine level 3 months after surgery was significantly lower in patients who had PN, with a difference between the means of 0.36 (0.23-0.48; P < 0.001).

CONCLUSIONS

Renal function was preserved after PN for 4-7 cm clear cell RCC tumours. When comparing the outcomes of PN and RN it is important to consider the intended operation as an independent variable. There was no clear evidence that PN was associated with worse cancer control, although a continued follow-up of this and other cohorts is warranted.

Partial nephrectomy for patients with a solitary kidney: the Memorial Sloan-Kettering experience

OBJECTIVE

To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival.

PATIENTS AND METHODS

We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined.

RESULTS

The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively.

CONCLUSIONS

Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.

Long-term survival of patients with unilateral sporadic multifocal renal cell carcinoma according to histologic subtype compared with patients with solitary tumors after radical nephrectomy

OBJECTIVES

To determine the pathologic features, including histologic subtype and tumor size, associated with multifocal renal cell carcinoma (RCC) and the impact of multifocality on survival after radical nephrectomy, about which controversy exists.

METHODS

We studied 2373 patients who underwent radical nephrectomy for RCC from 1970 to 2000. Histologic subtype, stage (2003 TNM), nuclear grade, tumor size, and multifocality, defined as the presence of more than one ipsilateral RCC tumor of the same histologic subtype, were evaluated. Associations of multifocality with ipsilateral and contralateral recurrence and death from RCC were evaluated using Cox proportional hazards models.

RESULTS

The incidence of sporadic histologically concordant multifocality was greater in papillary RCC (29 of 266; 10.9%) compared with clear cell RCC (40 of 1934; 2.0%; P <0.001) and chromophobe RCC (2 of 104; 1.9%; P = 0.005). Patients with solitary clear cell and papillary RCC had larger tumors compared with multifocal clear cell and papillary RCC (P <0.001 and P = 0.024, respectively). Patients with multifocal clear cell RCC were more likely to have a contralateral recurrence than were patients with solitary clear cell RCC (risk ratio 2.91, P = 0.142). Multifocality was not significantly associated with ipsilateral recurrence or death from RCC in patients with clear cell or papillary RCC.

CONCLUSIONS

The incidence of multifocality was significantly greater among patients with papillary RCC than among patients with clear cell or chromophobe RCC. Patients with multifocal clear cell RCC were more likely to experience a contralateral recurrence. Multifocality was not significantly associated with ipsilateral recurrence or death from RCC. In addition, multifocality was not associated with larger and higher stage tumors, as previously reported.

Effect of papillary and chromophobe cell type on disease-free survival after nephrectomy for renal cell carcinoma

BACKGROUND

The clinical staging of renal cortical tumors traditionally has not evaluated the potential effect of histological subtypes on survival. Evidence suggests that conventional clear cell renal cell carcinoma (RCC) and nonconventional clear cell RCC (chromophobe and papillary) have different metastatic potential. Using a large renal tumor database, we examined the effect of tumor histology on the pattern of metastasis and patient survival.

METHODS

All patients with nonmetastatic renal cortical tumors undergoing partial or radical nephrectomy were identified from a renal tumor database between July 1989 and July 2002. Kaplan-Meier and Cox regression tests were used for statistical analysis.

RESULTS

Analysis revealed 1057 patients: 794 with conventional clear cell RCC, 157 with papillary RCC, and 106 with chromophobe RCC. Metastasis occurred in 95 conventional clear cell RCC, 9 papillary RCC, and 6 chromophobe RCC with a median follow-up of 34.6, 43.0, and 33.2 months, respectively. Using log-rank analysis, chromophobe and papillary RCC were associated with an improved disease-free survival at 5 years (P =.009 and.015, respectively). Multivariate analysis revealed tumor size, stage, and chromophobe histology as significant variables for disease progression.

CONCLUSIONS

Renal cortical tumors have distinct histological subtypes with varying degrees of metastatic potential. Conventional clear cell RCC, which comprises two thirds of renal cortical tumors presenting with localized disease, has a less favorable outcome when compared with papillary and chromophobe RCC. Controlling for size and stage, chromophobe, and not papillary, RCC was a significant variable for disease progression compared with conventional clear cell RCC. Knowledge of renal cortical tumor histological subtype is critical for projecting prognosis, tailoring follow-up strategies, and designing clinical trials.