1
|
Moreno-Olmedo E, Sabharwal A, Das P, Dallas N, Ford D, Perna C, Camilleri P. The Landscape of Stereotactic Ablative Radiotherapy (SABR) for Renal Cell Cancer (RCC). Cancers (Basel) 2024; 16:2678. [PMID: 39123406 PMCID: PMC11311416 DOI: 10.3390/cancers16152678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Renal cell cancer (RCC) has traditionally been considered radioresistant. Because of this, conventional radiotherapy (RT) has been predominantly relegated to the palliation of symptomatic metastatic disease. The implementation of stereotactic ablative radiotherapy (SABR) has made it possible to deliver higher ablative doses safely, shifting the renal radioresistance paradigm. SABR has increasingly been adopted into the multidisciplinary framework for the treatment of locally recurrent, oligoprogressive, and oligometastatic disease. Furthermore, there is growing evidence of SABR as a non-invasive definitive therapy in patients with primary RCC who are medically inoperable or who decline surgery, unsuited to invasive ablation (surgery or percutaneous techniques), or at high-risk of requiring post-operative dialysis. Encouraging outcomes have even been reported in cases of solitary kidney or pre-existing chronic disease (poor eGFR), with a high likelihood of preserving renal function. A review of clinical evidence supporting the use of ablative radiotherapy (SABR) in primary, recurrent, and metastatic RCC has been conducted. Given the potential immunogenic effect of the high RT doses, we also explore emerging opportunities to combine SABR with systemic treatments. In addition, we explore future directions and ongoing clinical trials in the evolving landscape of this disease.
Collapse
Affiliation(s)
- Elena Moreno-Olmedo
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Radiotherapy and Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
| | - Ami Sabharwal
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Radiotherapy and Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
| | - Prantik Das
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Oncology, Royal Derby Hospital, Derby DE22 3NE, UK
| | - Nicola Dallas
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Oncology, Royal Berkshire Hospital, Reading RG1 5AN, UK
| | - Daniel Ford
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Oncology, University Hospitals Birmingham, Birmingham B15 2GW, UK
| | - Carla Perna
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Oncology, Royal Surrey NHS Foundation Trust, Guildford GU2 7XX, UK
| | - Philip Camilleri
- GenesisCare, Oxford OX4 6LB, UK; (A.S.); (P.D.); (N.D.); (D.F.); (C.P.); (P.C.)
- Department of Radiotherapy and Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
| |
Collapse
|
2
|
Zhong S, Chen S, Lin H, Luo Y, He J. Selection of M7G-related lncRNAs in kidney renal clear cell carcinoma and their putative diagnostic and prognostic role. BMC Urol 2023; 23:186. [PMID: 37968670 PMCID: PMC10652602 DOI: 10.1186/s12894-023-01357-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/01/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Kidney renal clear cell carcinoma (KIRC) is a common malignant tumor of the urinary system. This study aims to develop new biomarkers for KIRC and explore the impact of biomarkers on the immunotherapeutic efficacy for KIRC, providing a theoretical basis for the treatment of KIRC patients. METHODS Transcriptome data for KIRC was obtained from the The Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC) databases. Weighted gene co-expression network analysis identified KIRC-related modules of long noncoding RNAs (lncRNAs). Intersection analysis was performed differentially expressed lncRNAs between KIRC and normal control samples, and lncRNAs associated with N(7)-methylguanosine (m7G), resulting in differentially expressed m7G-associated lncRNAs in KIRC patients (DE-m7G-lncRNAs). Machine Learning was employed to select biomarkers for KIRC. The prognostic value of biomarkers and clinical features was evaluated using Kaplan-Meier (K-M) survival analysis, univariate and multivariate Cox regression analysis. A nomogram was constructed based on biomarkers and clinical features, and its efficacy was evaluated using calibration curves and decision curves. Functional enrichment analysis was performed to investigate the functional enrichment of biomarkers. Correlation analysis was conducted to explore the relationship between biomarkers and immune cell infiltration levels and common immune checkpoint in KIRC samples. RESULTS By intersecting 575 KIRC-related module lncRNAs, 1773 differentially expressed lncRNAs, and 62 m7G-related lncRNAs, we identified 42 DE-m7G-lncRNAs. Using XGBoost and Boruta algorithms, 8 biomarkers for KIRC were selected. Kaplan-Meier survival analysis showed significant survival differences in KIRC patients with high and low expression of the PTCSC3 and RP11-321G12.1. Univariate and multivariate Cox regression analyses showed that AP000696.2, PTCSC3 and clinical characteristics were independent prognostic factors for patients with KIRC. A nomogram based on these prognostic factors accurately predicted the prognosis of KIRC patients. The biomarkers showed associations with clinical features of KIRC patients, mainly localized in the cytoplasm and related to cytokine-mediated immune response. Furthermore, immune feature analysis demonstrated a significant decrease in immune cell infiltration levels in KIRC samples compared to normal samples, with a negative correlation observed between the biomarkers and most differentially infiltrating immune cells and common immune checkpoints. CONCLUSION In summary, this study discovered eight prognostic biomarkers associated with KIRC patients. These biomarkers showed significant correlations with clinical features, immune cell infiltration, and immune checkpoint expression in KIRC patients, laying a theoretical foundation for the diagnosis and treatment of KIRC.
Collapse
Affiliation(s)
- Shuangze Zhong
- Guangdong Medical University, Zhanjiang City, 524023, Guangdong Province, China
| | - Shangjin Chen
- Guangdong Medical University, Zhanjiang City, 524023, Guangdong Province, China
| | - Hansheng Lin
- Guangdong Medical University, Zhanjiang City, 524023, Guangdong Province, China
- Department of Urology, Yangjiang People's Hospital affiliated to Guangdong Medical University, Yangjiang, 42 Dongshan Road, Jiangcheng District, Guangdong Province, 529500, China
| | - Yuancheng Luo
- Guangdong Medical University, Zhanjiang City, 524023, Guangdong Province, China
| | - Jingwei He
- Department of Urology, Yangjiang People's Hospital affiliated to Guangdong Medical University, Yangjiang, 42 Dongshan Road, Jiangcheng District, Guangdong Province, 529500, China.
| |
Collapse
|
3
|
Abdelsalam ME, Hudspeth TN, Leonards L, Kusin SB, Buckley JR, Bassett R, Awad A, Karam JA, Matin SF, Lu T, Ahrar K. Effectiveness of Thermal Ablation for Renal Cell Carcinoma after Prior Partial Nephrectomy. EUR UROL SUPPL 2023; 57:45-50. [PMID: 38020520 PMCID: PMC10658406 DOI: 10.1016/j.euros.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Repeat partial nephrectomy (PN) for tumors recurring in the ipsilateral kidney is associated with surgical complexity and a higher rate of complications. Objective To evaluate the local oncologic efficacy of thermal ablation (TA) for renal cell carcinoma (RCC) in the ipsilateral kidney following PN. Design setting participation We included patients who underwent ablation for renal tumors in the ipsilateral kidney after PN between January 2005 and December 2019. Demographics, tumor size, procedural details, complications, pathology, local oncologic outcomes, and survival outcomes are described. Outcome measurements and statistical analysis The procedural, pathologic, and oncologic outcomes are described. Survival rates were estimated using the Kaplan-Meier method. Results and limitations A total of 66 patients (46 male and 20 female) with a median age of 62 yr (interquartile range [IQR] 52-69) met our inclusion criteria. In these patients, 74 TA procedures were performed for 86 lesions (median tumor size 1.9 cm, IQR 1.6-2.5). Radiofrequency ablation and cryoablation accounted for 60 (81%) and 14 (19%) procedures, respectively. Three patients (3.7%) had Clavien-Dindo grade III complications. Of 65 lesion biopsies, 62 (95.5%) were diagnostic. The most common subtype was clear cell RCC (n = 37). The median imaging follow-up duration was 60 mo (IQR 43-88). Recurrence in the ablation zone occurred for four lesions (4.6%) at a median of 6.9 mo (IQR 6.4-10.7). The rates of overall, recurrence-free, and disease-free survival were 93.1%, 94.4%, and 65.6% at 5 yr, and 71.6%, 94.4%, and 60.1% at 10 yr, respectively. Limitations include the retrospective design and the lack of a control group. Conclusions TA is effective for the treatment of RCC in the ipsilateral kidney following PN. Patient summary Heat treatment to remove tumor tissue is an effective option for small kidney masses recurring after partial kidney removal for cancer. Long-term follow-up data revealed that this treatment resulted in low recurrence and complication rates.
Collapse
Affiliation(s)
- Mohamed E. Abdelsalam
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tessa N. Hudspeth
- Department of Radiology, Texas Radiology Associates, LLP, Plano, TX, USA
| | - Laura Leonards
- Department of Radiology, North Oaks Medical Center, Hammond, LA, USA
| | - Samuel B. Kusin
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Roland Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed Awad
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A. Karam
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Surena F. Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Lu
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
4
|
Okhawere KE, Grauer R, Zuluaga L, Meilika KN, Ucpinar B, Beksac AT, Razdan S, Saini I, Abramowitz C, Abaza R, Eun DD, Bhandari A, Hemal AK, Porter J, Stifelman MD, Menon M, Badani KK. Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience. J Robot Surg 2023:10.1007/s11701-023-01538-6. [PMID: 36928751 DOI: 10.1007/s11701-023-01538-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/08/2023] [Indexed: 03/18/2023]
Abstract
We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.
Collapse
Affiliation(s)
- Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Ralph Grauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Laura Zuluaga
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Kirolos N Meilika
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Burak Ucpinar
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Alp Tuna Beksac
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Shirin Razdan
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Indu Saini
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Chiya Abramowitz
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Ronney Abaza
- Department of Urology, OhioHealth Dublin Methodist Hospital, Dublin, OH, USA
| | - Daniel D Eun
- Department of Urology, Lewis Katz School of Medicine Temple University, Philadelphia, PA, USA
| | - Akshay Bhandari
- Division of Urology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - James Porter
- Department of Urology, Swedish Urology, Seattle, WA, USA
| | - Michael D Stifelman
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mani Menon
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, 6th Floor, New York City, NY, 10029, USA.
| |
Collapse
|
5
|
Hur KJ, Hooti Q, Shin D, Park YH, Bae WJ, Cho H, Ha US, Lee JY, Choi YJ, Hong SH. Implication of cystic fluid cytology of renal cell carcinoma on surgical practice. BMC Urol 2022; 22:192. [PMID: 36434618 PMCID: PMC9700985 DOI: 10.1186/s12894-022-01144-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/08/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To evaluate the incidence of positive cystic fluid cytology and its risk factors in cystic renal cell carcinoma (RCC) addressing its implication on the current surgical practice. METHODS All clinically diagnosed Bosniak III, IV cystic renal masses from March 2019 to August 2022 were studied prospectively. Database of patients' demographics and cystic tumor characteristics were recorded. Partial or radical nephrectomies were performed by either laparoscopic or robotic approach. Cystic fluid was collected right after specimen retrieval in the surgical field and examined by pathologist. Cytology results were compared to the demographic, perioperative variables using univariate and multivariate analysis. RESULTS A total of 70 patients of histologically confirmed cystic RCC were included. Sixty seven patients underwent radical nephrectomy with laparoscopic or robotic approaches, while 3 patients underwent radical nephrectomy. There was no intraoperative cystic rupture or fluid spillage. Positive cystic fluid cytology findings were identified in 34 (48.6%) patients, while negative cystic fluid cytology were identified in 36 (51.4%) cases. Definite malignant cells were observed in 28 patients while the other six patients showed highly suspicious atypical cells. Histologically, 24 (70.8%) patients were proven clear cell RCC and 25 (73%) showed Fuhrman grade 1 or 2 in final histologic review in positive group. Univariate and multivariate regression analysis between positive and negative cytology groups showed that the presence of the malignant cells in cystic fluid was significantly associated with patients' age (> 55 years) and Bosniak grade of cystic tumor (p < 0.05). CONCLUSIONS Definite malignant cells in cystic fluid cytology were observed through our study. Additionally, patients' age (> 55 years) and Bosniak grade were the significant risk factors of positive cytology in cystic RCC. Therefore, necessity of meticulous manipulation of cystic renal tumors, despite their clinical features, should not be underemphasized to avoid the least possible tumor cell seeding in case of cystic rupture when operating such high risk of positive cytology.
Collapse
Affiliation(s)
- Kyung Jae Hur
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea ,grid.413395.90000 0004 0647 1890Department of Urology, Daegu Fatima Hospital, Daegu, South Korea
| | - Qais Hooti
- grid.416132.30000 0004 1772 5665Department of Urology, The Royal Hospital, Muscat, Sultanate of Oman
| | - Dongho Shin
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| | - Yong Hyun Park
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| | - Woong Jin Bae
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| | - Hyukjin Cho
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| | - U-syn Ha
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| | - Ji Youl Lee
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| | - Yeong Jin Choi
- grid.411947.e0000 0004 0470 4224Department of Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hoo Hong
- grid.411947.e0000 0004 0470 4224Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591 Republic of Korea
| |
Collapse
|
6
|
Zhang G, Chen X, Fang J, Tai P, Chen A, Cao K. Cuproptosis status affects treatment options about immunotherapy and targeted therapy for patients with kidney renal clear cell carcinoma. Front Immunol 2022; 13:954440. [PMID: 36059510 PMCID: PMC9437301 DOI: 10.3389/fimmu.2022.954440] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/05/2022] [Indexed: 01/10/2023] Open
Abstract
The development of immunotherapy has changed the treatment landscape of advanced kidney renal clear cell carcinoma (KIRC), offering patients more treatment options. Cuproptosis, a novel cell death mode dependent on copper ions and mitochondrial respiration has not yet been studied in KIRC. We assembled a comprehensive cohort of The Cancer Genome Atlas (TCGA)-KIRC and GSE29609, performed cluster analysis for typing twice using seven cuproptosis-promoting genes (CPGs) as a starting point, and assessed the differences in biological and clinicopathological characteristics between different subtypes. Furthermore, we explored the tumor immune infiltration landscape in KIRC using ESTIMATE and single-sample gene set enrichment analysis (ssGSEA) and the potential molecular mechanisms of cuproptosis in KIRC using enrichment analysis. We constructed a cuproptosis score (CUS) using the Boruta algorithm combined with principal component analysis. We evaluated the impact of CUS on prognosis, targeted therapy, and immunotherapy in patients with KIRC using survival analysis, the predictions from the Cancer Immunome Atlas database, and targeted drug susceptibility analysis. We found that patients with high CUS levels show poor prognosis and efficacy against all four immune checkpoint inhibitors, and their immunosuppression may depend on TGFB1. However, the high-CUS group showed higher sensitivity to sunitinib, axitinib, and elesclomol. Sunitinib monotherapy may reverse the poor prognosis and result in higher progression free survival. Then, we identified two potential CPGs and verified their differential expression between the KIRC and the normal samples. Finally, we explored the effect of the key gene FDX1 on the proliferation of KIRC cells and confirmed the presence of cuproptosis in KIRC cells. We developed a targeted therapy and immunotherapy strategy for advanced KIRC based on CUS. Our findings provide new insights into the relationship among cuproptosis, metabolism, and immunity in KIRC.
Collapse
Affiliation(s)
| | | | | | | | | | - Ke Cao
- *Correspondence: Ke Cao, ;
| |
Collapse
|
7
|
Liu Y, Zhang X, Ma H, Tian L, Mai L, Long W, Zhang Z, Han H, Zhou F, Dong P, He L. Locoregional recurrence after nephrectomy for localized renal cell carcinoma: Feasibility and outcomes of different treatment modalities. Cancer Med 2022; 11:4430-4439. [PMID: 35506551 PMCID: PMC9741970 DOI: 10.1002/cam4.4790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/10/2022] [Accepted: 04/15/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Locoregional recurrence after nephrectomy for localized renal cell carcinoma (RCC) is rare with diverse manifestations. The selection criteria and efficacy of different treatments are unanswered. The objective was to compare different treatment modalities and present data on stereotactic body radiotherapy (SBRT) for recurrent RCC. MATERIALS AND METHODS Patients with locoregional recurrence after nephrectomy without distant metastasis were identified from institutional big data intelligence platform between 2001 and 2020. Patients receiving local therapy (surgery or SBRT) or systemic therapy alone (targeted therapy or PD-1 inhibitors) were divided into two groups. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier method, Cox regression model. Patients were matched with propensity score matching. RESULTS Among 106 patients, 33 (31.1%) received systemic therapy alone and 73 (68.9%) received local therapy. Local therapy was surgery in 34 patients (32.1%) and SBRT in 39 (36.8%) patients. Patients treated with systemic therapy alone had more non-clear cell type (p = 0.044), more advanced T stage (p = 0.006), higher number (p = 0.043) but smaller size of lesions (p = 0.042). Patients receiving local therapy had significantly longer PFS than systemic therapy (19.7 vs. 7.5 months, p = 0.001). After matching, the PFS in the local therapy group remained higher (23.9 vs. 7.5 months, p = 0.001). The 2-year OS of the local therapy group and systemic therapy group was 91.6% and 71.8%, respectively (p = 0.084). Local therapy was associated with better PFS (HR 0.37; p = 0.0003) and OS (HR 0.23; p = 0.002) in multivariate analysis. Grade 2 or higher toxicities related to local therapy occurred in nine patients. CONCLUSIONS Local therapy could delay disease progression compared with systemic therapy alone. SBRT is safe and effective for locally recurrent RCC.
Collapse
Affiliation(s)
- Yang Liu
- Department of Radiation OncologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Xinyue Zhang
- Department of Radiation OncologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Huali Ma
- Department of RadiologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Li Tian
- Department of RadiologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Lixin Mai
- Department of Radiation OncologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Wen Long
- Department of Nuclear MedicineSun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Zhiling Zhang
- Department of UrologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Hui Han
- Department of UrologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Fangjian Zhou
- Department of UrologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Pei Dong
- Department of UrologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| | - Liru He
- Department of Radiation OncologySun Yat‐Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer MedicineGuangzhouChina
| |
Collapse
|
8
|
Ray S, Cheaib JG, Biles MJ, Pineault KG, Johnson MH, Ged YM, Markowski MC, Singla N, Allaf ME, Pierorazio PM. Local and Regional Recurrences of Clinically Localized Renal Cell Carcinoma after Nephrectomy: A 15 Year Institutional Experience with Prognostic Features and Oncologic Outcomes. Urology 2021; 154:201-207. [PMID: 33864855 PMCID: PMC9774049 DOI: 10.1016/j.urology.2021.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate outcomes for patients with local recurrence (LR) of clinically localized renal cell carcinoma (RCC) without concurrent systemic metastasis from our institution, an event that occurs rarely (1%-3%) after surgery. LR may be a harbinger of poor outcomes, and the best management of these patients is unclear. MATERIALS/METHODS We retrospectively reviewed patients surgically treated for clinically localized RCC (cT1-2N0M0) with subsequent LR (in the partial or radical nephrectomy bed) and/or regional recurrence (RR; in the abdomen distant from the direct site of surgery) without concurrent metastasis from our institutional database (2004-2018). Comparative and survival analyses were performed. RESULTS Out of 3038 total patients, 1895 had clinically localized RCC, with 30 patients (1.6%) having isolated LR/RR. Median time to recurrence was 26.5 months (IQR:16-35). Of 26 patients treated with local therapy, 14 (53.8%) recurred over a median follow-up time of 29.5 months (IQR:12-45). The 1-year and 2-year secondary recurrence-free survival rates are 60.7% and 49.7%, respectively. Two or more sites of locoregional recurrence significantly predicted secondary recurrence/metastasis after local therapy for local recurrence (hazard ratio: 2.22, P= .04). CONCLUSION Our results suggest local therapy is appropriate for select patients with LR/RR, with almost 50% of patients undergoing a second local therapy remaining alive with "local cure" and no secondary recurrence. The number of sites of recurrence can be used to better select patients that will benefit from local therapy or systemic/combination therapy. This work provides a framework onto which further studies regarding local therapy and locoregional recurrence of RCC can be performed.
Collapse
|
9
|
The Limited Usefulness of Ultrasound Surveillance after Radical and Partial Nephrectomy for Renal Cell Carcinoma. UROLOGY PRACTICE 2020. [DOI: 10.1097/upj.0000000000000065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Renal fossa recurrence after radical nephrectomy: Current management, and oncological outcomes. Urol Oncol 2019; 38:42.e7-42.e12. [PMID: 31711833 DOI: 10.1016/j.urolonc.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/30/2019] [Accepted: 10/07/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Kidney cancers represent 2% of cancers worldwide; the most common type is renal clear cell carcinoma (RCC). Surgical treatment remains the only effective therapy for localized renal cell carcinoma. Approximately 20% to 38% of patients undergoing radical nephrectomy (RN) for localized RCC will have subsequent disease progression, with 0.8% to 3.6% of local recurrences within the ipsilateral retroperitoneum (RFR). The main objective of this study is to evaluate prognostic features, oncological outcomes, and current management for renal fossa recurrence in patients with history of RN for RCC. MATERIALS AND METHODS We retrospectively analyzed 733 patients who underwent open or laparoscopic RN for unilateral T1-T4 N0 M0 RCC between 2010 and 2016 at the Urology Department of Hospital Italiano de Buenos Aires. RESULTS During the mentioned period, of a total of 733 RNs (open/laparoscopic), 561 patients with RCC were included in the study. After a median follow-up time of 24 months (12-36) (interquartile range), 21 (3.74%) patients out of 561, developed renal fossa recurrence. Of these, 13 (2.31%) patients were diagnosed with isolated local renal fossa recurrence and different treatment approaches were adopted; 11 patients underwent open surgical resection, 1 patient laparoscopic surgical resection, and 1 case was treated with cryoablation. Regarding cancer-specific survival, estimated 4-year cancer-specific survival in patients without RFR, with isolated RFR (iRFR) and not isolated RFR (niRFR) was 82.7% (CI 95% 70.2-95.2), 69.2% (IC 44.2-94.2) and 0%, respectively (log rank test P < 0.0001 being niRFR group different to others. Non isolated RFR was a death risk factor with a HR of 11.4 (4.8-27.2) compared with iRFR or no recurrence. Overall, 51% (IC 26.6-71.2) of patients with any RFR died at 4 years follow-up. CONCLUSION Although RFR is a rare condition, in the absence of distant metastatic disease, aggressive surgical resection should be our aim. High pathological tumoral stage at original nephrectomy and high tumoral grade are independent risk factors for RFR. This group of patients needs closer follow-up to detect earlier recurrences and decide a treatment strategy.
Collapse
|
11
|
Gofrit ON, Rabinovich I, Yutkin V, Pode D, Duvdevani M, Landau EH, Hidas G, Goldberg SN. Abbreviated CT protocol for postoperative surveillance of renal cancer. Urol Oncol 2018; 36:498.e9-498.e13. [PMID: 30228095 DOI: 10.1016/j.urolonc.2018.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/24/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Postoperative surveillance protocols after nephrectomy for kidney cancer include periodic computed tomography (CT) scans of the chest and abdomen. A single study exposes the patient to 21 mSv (equivalent to 7-year exposure to natural background radiation). The objective of this study was to evaluate the hypothesis that an abbreviated CT protocol restricted to the chest and upper abdomen (i.e., to the level of the intervertebral disk L3-L4) is sufficient for routine postnephrectomy follow-up as it detects most tumor recurrence with lower radiation exposure. METHODS We identified 493 patients treated with radical or partial nephrectomy for localized kidney cancer and followed with periodic CT scans of the chest and abdomen for prolonged periods. The frequency and location of cancer recurrence were documented. The ratio of infield recurrence for the complete chest, and abdomen and for the abbreviated protocol was recorded. The decrease in radiation exposure was calculated. RESULTS At a median follow up of 96 months, 82 patients (16.6%) developed recurrence. The frequent sites of recurrence were the lungs (53), the bones (9), and local recurrence (22). Complete chest and abdominal CT identified 78 of the recurrences (95%) and the abbreviated protocol identifying all but one of these (94%). The abbreviated protocol exposed the patient to 48% (standard deviation 4.3%) less radiation compared to the full protocol. CONCLUSIONS Using an abbreviated CT protocol that includes the chest and upper abdomen for surveillance after surgery of localized kidney cancer decreases radiation exposure by half with only a minor decrease in the sensitivity of the examination.
Collapse
Affiliation(s)
- Ofer N Gofrit
- Department of Urology, Hadassah University Hospital, Jerusalem, Israel.
| | - Igal Rabinovich
- Department of Urology, Hadassah University Hospital, Jerusalem, Israel
| | - Vladimir Yutkin
- Department of Urology, Hadassah University Hospital, Jerusalem, Israel
| | - Dov Pode
- Department of Urology, Hadassah University Hospital, Jerusalem, Israel
| | | | - Ezekiel H Landau
- Department of Urology, Hadassah University Hospital, Jerusalem, Israel
| | - Guy Hidas
- Department of Urology, Hadassah University Hospital, Jerusalem, Israel
| | - S Nahum Goldberg
- Department of Radiology, Hadassah University Hospital, Jerusalem, Israel
| |
Collapse
|
12
|
Systematic Review of the Management of Local Kidney Cancer Relapse. Eur Urol Oncol 2018; 1:512-523. [PMID: 31158097 DOI: 10.1016/j.euo.2018.06.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/03/2018] [Accepted: 06/15/2018] [Indexed: 12/26/2022]
Abstract
CONTEXT Management of locally recurrent renal cancer is complex. OBJECTIVE In this systematic review we analyse the available literature on the management of local renal cancer recurrence. EVIDENCE ACQUISITION A systematic search (PubMed, Web of Science, CINAHL, Clinical Trials, and Scopus) of English literature from 2000 to 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. EVIDENCE SYNTHESIS The search identified 1838 articles. Of those, 36 were included in the evidence synthesis. The majority of the studies identified were retrospective and not controlled. Local recurrence after thermal ablation (TA) may be managed with repeat TA. Alternatively, salvage nephrectomy is possible. However, a higher rate of complications should be expected than after primary nephrectomy. Salvage nephrectomy and TA represent treatment options for local recurrence after partial nephrectomy. Local retroperitoneal recurrence after radical nephrectomy is ideally treated with surgical resection, for which minimally invasive approaches might be applicable to select patients. For large recurrences, addition of intraoperative radiation may improve local control. Local tumour destruction appears to be more beneficial than systemic therapy alone for local recurrences. CONCLUSIONS Management of local renal cancer relapse varies according to the clinical course and prior treatments. The available data are mainly limited to noncontrolled retrospective series. After nephron-sparing treatment, TA represents an effective treatment with low morbidity. For local recurrence after radical nephrectomy, the low-level evidence available suggests superiority of surgical excision relative to systemic therapy or best supportive care. As a consequence, surgery should be prioritised when feasible and applicable. PATIENT SUMMARY In renal cell cancer, the occurrence and management of local recurrence depend on the initial treatment. This cancer is a disease with a highly variable clinical course. After initial organ-sparing treatment, thermal ablation offers good cancer control and low rates of complications. For recurrence after radical nephrectomy, surgical excision seems to provide the best long-term cancer control and it is superior to medical therapy alone.
Collapse
|
13
|
Pradere B, Peyronnet B, Delporte G, Manach Q, Khene ZE, Moulin M, Roumiguié M, Rizk J, Brichart N, Beauval JB, Cormier L, Bex A, Rouprêt M, Bruyère F, Bensalah K. Intraoperative Cyst Rupture during Partial Nephrectomy for Cystic Renal Masses-Does it Increase the Risk of Recurrence? J Urol 2018; 200:1200-1206. [PMID: 29935273 DOI: 10.1016/j.juro.2018.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Our objective was to assess the prevalence of intraoperative cyst rupture and its impact on oncologic outcomes. MATERIALS AND METHODS All patients who underwent partial nephrectomy for a cystic renal mass via an open or robot-assisted approach at a total of 8 academic institutions were included in this retrospective study. All operative reports were carefully reviewed and any description of cyst rupture, cyst effraction or local spillage intraoperatively was recorded as cyst rupture. Multivariate logistic regression analysis was done to assess the variables associated with cyst rupture. Recurrence-free, cancer specific and overall survival was estimated by the Kaplan-Meier method and compared with the log rank test. RESULTS Overall 268 patients were included in study. There were 50 intraoperative cyst ruptures (18.7%) in the whole cohort. No preoperative parameter was significantly associated with a risk of intraoperative cyst rupture on univariate or multivariate analysis. Of the cystic renal masses 75% were malignant on the final pathology report. At a median followup of 32 months 5 patients (2.5%) had local recurrence while progression to metastasis was observed in 2%. There were no peritoneal carcinomatosis nor port site metastasis. There was also no local or metastatic recurrence in the subgroup with intraoperative cyst rupture. Estimated recurrence-free survival did not differ significantly between patients with vs without intraoperative cyst rupture at 100% vs 92.7% at 5 years (p = 0.20). CONCLUSIONS Intraoperative cyst rupture during partial nephrectomy is a relatively common occurrence but with few oncologic implications.
Collapse
Affiliation(s)
- Benjamin Pradere
- Department of Urology, Centre Hospitalier Universitaire Tours, Tours, France.
| | - Benoit Peyronnet
- Department of Urology, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Gauthier Delporte
- Department of Urology, Centre Hospitalier Régional Universitaire Lille, Lille, France
| | - Quentin Manach
- Department of Urology, Hôpital Pitié-Salpetrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Zine-Eddine Khene
- Department of Urology, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Morgan Moulin
- Department of Urology, Centre Hospitalier Universitaire Dijon, Dijon, France
| | - Mathieu Roumiguié
- Department of Urology, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Jérome Rizk
- Department of Urology, Centre Hospitalier Régional Universitaire Lille, Lille, France
| | - Nicolas Brichart
- Department of Urology, Centre Hospitalier Orléans, Orléans, France
| | | | - Luc Cormier
- Department of Urology, Centre Hospitalier Universitaire Dijon, Dijon, France
| | - Axel Bex
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- Department of Urology, Hôpital Pitié-Salpetrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Franck Bruyère
- Department of Urology, Centre Hospitalier Universitaire Tours, Tours, France
| | - Karim Bensalah
- Department of Urology, Centre Hospitalier Universitaire Rennes, Rennes, France
| |
Collapse
|
14
|
Laguna MP. Re: Stereotactic Ablative Body Radiotherapy for Inoperable Primary Kidney Cancer: A Prospective Clinical Trial. J Urol 2018; 199:1393-1394. [PMID: 29783588 DOI: 10.1016/j.juro.2018.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
|
15
|
Zhou W, Herwald SE, Uppot RN, Arellano RS. Image-Guided Thermal Ablation for Non-resectable Recurrence of Renal Cell Cancer Following Nephrectomy: Clinical Experience with Eleven Patients. Cardiovasc Intervent Radiol 2018; 41:1743-1750. [DOI: 10.1007/s00270-018-1976-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/24/2018] [Indexed: 01/20/2023]
|
16
|
Psutka SP, Master VA. Role of metastasis-directed treatment in kidney cancer. Cancer 2018; 124:3641-3655. [PMID: 29689599 DOI: 10.1002/cncr.31341] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 02/05/2018] [Accepted: 02/09/2018] [Indexed: 12/12/2022]
Abstract
Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.
Collapse
Affiliation(s)
- Sarah P Psutka
- Division of Urology, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois.,Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Viraj A Master
- Department of Urology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
17
|
Pilar A, Gupta M, Ghosh Laskar S, Laskar S. Intraoperative radiotherapy: review of techniques and results. Ecancermedicalscience 2017; 11:750. [PMID: 28717396 PMCID: PMC5493441 DOI: 10.3332/ecancer.2017.750] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Indexed: 12/14/2022] Open
Abstract
Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community. Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise. IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers). This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.
Collapse
Affiliation(s)
- Avinash Pilar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Meetakshi Gupta
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| |
Collapse
|
18
|
Role of Radiotherapy in the Treatment of Renal Cell Cancer: Updated and Critical Review. TUMORI JOURNAL 2017; 103:504-510. [DOI: 10.5301/tj.5000640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 12/22/2022]
Abstract
Purpose The growing incidence of renal cell carcinoma (RCC) raises many questions about the management of these patients. The late clinical presentation, the presence of locally advanced or metastatic disease at diagnosis, the difficulty of radical surgical excision, and radioresistance make it one of the more challenging tumors to treat. The primary objective of this article is to propose an updated and critical review of the role of radiotherapy (RT) in the treatment of RCC. Methods This literature review is based on data from meta-analyses and randomized, prospective, and retrospective studies. We collected reports from 1970 to the present about preoperative RT, postoperative RT, stereotactic body RT, radiosurgery, and intraoperative RT in locally advanced renal cancer and in metastatic diseases. Results We emphasize the progress made in RT technology that allowed the creation of a more personalized and focused treatment with a minimum rate of complications. Conclusions In the coming years, new studies will be published to confirm and increase the indications for use of RT.
Collapse
|
19
|
Krengli M, Pisani C, Deantonio L, Surico D, Volpe A, Surico N, Terrone C. Intraoperative radiotherapy in gynaecological and genito-urinary malignancies: focus on endometrial, cervical, renal, bladder and prostate cancers. Radiat Oncol 2017; 12:18. [PMID: 28100242 PMCID: PMC5244540 DOI: 10.1186/s13014-016-0748-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 12/21/2016] [Indexed: 01/07/2023] Open
Abstract
Intraoperative radiotherapy (IORT) refers to the delivery of a single radiation dose to a limited volume of tissue during a surgical procedure. A literature review was performed to analyze the role of IORT in gynaecological and genito-urinary cancer including endometrial, cervical, renal, bladder and prostate cancers. Literature search was performed by Pubmed and Scopus, using the words “intraoperative radiotherapy/IORT”, “gynaecological cancer”, “uterine/endometrial cancer”, “cervical/cervix cancer”, “renal/kidney cancer”, “bladder cancer” and “prostate cancer”. Forty-seven articles were selected from the search databases, analyzed and briefly described. Literature data show that IORT has been used to optimize local control rate in genito-urinary tumours mainly in retrospective studies. The results suggest that IORT could be advantageous in the setting of locally advanced and recurrent disease although further prospective trials are needed to confirm this findings.
Collapse
Affiliation(s)
- Marco Krengli
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy. .,Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy.
| | - Carla Pisani
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy.,Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Letizia Deantonio
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy.,Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Daniela Surico
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy.,Department of Obstetrics and Gynecology, University Hospital Maggiore della Carità, Novara, Italy
| | - Alessandro Volpe
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy.,Department of Urology, University Hospital Maggiore della Carità, Novara, Italy
| | - Nicola Surico
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy.,Department of Obstetrics and Gynecology, University Hospital Maggiore della Carità, Novara, Italy
| | - Carlo Terrone
- Department of Translational Medicine, University of Piemonte Orientale, Via Solaroli, 17-28100, Novara, Italy.,Department of Urology, University Hospital Maggiore della Carità, Novara, Italy
| |
Collapse
|
20
|
Psutka SP, Heidenreich M, Boorjian SA, Bailey GC, Cheville JC, Stewart-Merrill SB, Lohse CM, Atwell TD, Costello BA, Leibovich BC, Thompson RH. Renal fossa recurrence after nephrectomy for renal cell carcinoma: prognostic features and oncological outcomes. BJU Int 2016; 119:116-127. [DOI: 10.1111/bju.13620] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sarah P. Psutka
- Department of Urology; Mayo Clinic; Rochester MN USA
- Division of Urology; John H. Stroger Jr. Hospital of Cook County; Chicago IL USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Rausch S, Kruck S, Walter K, Stenzl A, Bedke J. Metastasectomy for metastatic renal cell carcinoma in the era of modern systemic treatment: C-reactive protein is an independent predictor of overall survival. Int J Urol 2016; 23:916-921. [PMID: 27520319 DOI: 10.1111/iju.13171] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/26/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To define the predictive capability of serum C-reactive protein for a contemporary patient collective undergoing metastasectomy for metastatic renal cell carcinoma with access to modern targeted therapies. METHODS A total of 88 patients treated with metastasectomy for metastatic renal cell carcinoma from 2003 to 2014 were evaluated for putative clinicopathological risk factors and survival. Kaplan-Meier analyses, univariate and multivariate testing were carried out. Receiver operating characteristic curve analysis was applied to evaluate available risk stratification instruments for patients undergoing metastasectomy. RESULTS Median overall survival for the collective was 66.31 months (95% confidence interval 50.67-135.47; 5-year overall survival 55%). The median preoperative C-reactive protein level was 6.7 mg/L (range 0.1-161.7). A C-reactive protein cut-off value of 5 mg/dL was significantly discriminative of survival (P = 0.029). Median survival in dependence of C-reactive protein accounted for 50.67 months (range 33.86-63.05 months) in the C-reactive protein >5 mg/L group, and 135.47 months in the C-reactive protein ≤5 mg/L group (range 66.31-135.47 months). C-reactive protein elevation >5 mg/L, anemia and surgical margin status were identified as significant predictors of overall survival in univariate analysis. In a multivariate model, resection margin status (P = 0.015) and C-reactive protein elevation (P = 0.038) were confirmed as independent predictive variables. CONCLUSIONS Elevated C-reactive protein >5 mg/L was identified as an independent predictor of survival in a contemporary patient collective undergoing metastasectomy for metastatic renal cell carcinoma. Future analyses and risk stratification tools for patients undergoing metastasectomy for metastatic renal cell carcinoma should aim to evaluate and include C-reactive protein. To overcome low patient numbers, multi-institutional studies should be carried out.
Collapse
Affiliation(s)
- Steffen Rausch
- Department of Urology, Eberhard Karls University, Tübingen, Germany.
| | - Stephan Kruck
- Department of Urology, Eberhard Karls University, Tübingen, Germany
| | - Kerstin Walter
- Department of Urology, Eberhard Karls University, Tübingen, Germany
| | - Arnulf Stenzl
- Department of Urology, Eberhard Karls University, Tübingen, Germany
| | - Jens Bedke
- Department of Urology, Eberhard Karls University, Tübingen, Germany
| |
Collapse
|
22
|
Surgical Management of Local Recurrences of Renal Cell Carcinoma. Surg Res Pract 2016; 2016:2394942. [PMID: 26925458 PMCID: PMC4746394 DOI: 10.1155/2016/2394942] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/10/2016] [Indexed: 01/20/2023] Open
Abstract
Surgical resection either in the form of radical nephrectomy or in the form of partial nephrectomy represents the mainstay options in the treatment of kidney cancer. In most instances, resecting the tumor bearing kidney or the tumor itself provides durable cancer specific survival rates. However, recurrences may rarely develop in the renal fossa or remnant kidney. Despite its rarity, locally recurrent RCC is a challenging condition in terms of the possible management options and relatively poor prognosis. If technically feasible, wide surgical excision and ensuring negative surgical margins are the most effective treatment options. Repeat surgeries (completion nephrectomy, excision of locally recurrent tumor, or repeat partial nephrectomy) may often be complicated, and perioperative morbidity is a major concern. Open approach has been extensively applied in this context and 5-year cancer specific survival rates have been reported to be around 50%. The roles of minimally invasive surgical options (laparoscopic and robotic approach) and nonsurgical alternatives (cryoablation, radiofrequency ablation) have yet to be described. In selected patients, surgical resection may have to be complemented with (neo)adjuvant radiotherapy or medical treatment.
Collapse
|
23
|
Thomas AZ, Adibi M, Borregales LD, Hoang LN, Tamboli P, Jonasch E, Tannir NM, Matin SF, Wood CG, Karam JA. Surgical Management of Local Retroperitoneal Recurrence of Renal Cell Carcinoma after Radical Nephrectomy. J Urol 2015; 194:316-22. [PMID: 25758610 PMCID: PMC4666307 DOI: 10.1016/j.juro.2015.02.2943] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2015] [Indexed: 01/01/2023]
Abstract
PURPOSE Isolated local retroperitoneal recurrence after radical nephrectomy for renal cell carcinoma poses a therapeutic challenge. We investigated outcomes in patients with localized retroperitoneal recurrence treated with surgical resection. MATERIALS AND METHODS This was a retrospective, single institutional study of 102 patients with retroperitoneal recurrence treated with surgery from 1990 to 2014. Demographics, clinical and pathological features, location of retroperitoneal recurrence and perioperative complications are reported using descriptive statistics. We studied recurrence-free and cancer specific survival using univariate and multivariate analyses. RESULTS Median age at retroperitoneal recurrence diagnosis was 55 years (IQR 49-64). Cancer was pT3-4 in 62 patients (60.8%) and pN1 in 20 (19.6%). No patients had distant metastatic disease at retroperitoneal recurrence surgery. Median time from nephrectomy to retroperitoneal recurrence diagnosis was 19 months (IQR 5-38.8). The median size of the resected retroperitoneal recurrence was 4.5 cm (IQR 2.7-7). Median followup after recurrence surgery was 32 months (IQR 16-57). Metastatic progression was observed in 60 patients (58.8%) postoperatively. Neoadjuvant and salvage systemic therapy was administered in 46 (45.1%) and 48 patients (47.1%), respectively. On multivariate analysis pathological nodal stage at original nephrectomy and maximum diameter of retroperitoneal recurrence were identified as independent risk factors for cancer specific death. CONCLUSIONS Clinicopathological factors at nephrectomy as well as retroperitoneal recurrence surgery are important prognosticators. Aggressive surgical resection offers potential cure in a substantial number of patients with retroperitoneal recurrence with acceptable complications and still has a dominant role in the management of isolated locally recurrent RCC.
Collapse
Affiliation(s)
- Arun Z Thomas
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mehrad Adibi
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Leonardo D Borregales
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ly N Hoang
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pheroze Tamboli
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher G Wood
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jose A Karam
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| |
Collapse
|
24
|
Fayek IS, Habashy HF, Habashy NF. Isolated loco-regional recurrence after radical nephrectomy for renal cell carcinoma: A study of 22patients. J Egypt Natl Canc Inst 2014; 26:161-6. [DOI: 10.1016/j.jnci.2014.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 05/23/2014] [Accepted: 05/29/2014] [Indexed: 01/15/2023] Open
|
25
|
Russell CM, Espiritu PN, Kassouf W, Schwaab T, Buethe DD, Dhilon J, Sexton WJ, Poch M, Powsang JM, Tanguay S, Nayan M, Alsaadi H, Hanzly MI, Spiess PE. Surgical Outcomes in the Management of Isolated Nodal Recurrences: A Multicenter, International Retrospective Cohort. J Urol 2014; 192:350-6. [DOI: 10.1016/j.juro.2014.02.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2014] [Indexed: 11/26/2022]
|
26
|
Paly JJ, Hallemeier CL, Biggs PJ, Niemierko A, Roeder F, Martínez-Monge R, Whitson J, Calvo FA, Fastner G, Sedlmayer F, Wong WW, Ellis RJ, Haddock MG, Choo R, Shipley WU, Zietman AL, Efstathiou JA. Outcomes in a Multi-institutional Cohort of Patients Treated With Intraoperative Radiation Therapy for Advanced or Recurrent Renal Cell Carcinoma. Int J Radiat Oncol Biol Phys 2014; 88:618-23. [DOI: 10.1016/j.ijrobp.2013.11.207] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/04/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
|
27
|
Habl G, Uhl M, Hensley F, Pahernik S, Debus J, Röder F. Intraoperative electron radiation therapy (IOERT) in patients with locally recurrent renal cell carcinoma. Radiat Oncol 2013; 8:282. [PMID: 24295293 PMCID: PMC3922867 DOI: 10.1186/1748-717x-8-282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To analyze our experience with intraoperative electron radiation therapy (IOERT) followed by moderate doses of external beam radiation therapy (EBRT) in patients with locally recurrent renal cell carcinoma. METHODS From 1992 to 2010, 17 patients with histologically proven, locally recurrent renal cell carcinoma (median tumor size 7 cm) were treated by surgery and IOERT with a median dose of 15 Gy. All patients met the premise of curative intent including 7 patients with oligometastases at the time of recurrent surgery, which were resected and/or irradiated. The median time interval from primary surgery to local recurrence was 26 months. Eleven patients received additional 3D-conformal EBRT with a median dose of 40 Gy. RESULTS Surgery resulted in free but close margins in 6 patients (R0), while 9 patients suffered from microscopic (R1) and 2 patients from macroscopic (R2) residual disease. After a median follow-up of 18 months, two local recurrences were observed, resulting in an actuarial 2-year local control rate of 91%. Eight patients developed distant failures, predominantly to liver and bone, resulting in an actuarial 2-year progression free survival of 32%. An improved PFS rate was found in patients with a larger time interval between initial surgery and recurrence (> 26 months). The actuarial 2-year overall survival rate was 73%. Lower histological grading (G1/2) was the only factor associated with improved overall survival. Perioperative complications were found in 4 patients. No IOERT specific late toxicities were observed. CONCLUSIONS Combination of surgery, IOERT and EBRT resulted in high local control rates with low toxicity in patients with locally recurrent renal cell cancer despite an unfavorable surgical outcome in the majority of patients. However, progression-free and overall survival were still limited due to a high distant failure rate, indicating the need for intensified systemic treatment especially in patients with high tumor grading and short interval to recurrence.
Collapse
Affiliation(s)
- Gregor Habl
- Department of Radiation Oncology, University of Heidelberg, Im Neuenheimer Feld 400 Heidelberg 69120, Germany.
| | | | | | | | | | | |
Collapse
|
28
|
Paparel P, Bigot P, Matillon X, Bensalah K, Salomon L, Baumert H, Bastide C, Thuret R, Karsenty G, Long JA, Ammi M, Bessede T, Bin S, Roux A, Escudier B, Rioux Leclercq N, Pignot G, Soulie M, Patard JJ. Local recurrence after radical nephrectomy for kidney cancer: management and prediction of outcomes. a multi-institutional study. J Surg Oncol 2013; 109:126-31. [DOI: 10.1002/jso.23473] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 09/25/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Philippe Paparel
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Lyon Sud University Hospital, Claude Bernard University Lyon 1; Lyon France
| | - Pierre Bigot
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Angers University Hospital; Angers France
| | - Xavier Matillon
- Department of Urology; Lyon Sud University Hospital, Claude Bernard University Lyon 1; Lyon France
| | - Karim Bensalah
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Pontchaillou University Hospital; Rennes France
| | - Laurent Salomon
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Henri Mondor University Hospital; Créteil France
| | - Hervé Baumert
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Saint-Louis University Hospital; Paris France
| | - Cyril Bastide
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Nord University Hospital; Marseille France
| | - Rodolphe Thuret
- Department of Urology; Lapeyronie University Hospital; Montpellier France
| | - Gilles Karsenty
- Department of Urology; La conception University Hospital; Marseille France
| | - Jean Alexandre Long
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Grenoble University Hospital; Grenoble France
| | - Myriam Ammi
- Department of Urology; Angers University Hospital; Angers France
| | - Thomas Bessede
- Department of Urology; Bicêtre University Hospital, Le Kremlin Bicêtre; France
| | - Sylvie Bin
- Hospices Civils de Lyon; Pôle Information Médicale Evaluation Recherche, Unité de Recherche Clinique; Lyon France
| | - Adeline Roux
- Hospices Civils de Lyon; Pôle Information Médicale Evaluation Recherche, Unité de Recherche Clinique; Lyon France
| | - Bernard Escudier
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Medical Oncology; Institut Gustave Roussy; Villejuif France
| | - Nathalie Rioux Leclercq
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Pathology; Pontchaillou University Hospital; Rennes France
| | - Géraldine Pignot
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Bicêtre University Hospital, Le Kremlin Bicêtre; France
| | - Michel Soulie
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Toulouse University Hospital; Toulouse France
| | - Jean-Jacques Patard
- Cancerology Committee of the French Association of Urology (CCAFU); Paris France
- Department of Urology; Bicêtre University Hospital, Le Kremlin Bicêtre; France
| |
Collapse
|
29
|
Sanli O, Erdem S, Tefik T, Aytac O, Yucel OB, Oktar T, Ozcan F. Laparoscopic excision of local recurrence of renal cell carcinoma. JSLS 2013; 16:597-605. [PMID: 23484571 PMCID: PMC3558899 DOI: 10.4293/108680812x13517013316393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Laparoscopic excision of local recurrent renal cell carcinoma appears to be a feasible technique in wellselected patients with low-volume mass not involving adjacent organs. Background and Objective: To report a single center's experience with laparoscopic excision of local recurrence of renal cell carcinoma. Methods: Between January and August 2011, 5 patients who underwent laparoscopic excision of local recurrence were identified from the institutional laparoscopic surgery database. Results: Four radical nephrectomies and 1 partial nephrectomy were performed for primary tumors. The mean ages of the patients were 57.4 y (range, 48 to 68) and 62.8 y (range, 53 to 71) at the time of primary surgery and laparoscopic recurrence excision, respectively. The average size of the primary tumor was 7.2cm (range, 4.5 to 11). The mean size of local recurrence was 3.46cm (range, 2.8 to 4.5). The original tumor T stages were T1b, T2b, and T4 in 3, 1, and 1 cases, respectively. The mean time to diagnosis of recurrence was 51.2 mo (range, 15 to 136). The pathology of one patient who had previously received targeted therapy with sunitinib, was necrosis, unlike the other 4 pathologies which revealed renal cell carcinoma. The mean operative time, estimated blood loss, and length of hospital stay were 86 min (range, 70 to 100), 100 mL (range, 20 to 300), and 4 d (range, 2 to 8), respectively. One pleural injury did not need open conversion and was repaired laparoscopically. At a mean follow-up of 8.4 mo, the cancer-specific and disease-free survival rates were 100% and 60%, respectively. Conclusion: Laparoscopic excision of local recurrence of RCC is a feasible technique in well-selected patients with low-volume mass not involving the adjacent organs.
Collapse
Affiliation(s)
- Oner Sanli
- Department of Urology, Istanbul Faculty of Medicine, Istanbul, Turkey.
| | | | | | | | | | | | | |
Collapse
|
30
|
Calvo FA, Sole CV, Martinez-Monge R, Azinovic I, Aristu J, Zudaire J, Garcia-Sabrido JL, Berian JM. Intraoperative EBRT and resection for renal cell carcinoma : twenty-year outcomes. Strahlenther Onkol 2012; 189:129-36. [PMID: 23223810 DOI: 10.1007/s00066-012-0272-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 11/08/2012] [Indexed: 01/21/2023]
Abstract
PURPOSE We report the outcomes of a multimodality treatment approach combining maximal surgical resection and intraoperative electron radiotherapy (IOERT) with or without external beam radiation therapy (EBRT) in patients with locoregionally (LR) recurrent renal cell carcinoma (RCC) after radical nephrectomy or LR advanced primary RCC. PATIENTS AND METHODS From 1983 to 2008, 25 patients with LR recurrent (n = 10) or LR advanced primary (n = 15) RCC were treated with this approach. Median patient age was 60 years (range, 16-79 years). Fifteen patients (60%) received perioperative EBRT (median dose, 44 Gy). Surgical resection was R0 (negative margins) in 6 patients (24%) and R1 (residual microscopic disease) in 19 patients (76%). The median dose of IOERT was 14 Gy (range, 9-15). Overall survival (OS) and relapse patterns were calculated using the Kaplan-Meier method. RESULTS Median follow-up for surviving patients was 22.2 years (range, 3.6-26 years). OS and DFS at 5 and 10 years were 38% and 18% and 19% and 14%, respectively. LR control (tumor bed or regional lymph nodes) and distant metastases-free survival rates at 5 years were 80% and 22%, respectively. The death rate within 30 days of surgery and IOERT was 4% (n = 1). Six patients (24%) experienced acute or late toxicities of grade 3 or higher according to the National Cancer Institute Common Toxicity Criteria (NCI-CTCAE) v4. CONCLUSION In patients with LR recurrent or LR advanced primary RCC, a multimodality approach consisting of maximal surgical resection and IOERT with or without adjuvant EBRT yielded encouraging local control results, justifying further evaluation.
Collapse
Affiliation(s)
- F A Calvo
- Department of Oncology, Institute of Sanitary Research, Hospital General Universitario Gregorio Marañon, Madrid, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Abel EJ, Karam JA, Carrasco A, Matin SF. Laparoscopic adrenalectomy for metachronous metastases after ipsilateral nephrectomy for renal-cell carcinoma. J Endourol 2011; 25:1323-7. [PMID: 21774667 DOI: 10.1089/end.2011.0066] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE While laparoscopic adrenalectomy (LA) is considered the standard of care for removal of small adrenal masses, there are minimal data describing the feasibility and outcomes of LA after previous ipsilateral nephrectomy (PIN). The purpose of the study was to describe the perioperative outcomes in a series of patients who were undergoing LA after PIN. PATIENTS AND METHODS Using an institutional database, we identified patients who underwent LA since 2002 by a single surgeon. Clinical and pathologic data were collected and analyzed. To evaluate outcomes, patients undergoing LA after PIN were compared with patients undergoing LA without PIN. RESULTS Of 54 consecutive patients undergoing LA, 8 had PIN for renal-cell carcinoma (RCC). Estimated blood loss was not significantly greater in patients with PIN: 50 mL vs 100 mL, P=0.109. Operative time was longer in patients with PIN: 120 minutes vs 156 minutes, P=0.015. There was no difference in length of hospital stay between groups: Median 2 days for both groups, P=0.635. One patient in the PIN group had a conversion to open adrenalectomy and needed blood transfusion. Perioperative complications were seen in 5/46 (10.6%) patients without and in 1/8 (12.5%) patients with PIN. Surgical margins were negative in all patients. CONCLUSIONS To the authors' knowledge, this study represents the largest experience with adrenalectomy in the reoperative setting. LA after PIN is associated with a longer operative time. While the potential for conversion is possible, it is technically feasible in selected patients and thus far appears to be associated with similar perioperative outcomes compared with patients without PIN.
Collapse
Affiliation(s)
- E Jason Abel
- Department of Urology, The University of Texas M.D. Anderson Cancer Center , Houston, TX 77030, USA
| | | | | | | |
Collapse
|
32
|
Hallemeier CL, Choo R, Davis BJ, Pisansky TM, Gunderson LL, Leibovich BC, Haddock MG. Long-term outcomes after maximal surgical resection and intraoperative electron radiotherapy for locoregionally recurrent or locoregionally advanced primary renal cell carcinoma. Int J Radiat Oncol Biol Phys 2011; 82:1938-43. [PMID: 21514065 DOI: 10.1016/j.ijrobp.2011.02.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/02/2011] [Accepted: 02/11/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To report outcomes of a multimodality therapy combining maximal surgical resection and intraoperative electron radiotherapy (IOERT) for patients with locoregionally (LR) recurrent renal cell carcinoma (RCC) after radical nephrectomy or LR advanced primary RCC. METHODS AND MATERIALS From 1989 through 2005, a total of 22 patients with LR recurrent (n = 19) or LR advanced primary (n = 3) RCC were treated with this multimodality approach. The median patient age was 63 years (range 46-78). Twenty-one patients (95%) received perioperative external beam radiotherapy (EBRT) with a median dose of 4,500 cGy (range, 4,140-5,500). Surgical resection was R0 (negative margins) in 5 patients (23%) and R1 (residual microscopic disease) in 17 patients (77%). The median IOERT dose delivered was 1,250 cGy (range, 1,000-2,000). Overall survival (OS) and disease-free survival (DFS) and relapse patterns were estimated using the Kaplan-Meier method. RESULTS The median follow-up for surviving patients was 9.9 years (range, 3.6-20 years). The OS and DFS at 1, 5, and 10 years were 91%, 40%, and 35% and 64%, 31%, and 31%, respectively. Central recurrence (within the IOERT field), LR relapse (tumor bed or regional lymph nodes), and distant metastases at 5 years were 9%, 27%, and 64%, respectively. Mortality within 30 days of surgery and IOERT was 0%. Five patients (23%) experienced acute or late National Cancer Institute Common Toxicity Criteria (NCI-CTCAE) Version 4 Grade 3 to 5 toxicities. CONCLUSIONS In patients with LR recurrent or LR advanced primary RCC, a multimodality approach of perioperative EBRT, maximal surgical resection, and IOERT yielded encouraging results. This regimen warrants further investigation.
Collapse
|
33
|
Alt AL, Boorjian SA, Lohse CM, Costello BA, Leibovich BC, Blute ML. Survival after complete surgical resection of multiple metastases from renal cell carcinoma. Cancer 2011; 117:2873-82. [PMID: 21692048 DOI: 10.1002/cncr.25836] [Citation(s) in RCA: 283] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 11/12/2010] [Accepted: 11/12/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although a role for resection of solitary metastases from renal cell carcinoma (RCC) has been described, the utility of surgery in patients with multiple sites of disease has been less well defined. The authors report the survival of patients who underwent complete metastasectomy for multiple RCC metastases. METHODS The authors identified 887 patients who underwent nephrectomy for RCC between 1976 and 2006 who developed multiple metastatic lesions. The impact of complete metastasectomy on survival was evaluated controlling for the timing, location, and number of metastases and for patient performance status. RESULTS Of 887 patients, 125 (14%) underwent complete surgical resection of all metastases. Complete metastasectomy was associated with a significant prolongation of median cancer-specific survival (CSS) (4.8 years vs 1.3 years; P < .001). Patients who had lung-only metastases had a 5-year CSS rate of 73.6% with complete resection versus 19% without complete resection (P < .001). A survival advantage from complete metastasectomy also was observed among patients with multiple, nonlung-only metastases, who had a 5-year CSS rate of 32.5% with complete resection versus 12.4% without complete resection (P < .001). Complete resection remained predictive of improved CSS for patients who had ≥ 3 metastatic lesions (P < .001) and for patients who had synchronous (P < .001) and asynchronous (P = .002) multiple metastases. Moreover, on multivariate analysis, the absence of complete metastasectomy was associated significantly with an increased risk of death from RCC (hazard ratio, 2.91; 95% confidence interval, 2.17-3.90; P < .001). CONCLUSIONS The current results indicated that complete resection of multiple RCC metastases may be associated with long-term survival and should be considered when technically feasible in appropriate surgical candidates.
Collapse
Affiliation(s)
- Angela L Alt
- Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | |
Collapse
|
34
|
Yohannan J, Feng T, Berkowitz J, Connolly SS, Pierorazio P, Allaf ME. Laparoscopic Resection of Local Recurrence After Previous Radical Nephrectomy for Clinically Localized Renal-Cell Carcinoma: Perioperative Outcomes and Initial Observations. J Endourol 2010; 24:1609-12. [DOI: 10.1089/end.2010.0051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jithin Yohannan
- James Buchanan Brady Urological Institute, Baltimore, Maryland
| | - Tom Feng
- James Buchanan Brady Urological Institute, Baltimore, Maryland
| | - Jared Berkowitz
- James Buchanan Brady Urological Institute, Baltimore, Maryland
| | | | | | | |
Collapse
|
35
|
Tsivian A, Benjamin S, Shtricker A, Tsivian M, Kyzer S, Sidi AA. Laparoscopic removal of local renal cell carcinoma recurrence. Int Braz J Urol 2009; 35:436-41. [PMID: 19719859 DOI: 10.1590/s1677-55382009000400007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2009] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To describe an entirely laparoscopic technique for excising a recurrence of local renal cell carcinoma (RCC). MATERIALS AND METHODS The patient is placed in a full flank position. A 10-mm trocar is inserted using Hasson's technique with three additional ports in the upper abdomen. After lysis of adhesions, the psoas muscle, ureteral and gonadal vein remnants, inferior vena cava or aorta, and renal vessel stumps are dissected and isolated. The specimen, including the mass, the adrenal gland, and the ipsilateral pararenal and paracaval or para-aortic tissue within Gerota's fascia remnants, are excised en bloc and removed inside an Endocatch-II bag. RESULTS To date we have used this technique for excising RCC recurrences in three patients. Pathologic examination showed clear cell type RCC Fuhrman grade 2 in the specimens of two patients and chromophobe type in one. No patient has had further recurrence after 50, 38 and 12 months of follow-up. CONCLUSIONS An entirely laparoscopic surgical approach for excising local RCC recurrence has not, to our knowledge, been previously described. This method can be effectively applied while adhering to oncologic principles, with minimal blood loss and low morbidity.
Collapse
Affiliation(s)
- Alexander Tsivian
- Departments of Urologic Surgery and Surgery B, Wolfson Medical Center, Holon, Israel
| | | | | | | | | | | |
Collapse
|
36
|
Cho J, Kim GE, Rha KH, Ahn JB, Lee CG, Suh CO, Seong J, Keum KC, Kim SI, Lee YH. Hypofractionated high-dose intensity-modulated radiotherapy (60 Gy at 2.5 Gy per fraction) for recurrent renal cell carcinoma: a case report. J Korean Med Sci 2008; 23:740-3. [PMID: 18756070 PMCID: PMC2526393 DOI: 10.3346/jkms.2008.23.4.740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A patient with renal cell carcinoma (RCC) developed synchronous bone metastasis with metachronous relapses to the bone and renal fossa. The primary lesion was initially removed surgically, and the metastatic bone lesions and locally recurrent tumours were treated by a high-fractional dose and high-total-dose intensity-modulated radiotherapy (IMRT, 60 Gy at 2.5 Gy per fraction) without significant side effects. All the grossly relapsed tumors underwent complete remission (CR) within a short time after IMRT. To date, CR has been maintained for more than two years. This case study reports the successful treatment of radioresistant RCC using a new scheme that involves a fractionation regimen with a high precision radiotherapy.
Collapse
Affiliation(s)
- Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seodaemoon-gu, Seoul, Korea.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Eggener SE, Yossepowitch O, Kundu S, Motzer RJ, Russo P. Risk score and metastasectomy independently impact prognosis of patients with recurrent renal cell carcinoma. J Urol 2008; 180:873-8; discussion 878. [PMID: 18635225 DOI: 10.1016/j.juro.2008.05.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 01/07/2023]
Abstract
PURPOSE We evaluated the prognostic roles of metastasectomy and an established risk stratification system in patients with disease recurrence following nephrectomy for nonmetastatic renal cell carcinoma. MATERIALS AND METHODS A retrospective analysis was performed in 129 patients with localized renal cell carcinoma treated with partial or radical nephrectomy and subsequently diagnosed with disease recurrence. At recurrence a previously validated risk score based on Karnofsky performance status, interval from nephrectomy, and serum hemoglobin, calcium and lactate dehydrogenase was used to categorize patients as being at favorable, intermediate or poor risk. Survival from time of recurrence was assessed based on risk categorization and metastasectomy. RESULTS Median time from nephrectomy to recurrence was 16 months. The risk score was strongly associated with median survival and the 2-year survival rate, including 73 months and 81% for favorable risk, 28 months and 54% for intermediate risk, and 6 months and 11% for poor risk, respectively (log rank <0.001). Metastasectomy performed in 44 patients (34%) was found to be of clinical benefit across the various risk categories (interaction analysis p = 0.8). On multivariate analysis a better risk category and metastasectomy were each independently associated with more favorable survival (each p <0.001). When combined, they provided 6 risk categories with an estimated 2-year survival of 0% to 93%. CONCLUSIONS The clinical course in patients with recurrent renal cell carcinoma following nephrectomy can be variable. It is independently impacted by an objectively determined risk score and whether the patient undergoes metastasectomy.
Collapse
Affiliation(s)
- Scott E Eggener
- Department of Urology and Division of Solid Tumor Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
| | | | | | | | | |
Collapse
|
38
|
Boorjian SA, Crispen PL, Lohse CM, Leibovich BC, Blute ML. Surgical resection of isolated retroperitoneal lymph node recurrence of renal cell carcinoma following nephrectomy. J Urol 2008; 180:99-103; discussion 103. [PMID: 18485415 DOI: 10.1016/j.juro.2008.03.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Indexed: 01/24/2023]
Abstract
PURPOSE Durable survival has been reported following the resection of solitary metachronous metastasis of renal cell carcinoma at sites including the lung, bone and adrenal. We report our experience with resection of isolated retroperitoneal lymph node recurrence. MATERIALS AND METHODS Patients who underwent surgical resection of isolated metachronous recurrence of renal cell carcinoma in the retroperitoneal lymph nodes following radical nephrectomy for pT(any)N(any)M0 tumors were identified (group 1). Progression-free and cancer specific survival were estimated using the Kaplan-Meier method and compared to survival in patients who had pT(any)N+M0 disease at nephrectomy (group 2) and in patients who underwent complete resection of a solitary metachronous metastasis at other sites (group 3). RESULTS A total of 15 patients underwent resection of isolated retroperitoneal lymph node recurrence of renal cell carcinoma. Median time from nephrectomy to resection was 10.3 months (range 3 to 159). No patient received systemic therapy before resection. Recurrence was asymptomatic in all except 1 patient. No intraoperative or postoperative mortality occurred. Six patients subsequently died of renal cell carcinoma at a median of 18 months (range 6 to 33.6) following resection. Median progression-free survival in groups 1 to 3 was 9.1, 8.7 and 15.6 months, while median cancer specific survival was 33.3, 20.8 and 46.9 months, respectively. CONCLUSIONS Resection of isolated retroperitoneal lymph node recurrence may be associated with survival rates approaching those of resection of solitary metastasis at other sites. The decreased time to progression relative to patients with resected metastasis at other sites likely reflects the aggressive biology of nodal disease.
Collapse
Affiliation(s)
- Stephen A Boorjian
- Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | |
Collapse
|
39
|
Editorial Comment. Urology 2008. [DOI: 10.1016/j.urology.2007.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
40
|
Single Center Preliminary Experience with Hand-Assisted Laparoscopic Resection of Isolated Renal Cell Carcinoma Fossa Recurrences. Urology 2008; 71:495-9; discussion 499-500. [DOI: 10.1016/j.urology.2007.08.067] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 06/28/2007] [Accepted: 08/15/2007] [Indexed: 11/18/2022]
|
41
|
Mejean A, Correas JM, Escudier B, de Fromont M, Lang H, Long JA, Neuzillet Y, Patard JJ, Piechaud T. [Kidney tumors]. Prog Urol 2007; 17:1101-44. [PMID: 18153989 DOI: 10.1016/s1166-7087(07)74782-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
42
|
Longo R, D'Andrea MR, Sarmiento R, Salerno F, Gasparini G. Integrated therapy of kidney cancer. Ann Oncol 2007; 18 Suppl 6:vi141-8. [PMID: 17591809 DOI: 10.1093/annonc/mdm244] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Historically, treatment options for metastatic renal cell carcinoma (RCC) have been limited because of inherent tumor resistance to chemotherapy and radiotherapy. The only approved drug for RCC in the past 30 years has been high-dose interleukin-2. Its benefit is observed in a small percentage (20%-25%) of highly selected good performance status RCC patients. The treatment of advanced RCC has recently undergone a major change with the development of potent angiogenesis inhibitors and targeted agents. In fact, advanced RCC is a highly vascular tumor associated with expression of vascular endothelial growth factor (VEGF); thereafter, antiangiogenic strategies have become an attractive approach. Several multitargeted tyrosine kinase inhibitors (sorafenib and sunitinib) have already been approved for the treatment of advanced RCC; bevacizumab, a monoclonal antibody anti-VEGF, has shown promising clinical activity. Temsirolimus, a derivative of rapamycin (CCI-779), has also shown a survival advantage over interferon in advanced, poor-prognosis RCC patients. The aim of this review is to describe these agents in terms of mechanisms of action, efficacy, and toxicity profile and also to analyze future development strategies.
Collapse
Affiliation(s)
- R Longo
- Division of Clinical Oncology, San Filippo Neri Hospital, Rome, Italy
| | | | | | | | | |
Collapse
|
43
|
Skolarikos A, Alivizatos G, Laguna P, de la Rosette J. A Review on Follow-Up Strategies for Renal Cell Carcinoma after Nephrectomy. Eur Urol 2007; 51:1490-500; discussion 1501. [PMID: 17229521 DOI: 10.1016/j.eururo.2006.12.031] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2006] [Accepted: 12/24/2006] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To provide a comprehensive review of the evidence supporting the necessity for follow-up after nephrectomy for renal cell carcinoma. METHODS We searched the Medline, MeSH, EMBASE, and Cochrane databases using the terms "renal cell cancer," "kidney neoplasm," "follow-up," "surveillance," "prognosis," and "staging" to look for human/English language/Randomized Controlled Trials/Clinical trials/Review articles/Meta-analysis/Practiced Guidelines, and Editorials. RESULTS No consensus currently exists on surveillance guidelines after radical or partial nephrectomy for renal cell carcinoma. The rationale for follow-up strategies is to detect local recurrence or metastatic disease and to allow appropriate treatment. Most of the surveillance protocols recommend various follow-up strategies for all tumour stages. The emphasis on follow-up should be during the first 3-5 yr after nephrectomy. There is no consensus about which investigations should be performed and at what intervals. Most surgeons rely on symptom enquiry, physical examination, chest x-ray, and computed tomography scanning. A protocol based on the stage of the initial tumour is adapted by the majority of the investigators. Patients should be followed similarly after radical or partial nephrectomy on the basis of stage-oriented protocols. The combination of various prognostic factors requires further validation over stage-based protocols. There is a paucity of guidelines in the literature regarding follow-up for patients with hereditary forms of renal cell carcinoma. CONCLUSIONS Current guidelines for follow-up are based on observational and case studies. While this fact precludes a high level of evidence-based guidelines, we have to conclude that this is the best available evidence to date.
Collapse
Affiliation(s)
- Andreas Skolarikos
- Athens Medical School, 2nd Department of Urology, Sismanoglio Hopsital, Athens, Greece.
| | | | | | | |
Collapse
|
44
|
Nelson EC, Evans CP, Lara PN. Renal cell carcinoma: Current status and emerging therapies. Cancer Treat Rev 2007; 33:299-313. [PMID: 17329029 DOI: 10.1016/j.ctrv.2006.12.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Revised: 12/19/2006] [Accepted: 12/21/2006] [Indexed: 11/16/2022]
Abstract
Renal cell carcinoma (RCC) accounts for about 3% of all adult malignancies and its incidence is increasing. Smoking, obesity, and end-stage renal disease are important risk factors. Localized RCC may be cured with surgical excision. However, over one-third of patients eventually develop metastatic disease. While chemotherapy and radiation therapy are relatively ineffective for RCC, immunotherapy modestly extends survival and may lead to tumor regression and long-term survival in a small minority of patients. Recently, research into the pathology of genetic syndromes associated with RCC has led to remarkable advances in our understanding of the pathogenesis of sporadic RCC. Rational therapeutic agents developed from this understanding have established new treatment paradigms for this disease.
Collapse
Affiliation(s)
- Eric C Nelson
- Department of Urology, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
| | | | | |
Collapse
|