Renal Cell Carcinoma: Alternative Nephron-Sparing Treatment Options for Small Renal Masses, a Systematic Review

Mechanisms of tyrosine kinase inhibitor resistance in renal cell carcinoma

Renal cell carcinoma (RCC), the most prevalent type of kidney cancer, is a significant cause of cancer morbidity and mortality worldwide. Antiangiogenic tyrosine kinase inhibitors (TKIs), in combination with immune checkpoint inhibitors (ICIs), are among the first-line treatment options for patients with advanced RCC. These therapies target the vascular endothelial growth factor receptor (VEGFR) tyrosine kinase pathway and other kinases crucial to cancer proliferation, survival, and metastasis. TKIs have yielded substantial improvements in progression-free survival (PFS) and overall survival (OS) for patients with advanced RCC. However, nearly all patients eventually progress on these drugs as resistance develops. This review provides an overview of TKI resistance in RCC and explores different mechanisms of resistance, including upregulation of alternative proangiogenic pathways, epithelial-mesenchymal transition (EMT), decreased intracellular drug concentrations due to efflux pumps and lysosomal sequestration, alterations in the tumor microenvironment including bone marrow-derived cells (BMDCs) and tumor-associated fibroblasts (TAFs), and genetic factors such as single nucleotide polymorphisms (SNPs). A comprehensive understanding of these mechanisms opens the door to the development of innovative therapeutic approaches that can effectively overcome TKI resistance, thereby improving outcomes for patients with advanced RCC.

The Judicious Use of Stereotactic Ablative Radiotherapy in the Primary Management of Localized Renal Cell Carcinoma

Localized renal cell carcinoma is primarily managed surgically, but this disease commonly presents in highly comorbid patients who are poor operative candidates. Less invasive techniques, such as cryoablation and radiofrequency ablation, are effective, but require percutaneous or laparoscopic access, while generally being limited to cT1a tumors without proximity to the renal pelvis or ureter. Active surveillance is another management option for small renal masses, but many patients desire treatment or are poor candidates for active surveillance. For poor surgical candidates, a growing body of evidence supports stereotactic ablative radiotherapy (SABR) as a safe and effective non-invasive treatment modality. For example, a recent multi-institution individual patient data meta-analysis of 190 patients managed with SABR estimated a 5.5% five-year cumulative incidence of local failure with one patient experiencing grade 4 toxicity, and no other grade ≥3 toxic events. Here, we discuss the recent developments in SABR for the management of localized renal cell carcinoma, highlighting key concepts of appropriate patient selection, treatment design, treatment delivery, and response assessment.

Intraoperative MRI-derived volumetric ablation margins and initial correlation with local outcome after MRI-guided cryoablation of renal tumors

PURPOSE

To assess volumetric ablation margins derived from intraoperative pre- and post-ablation MRI after magnetic resonance imaging (MRI)-guided percutaneous cryoablation of renal tumors and explore its correlation with local treatment success.

METHODS

Retrospective analysis was performed on 30 patients (mean age 69y) who underwent percutaneous MRI-guided cryoablation between May 2014 and May 2020 for 32 renal tumors (size: 1.6-5.1 cm). Tumor and ice-ball volumes were segmented on intraprocedural pre- and post-ablation MR images using Software Assistant for Interventional Radiology (SAFIR) software. After MRI-MRI co-registration, the software automatically quantified the minimal treatment margin (MTM),defined as the smallest 3D distance between the tumor and ice-ball surface. Local tumor progression (LTP) after cryoablation was assessed on follow-up imaging.

RESULTS

Median follow-up was 16 months (range: 1-58). Local control after cryoablation was achieved in 26 cases (81%) while LTP occurred in 6 (19%). The intended MTM of ≥5 mm was achieved in 3/32 (9%) cases. Median MTM was significantly smaller for cases with (- 7 mm; IQR:-10 to - 5) vs. without LTP (3 mm; IQR:2 to 4) (P < .001). All cases of LTP had a negative MTM. All negative treatment margins occurred in tumors > 3 cm.

CONCLUSIONS

Determination of volumetric ablation margins from intraoperative MRI was feasible and may be useful in predicting local outcome after MRI-guided renal cryoablation. In our preliminary data, an intraoperative MRI-derived minimal margin extending at least 1 mm beyond the MRI-visible tumor led to local control and this was more difficult to achieve in tumors > 3 cm. Ultimately, online margin analysis may be a valuable tool to intraoperatively assess therapy success, but larger prospective studies are needed to establish a reliable threshold for clinical use.

Establishing a novel model of malignant airway stenosis in rabbit

Background

Malignant central airway stenosis is a life-threatening condition. However, treatment of malignant airway stenosis remains challenging. There is currently a severe lack of an excellent animal model of malignant airway stenosis to facilitate treatment approaches. This is the first study to establish a rabbit model of malignant airway stenosis for bronchoscopic interventional studies.

Materials and methods

New Zealand White rabbits were used in this study, randomly divided into group A (18 rabbits) and group B (6 rabbits). A VX2 fragment suspension was injected into the submucosal layer of rabbits’ airway by bronchoscopy. Bronchoscopic examinations were performed once a week after VX2 tumor implantation to observe tumor growth and the degree of airway stenosis. Randomly, three rabbits were generally dissected after a weekly bronchoscopic examination in group A. The rabbits that reached grade III airway stenosis underwent stent implantation in group B.

Results

A total of 24 rabbits were successfully implanted with the VX2 fragment suspension in the airway without significant adverse events, and the success rate of the tumor growth was 100%. The degree of airway stenosis reaching grade III took 2 to 3 weeks after implantation of the VX2 tumor. The median survival time of rabbit models without stent implantation and rabbits with stent implantation was 32.5 and 32.0 days, respectively.

Conclusions

The implanting method is safe and effective for the establishment of a rabbit model of malignant airway stenosis. When the tumor grows to 2 to 3 weeks, the rabbit model is available for stent implantation. We recommend the models for more preclinical animal studies on bronchoscopic interventional treatments.

Irreversible electroporation in renal tumours: A systematic review of safety and early oncological outcomes

We review the safety and early oncological outcomes of irreversible electroporation (IRE), a novel non-thermal ablation technique, in small renal masses (SRMs). Following PROSPERO registration (CRD42020197943), a systematic search of MEDLINE, EMBASE and SCOPUS databases according to PRISMA guidelines was performed. Critical appraisal of the included studies was performed using the Newcastle-Ottawa Scale. Of 224 articles screened, 10 met the inclusion criteria. In total, 83 patients were identified. Except for one cohort study (n = 41), the remaining studies were case series of n < 10. Follow up was <12 months in 7/10 articles (range 3–34 months). About 10/10 articles reported safety outcomes. There were no 30-day mortalities. The most frequently reported adverse events were transient haematuria (11/83) and asymptomatic perirenal haematomas (7/83). About 62/63 patients with reported length of stay were discharged within 24 h. No significant long-term changes in renal function were reported. About 7/10 articles reported oncological outcomes. Only one article assessed histopathological outcomes, whilst the remaining studies used cross-sectional imaging modalities to assess efficacy, recurrence or disease progression. About 4/7 patients with histopathology outcomes, showed complete response (CR). About 43/55 patients with radiological outcomes showed CR. No mortalities were reported due to SRMs. These initial findings support IRE as safe and feasible in managing SRMs. However, results from larger studies with longer follow-up are needed to evaluate oncological outcomes and compare these with other ablation methods.

Percutaneous microwave ablation of renal cell carcinoma: practice guidelines of the ultrasound committee of Chinese medical association, interventional oncology committee of Chinese research hospital association

Imaging-guided percutaneous microwave ablation (MWA) with high thermal efficiency comprises rapid, successful management of small renal cell carcinomas (RCCs) in selected patients. Ultrasound Committee of Chinese Medical Association, Interventional Oncology Committee of Chinese Research Hospital Association developed evidence-based guidelines for MWA of RCCs after systematically reviewing the 1969-2019 literature. Systematic reviews, meta-analyses, randomized controlled trials, cohort, and case-control studies reporting MWA of RCCs were included and levels of evidence assessed. Altogether, 146 articles were identified, of which 35 reported percutaneous MWA for T1a RCCs and 5 articles for T1b RCCs. Guidelines were established based on indications, techniques, safety, and effectiveness of MWA for RCCs, with the goal of standardizing imaging-guided percutaneous MWA treatment of RCCs. Key points Microwave ablation is recommended for managing small renal cell carcinoma in selected patients. Imaging protocols are tailored based on the procedural plan, guidance, and evaluation. Patient's selection evaluation, updated technique information, clinical efficacy, and complications are recommended to standardize management. A joint task force (multidisciplinary team) summarized the key elements of the standardized report.

Renal biopsies performed before versus during ablation of T1 renal tumors: implications for prevention of overtreatment and follow-up

Purpose

To assess the difference between renal mass biopsy (RMB) performed either before or during the ablation procedure.

Methods

A retrospective multicenter study was performed in patients with a cT1 renal mass treated with ablation between January 2007 and July 2019, including a search in the national pathology database for patients with a RMB planned for ablation. Patient and tumor characteristics and information on malignant, benign, and non-diagnostic biopsy results were collected to establish rates of overtreatment and number of ablations avoided in case of benign or non-diagnostic histology.

Results

RMB was performed in 714 patients, of which 231 patients received biopsy before planned ablation, and 483 patients at the time of ablation. Pathology results before ablation were malignant in 63% (145/231), benign in 20% (46/231) and non-diagnostic in 17% (40/231). Pathology results at the time of ablation were malignant in 67.5% (326/483), benign in 16.8% (81/483) and non-diagnostic in 15.7% (76/483), leading to a total of 32.5% of ablation of benign or non-diagnostic lesions. Of the patients with a benign biopsy obtained before ablation, 80.4% (37/46) chose not to undergo ablation. Patients with inconclusive biopsy before planned ablation chose an informed individualized approach including ablation, repeated biopsy, or no intervention in 56%, 34% and 10%.

Conclusion

This study emphasizes the importance of obtaining a biopsy prior to the ablation procedure in a separate session to lower the rate of potentially unnecessary ablations.

[Radical nephrectomy and partial nephrectomy]

Renal cell carcinoma is the 2nd most frequent urological malignancy in women and the third most frequent in men, with an age peak in the seventh decade of life. If detected early in a local non-metastatic stage, options for complete recovery are excellent. While two decades ago, even locally limited cancers of the kidney were cured by radical nephrectomy, treatment today mostly consists of local treatment for locally confined cancers. Guidelines today recommend local surgical excision (open or minimally-invasive) or - in selected cases - topical energy application (radio-frequency ablation, cryoablation). The surgeon's expertise is most important in the selection of the appropriate kind of surgery and different guidelines have slightly different recommendations.Treatment decisions should be made on an individual basis in due consideration of an individual's age and co-morbidities. This may lead to the recommendation that, due to low perioperative morbidity, even localised carcinomas should be treated by (minimally-invasive) radical nephrectomy instead of nephron-sparing surgery and, in other cases, a non-interventional, active surveillance strategy may be pursued without compromising the patient's life expectancy. For higher-grade renal cell carcinomas, there is usually an indication for radical nephrectomy, as long as no metastases are detected. This also applies to carcinomas with venous thrombi extending into the atrium of the heart. Complications in the treatment of renal carcinomas are usually rare and easily treatable in most cases.

Diagnostic accuracy of contrast-enhanced ultrasound in the detection of small renal masses: A protocol of systematic review and meta-analysis

BACKGROUND

The small renal masses (SRMs) were defined that the diameter of renal masses measured by enhanced image was ≤4 cm. The diagnostic accuracy of contrast-enhanced ultrasound (CEUS) for SRMs is apparently variable among previous studies. Hence, this study will evaluate the diagnostic accuracy of CEUS in the identification of benign and malignant SRMs.

METHODS

A comprehensive search using the databases of Cochrane Library, Embase, PubMed, WANGFANG, and China National Knowledge Infrastructure will be carried out to identify studies in which patients with SRMs are assessed by CEUS. Two investigators will independently screen the literature and extract the data. Any discrepancies will be resolved via discussion with the senior author. Study quality will be assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 tool, and pooled sensitivity and specificity of various CEUS findings for the diagnosis of SRMs will be determined. Summary receiver operating characteristic curve will be used to assess the overall performance of CEUS.

RESULTS

This study will evaluate the diagnostic accuracy of CEUS for the diagnosis of SRMs through sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio.

CONCLUSION

This study will summarize the most recent evidence that focusing on the diagnosis of CEUS for SRMs.

STUDY REGISTRATION

INPLASY202060040.

Treatment options for localised renal cell carcinoma of the transplanted kidney

Currently, there is no consensus among the transplant community about the treatment of renal cell carcinoma (RCC) of the transplanted kidney. Until recently, graftectomy was universally considered the golden standard, regardless of the characteristics of the neoplasm. Due to the encouraging results observed in native kidneys, conservative options such as nephron-sparing surgery (NSS) (enucleation and partial nephrectomy) and ablative therapy (radiofrequency ablation, cryoablation, microwave ablation, high-intensity focused ultrasound, and irreversible electroporation) have been progressively used in carefully selected recipients with early-stage allograft RCC. Available reports show excellent patient survival, optimal oncological outcome, and preserved renal function with acceptable complication rates. Nevertheless, the rarity and the heterogeneity of the disease, the number of options available, and the lack of long-term follow-up data do not allow to adequately define treatment-specific advantages and limitations. The role of active surveillance and immunosuppression management remain also debated. In order to offer a better insight into this difficult topic and to help clinicians choose the best therapy for their patients, we performed and extensive review of the literature. We focused on epidemiology, clinical presentation, diagnostic work up, staging strategies, tumour characteristics, treatment modalities, and follow-up protocols. Our research confirms that both NSS and focal ablation represent a valuable alternative to graftectomy for kidney transplant recipients with American Joint Committee on Cancer stage T1aN0M0 RCC. Data on T1bN0M0 lesions are scarce but suggest extra caution. Properly designed multi-centre prospective clinical trials are warranted.

Prognostic Effect of Preoperative Apolipoprotein B Level in Surgical Patients with Clear Cell Renal Cell Carcinoma

BACKGROUND

The aim of this study was to assess the prognostic value of the preoperative apolipoprotein B (ApoB) level in surgical patients with clear cell renal cell carcinoma (ccRCC).

MATERIALS AND METHODS

The study included 307 ccRCC patients receiving radical or partial nephrectomy between 2003 and 2012 in our center. The correlations among the preoperative ApoB, clinicopathological parameters, and overall survival (OS) were evaluated.

RESULTS

A total of 193 males (62.9%) and 114 females (37.1%) with ccRCC who underwent radical or partial nephrectomy were enrolled in the present study. The OS at 5 years after the operation was 90.6% for all patients, 87.4% for the lower ApoB group, and 97.0% for the higher-ApoB group. The cause-specific survival (CSS) at 5 years after surgery was 90.2% for all patients, 86.7% for the lower-ApoB group, and 97.0% for the higher-ApoB group. A higher-ApoB level was related to a better OS and CSS in ccRCC patients (p = 0.001 and p < 0.001, respectively). In multivariate analysis, age >60 years (p = 0.008 and p = 0.023) and a lower Apo B level (p = 0.019 and p = 0.018) were independent prognostic factors for OS and CSS, respectively.

CONCLUSIONS

In the Apo apolipoprotein family, the preoperative ApoB level had an important clinical significance for predicting the prognosis and survival rate of ccRCC patients.

Transarterial Chemoembolization and Sorafenib Combined with Microwave Ablation for Advanced Primary Hepatocellular Carcinoma: A Preliminary Investigation of Safety and Efficacy

Purpose

The aim of this study was to investigate the safety and efficacy of transarterial chemoembolization and sorafenib (TACE-S) combined with microwave ablation (TACE-S-MWA) for the treatment of patients with advanced primary hepatocellular carcinoma (HCC).

Methods

Between January 2015 and December 2018, 152 consecutive advanced HCC patients, who underwent TACE-S-MWA (MWA group, n=77) or TACE-S (Non-MWA group, n=75), were investigated. Overall survival (OS), time to progression (TTP) and safety were compared between the two groups. Prognostic factors were analyzed using the Cox proportional hazard regression model.

Results

Baseline patient characteristics were balanced between the two groups. MWA group was associated with a higher OS (median, 19.0 vs 13.0 months; P<0.001) and a longer TTP (median, 6.0 vs 3.0 months; P<0.001) compared with non-MWA group. Multivariate analyses showed that portal vein tumor thrombosis (PVTT) (P=0.002), duration of sorafenib (P<0.001), and MWA treatment (P=0.011) were independently associated with OS. MWA treatment strategy (P<0.001) was a significant predictor of TTP. There were no treatment-related mortalities in either group. The rates of minor complications (42.9% vs 38.7%, P=0.599) and major complications (1.29% vs 1.33%, P=0.985) in the MWA group were similar to those in the non-MWA group.

Conclusion

TACE-S-MWA was safe and effective for advanced primary HCC. TACE-S-MWA resulted in better OS and TTP than did TACE-S for treatment of patients with advanced primary HCC.

Percutaneous Microwave Ablation of Histologically Proven T1 Renal Cell Carcinoma

Objectives

To assess the safety and efficacy of percutaneous microwave ablation (MWA) of histologically proven T1 renal cell carcinoma (RCC).

Methods

We analysed patients with a histologically proven RCC (≤ 7 cm) treated by MWA from April 2012–April 2018. Primary and secondary efficacy, local tumour recurrence (LTR), morbidity and mortality were reported. Efficacy was defined as no residual tumour enhancement on follow-up imaging 1 month after the first ablation (primary efficacy) and after re-ablation(s) for residual disease (secondary efficacy). Adverse events (AE) were registered by the Clavien–Dindo classification and the common terminology criteria for AE. Univariable and multivariable logistic regression analyses were performed to investigate a relation among pre-treatment factors incomplete ablation and complications.

Results

In 100 patients, a total of 108 RCCs (85 T1a and 23 T1b) were treated by MWA. Median size was 3.2 cm (IQR 2.4–4.0). Primary efficacy was 89% (95%CI 0.81–0.94) for T1a lesions and 52% (95%CI 0.31–0.73) for T1b lesions (p < 0.001). Fifteen lesions (7 T1a) were re-ablated for residual disease by MWA in one (n = 13) and two (n = 2, both T1b) sessions resulting in secondary efficacy rates of 99% (T1a) and 95% (T1b, p = 0.352). LTR occurred in four tumours (2 T1a, 2 T1b) after 10–60 months. Six (4%) AEs grade > 3–5 were observed (2 T1a, 4 T1b, p = 0.045). Multivariable analysis showed that mR.E.N.A.L. nephrometry was independently associated with incomplete ablation (p = 0.012).

Conclusion

Microwave ablation is safe and effective for T1a and T1b RCC lesions with a significantly lower primary efficacy for T1b lesions.

Endobronchial Ultrasound-Guided Radiofrequency Ablation of Lung Tumors and Mediastinal Lymph Nodes: A Preclinical Study in Animal Lung Tumor and Mediastinal Adenopathy Models

Radiofrequency ablation (RFA) can be a therapeutic option in medically inoperable lung cancer patients. In this study, we evaluated a prototype bipolar RFA device applicator that can be deployed from a standard endobronchial ultrasound (EBUS) bronchoscope to determine feasibility and histopathological analysis in animal models. Rabbit lung cancers were created by transbronchial injection of VX2 rabbit cancer cells. Once the tumors were developed, they were ablated transpleurally, under EBUS guidance using the prototype RFA device. The animals were then sacrificed for specimen resection. Pig inflammatory lung pseudo-tumors and lymphadenopathy were created by transbronchial injection of a talc paste and ablated transbronchially under EBUS guidance. Pigs were evaluated at 5 days, 2 weeks, and 4 weeks following ablation by bronchoscopy and cone beam computed tomography before necropsy. Nicotinamide adenine dinucleotide hydrogen diaphorase staining was employed to measure the ablation area. Twenty-four VX2 rabbit tumors were ablated. The total ablated area ranged from 0.6 to 3.0 cm² (mean: 1.8 cm²), corresponding to a total energy range of 1 to 6 kJ. Six pig lung pseudo-tumors and 5 mediastinal lymph nodes were ablated. Adjacent airway ulceration was observed in 3 ablations of lymph nodes. These airway complications resolved within 4 weeks of RFA without any treatment. There was no hemoptysis, air embolism, respiratory distress, or other serious complication noted. In these 2 animal models, we provide evidence that EBUS-guided bipolar RFA is feasible and histopathology shows that can ablate lung tumors and mediastinal lymph nodes under real-time ultrasound guidance.

Systematic Review of Contemporary Evidence for the Management of T1 Renal Cell Carcinoma: What IRs Need to Know for Kidney Cancer Tumor Boards

Renal cell carcinoma is a relatively common malignancy, with 60 to 70 thousand cases a year in the United States alone. Increased utilization of cross-sectional imaging has led to an increase in the number of early renal cell cancers seen by the medical establishment. In addition, certain patient populations have an increased risk of developing kidney cancers which may mandate aggressive screening protocols. This article discusses the epidemiology of renal cell cancers; discusses the current management guidelines from multiple specialty societies; discusses some of the surgical and interventional techniques used in the treatment of such lesions; and provides a review of the literature regarding treatments of early-stage renal cell cancers.

Percutaneous cryoablation for renal cell carcinoma using ultrasound-guided targeting and computed tomography-guided ice-ball monitoring: radiation dose and short-term outcomes

BACKGROUND

Usefulness of ultrasound (US)-guided mass targeting and computed tomography (CT)-guided ice-ball monitoring in percutaneous cryoablation (PCA) for renal cell carcinoma (RCC) is still uncertain.

PURPOSE

To assess radiation dose and short-term outcomes of PCA for RCC using US-guided targeting and CT-guided ice-ball monitoring.

MATERIAL AND METHODS

Thirty-nine consecutive patients who underwent PCA for biopsy-proven RCC were included. Mass targeting was performed with US and ice-ball was monitored with CT guidance. Effective radiation dose of CT during PCA was recorded. Follow-up was conducted with contrast-enhanced CT or magnetic resonance imaging (MRI) (mean follow-up time = 10.1 ± 7.0 months). Local tumor progression was defined by the presence of focal enhancing areas at the ablation zone (CT, ≥ 20 HU; MRI, presence of focal enhancement on subtraction contrast-enhanced image). Technical success, major complication rate (e.g. Clavien-Dindo classification ≥ 3), and one-year local tumor progression-free survival (PFS) rate were analyzed.

RESULTS

Mean effective radiation dose in association with PCA was 12.1 ± 4.5 mSv (range = 7.0-25.2 mSv). Technical success was achieved in 100%. Local tumor progression occurred in a single patient (2.6%, 1/39), and one-year local tumor PFS rate was 95.7%. No major complication was found.

CONCLUSION

PCA using US-guided targeting and CT-guided ice-ball monitoring may allow acceptable local tumor control for RCC, as a radiation-reducing strategy.

European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update

CONTEXT

The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.

OBJECTIVE

To provide an updated RCC guideline based on standardised methodology including systematic reviews, which is robust, transparent, reproducible, and reliable.

EVIDENCE ACQUISITION

For the 2019 update, evidence synthesis was undertaken based on a comprehensive and structured literature assessment for new and relevant data. Where necessary, formal systematic reviews adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were undertaken. Relevant databases (Medline, Cochrane Libraries, trial registries, conference proceedings) were searched until June 2018, including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm, systematic reviews, and meta-analyses. Where relevant, risk of bias (RoB) assessment, and qualitative and quantitative syntheses of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Clinical practice recommendations were developed and issued based on the modified GRADE framework.

EVIDENCE SYNTHESIS

All chapters of the RCC guidelines were updated based on a structured literature assessment, for prioritised topics based on the availability of robust data. For RCTs, RoB was low across studies. For most non-RCTs, clinical and methodological heterogeneity prevented pooling of data. The majority of included studies were retrospective with matched or unmatched cohorts, based on single- or multi-institutional data or national registries. The exception was for the treatment of metastatic RCC, for which there were several large RCTs, resulting in recommendations based on higher levels of evidence.

CONCLUSIONS

The 2019 RCC guidelines have been updated by the multidisciplinary panel using the highest methodological standards. These guidelines provide the most reliable contemporary evidence base for the management of RCC in 2019.

PATIENT SUMMARY

The European Association of Urology Renal Cell Carcinoma Guideline Panel has thoroughly evaluated the available research data on kidney cancer to establish international standards for the care of kidney cancer patients.

Organ-sparing procedures in GU cancer: part 1-organ-sparing procedures in renal and adrenal tumors: a systematic review

PURPOSE

Organ-sparing surgery (OSS) for the kidney and adrenals has emerged as the need for preservation of function is paramount in patients with poor functional reserve. As reports increasingly showed that oncological outcomes were equivalent to radical excision, elective OSS became a viable alternative in patients with otherwise normal reserve. In this review, we summarize the current knowledge of OSS for adrenal and renal tumors.

MATERIALS AND METHODS

PubMed, Web of Science and Cochrane Library Central Search were searched for recently published articles up to December 2017. The following keywords were used; "partial adrenalectomy", "adrenal sparing", "partial nephrectomy", "nephron sparing", "kidney/renal cancer".

RESULTS

Partial adrenalectomy became an attractive alternative to total adrenalectomy avoiding adrenal insufficiency. Both minimally invasive surgery and ablative techniques were increasingly reported for adrenal OSS with adequate residual adrenal function and excellent oncological outcome. Radical nephrectomy remained for many years as the gold standard of treatment for organ-confined renal cell carcinoma. As the need to reduce the impact on renal function, more conservative approaches were utilized. Soon, the non-inferiority of nephron-sparing surgery to that of radical excision became evident and elective partial nephrectomy was gaining ground as the standard of care for small renal masses in patients with normal contralateral kidneys.

CONCLUSIONS

Herein, we present a comprehensive review of the current status of OSS in renal and adrenal tumors.

Primary small cell carcinoma after renal transplant: A case report

INTRODUCTION

Primary small cell carcinoma (SCC) after renal transplantation is very rare. Here, we reported 1 case of primary SCC after renal transplantation and analyzed its clinical and pathological characteristics.

CASE PRESENTATION

A 55-year-old female underwent renal transplantation in our hospital 2 years ago and had been using tacrolimus for immunosuppressive therapy. Because of abdominal distention, the patient was admitted to our hospital. Computed tomography (CT) showed a malignant tumor of left kidney. Patient underwent surgical treatment and radical nephrectomy and lymph node dissection were selected. Postoperative pathological diagnosis was primary renal parenchyma and ureteral SCC. The patient has been treated with combination chemotherapy of lowpol (100 mg per day) and etoposide (10 mg per day). His vital signs are stable now, and he is receiving further treatment in our hospital.

CONCLUSION

Because of immunosuppressive drugs use, the incidence of malignancies has increased significantly after renal transplantation. This case highlights the difficulty of diagnosis of primary SCC and the necessity of checking for neuroendocrine tumor after organ transplantation.

Comparison of selective and main renal artery clamping in partial nephrectomy of renal cell cancer: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

The aim of the present study was to perform a systematic review and meta-analysis of the studies comparing the efficiency and safety of selective renal artery clamping (SAC) and main renal artery clamping (MAC) in partial nephrectomy (PN) for renal cell cancer (RCC).

METHODS

According to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, a literature search on PubMed, EMBASE, Web of Science, and Chinese National Knowledge Infrastructure were conducted to identify relevant studies published through December 2017. Outcomes of interest included baseline characteristics and perioperative surgical variables.

RESULTS

In all, 14 studies involving 2824 RCC patients comparing SAC and MAC were included in this meta-analysis. No differences were detected in mean patient body mass index (P = .08), tumor size (P = .22), baseline estimated glomerular filtration rate (eGFR) (P = .60), American Society of Anesthesiologists score (P = .97), or RENAL score (P = .70). The mean age was significantly younger in the SAC group compared with the MAC group (P = .002). There was no difference between SAC and MAC groups in terms of warm ischemia time (P = .31), transfusion rate (P = .18), length of hospital stay (P = .47), or postoperative complication rate (P = .23). Although SAC had longer operating time (OT) (P = .04) and more estimated blood loss (EBL) (P = .0002), a lower percentage decrease in eGFR in the SAC group was found compared to the MAC group (P = .002).

CONCLUSIONS

Patients undergoing PN with SAC had longer OT and higher EBL. SAC was more frequently used in younger patient. SAC offered better renal function preservation when compared with MAC for RCC. Given the inherent limitations of the included studies, further well-designed randomized controlled trials are required to verify these findings.

Long-term oncological outcomes after robotic partial nephrectomy for renal cell carcinoma: a prospective multicentre study

PURPOSE

This study aimed at reporting the long-term oncological outcomes of robotic partial nephrectomy (RPN) for renal cell carcinoma (RCC).

METHODS

Data from all consecutive patients who underwent RAPN for RCC from July 2009 to January 2012 in three departments of urology were prospectively collected. Overall survival (OS), cancer-specific survival (CSS) and disease free-survival (DFS) were estimated using the Kaplan-Meier method. Prognostic factors associated with CSS were sought in univariate analysis. The log-rank test was used for categorical variables and the Cox model for continuous variables.

RESULTS

110 patients were included with a median follow-up of 64.4 months [95% CI = (61.0-66.7)]. Median age was 61 years (29-83) with 62.7% of men and 37.3% of women. Median RENAL score was 6 (4-10) with elective indications accounting for 95% of cases. Out of 27 patients (24.5%) who experienced peri-operative complication, 12 patients (10.9%) had a major complication (Clavien-Dindo grade ≥ 3). The TRIFECTA achievement rate was 52.7%. Three patients (2.7%) experienced local recurrence and seven patients (6.4%) progressed to a metastatic disease. 5-year OS, CSS, DFS were 94.9, 96.8, 86.4%, respectively. In univariate analysis, no pre/peri-operative characteristic was associated with DFS. No port-site metastasis was observed and there was one case of peritoneal carcinomatosis.

CONCLUSION

In this multicenter series, long-term OS, DFS and CSS after RPN appeared comparable to large series of open partial nephrectomy, with no port-site metastasis and one case of peritoneal carcinomatosis.