Intermediate- and long-term oncological outcomes of active surveillance for localized renal masses: a systematic review and quantitative analysis

Renal cell carcinoma

The landscape of the management of renal cell carcinoma has evolved substantially in the last decade, leading to improved survival in localised and advanced disease. We review the epidemiology, pathology, and diagnosis of renal cell carcinoma and discuss the evidence for current management strategies from localised to metastatic disease. Developments in adjuvant therapies are discussed, including use of pembrolizumab-the first therapy to achieve overall survival benefit in the adjuvant setting. The treatment of advanced disease, including landmark trials that have established immune checkpoint inhibition as a standard of care, are also reviewed. We also discuss the current controversies that exist surrounding the management of metastatic renal cell carcinoma, including the use of risk assessment models for disease stratification and treatment selection for frontline therapy. Management of non-clear cell renal cell carcinoma subtypes is also reviewed. Future directions of research, including a discussion of ongoing clinical trials and the need for reliable biomarkers to guide treatment in kidney cancer, are also highlighted.

Development and validation of a multicenter Cox regression model to predict all-cause mortality in patients with renal masses suspicious for renal cancer

OBJECTIVE

Life expectancy models are useful tools to support clinical decision-making. Prior models have not been used widely in clinical practice for patients with renal masses. We sought to develop and validate a model to predict life expectancy following the detection of a localized renal mass suspicious for renal cell carcinoma.

MATERIALS AND METHODS

Using retrospective data from 2 large centers, we identified patients diagnosed with clinically localized renal parenchymal masses from 1998 to 2018. After 2:1 random sampling into a derivation and validation cohort stratified by site, we used age, sex, log-transformed tumor size, simplified cardiovascular index and planned treatment to fit a Cox regression model to predict all-cause mortality from the time of diagnosis. The model's discrimination was evaluated using a C-statistic, and calibration was evaluated visually at 1, 5, and 10 years.

RESULTS

We identified 2,667 patients (1,386 at Corewell Health and 1,281 at Johns Hopkins) with renal masses. Of these, 420 (16%) died with a median follow-up of 5.2 years (interquartile range 2.2-8.3). Statistically significant predictors in the multivariable Cox regression model were age (hazard ratio [HR] 1.04; 95% confidence interval [CI] 1.03-1.05); male sex (HR 1.40; 95% CI 1.08-1.81); log-transformed tumor size (HR 1.71; 95% CI 1.30-2.24); cardiovascular index (HR 1.48; 95% CI 1.32-1.67), and planned treatment (HR: 0.10, 95% CI: 0.06-0.18 for kidney-sparing intervention and HR: 0.20, 95% CI: 0.11-0.35 for radical nephrectomy vs. no intervention). The model achieved a C-statistic of 0.74 in the derivation cohort and 0.73 in the validation cohort. The model was well-calibrated at 1, 5, and 10 years of follow-up.

CONCLUSIONS

For patients with localized renal masses, accurate determination of life expectancy is essential for decision-making regarding intervention vs. active surveillance as a primary treatment modality. We have made available a simple tool for this purpose.

Surgical Management of Localized Disease and Small Renal Masses

The incidence of renal cancer has increased over the past several decades, but mortality has declined. This is thought to be related in part to earlier detection of renal masses which portend excellent 5-year survival rates. Management of small renal masses and localized disease include both nonsurgical and surgical options. The choice of intervention is ultimately based on comprehensive evaluation and shared decision-making. This article provides a comprehensive review of the current surgical management options for localized renal cancer.

Reliability and Management Outcomes Following a Percutaneous Biopsy Diagnosis of Oncocytoma: A 15-year Retrospective Analysis

Background There is uncertainty in the management of renal masses diagnosed as oncocytomas with image-guided percutaneous biopsy. Purpose To assess the reliability of a diagnosis of oncocytoma based on image-guided percutaneous renal mass biopsy and evaluate patient outcomes following different management strategies. Materials and Methods In this retrospective study, image-guided percutaneous biopsy pathology reports from April 2004 to April 2019 were searched for keywords "oncocytoma" and "oncocytic neoplasm" and compared with surgical pathology or repeat biopsy results. Patients with at least 12 months of clinical follow-up and known cause of death were grouped according to management strategies, and disease-specific survival and metastatic renal cell carcinoma (RCC)-free survival were compared. Mass growth rates were calculated with use of a normal linear mixed model. Results The database yielded 160 biopsy reports of 149 renal masses in 139 patients; 149 masses were categorized as oncocytoma (n = 107), likely oncocytoma (n = 12), oncocytic neoplasm (n = 28), and indeterminate with oncocytoma in differential (n = 2). Biopsied masses categorized as oncocytoma or likely oncocytoma were oncocytomas in 16 of 17 masses (94%) based on surgical pathology or repeat biopsy; four of eight masses (50%) categorized as oncocytic neoplasms were low-grade RCCs. Outcome analysis included 121 patients (mean age ± SD, 68 years ± 9.1; 82 men); 80 patients initially underwent active surveillance (11 were later treated), 33 underwent ablation, and eight underwent surgery. Disease-specific survival and metastatic-free survival were 100% after each management strategy (median follow-up, 86.6 months; range, 14.2-207.9 months). Mass growth rate (mean, 1.7 mm per year) showed no evidence of a significant difference among biopsy result categories (P = .37) or initial (P = .84) or final management strategies (P = .11). Conclusion Image-guided percutaneous biopsy diagnosis of renal oncocytoma was reliable. Although some masses diagnosed as oncocytic neoplasms were low-grade renal cell carcinomas (RCCs) at final diagnosis, no patients died of RCC, including those managed with active surveillance. © RSNA, 2023 See also the editorial by Lockhart in this issue.

The multispeciality approach to the management of localised kidney cancer

Historically, kidney cancer was approached in a siloed single-speciality way, with urological surgeons managing the localised stages of the disease and medical oncologists caring for patients if metastases developed. However, improvements in the management of localised kidney cancer have occurred rapidly over the past two decades with greater understanding of the disease biology, diagnostic options, and innovations in curative treatments. These developments are favourable for patients but provide a substantially more complex landscape for patients and clinicians to navigate, with associated challenging decisions about who to treat, how, and when. As such, the skill sets needed to manage the various aspects of the disease and guide patients appropriately outstrips the capabilities of one particular specialist, and the evolution of a multispeciality approach to the management of kidney cancer is now essential. In this Review, we summarise the current best multispeciality practice for the management of localised kidney cancer and the areas in need of further research and development.

Exploring the Diversity and Predictors of Histopathological Findings Across the European Association of Urology Guidelines Office Rapid Reaction Group Priority Groups for Patients with Renal Tumors: Implications for Individualized Prioritization of Renal Cancer Care

In response to the COVID-19 pandemic, the European Association of Urology (EAU) Guidelines Office Rapid Reaction Group (GORRG) defined priority groups to guide the prioritization of surgery for nonmetastatic renal cell carcinoma (RCC). In this study we explored the diversity and predictors of histopathological findings across the EAU GORRG priority groups using a large database of 1734 consecutive patients undergoing elective surgery for nonmetastatic renal masses between 2017 and 2020 at a referral institution. Overall, 940 (54.2%), 358 (20.6%), and 436 (25.2%) patients were classified as low-, intermediate-, and high-priority, respectively. The low-, intermediate-, and high-risk groups significantly differed regarding all primary histopathological outcomes: benign histology (21.6% vs 15.9% vs 6.4%; p < 0.001); non–organ-confined disease (5.0% vs 19.0% vs 45.4%; p < 0.001); and adverse pathological features according to validated prognostic models (including the median Leibovich score for clear-cell RCC: 0 vs 2 vs 4; p < 0.001). On multivariable analysis, beyond the EAU GORRG priority groups, specific patient and/or tumor-related characteristics were independent predictors of the aforementioned histopathological outcomes. To the best of our knowledge, our study shows for the first time the value of the EAU GORRG priority groups from a histopathological standpoint and supports implementation of such a prioritization scheme beyond the COVID-19 pandemic.

Patient summary

During the COVID-19 pandemic, the European Association of Urology designed a scheme to prioritize patients needing surgery for kidney cancer according to their tumor characteristics and symptoms. We used results from our hospital database to test the scheme and found that the priority classification can be used to predict cancer outcomes after surgery. This scheme may be useful in prioritizing kidney cancer surgeries after the COVID-19 pandemic.