Efficacy and safety of surgery in renal carcinoma patients 75 years and older: a retrospective analysis

Objective

To investigate the efficacy and complications of surgical treatment in patients with renal cell carcinoma aged ≥ 75 years.

Methods

From January 2009 to May 2019, we assessed 166 patients aged 75 years and older, who either had radical nephrectomy (RN) or partial nephrectomy (PN) as treatments for diagnosed renal cell carcinoma. Patients were divided into one group of patients aged 75–79 years and the second group of patients ≥ 80 years. The complications and survival were compared between the two groups.

Results

All 166 patients were successfully operated on. Differences between the two groups were statistically significant in intraoperative and postoperative complications and Clavien–Dindo score of ≥ 1 (P = 0.02, P < 0.001, P = 0.001). Univariate analysis revealed no significant correlation between a Clavien–Dindo score ≥ 1 versus gender, body mass index (BMI), lack of symptoms, KPS, baseline GFR, postoperative GFR, tumor size, tumor location, surgical method, and transfusion or no transfusion (ALL P > 0.05). Multifactor analysis showed that age ≥ 80 years, partial nephrectomy, and operation time were independent predictors of a Clavien–Dindo score ≥ 1. No significant difference was found in OS between the two groups, (P < 0.0001), and no significant difference in CSS (P = 0.056). There was no significant difference in OS and CSS between the RN and PN groups (P = 0.143, P = 0.281, respectively).

Conclusions

According to our findings, the overall safety of surgical therapy for elderly patients with renal cell carcinoma is adequate. PN should be carefully examined, especially over the age of 80. To select suitable patients based on an assessment of the tumor's complexity and patients' physical condition, such as age, underlying diseases and other conditions, technical feasibility, balance of benefits and a case-by-case.

Perioperative outcomes in elderly patients undergoing nephrectomy for renal cell carcinoma

Purpose

To determine if age should be considered a relative contraindication to surgery for safety reasons.

Methods

Renal cell carcinoma (RCC) patients who underwent nephrectomy from January 2007 to December 2017 were analyzed retrospectively. Patients were grouped into age<65 and age≥65 years. The demographic data, surgical outcomes, complication, hospital stay, blood loss, and survival were compared between the two groups.

Results

A total of 101 patients were included; 74 in the younger group, and 27 in the older group. Compared to the young group, lower BMI, higher anemia, higher ASA grade, and comorbidities were frequent in the elderly. The operative time, blood loss, and renal function decline were comparable between two age groups. The complication rates in the older and younger group were 22% and 12%, respectively. The survival time was shorter in older patients compared to the younger ones; hazard ratio 2.25; 95%CI 1.08–4.69, p-value=0.031.

Conclusion

Nephrectomy in elderly patients is safe and feasible and preoperative assessment along with diligent postoperative care may further increase survival. Age alone cannot be regarded as a contraindication for nephrectomy in RCC.

A nonrandomized prospective comparison of robotic-assisted partial nephrectomy in the elderly to a younger cohort: an analysis of 339 patients with intermediate-term follow-up

OBJECTIVE

To assess the role of robotic-assisted partial nephrectomy (RAPN) in elderly patients focusing on perioperative, functional, and oncologic outcomes in comparison with a younger cohort.

MATERIALS AND METHODS

From a prospectively maintained institutional review board-approved database, 339 patients were divided into 2 groups defined by age ≥ 70 (n = 71) or <70 years (n = 268) at the time of RAPN. They were compared for perioperative outcomes and complications, including risk of chronic kidney disease (CKD) stage progression. The standard t test and chi square test were used for continuous and categorical variables, respectively. Logistic regression identified risk factors for progression of renal dysfunction. Kaplan-Meier estimates modeled tumor recurrence at 368 and 462 days in the elderly and young, respectively.

RESULTS

Elderly patients were more likely to have hypertension (86% vs 60%; P < .001) or coronary artery disease (27% vs 9%; P < .001), and rates of chronic obstructive pulmonary disorder and diabetes were also higher. Preoperative estimated glomerular filtration rate was significantly lower in the elderly (70 vs 82 mL/min/1.73 m2; P < .001). Twenty-four percent of elderly patients progressed in CKD stage as compared to 14% in the younger cohort (P = .08). Elderly age was not a statistically significant risk factor for CKD progression (relative risk, 2.34; 95% confidence interval, 0.81-6.05; P = .11). Surgical and medical complication rates were similar between the cohorts (P = .75 and .80, respectively) as were Kaplan-Meier estimates of risk of tumor recurrence (P = .47). Limitations include nonrandomized, single-center study, and intermediate-term follow-up for oncologic outcomes.

CONCLUSION

Elderly patients undergoing RAPN had no increased risk of perioperative complications. CKD progression and risk of oncologic recurrence were similar to younger patients at intermediate-term follow-up.

What is the effect of advanced age and comorbidity on postoperative morbidity and mortality after musculoskeletal tumor surgery?

BACKGROUND

Although the elderly population is increasing rapidly, little information is available regarding how the risk of postoperative mortality and morbidity increases when combined with age and comorbidity burden in patients undergoing musculoskeletal tumor surgery.

QUESTIONS/PURPOSES

We evaluated the effect of age and comorbidity burden on the (1) postoperative complication rate and (2) in-hospital mortality rate after musculoskeletal tumor surgery.

METHODS

We identified 5716 patients undergoing musculoskeletal tumor surgery during 2007 to 2012 using a Japanese national inpatient database. Logistic regression analyses were performed to examine the relationships of various factors with the rates of mortality and morbidity.

RESULTS

The postoperative complication rate (6.7%) was associated with male sex (p = 0.033), age 80 years or older (p = 0.001), tumor located in the lower extremity (p = 0.001) or trunk (p = 0.019), Charlson Comorbidity Index of 4 or greater (p < 0.001), blood transfusion (p < 0.001), and duration of anesthesia of 240 minutes or longer (p < 0.001). The in-hospital mortality (0.8%) was related to the Charlson Comorbidity Index of 4 or greater (p < 0.001), blood transfusion (p < 0.001), and high hospital volume (p = 0.016). The morbidity (21.6%; OR, 3.29; p < 0.001) and mortality (4.1%; OR, 5.95; p < 0.001) in patients 80 years or older with a Charlson Comorbidity Index of 4 or greater was increased three and six times, respectively, compared with patients 64 years or younger with no comorbidity.

CONCLUSIONS

We found that age and comorbidity burden together greatly increased the risk of morbidity and mortality. Our study showed quantitative evidence that will assist physicians in assessing perioperative risk accurately and provide a more informative explanation to elderly patients undergoing musculoskeletal tumor surgery.

LEVEL OF EVIDENCE

Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The type of nephrectomy has little effect on overall survival or cardiac events in patients of 70 years and older with localized clinical t1 stage renal masses

Purpose

To compare the outcomes of nephron-sparing options (e.g., partial nephrectomy [PN]) and low-surgical-morbidity options (e.g., radical nephrectomy [RN]) in elderly patients with limited life expectancy.

Materials and Methods

We retrospectively reviewed 135 patients aged 70 years or older who underwent RN (n=82) or PN (n=53) for clinical T1 stage renal masses between January 2000 and December 2012. Clinicopathologic data were thoroughly analyzed and compared between the RN and PN groups. The modification of diet in renal disease equation was used to estimate glomerular filtration. Overall survival and cardiac events were assessed by using Kaplan-Meier survival analysis and Cox proportional-hazards regression modeling.

Results

Over a median follow-up period of 59.72 months, 17 patients (20.7%) in the RN group and 3 patients (5.7%) in the PN group died. Chronic kidney disease (<60 mL/min/1.73 m²) developed more frequently in RN patients than in PN patients (75.6% vs. 41.5%, p<0.001). The 5-year overall survival rate did not differ significantly between the RN and PN groups (90.7% vs. 93.8%; p=0.158). According to the multivariate analysis, the Charlson comorbidity index score was an independent predictor of overall survival (hazard ratio [HR], 2.679, p=0.037). Type of nephrectomy was not significantly associated with overall survival (HR, 2.447; p=0.167) or cardiac events (HR, 1.147; p=0.718).

Conclusions

Although chronic kidney disease was lower after PN, overall survival and cardiac events were similar regardless of type of nephrectomy.

Optimal management of renal cell carcinoma in the elderly: a review

Both the aging population and the incidence of renal cell carcinoma (RCC) are growing, making the question of tumor management in the elderly a real challenge. Doctors should be aware of the importance of assessing this specific subpopulation. An aggressive therapeutic approach may be balanced by the benefit of the treatment - care or cure - and the life expectancy and willingness of the patient. The treatment for local disease can be surgery (radical or partial nephrectomy) or ablative therapies (radiofrequency, cryotherapy). Even if in most cases surgery is safe, complications such as alteration of renal function may occur, especially in the elderly, with physiological renal impairment at baseline. More recently, another option has been developed as an alternative: active surveillance. In the past decade, new drugs have been approved in the metastatic setting. All the phase 3 trials have included patients without a limit on age. Nevertheless, data concerning the elderly are still poor and concern only a very selective subpopulation. The toxicity profile of targeted agents may interfere with pre-existent comorbidities. Furthermore, the metabolism of several agents via cytochrome P450 can cause drug interaction. The importance of quality of life is a major factor with regard to management of therapy. Finally, to date, there is no recommendation of systematic a priori dose reduction in the elderly. In this review we describe the various possibilities of treatment for localized RCC or metastatic RCC in an aging population.

Renal cell carcinoma with IVC and atrial thrombus: a single centre's 10 year surgical experience

Renal cell carcinoma (RCC) propagates into the IVC in 4% of cases with 1% extending into the right atrium. Radical surgical resection remains the definitive curative/palliative treatment in those without significant metastases. The aim was to review our experience in patients with different levels of IVC involvement, cardiopulmonary bypass (CPB) and perioperative/long term outcomes.

PATIENTS AND METHODS

From 2001 to 2012, 24 radical nephrectomies with IVC thrombectomy were performed. A retrospective chart review was undertaken to record demographics, presenting symptoms, duration of surgery, peri-operative transfusion, CPB and peri-operative complications, tumour grade/stage, and patient survival.

RESULTS

We identified 24 patients (18 male, Age median 59 range 35-78). The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n = 17) with 8 having lung metastases at presentation. Thrombus level was 16 (infradiaphragmatic), 2 (supradiaphragmatic), 6 (intra-atrial). 15 patients required sternotomy for vascular control and 9 required CPB both with a significantly longer operative time compared (6.1 ± 3.5 vs. 7.2 ± 1.2 vs. 3.5 ± 1.1 h, respectively). Peri-operative complications (n = 21) included cardiopulmonary, renal, gastrointestinal and septic problems. There were 2 peri-operative deaths. Blood transfusion was significantly less in those not requiring sternotomy or CPB using the "Cell Saver" device. The majority were Fuhrman grade 3 (n = 16) and clear cell type (n = 14). Overall 3-year survival was 100% (Laparotomy only), 40% (sternotomy + cross-clamp), and 20% (CPB).

CONCLUSIONS

IVC thrombectomy has significant morbidity and requires careful patient selection and a multi-disciplinary approach to optimise patient outcomes. In this series, the level of IVC thrombus and requirement for CPB directly affects patient morbidity and outcome.

[Renal function in the elderly after radical tumor nephrectomy and partial nephrectomy]

Due to rising life-expectancy and increasing use of tomography more elderly patients with incidental renal tumors are being diagnosed. The current article gives an overview of kidney function after renal surgery in the elderly and the aim is to give assistance in clinical practice for deciding how to adequately treat these patients.

[Coping with small renal tumors in the elderly]

With the continually increasing number of elderly patients and the widely distributed use of radiological imaging techniques, the number of elderly patients with incidentally discovered asymptomatic small renal tumors will increase further. Treatment options range from active surveillance, minimally invasive (ablative) techniques, to open or laparoscopic surgery including radical nephrectomy. Many studies have been published on the operative treatment of small renal tumors in the elderly; however, all are limited by the retrospective nature and the small number of cases. Chronological age per se should not be a deciding factor or even an exclusion criterion for treatment of small renal tumors. The decision for therapy should be based on the physical state (comorbidities), mental and emotional state of the patient as well as the individual psychosocial environment. The decision for surgery should be based on organ preservation, depending on the tumor size of ˂7 cm and location, whenever possible.

The effect of age on the morbidity of kidney surgery

PURPOSE

Previous reports of the morbidity of renal surgery have been primarily from academic tertiary referral centers and, thus, they may not reflect general clinical practice. We determined the effect of age and comorbidity on in-hospital surgical morbidity for radical and partial nephrectomy on a population level.

MATERIALS AND METHODS

Data were obtained from a Canadian national discharge abstract database. From April 1998 to March 2008 information was available on 20,286 radical and 4,292 partial nephrectomies. Complications were identified using specific ICD-9 and 10 diagnosis and procedure codes. Complication rates were estimated by procedure type and by various explanatory variables, including patient age and Charlson comorbidity score. Multivariate logistic regressions were constructed for radical and partial nephrectomy to determine associations between explanatory variables and complications.

RESULTS

Overall complications developed in 34.1% of radical and 34.3% of partial nephrectomy cases. Patients were more likely to have cardiac, respiratory, vascular and surgical complications after radical nephrectomy while they were more likely to experience genitourinary and nephrectomy specific complications after partial nephrectomy. On multivariate logistic regression after radical and partial nephrectomy complications increased with age and Charlson score. After adjusting for other covariates patients with a Charlson score of greater than 2 were approximately 6 times more likely to experience a complication than patients with a Charlson score of 0 for radical and partial nephrectomy (OR 6.22, 95% CI 5.18-7.48 and OR 5.68, 95% CI 3.72-8.66, respectively).

CONCLUSIONS

In our population based study radical nephrectomy and partial nephrectomy were associated with higher morbidity than previously reported, particularly in the elderly population and in patients with comorbidity.

Final results of the European Advanced Renal Cell Carcinoma Sorafenib (EU-ARCCS) expanded-access study: a large open-label study in diverse community settings

BACKGROUND

The European Advanced Renal Cell Carcinoma Sorafenib (EU-ARCCS) expanded-access study provided sorafenib to advanced renal cell carcinoma (RCC) patients in whom previous systemic therapy had failed. The study assessed the safety and use of sorafenib for the treatment of advanced RCC in a large community-based patient population across 11 countries in Europe.

PATIENTS AND METHODS

EU-ARCCS was a single-arm, open-label trial of sorafenib in advanced RCC patients. End points included safety, time to progression, progression-free survival (PFS), and disease control rate (DCR). Subgroup analyses included age, Eastern Cooperative Oncology Group performance status, histology, prior therapy, and number and sites of metastases.

RESULTS

About 1159 advanced RCC patients were enrolled. Most patients (94%) experienced drug-related adverse events (AEs) of any grade, with the most common grade ≥3 AEs including hand-foot skin reaction (13%), diarrhea (7%), fatigue (7%), hypertension (6%), and rash/desquamation (5%). The incidence of AEs in the subgroups was similar to that in the overall population. Median PFS was 6.6 months; DCR at ≥8 and ≥12 weeks was 85% and 78%, respectively.

CONCLUSIONS

The sorafenib safety profile in European community-based practice settings was similar to that reported in clinical trials. The heterogeneous advanced RCC patient population in EU-ARCCS permitted assessment of sorafenib in important subpopulations of advanced RCC patients.

Comparison of guideline recommendations with daily practice in patients with renal cell carcinoma

Objectives and Aims

To compare guideline recommendations with daily practice patterns in a German patient cohort with renal cell carcinoma.

Patients and methods

81 patients with T1 oder T2 renal cell carcinoma (RCC) were included in this prospective single-center study. All patients were operated in a single institution either by open radical nephrectomy (ORN) or nephron sparing surgery (NSS). Patients and doctors were evaluated using a written questionnaire with a follow-up of 12 months. Follow-up intervals, follow-up modalities (e. g. imaging modalities, laboratory controls of blood and urine) and the call on psycho-oncological support were evaluated.

Results

The majority of patients (72%) were followed up by their urologists. Follow-up examinations included abdominal ultrasound, urine and blood diagnostics, conventional chest x-rays, computed tomography (CT) of abdomen, chest or head or abdominal Magnetic Resonance Imaging (MRI). There were no significant differences between patients operated by ORN or NSS. In total, 12.5% of patients were asking for psycho-oncological support.

Conclusions

In general, patients were followed up according to existing guideline recommendations. Only a small proportion of patients asked for psycho-oncological treatment.