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Mosholt KSS, Aagaard M, Røder A, Azawi N. The Prognostic Impact of the Surgical Margin in Renal Cell Carcinoma Treated with Partial Nephrectomy: A Multi-Center Study. Cancers (Basel) 2024; 16:1449. [PMID: 38672530 PMCID: PMC11048438 DOI: 10.3390/cancers16081449] [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: 03/05/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Partial nephrectomy (PN) is the preferred treatment for small, localized kidney tumors. Incomplete resection resulting in positive surgical margins (PSM) can occur after PN. The impact of PSM on the risk of recurrence and survival outcomes is not fully understood. We aimed to explore the relationship between PSM, the risk of recurrence and impact on survival after PN in a large multicenter cohort from Denmark. Methods: This was a retrospective cohort study including patients who underwent PN for renal cell carcinoma (RCC) at three departments in Denmark between 2010 and 2016. Data including pathological features, surgical techniques, and patient follow-up was retrieved from electronic medical health records and national databases. We used a combination of descriptive statistics, comparative analysis (comparisons were carried out by Mann-Whitney Test, independent Student's t-test, or Pearson's chi-Square Test), univariate and multivariate logistic regression analyses, and survival analysis methods. Results: A total of 523 patients were included, of which 48 (9.1%) had a PSM. Recurrence was observed in 55 patients (10.5%). Median follow-up time was 75 months. We found a lower incidence of PSM with robot-assisted PN (p = 0.01) compared to open or laparoscopic PN. PSM was associated with a higher risk of recurrence compared to negative margins in univariate analysis, but not multivariate analysis. However, the study was underpowered to describe this association with other risk factors. Overall survival did not differ between patients with PSM and negative margins. Conclusions: Our study presents further evidence on the negative impact of PSM on recurrence after PN for RCC, highlighting the importance of achieving NSM, thus potentially improving clinical outcomes. A surgical approach was found to be the only predictive factor influencing the risk of PSMs, with a reduced risk observed with robot-assisted laparoscopy.
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Affiliation(s)
| | - Mark Aagaard
- Department of Urology, Zealand University Hospital, Sygehsuvej 10, 4000 Roskilde, Denmark
| | - Andreas Røder
- Department of Urology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; (K.S.S.M.); (A.R.)
- Institute of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2100 Copenhagen, Denmark
| | - Nessn Azawi
- Department of Urology, Zealand University Hospital, Sygehsuvej 10, 4000 Roskilde, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2100 Copenhagen, Denmark
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2
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Hakimi K, Saidian A, Panian J, Barata P, Berg S, Chang SL, Saliby RM, Dzimitrowicz H, Emamekhoo H, Gross E, Kilari D, Lam E, Nguyen M, Meagher M, Wang L, Rauterkus GP, D'Andrea V, Yim K, Psutka S, Thapa B, Weise N, Zhang T, McKay RR, Derweesh IH. Outcomes of Consolidative Nephrectomy following Primary Immunotherapy in Advanced Renal Cell Carcinoma: A Multicenter Analysis. Clin Genitourin Cancer 2023; 21:694-702. [PMID: 37558529 DOI: 10.1016/j.clgc.2023.07.007] [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: 03/20/2023] [Revised: 07/09/2023] [Accepted: 07/16/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND To evaluate effect and outcomes of combination primary immunotherapy (IO) and nephrectomy for advanced renal cell carcinoma (RCC). METHODS We conducted a multicenter, retrospective analysis of patients with advanced/metastatic RCC who received IO followed by nephrectomy. Primary outcome was Bifecta (negative surgical margins and no 30-day surgical complications). Secondary outcomes included progression-free survival (PFS) following surgery, reduction in tumor/thrombus size, RENAL score, and clinical/pathologic downstaging. Cox regression multivariable analysis was conducted for predictors of Bifecta and PFS. Kaplan-Meier analysis assessed PFS, comparing Bifecta and non-Bifecta groups. RESULTS A total of 56 patients were analyzed (median age 63 years; median follow-up 22.5 months). A total of 40 (71.4%) patients were intermediate IMDC risk. Patients were treated with immunotherapy for median duration of 8.1 months. Immunotherapy resulted in reductions in tumor size (P < .001), thrombus size (P = .02), and RENAL score (P < .001); 38 (67.9%) patients were clinically downstaged on imaging (P < .001) and 25 (44.6%) patients were pathologically downstaged following surgery (P < .001). Bifecta was achieved in 38 (67.9%) patients. Predictors for bifecta achievement included decreasing tumor size (HR 1.08, P = .043) and pathological downstaging (HR 2.13, P = .047). Bifecta (HR 5.65, P = .009), pathologic downstaging (HR 5.15, P = .02), and increasing reduction in tumor size (HR 1.2, P = .007) were associated with improved PFS. Bifecta patients demonstrated improved 2-year PFS (84% vs. 71%, P = .019). CONCLUSIONS Primary immunotherapy reduced tumor/thrombus size and complexity. Pathologically downstaged patients were more likely to achieve bifecta, and these patients displayed improved 2-year PFS. Our study supports further inquiry in the use of CRN following primary immunotherapy for advanced renal cancer.
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Affiliation(s)
- Kevin Hakimi
- Department of Urology, UC San Diego School of Medicine, San Diego, CA
| | - Ava Saidian
- Department of Urology, UC San Diego School of Medicine, San Diego, CA
| | - Justine Panian
- Deparment of Internal Medicine, Division of Hematology and Medical Oncology, UC San Diego School of Medicine, San Diego, CA
| | - Pedro Barata
- Department of Hematology and Medical Oncology, Tulane University School of Medicine, New Orleans, LA
| | - Stephanie Berg
- Department of Hematology and Medical Oncology, Loyola University Medical Center, Maywood, IL
| | - Steven L Chang
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Renee M Saliby
- Lark Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Hamid Emamekhoo
- Department of Hematology and Medical Oncology, University of Wisconsin School of Medicine, Madison, WI
| | - Evan Gross
- Department of Hematology and Medical Oncology, University of Washington School of Medicine, Seattle, WA
| | - Deepak Kilari
- Division of Hematology and Medical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Elaine Lam
- Department of Hematology and Medical Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Mimi Nguyen
- Department of Urology, UC San Diego School of Medicine, San Diego, CA
| | - Margaret Meagher
- Department of Urology, UC San Diego School of Medicine, San Diego, CA
| | - Luke Wang
- Department of Urology, UC San Diego School of Medicine, San Diego, CA
| | - Grant P Rauterkus
- Department of Hematology and Medical Oncology, Tulane University School of Medicine, New Orleans, LA
| | - Vincent D'Andrea
- Lark Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kendrick Yim
- Lark Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sarah Psutka
- Department of Hematology and Medical Oncology, University of Washington School of Medicine, Seattle, WA
| | - Bicky Thapa
- Division of Hematology and Medical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Nicole Weise
- Deparment of Internal Medicine, Division of Hematology and Medical Oncology, UC San Diego School of Medicine, San Diego, CA
| | - Tian Zhang
- Department of Hematology and Medical Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rana R McKay
- Deparment of Internal Medicine, Division of Hematology and Medical Oncology, UC San Diego School of Medicine, San Diego, CA
| | - Ithaar H Derweesh
- Department of Urology, UC San Diego School of Medicine, San Diego, CA.
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Tully KH, Berg S, Paciotti M, Janisch F, Reese SW, Noldus J, Shariat SF, Choueiri T, Müller G, McGregor B, Chang SL, Trinh QD, Mossanen M. The Natural History of Renal-Cell Carcinoma with Sarcomatoid Differentiation, a Stage-by-Stage Analysis. Clin Genitourin Cancer 2023; 21:63-68. [PMID: 36517393 DOI: 10.1016/j.clgc.2022.11.015] [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: 10/08/2022] [Revised: 11/20/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sarcomatoid differentiation in patients diagnosed with renal cell carcinoma (sRCC) imply aggressive behavior and often metastatic disease at the time of diagnosis. We aim to examine the overall survival (OS) in patients with sRCC using the National Cancer Database (NCDB). MATERIALS AND METHODS We identified patients diagnosed with sRCC between 2010-2015. We employed Kaplan-Meier curves and multivariable Cox proportional hazards regression models to examine the impact of several potential risk factors on OS in patients diagnosed with sRCC. RESULTS In total, 8582 patients with renal cancer were found to have sarcomatoid differentiation, with 4105 patients (47.8%) being diagnosed with AJCC stage IV disease. The median OS was 17.2 months (IQR 5.4, 68.7 months). Compared to patients who did not undergo surgery, OS was significantly longer in patients undergoing partial or total nephrectomy across all stages. This result remained consistent on multivariable Cox proportional hazards regression adjusting for patient and tumor characteristics (Surgery: Hazard ratio 0.54, 95%Confidence interval 0.43 - 0.68, P < .001). CONCLUSION In our cohort sRCC was found to have an unfavorable median OS, which was mainly caused by the high number of cases diagnosed with late-stage disease. Additionally, surgery was associated with favorable OS across all stages. This study supports the notion that surgical therapy, even in the setting of cytoreductive surgery, provides a survival benefit in patients with sRCC.
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Affiliation(s)
- Karl H Tully
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Sebastian Berg
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Marco Paciotti
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Florian Janisch
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Hamburg, Hamburg, Germany
| | - Stephen W Reese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joachim Noldus
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Hamburg, Hamburg, Germany; Department of Urology, Weill Cornell Medical School, New York, NY; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Toni Choueiri
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Guido Müller
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany; Center for Urological Rehabilitation, Kliniken Hartenstein, Bad Wildungen, Germany
| | - Bradley McGregor
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Matthew Mossanen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Gaas MY, Kaprin AD, Vorobyev NV, Rapoport LM, Korolev DO, Kalpinsky AS. Markers of local kidney cancer recurrence: A surgeon's mistake or a pattern? Review. Urologia 2022:3915603221140964. [PMID: 36515572 DOI: 10.1177/03915603221140964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The influence of various morphological, anatomical, genetic and other factors on the local recurrence-free survival of patients who have undergone different renal cell cancer (RCC) treatment is still a rather complex, ambiguous and controversial issue for practicing oncourologists. This review evaluates the effect of several factors on both recurrence-free survival and local recurrence-free survival. The review includes articles, clinical cases, literature reviews, and meta-analyses highlighting the analysis of independent and interrelated predisposing factors for developing local recurrence of RCC from 1984 to 2020. The PubMed, Web of Science, and Scopus databases were searched in English, Spanish, and German. A review of the literature showed the role of the following indices in the local recurrence RCC: microvascular invasion (p = 0.001), tumor necrosis (p = 0.0001), high malignancy (Fuhrman III or IV) (HR = 38.3, 95% CI 3.1-467, p = 0.004) as histological factors, tumor size as an anatomical factor. Thus, the authors state that every centimeter of the tumor increases the risk of local recurrence (p < 0.05). A group from the Mayo Clinic showed the equivalence of different treatment methods in local RCC recurrence. Thus, in the group of patients with cT1a stage kidney cancer, the 5-year local recurrence-free survival rates were 97.7% (96.7-98.6), 95.9% (92.3-99.6), and 95.9% (92.3-99.6) for renal resection, RFA, and cryoablation, respectively. Surgical margin status is the most studied and controversial marker of local renal cell carcinoma recurrence. Researchers found a direct effect of PSM on the risk of local RCC recurrence (p < 0.01). The personalized approach with the search and evaluation of predisposing factors for the local recurrence, as well as further selection of the most optimal treatment, will allow oncourologists to improve both the effectiveness of primary treatment and the recurrence-free survival of patients.
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Affiliation(s)
- Margarita Y Gaas
- Department Urology and Operative Nephrology with the Course of Oncourology of Medical Institute of Peoples' Friendship University of Russia, Moscow, Russian Federation
| | - Andrey D Kaprin
- Department Urology and Operative Nephrology with the Course of Oncourology of Medical Institute of Peoples' Friendship University of Russia, Moscow, Russian Federation
| | - Nikolay V Vorobyev
- Department of Oncology, Radiotherapy and Plastic Surgery of I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation.,P.A. Hertsen Moscow Oncology Research Center, A Branch of FSBI NMRRC of the Ministry of Health of Russia, Moscow, Russian Federation
| | - Leonid M Rapoport
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Dmitry O Korolev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Alexey S Kalpinsky
- Department of Tumors of the Reproductive and Urinary Organs, Moscow Research Oncological Institute, P. A. Herzen, Branch of the Federal State Budgetary Institution "National Research Center of Radiology," Moscow, Russian Federation
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5
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Perri D, Palumbo C, Billia M, Umari P, Zacchero M, D'Agate D, Bondonno G, Volpe A. Assessment of predictors of renal cell carcinoma progression after nephrectomy at short and intermediate term follow-up and implication on surveillance protocols. Minerva Urol Nephrol 2021; 74:599-606. [PMID: 34114786 DOI: 10.23736/s2724-6051.21.04322-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prediction of risk of RCC progression after surgery is important for follow-up planning. We identified predictors of progression-free survival (PFS) and cancer-specific survival (CSS) in a large single institutional cohort and investigated patterns and sites of progression according to stage and grade. METHODS Node-negative non-metastatic clear-cell RCC (ccRCC) patients treated with radical or partial nephrectomy from 2000 to 2020 were included. Sites of progression were defined as thoracic, abdominal and others (bone/brain). Kaplan Meier curves and multivariable Cox regression (MCR) models tested for PFS and CSS. RESULTS Of 384 clear cell RCC N0M0 patients, 301 (78.4%) vs. 83 (21.6%) were pT1-2 vs. pT3-4, respectively; 253 (65.9%) vs. 130 (33.9%) were G1-G2 vs. G3-G4. Thoracic progressions occurred in 2.7% pT1-T2 vs. 21.7% pT3-T4 and 2.8% G1-G2 vs. 14.6% G3-G4 tumors. Abdominal progressions occurred in 4.0% pT1-T2 vs. 13.3% pT3-T4 and 4.3% G1-G2 vs. 9.2% G3-G4. Other progressions occurred in 0.3% pT1-T2 vs. 9.6% pT3-T4 and 0.8% G1-G2 vs. 5.4% G3-G4 (5.4%). Five-year PFS and CSS were 81.7 and 90.6%, respectively. At MCR models, pT3-4 (HR 9.1, p<0.001), G3-G4 (HR 2.7, p=0.003) and PSMs (HR 6.1, p<0.001) independently predicted PFS. Similarly, pT3-4 (HR 10.1, p<0.001), G3-G4 (HR 4.1, p=0.02), and PSMs (HR 5.2, p=0.04) independently predicted CSS. CONCLUSIONS In ccRCC N0M0 patients, G3-G4, pT3-4, PSMs were independent predictors of progression after surgery. Lower stage and grade ccRCCs progress predominantly in the abdominal sites and may be followed with less frequent extra-abdominal imaging compared to more advanced/aggressive tumors.
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Affiliation(s)
- Davide Perri
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Carlotta Palumbo
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Michele Billia
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Paolo Umari
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Monica Zacchero
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Daniele D'Agate
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Gianmarco Bondonno
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Alessandro Volpe
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy -
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Unplanned Open Conversion During Radical or Partial Nephrectomy: Comparing Outcomes and Trends. Urology 2021; 154:170-176. [PMID: 33961889 DOI: 10.1016/j.urology.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/01/2021] [Accepted: 04/18/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare perioperative outcomes between open conversion and planned open surgical approach and to investigate trends. MATERIALS AND METHODS The National Cancer Database (NCDB) was queried for cT1 and cT2 RCC treated by radical (RN) or partial (PN) nephrectomy between 2010 and 2016. We retrospectively analyzed patient demographics, clinical tumor characteristics, and perioperative outcomes between unplanned open conversion and planned open approaches for RN and PN. RESULTS In total, 152,919 patients underwent RN or PN for cT1 or cT2 RCC over the 7-year span. The rate of unplanned open conversion from MIS was 3.9% overall, remaining lowest for cT1 PN (2.7%) and highest for cT2 RN (5.9%). Cases of open conversion tended to have higher rate of upstaged disease. When comparing open conversion to a planned open case, there was no difference in the length of post-operative hospitalization. On logistic regression, unplanned open conversion from MIS was associated with higher odds of positive margin for RN but not for PN. Increased odds of 30-day's readmission were associated with unplanned open conversion from MIS in the setting of cT1 PN only. CONCLUSION When compared to a planned open approach, conversion to open from MIS does not affect length of hospital stay but is associated with higher odds of positive surgical margins for RN and higher odds of 30-day's readmission for cT1 PN. Advanced pathologic stage is associated with an open conversion, likely relating to increased tumor complexity. These findings should be considered preoperatively when determining the best surgical approach.
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Chang TW, Cheng WM, Fan YH, Lin CC, Lin TP, Yi-Hsiu Huang E, Chung HJ, Huang WJS, Weng SH. Predictive factors for disease recurrence in patients with locally advanced renal cell carcinoma treated with curative surgery. J Chin Med Assoc 2021; 84:405-409. [PMID: 33595988 DOI: 10.1097/jcma.0000000000000501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Few prognostic factors have been proposed for patients with locally advanced renal cell carcinoma (RCC). This study aimed to investigate the possible predictive factors for disease-free survival (DFS) after curative surgery for RCC stage T3 or higher. METHODS Patients with locally advanced RCC who underwent cure-intended partial or radical nephrectomy, with or without tumor thrombectomy, at our institution from April 1, 2005 to October 31, 2013 were retrospectively reviewed. Those undergoing cytoreductive nephrectomy were excluded. Preoperative data, including surgical and pathologic characteristics, were assessed for correlation with DFS. Chi-square tests, univariate and multivariate Cox regression analysis, and Kaplan-Meier survival curve analyses were performed to determine potential predictive factors. A p value less than 0.05 was considered statistically significant. RESULTS A total of 159 patients were included for analysis. The mean duration of follow-up was 37.9 months, and 119 (74.8%) patients remained disease-free during follow-up. Disease recurrence was found in 40 (25.2%) patients, and pathologic T stage, capsule penetration, Fuhrman grade, thrombocytosis, renal vein thrombosis, and elevated serum alkaline phosphatase, platelet/lymphocyte ratio, and γ-glutamyl transpeptidase levels were significantly associated with disease recurrence on univariate analysis. On multivariate analysis, Fuhrman grade 3 or 4 (HR = 5.70, p = 0.0003, 95% CI = 2.23-14.56) showed significant associations with DFS. CONCLUSION In patients with locally advanced RCC, Fuhrman grade was associated with worse DFS after curative surgery. Urologists should closely monitor patients with high Fuhrman grades.
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Affiliation(s)
- Te-Wei Chang
- Division of Urology, Department of Surgery, Zhongxiao Branch, Taipei City Hospital, Taipei, Taiwan, ROC
| | - Wei-Ming Cheng
- Division of Urology, Department of Surgery, Zhongxiao Branch, Taipei City Hospital, Taipei, Taiwan, ROC
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Hua Fan
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Chieh Lin
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tzu-Ping Lin
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Eric Yi-Hsiu Huang
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsiao-Jen Chung
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - William J S Huang
- Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Morris LK, Altahan A, Gandhi J, Mays J, Giri U, Fleming M, Martin MG. Impact of margin status on survival after radical nephrectomy for renal cell carcinoma. J Surg Oncol 2020; 123:687-692. [PMID: 33333591 DOI: 10.1002/jso.26321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Data about the impact of surgical margin positivity on patient outcomes following radical nephrectomy (RN) for renal cell carcinoma (RCC) is limited. We evaluate the effect of positive surgical margins (PSMs) on relapse-free survival (RFS) and overall survival (OS.) METHODS: Clinicopathologic data of patients who underwent RN for RCC was analyzed based on margin status. χ2 and Student t test were used to compare groups. Cox regression analysis was used for the analysis. Kaplan-Meier method was used for survival curves. RESULTS A total of 485 patients who underwent RN for RCC were analyzed. Most patients with T1/T2 stage had NSM. Most patients with T4 had PSM. T3 patients were split between the two groups. Analysis of the T3 group showed shorter RFS in the PSM group at 3 years (hazard ratio [HR]: 4.3, p = .01), and 5 years (HR: 4.3, p = .01.) OS analysis showed worse OS in PSM but not statistically significant. There was a significant association between PSM and laterality (p = .023) and histologic type (p = .025.) CONCLUSIONS: PSM was associated with shorter RFS after RN in T3 RCC patients. There was a trend towards worse OS in the PSM group, but it did not reach statistical significance. Laterality and histologic type were associated with surgical margin status.
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Affiliation(s)
- Lindsay K Morris
- College of Medicine (Medical School), University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Alaa Altahan
- Department of Hematology and Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jatin Gandhi
- Department of Pathology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - John Mays
- College of Medicine (Medical School), University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Upama Giri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin Fleming
- Department of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mike G Martin
- Medical Oncology Division, West Cancer Center Research & Institute, Germantown, Tennessee, USA
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Chen H, Yang S, Qian C. Effectiveness of Nephron Sparing Surgery and Radical Nephrectomy in the Management of Unilateral Wilms Tumor: A Meta-Analysis. Front Oncol 2020; 10:1248. [PMID: 33014769 PMCID: PMC7498664 DOI: 10.3389/fonc.2020.01248] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/17/2020] [Indexed: 01/15/2023] Open
Abstract
Background: Unilateral Wilms tumor is the most common renal malignancy in the pediatric population. Although the onset of surgical intervention like radical nephrectomy has substantially reduced the mortality rate, recent evidence has raised concerns regarding several postoperative complications associated with this procedure. Nephron sparing surgery has been reported to avoid such postoperative complications and have high technical success rate. However, no attempt to date has been made to synthesize the evidence comparing the efficacy of radical nephrectomy and nephron sparing surgery for managing unilateral Wilms tumor. Methods and Results: To metastatistically compare the efficiency of radical nephrectomy with nephron sparing surgery for managing unilateral Wilms tumor, a systematic identification of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines on four academic databases: MEDLINE, Scopus, EMBASE, and CENTRAL. A meta-analysis comparing renal function (estimated glomerular filtration rate), survival rate, and rate of relapse was performed to compare the efficacy of radical nephrectomy and nephron sparing surgery. Out of 1,283 records, 20 articles including 5,246 children (mean age, 4.3 ± 3.0 years) were included in this review. Radical nephrectomy was performed on 11 of the included studies, whereas nephron sparing surgery was performed on five studies. Two studies compared the efficacy of both interventions. The meta-analysis reveals the beneficial effects of nephron sparing surgery (Hedge's g, 0.76) as compared to radical nephrectomy (-0.16) for the estimated glomerular filtration rate for children with unilateral Wilms tumor. Moreover, higher survivability (0.59) and lesser occurrence of relapse were (-1.0) also reported for cases operated with nephron sparing surgery. Conclusion: The current meta-analysis recommends the use of nephron sparing surgery for unilateral Wilms tumor. The procedure accounts for higher survivability and postoperative renal function and lesser incidence of relapse as compared to radical nephrectomy.
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Affiliation(s)
- Hongkun Chen
- Department of Pediatric Surgery, Zaozhuang Municipal Hospital, Zaozhuang, China
| | - Shuqing Yang
- Zaozhuang Hospital of Traditional Chinese Medicine, Zaozhuang, China
| | - Cheng Qian
- Department of Pediatric Surgery, Zaozhuang Municipal Hospital, Zaozhuang, China
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Przydacz M, Golabek T, Okon K, Dudek P, Chlosta P. Prognostic effect of renal collecting system invasion on survival of patients with renal cell carcinoma and tumor thrombus. Cent European J Urol 2020; 73:280-286. [PMID: 33133654 PMCID: PMC7587485 DOI: 10.5173/ceju.2020.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/30/2020] [Accepted: 08/30/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Urinary collecting system invasion (UCSI) has been found to have significant prognostic value for patients with renal cell carcinoma (RCC). However, for RCC patients with venous tumor thrombus (VTT), only contradictory data exist regarding the prognostic efficacy of UCSI. Therefore, the aim of this study is to assess the prognostic relevance of UCSI in survival of patients with RCC and VTT. Material and methods Medical records in a prospectively maintained institutional database were analyzed for RCC-VTT patients who had undergone nephrectomy with thrombectomy. Then, the effect of UCSI on overall survival was analyzed. Results The study examined data for 114 patients, including patients with VTT present in the renal vein (35 patients, 31%), infrahepatic inferior vena cava (28 patients, 24%), and suprahepatic inferior vena cava (51 patients, 45%). Nineteen percent of patients had UCSI. The median overall survival of patients with UCSI was 9 months, whereas median overall survival was 10 months for patients without collecting system invasion. Survival and regression analyses rejected UCSI as a prognostic marker for overall survival. Conclusions UCSI has no effect on survival in our cohort of RCC-VTT patients. Therefore, it should not be considered in risk stratification models or in treatment decision-making for this patient group.
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Affiliation(s)
- Mikolaj Przydacz
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Golabek
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Krzysztof Okon
- Department of Pathology, Jagiellonian University Medical College, Cracow, Poland
| | - Przemyslaw Dudek
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
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11
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Rothberg MB, Peak TC, Reynolds CR, Hemal AK. Long-term oncologic outcomes of positive surgical margins following robot-assisted partial nephrectomy. Transl Androl Urol 2020; 9:879-886. [PMID: 32420203 PMCID: PMC7214993 DOI: 10.21037/tau.2019.11.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Previous reports on positive surgical margin (PSM) after robot-assisted partial nephrectomy (RAPN) have reached inconsistent conclusions as to the impact of a PSM on oncologic outcomes. We sought to determine the effect of PSM on long-term cancer recurrence and survival outcomes. Methods We queried our renal oncology database for patients having undergone RAPN and compared recurrence-free survival (RFS) and overall survival (OS) between patients with PSM and negative surgical margin (NSM). Kaplan-Meier analysis was also performed for RFS and OS for PSM versus NSM. Results Of the 432 patients who underwent RAPN we identified 29 (6.7%) patients with PSM and 403 (93.3%) patients with NSM. Median follow-up for the overall cohort was 45.1 months. Three of the 29 patients with PSM and fourteen of the 403 patients with NSM had disease recurrence (P=0.09). RFS at 24, 48, and 72 months was 95.8%, 90%, and 85.5% for patients with NSM and 96.6%, 86.6%, and 80.4% for patients with PSM, respectively (log-rank P value =0.382). OS at 24, 48, and 72 months was 98%, 93.1%, and 89.7% for patients with NSM and 96.3%, 91.2%, and 85.2% for patients with PSM, respectively (log-rank P value =0.584). Conclusions While PSM are relatively uncommon, their presence still serves as a potential risk factor for worse oncologic outcomes. In instances of PSM, immediate secondary intervention is most likely unnecessary and more attentive long-term clinical follow-up, especially in patients with high-risk features, may be more advisable.
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Affiliation(s)
- Michael B Rothberg
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Taylor C Peak
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Davaro F, Roberts J, May A, McFerrin C, Siddiqui S, Hamilton Z. Robotic surgery does not affect upstaging of T1 renal masses. J Robot Surg 2019; 14:447-454. [PMID: 31456083 DOI: 10.1007/s11701-019-01015-z] [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: 06/20/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022]
Abstract
Partial nephrectomy is the mainstay of treatment for localized kidney cancer. A proportion of patients are upstaged post-operatively to locally advanced disease (pT3a). We aimed to identify the incidence of upstaging to pT3a during partial nephrectomy and its relationship to a robotic approach. The National Cancer Database was queried for patients diagnosed with cT1M0 disease between 2010 and 2015 who underwent an open or robotic partial nephrectomy with final stage pT1-3a. Our primary outcome was rate of upstaging to pT3a in patients undergoing partial nephrectomy and secondary outcomes were stage migration, rate of positive margins, and overall survival (OS). The relationship between open and robotic surgery was examined. Logistical regression and Kaplan-Meier analyses were performed. Of 68,976 patients identified, 5.9% of patients were upstaged from cT1 to pT3a post-operatively. The incidence of upstaging to pT3a disease has increased from 5.7% in 2010 to 6.9% in 2015. Similarly, the proportion of patients undergoing a robotic approach is also increasing (31.6-64.4%); however, a robotic approach is not associated with pT3a upstaging on multivariable analysis. The probability of being upstaged was significantly proportional to increasing tumor size (OR 2.634-11.641, p < 0.05). pT3a disease was associated with a significant increase in positive margins (10.7% vs 5.0%, p < 0.001). Interestingly, pT3a patients with positive margin had worsened survival (5-year OS 75.5% vs 65.9%, p < 0.001). A robotic surgical approach to partial nephrectomy does not increase risk of upstaging to pT3a disease. Those who are upstaged have increased risk of positive margins and associated risk of decreased survival.
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Affiliation(s)
- Facundo Davaro
- Division of Urology, Department of Surgery, Saint Louis University, 3635 Vista Ave, 3rd Floor Desloge Towers, St. Louis, MO, 63110, USA
| | - Jacob Roberts
- Saint Louis University School of Medicine, St Louis, MO, USA
| | - Allison May
- Division of Urology, Department of Surgery, Saint Louis University, 3635 Vista Ave, 3rd Floor Desloge Towers, St. Louis, MO, 63110, USA
| | | | - Sameer Siddiqui
- Division of Urology, Department of Surgery, Saint Louis University, 3635 Vista Ave, 3rd Floor Desloge Towers, St. Louis, MO, 63110, USA
| | - Zachary Hamilton
- Division of Urology, Department of Surgery, Saint Louis University, 3635 Vista Ave, 3rd Floor Desloge Towers, St. Louis, MO, 63110, USA.
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