Pathological T3a Upstaging of Clinical T1 Renal Cell Carcinoma: Outcomes According to Surgical Technique and Predictors of Upstaging

The preoperative predictive factors for pathological T3a upstaging and positive surgical margin of clinical T1 renal cell carcinoma

OBJECTIVES

The objective of this study is predict positive surgical margin (PSM) and pathological T3a (pT3a) upstaging in patients with clinical T1 (cT1) renal cell carcinoma (RCC).

MATERIALS AND METHODS

159 patients who underwent radical nephrectomy (RN) or partial nephrectomy (PN) for RCC. Patients' demographic, laboratory, radiological and pathological data that could predict PSM and pT3a upstaging pre-operatively were evaluated. The categorical and continuous variables were compared between the patient groups with or without PSM and/or pT3a upstaging using Pearson's chi-square test, and independent samples t-test or the Mann-Whitney U test, respectively.

RESULTS

PT3a upstaging was detected in 32 (20.1%) patients, and PSM was detected in 28 (17.6%) patients. PT3a upstaging was detected in 27 and 5 patients who underwent open surgery and laparoscopic surgery, respectively (P < .001). In addition, pT3a upstaging was detected in 6 and 26 patients who underwent RN and PN, respectively (P < .001). Peritumoral fatty tissue thickness was 11.97 and 15.38 in the pT1 and pT3a patient groups, respectively (P = .022). In patients with pT3a upstaging, tumor size was larger, and renal nephrometry score and systemic immune-inflammation index (SII) were higher (P < .001, P < .001, and P = .022, respectively). It was determined that De Ritis ratio (DRR) and albumin-to-alkaline phosphatase (ALP) ratio (AAPR) parameters had significant prognostic values in predicting PSM (P = .024, and P = .001, respectively). ROC analysis indicated that tumor size predicted pT3a upstaging with 100% sensitivity and 98.6% specificity when its cut-off value was taken as 6.85 mm (AUC: 1.000, P < .001). In addition, logistic regression analysis revealed AAPR and DRR as significant predictors of PSM (P < .001, and P = .009, repsectively).

CONCLUSION

The findings of this study indicated that the surgical technique of choice and the type of operation, tumor size, RNS value, peritumoral fatty tissue thickness, HU values of peritumoral and tumor side fatty tissues, and DRR and SII values can predict pT3a upstaging of patients with cT1 RCC, and that AAPR and DRR values can predict PSM.

Outcomes and predictors of clinical T1 renal mass (cT1) upstaged to pathological T3a (pT3a) after partial nephrectomy: A single-center experience

OBJECTIVES

Clinical T1 (cT1) renal mass treated surgically has a good prognosis, but there is an upstaging risk that potentially threatens oncological outcomes after partial nephrectomy (PN). We aim to analyze and study the incidence, predictors, perioperative morbidity, and oncological outcomes of pT3a upstaging.

METHODOLOGY

A retrospective study of 313 patients who underwent PN for cT1 renal mass at a single center from a single tertiary referral center between 2000 and 2021 was done. Demographic, perioperative, pathological, and outcome variables were reviewed. We compared these parameters between upstaged and non-upstaged groups. Multivariate logistic regression analysis was used to study preoperative variables associated with upstaging.

RESULTS

Nineteen patients were upstaged to pT3a. Making an incidence of 6.1%. Upstaged tumors were bigger (5.02 cm vs. 4.08 cm, p = 0.004), had higher clinical stage T1b (84.2 vs. 40.5%, p < 0.001), had more tumors which were central location (21 vs. 3.4%, p < 0.001), had more endophytic and mesophytic tumors (15.8 vs. 5.8% and 52.6 vs. 9.5%, p < 0.001), and had higher R.E.N.A.L Nephrometry score (8.05 vs. 6, p < 0.001). Upstaged tumors had more operative times (227 vs. 203 min, p = 0.01), more postoperative complications (68.4 vs. 13.1%, p < 0.001), more major complications of Clavien Dindo Grade 3 and above (15.8 vs. 4.4%, p < 0.001). Age (OR 1.035, p = 0.034), Radiological tumor dimension (OR 1.578, p = 0.003), Radiological or Clinical stage (T1b) (9.19, p = 0.008), Higher Nephrometry score (Intermediate and High) (OR 6.184, p = 0.004) were preoperative predictors of upstaging. Oncological outcomes were comparable.

CONCLUSION

Tumor upstaging was uncommon with more perioperative morbidity. Higher age, larger tumor size, higher tumor stage, and higher nephrometry scores were preoperative predictors of upstaging.

Predictive factors and oncological outcomes of pathological T3a upstaging in patients with clinical T1 renal cell carcinoma undergoing partial nephrectomy

OBJECTIVES

To investigate predictive factors and oncological outcomes of pathological T3a upstaging in renal cell carcinoma patients who were initially diagnosed as clinical T1 and treated with partial nephrectomy.

METHODS AND MATERIALS

The clinical records and survival data of 1617 patients, who had undergone partial nephrectomy for clinical T1 renal cell carcinoma at Tokyo Women's Medical University, Tokyo, Japan between January 2011 and December 2020, were analyzed retrospectively.

RESULTS

Of 1617 clinical T1 renal cell carcinoma patients who underwent partial nephrectomy, 28 (1.73%) had pathological T3a upstaging. In the multivariable analysis for pathological T3a upstaging using logistic regression models, male sex and clinical T1b were significant factors associated with pathological T3a upstaging (male sex: odds ratio = 5.07, 95% confidence interval: 1.18-21.8, clinical T1b: odds ratio = 8.36, 95% confidence interval: 3.56-19.6). The Kaplan-Meier method of the recurrence-free survival showed shorter recurrence-free survival in patients with pathological T3a upstaging than in those with pathological T1 (P < 0.0001). In the multivariable analysis using Cox proportional hazards regression models, pathological T3a upstaging was no longer significantly associated with recurrence-free survival after adjustment for other pathological factors (hazard ratio = 1.59, 95% confidence interval: 0.58-4.36). In a sensitivity analysis that analyzed its components individually instead of whole pathological T3a, neither perinephric fat invasion, sinus fat invasion, nor renal vein invasion was associated with recurrence-free survival.

CONCLUSIONS

Male sex and clinical T1b were significant predictors for pathological T3a upstaging after partial nephrectomy in clinical T1 renal cell carcinoma patients. Although patients with pathological T3a upstaging had worse recurrence-free survival compared with those without upstaging, multivariable analyses revealed that pathological T3a upstaging was not an independent predictor for poor recurrence-free survival.

Adverse pathologic features impact survival outcomes for small renal masses following nephrectomy

PURPOSE

While most small renal masses (SRM) < 4 cm have an excellent prognosis following resection, the impact of adverse T3a pathologic features on oncologic outcomes of SRMs remains unclear. We sought to compare clinical outcomes for surgically resected pT3a versus pT1a SRMs at our institution.

MATERIALS AND METHODS

We retrospectively reviewed records of patients who underwent radical or partial nephrectomy (RN, PN) for renal tumors <4 cm at our institution between 2010 and 2020. We compared features and outcomes of pT3a vs pT1a SRMs. Continuous and categorical variables were compared using Student's t and Pearson's chi-squared tests, respectively. Postoperative outcomes of interest including overall, cancer-specific, and recurrence-free survival (OS, CSS, and RFS) were analyzed using Kaplan-Meier method, Cox proportional hazard regression, and competing risk analysis. Analyses were performed using R statistical package (R Foundation, v4.0).

RESULTS

We identified 1,837 patients with malignant SRMs. Predictors of postoperative pT3a upstaging included higher renal score, larger tumor size, and presence of radiologic features concerning for T3a disease (odds ratio [OR] = 5.45, 95% confidence interval [CI] 3.92-7.59, P < 0.001). On univariable modeling, pT3a SRMs had higher positive margin rates (9.6% vs 4.1%, P < 0.001), worse OS (hazard ratio [HR] = 2.9, 95% CI 1.6-5.3, P = 0.002), RFS (HR 9.32, 95% CI 2-40.1, P = 0.003), and CSS (HR = 3.6, 95% CI 1.5-8.2, P = 0.003). On multivariable modeling, pT3a status remained associated with worse RFS (HR = 2.7, 95% CI 1.04-7, P = 0.04), but not OS (HR 1.6, 95% CI = 0.83-3.1, P = 0.2); multivariable modeling was deferred for CSS due to low event rates.

CONCLUSIONS

Adverse T3a pathologic features portend worse outcomes for SRMs, highlighting the crucial role of pre-operative planning and case selection. These patients have relatively poor prognosis, and should be monitored more closely and counseled for consideration of adjuvant therapy or clinical trials.

Oncologic Outcomes and Predictors in Patients with Stage PT3aNxM0 Renal Cell Carcinoma Following Radical Nephrectomy

OBJECTIVE

The objective of this study is to evaluate oncologic outcomes in patients with PT3aNxM0 renal cell carcinoma following radical nephrectomy and also to investigate these outcomes in each specific subgroup of PT3a renal cell carcinoma and to determine predictive factors of recurrence, metastasis, and mortality.

MATERIALS AND METHODS

In this retrospective cohort study, we included 94 patients with stage PT3a renal cell carcinoma who had undergone radical nephrectomy from 2011 to 2016. All patients who had survived had at least 60 months of follow-up. Demographic and clinical data were collected; univariable and multivariable Cox proportional hazards regression analysis was performed to identify predictors of metastasis, recurrence, and cancer-related mortality.

RESULTS

Patients' mean age was 58.07 ± 11.17 years and 62/94 (65.9%) were male. The mean follow-up time was 48.1 ± 25.5 months. Forty-three patients (45.7%) had experienced cancer-related mortality. The mean cancer-specific survival time was 60.94 months and the mean metastasis-free and local recurrence-free survival times were 57.06 and 88.72 months, respectively. Metastasis and local recurrence had occurred in 42 (44.6%) and 4 (4.25%) patients, respectively. After performing multivariate analysis, higher nuclear Fuhrman's grade (P < .001) and simultaneous involvement of the renal vein and perinephric fat (P < .001) were found to be predictive of cancerrelated mortality. Advanced nuclear Fuhrman's grade was the only independent predictor of metastasis (P=.001).

CONCLUSION

Based on our results, advanced nuclear Fuhrman's grade and sarcomatoid change can independently predict mortality in patients with stage PT3aNxM0 renal cell carcinoma. Close monitoring during the follow-up period is recommended in patients with the mentioned risk factors.

Imaging Features of Renal Masses to Select Optimal Candidates for Tumor Enucleation Partial Nephrectomy

PURPOSE OF REVIEW

The goal of this paper was to critically evaluate preoperative findings that optimally select candidates for renal tumor enucleation partial nephrectomy.

RECENT FINDINGS

Tumor enucleation has been widely accepted as a management option for patients with chronic kidney disease, hereditary renal cell carcinoma, or multifocal disease. Recent evidence suggests safety and efficacy in the management of routine small renal masses. With recent advances in imaging, the literature for ruling out aggressive renal cell carcinoma and selection for tumor enucleation is robust. As the incidence of renal cell carcinoma rises, partial nephrectomy continues to be the mainstay of treatment for localized renal cell carcinoma. Tumor enucleation maximizes preservation of renal parenchyma without hindering oncologic outcomes. It is important to recognize key tumor radiologic findings which urologists may use to optimize patient selection for tumor enucleation.

A novel nomogram can predict pathological T3a upstaged from clinical T1a in localized renal cell carcinoma

HYPOTHESIS

Nomogram can be built to predict the pathological T3a upstaging from clinical T1a in patients with localized renal cell carcinoma before surgery.

PURPOSE

Renal cell carcinoma (RCC) patients with clinical T1a (cT1a) disease who are upstaged to pathological T3a (pT3a) have reduced survivals after partial nephrectomy. We aimed to develop a nomogram-based model predicting pT3a upstaging in RCC patients with preoperative cT1a based on multiple preoperative blood indexes and oncological characteristics.

MATERIALS AND METHODS

Between 2010 and 2019, 510 patients with cT1a RCC were individually matched according to pT3a upstaging and pathological T1a (pT1a) at a 1:4 ratio using clinicopathologic features. Least absolute shrinkage and selection operator regression analysis was used to identify the most important risk factor from 40 peripheral blood indicators, and a predictive model was established. Multivariate logistic regression analysis was performed with the screened blood parameters and clinical data to identify significant variables. Harrell's concordance index (C-index) was applied to evaluate the accuracy of the model for predicting pT3a upstaging in patients with cT1a RCC.

RESULTS

Out of 40 blood indexes, the top ranked predictor was fibrinogen (FIB). Age, the ratio of the tumor maximum and minimum diameter (ROD), FIB, and tumor size were all independent risk factors for pT3a upstaging in multivariate analysis. A predictive ARFS model (Age, ROD, FIB, tumor Size) was established, and the C-index was 0.756 (95% CI, 0.681-0.831) and 0.712 (95% CI, 0.638-0.785) in the training and validation cohorts, respectively.

CONCLUSIONS

Older age, higher ROD, increased FIB level, and larger tumor size were independent risk factors for upstaging. The ARFS model has a high prediction efficiency for pT3a upstaging in patients with cT1a RCC.

Comparison of prognosis between patients undergoing radical nephrectomy versus partial nephrectomy for renal cell carcinoma ≤7 cm T3aN0/xM0: Survival benefit is biased toward partial nephrectomy

BACKGROUND

There is limited and controversial evidence on the prognosis of partial nephrectomy (PN) versus radical nephrectomy (RN) in patients with T3aN0/xM0 renal cell carcinoma (RCC) upstaged from clinical T1 RCC. In this study, we aimed to assess the prognosis difference following PN versus RN in patients with ≤7 cm T3aN0/xM0 RCC.

METHODS

From the Surveillance, Epidemiology, and End Results database, a total of 3196 patients receiving treatment of PN/RN for ≤7 cm T3aN0/xM0 RCC with only extrarenal fat extension in 2010-2017 were identified. An inverse probability of treatment weighting (IPTW)-adjusted cause-specific Cox model with hazard ratio (HR) and 95% confidence interval (CI) was used for overall survival (OS) and cancer-specific survival (CSS) analyses. Sensitivity analysis was based on the propensity score matching of PN and RN groups and from the dataset of 2010-2013.

RESULTS

A total of 872 patients underwent PN, compared with 2324 undergoing RN. After IPTW adjustment, there was no significant difference in preoperative baseline characteristics between the PN and RN cohorts. Patients who underwent RN had worse OS (HR_{IPTW-adjusted} , 1.46; 95% CI, 1.16-1.84; p = 0.001) and comparable CSS (HR_{IPTW-adjusted} , 1.03; 95% CI, 0.64-1.66; p = 0.890) than those receiving PN in all cohorts and subgroups with T3a RCC of ≤4 cm and perinephric fat extension. Further, in patients with 4-7 cm T3a RCC with perinephric-fat invasion and all sizes of T3a RCC with sinus/perisinus fat extension, PN led to comparable OS and CSS. Sensitivity analyses validated these results.

CONCLUSION

PN provides comparable CSS and OS or even better OS than RN for patients with RCC ≤7 cm T3aN0/xM0. Although our study has some limitations, our results indicated that PN might oncologically safe for clinical T1 RCC, even confirmed a pathologically T3a upstaging post-PN.

[Risk factors of renal sinus invasion in clinical T1 renal cell carcinoma patients undergoing nephrectomy]

OBJECTIVE

To summarize the clinicoradiological characteristics of clinical T1 renal cell carcinoma patients and to investigate the risk factors of renal sinus invasion in cT1 renal cell carcinoma patients undergoing nephrectomy.

METHODS

A retrospective study was conducted in cT1 renal cell carcinoma patients from January 2016 to August 2019 in Department of Urology, Peking University Third Hospital, who underwent partial or radical nephrectomy by analyzing clinicopathological and radiological data. The influencing factors of renal sinus invasion for cT1 renal cell carcinoma were determined by χ² test, Mann-Whitney U test and Logistic regression analysis.

RESULTS

A total of 507 patients were enrolled, including 354 males (69.8%) and 153 females (30.2%). The median age was 59 years and the median body mass index (BMI) was 25.5 kg/m². Eighteen patients (3.6%) had gross hematuria preoperatively. The median tumor diameter was 3.5 cm. Three hundred twenty-two patients (63.5%) were staged clinical T1a and 165 cases (36.5%) were staged clinical T1b. The median R.E.N.A.L. score was 8. Three hundred fifty-nine patients (70.8%) had regular tumor border and 148 (29.2%) irregular. All the patients underwent surgical treatment, including 186 (36.7%) partial nephrectomy and 321 (63.3%) radical nephrectomy. Postoperative pathology showed seventy-five patients (14.8%) had renal sinus invasion, including 18 in cT1a (5.6%) and 57 in cT1b (30.8%). Univariate analysis showed that age (P=0.020), R.E.N.A.L. score (R value, E value, N value, P < 0.001) and tumor border (P < 0.001) were associated risk factors for cT1 renal cell carcinoma with renal sinus invasion. On multivariate binary Logistic analysis, R.E.N.A.L. score (P≤0.020) and irregular tumor border (P=0.001) were independent risk factors.

CONCLUSION

For cT1 renal cell carcinoma patients undergoing nephrectomy, about 15% had renal sinus invasion postoperatively. High R.E.N.A.L. score and irre-gular tumor border help predicting cT1 renal cell carcinoma renal sinus invasion.

Prognostic significance of subclassifying stage pT3a renal tumors with fat invasion: a retrospective study of 99 patients

PURPOSE

To analyze the recurrence in patients with clinic stage T1 renal cell carcinoma (RCC) who were upstaged to stage T3a after partial nephrectomy (PN) using a new sub-classification criterion.

METHODS

A retrospective study of pathological characteristics was performed in patients who were upstaged to pT3a on the basis of fat invasion (FI).

RESULTS

After analyzing the pathological findings, we proposed the following new sub-classification criteria for pT3a RCC with FI: (1) renal tumor invades the pseudo-capsule and contacts the perinephric adipose tissue directly or the tumor protrudes into the perinephric adipose tissue like a tongue (Type A); and (2) tumor nodules are distributed in perinephric adipose tissues (Type B). A significant difference was observed in the recurrence rate between the two subtypes A and B. For Type B, the recurrence rate after radical nephrectomy (RN) and PN was 15.79% and 63.64%, respectively. The recurrence rates for Types A and B after PN were 11.11% and 63.64%, respectively.

CONCLUSIONS

T3a RCC with tumor nodules in perinephric adipose and/or an irregular tumor protruding into the adipose tissues lead to a higher recurrence rate. We recommend that T3a RCC be carefully analyzed and patients be treated on an individual basis.

Added Value of Systemic Inflammation Markers in Predicting Clinical Stage T1 Renal Cell Carcinoma Pathologically Upstaged to T3a

Objectives

We aimed to determine preoperative risk factors associated with pathologic T3a (pT3a) upstaging of clinical T1 (cT1) renal cell carcinomas (RCCs) and develop a novel model capable of accurately identifying those patients at high risk of harboring occult pT3a characteristics.

Methods

A retrospective analysis of 1324 cT1 RCC patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) was performed. The study cohort was divided into training and testing datasets in a 70:30 ratio for further analysis. Univariable and multivariable logistic regression analyses were performed to identify predictors associated with cT1 to pT3a upstaging and subsequently, those significant risk factors were used to construct models. We used the area under the curve (AUC) to determine the model with the highest discrimination power. Decision curve analyses (DCAs) were applied to evaluate clinical net benefit associated with using the predictive models.

Results

The rates of upstaging were 6.1% (n = 81), 5.8% (n = 54) and 6.8% (n = 27) in the total population, training cohort and validation cohort, respectively. Tumor size, clinical T stage, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior) nephrometry score, lymphocyte to monocyte ratio (LMR), prognostic nutrition index (PNI) and albumin to globulin ratio (AGR) were significantly associated with pT3a upstaging. The model that consisted of R.E.N.A.L. score, LMR, AGR and PNI achieved the highest AUC of 0.70 in the validation cohort and yielded the highest net benefit. In the subpopulation with complete serum lipid profile, the inclusion of low-density lipoprotein cholesterol (LDL-C) and Castelli risk index-I (CRI-I) significantly improved the discrimination of model (AUC = 0.86).

Conclusions

Our finding highlights the importance of systemic inflammation response markers and serum lipid parameters in predicting pT3a upstaging. Our model had relatively good discrimination in predicting occult pT3a disease among patients with cT1 renal lesions, and the use of the model may be greatly beneficial to urologists in risk stratification and management decisions.

Preoperative Assessment of Renal Sinus Invasion by Renal Cell Carcinoma according to Tumor Complexity and Imaging Features in Patients Undergoing Radical Nephrectomy

Objective

To identify the association between renal tumor complexity and pathologic renal sinus invasion (RSI) and evaluate the usefulness of computed tomography tumor features for predicting RSI in patients with renal cell carcinoma (RCC).

Materials and Methods

This retrospective study included 276 consecutive patients who underwent radical nephrectomy for RCC with a size of ≤ 7 cm between January 2014 and October 2017. Tumor complexity and anatomical renal sinus involvement were evaluated using two standardized scoring systems: the radius (R), exophytic or endophytic (E), nearness to collecting system or sinus (N), anterior or posterior (A), and location relative to polar lines (RENAL) nephrometry and preoperative aspects and dimensions used for anatomical classification (PADUA) system. CT-based tumor features, including shape, enhancement pattern, margin at the interface of the renal sinus (smooth vs. non-smooth), and finger-like projection of the mass, were also assessed by two independent radiologists. Univariable and multivariable logistic regression analyses were performed to identify significant predictors of RSI. The positive predictive value, negative predictive value (NPV), accuracy of anatomical renal sinus involvement, and tumor features were evaluated.

Results

Eighty-one of 276 patients (29.3%) demonstrated RSI. Among highly complex tumors (RENAL or PADUA score ≥ 10), the frequencies of RSI were 42.4% (39/92) and 38.0% (71/187) using RENAL and PADUA scores, respectively. Multivariable analysis showed that a non-smooth margin and the presence of a finger-like projection were significant predictors of RSI. Anatomical renal sinus involvement showed high NPVs (91.7% and 95.2%) but low accuracy (40.2% and 43.1%) for RSI, whereas the presence of a non-smooth margin or finger-like projection demonstrated comparably high NPVs (90.0% and 91.3% for both readers) and improved accuracy (67.0% and 73.9%, respectively).

Conclusion

A non-smooth margin or the presence of a finger-like projection can be used as a preoperative CT-based tumor feature for predicting RSI in patients with RCC.

A comparison of oncologic and functional outcomes in patients with pt3a renal cell carcinoma treated with partial and radical nephrectomy

HYPOTHESIS

Partial Nephrectomy is oncological safe in patients with pT3a RCC.

PURPOSE

To compare the oncological and functional outcomes of patients with pT3a RCC scheduled for PN and RN.

MATERIALS AND METHODS

We retrospectively reviewed patients with pT3a N0 M0 RCC who underwent partial or radical nephrectomy from 2005 to 2016. Perioperative characteristics, including estimated glomerular filtration rate, tumor size, pathological histology, and RENAL nephrometry score, were compared between patients scheduled for partial or radical nephrectomy. We used multivariable Cox proportional hazards regression models to compare overall survival, cancer-specific survival, and recurrence-free survival between planned procedure type.

RESULTS

Of the 589 patients, 369 (63%) and 220 (37%) were scheduled for radical and partial nephrectomy, respectively; 26 (12%) of the scheduled partial nephrectomy cases were intraoperatively converted to radical nephrectomy. After adjusting for tumor size and histology, there were no statistically significant differences in overall survival (hazard ratio 0.66; 95% CI, 0.38-1.13), cancer-specific survival (hazard ratio 0.53; 95% CI, 0.16-1.75), or recurrence-free survival (hazard ratio 0.66; 95% CI, 0.34-1.28) between patients scheduled for partial or radical nephrectomy. Fewer patients scheduled for partial nephrectomy had estimated glomerular filtration rate reductions 3 to 9 months after surgery than patients scheduled for radical nephrectomy.

CONCLUSION

We found no evidence that patients scheduled to undergo partial nephrectomy had poorer oncologic outcomes than patients scheduled to undergo radical nephrectomy. In select patients with pT3a renal cell carcinoma in whom partial nephrectomy is deemed feasible by the surgeon, partial nephrectomy should not be discouraged.

Partial nephrectomy provides equivalent oncologic outcomes and better renal function preservation than radical nephrectomy for pathological T3a renal cell carcinoma: A meta-analysis

Purpose:

Radical nephrectomy (RN) is the standard surgical type for pathological stage T3a (pT3a) renal cell carcinoma (RCC). Recently, some studies have suggested equivalence between partial nephrectomy (PN) and RN for oncologic control and have shown the benefits of PN for better renal function. We conducted this meta-analysis to assess oncologic outcomes, perioperative outcomes and renal function between two groups among patients with pT3a RCC.

Materials and methods:

PubMed, Scopus, Web of Science, Science Direct, Ovid MEDLINE, The Cochrane Library, Embase and Google Scholar were searched for eligible articles. The endpoints of the final analysis included overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), surgical complications, operative time, estimated blood loss (EBL), serum creatinine and estimated glomerular filtration rate (eGFR).

Results:

Twelve studies of moderate to high quality, including 14.152 patients, were examined. PN showed superiority for renal functional preservation, providing higher eGFR (WMD=12.48mL/min; 95%CI: 10.28 to 14.67; P <0.00001) and lower serum creatinine (WMD=-0.31mg/dL; 95%CI: −0.40 to −0.21; P <0.00001). There were no significant differences between PN and RN regarding operative time, EBL, surgical complications, OS, RFS and CSS. Despite inherent selection bias, most pooled estimates were consistent in sensitivity analysis and subgroup analysis. More positive margins were found in the PN group (RR=2.42; 95%CI: 1.25-4.68; P=0.009).

Conclusions:

PN may be more suitable for treating pT3a RCC than RN because it provides a similar survival time (OS or RFS) and superior renal function. Nevertheless, this result is still disputed, and more high-quality studies are required.

Assessing the role of race in pathological upstaging of renal cell carcinoma: Results from the National Cancer Database

PURPOSE

Pathologic upstaging in renal cell carcinoma (RCC) is common and confers a significant risk of poor surgical and survival outcomes. Preoperative predictors of upstaging are of great clinical relevance but empirical evidence specific to racial minorities remains scarce.

METHODS

National Cancer Database (NCDB) analysis of T3a-specific upstaging among White, African-American, Hispanic and Asian Pacific Islander (API) patients with AJCC cT1N0M0 RCC who underwent partial or radical nephrectomy between 2010 and 2015. Independent preoperative predictors of tumour upstaging were identified using multivariate logistic regression analyses.

RESULTS

A total of 81 002 patients met the criteria for inclusion (5.6% T3a-specific upstaging). Increased age, increased Charlson-Deyo comorbidity index, clinical stages cT1b and unspecified cT1, and increased Fuhrman nuclear grade were identified as independent risk factors for upstaging. Independent protective factors for upstaging were younger age, female sex, African-American race and papillary, chromophobe, and unspecified RCC histologic subtypes. Significant risk factors and protective factors within individual racial subgroups were highly consistent with those observed in the overall study sample. All independent factors identified on race-specific subgroup analyses were significant in the same direction relative to the overall study sample. Variables found to be non-significant in the overall study sample remained non-significant across all racial subgroup analyses.

CONCLUSION

The present study of nationally representative data found no clinically significant differences in upstaging risk across individual racial subgroups relative to the overall study sample. Preoperative factors that can be used to predict pT3a-specific tumour upstaging in CT1N0M0 RCC likely persist across different racial groups.

A meta-analysis for comparison of partial nephrectomy vs. radical nephrectomy in patients with pT3a renal cell carcinoma

Background

Kidney cancer is the most common malignant tumor of the kidney in adults. However, in terms of the treatment for pT3a renal cell carcinoma (RCC), whether partial nephrectomy (PN) can be selected is still controversial. This study was conducted to compare the efficacy of PN and radical nephrectomy (RN) in treatment for patients with pT3a RCC.

Methods

The relative English databases including PubMed and EMBASE were searched for studies comparing PN and RN for pT3a RCC between 2010 and 2020. Stata 13.0 software was used to compare the cancer-specific survival (CSS), overall survival (OS), cancer-specific mortality (CSM), relapse-free survival (RFS), complications and positive surgical margin.

Results

Nine articles were included with a total of 3,391 patients, of whom 2,113 received RN and 1,278 received PN. The results showed that there is no statistical difference in CSS, OS, CSM, RFS, complications and positive surgical margin between RN and PN. No heterogeneity was shown in study.

Conclusions

There were no differences in the CSS, OS, CSM, RFS, complications and positive surgical margin of the patients in RN and PN group. For pT3a RCC, RN did not provide a better survival benefit compared to PN. Considering PN can suppress the progression of tumor and reduce the risk of postoperative chronic renal insufficiency, we found PN is a good choice for pT3a RCC. However, further large-sample, studies are still needed in future.

Comparison of oncologic outcomes between partial nephrectomy and radical nephrectomy in patients who were upstaged from cT1 renal tumor to pT3a renal cell carcinoma: an updated systematic review and meta-analysis

Aim

Owing to the limited ability of current imaging modalities, several clinical T1 renal cell carcinomas (cT1 RCCa) can be pathologically upstaged to T3a (pT3a) after surgery. There have been some controversies regarding the oncological safety of partial nephrectomy (PNx) compared with radical nephrectomy (RNx) in these patients. We compared oncological outcomes of PNx and RNx in patients with upstaged pT3a RCCa.

Methods

A systematic review was performed following the PRISMA guideline. PubMed, MEDLINE, Embase were searched. Oncological outcomes [recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS)] between PNx and RNx were compared. The GRADE approach was used to rate the certainty of evidence.

Results

A total of 7406 patients in 12 articles related to upstaged pT3a RCCa were included. In adjusted analysis, no difference was observed in RFS [hazard ratios (HR) 0.87; 95% confidence intervals (CI), 0.57-0.95; p = 0.88] and CSS (HR, 0.78; 95% CI, 0.59-1.04; p = 0.09) for PNx and RNx. Meanwhile, PNx was significantly associated with favorable OS compared with RNx (HR, 0.74; 95% CI, 0.57-0.95; p = 0.02).

Conclusions

Our meta-analysis shows that patients treated with PNx have better or at least similar oncological outcomes compared with RNx in patients with upstaged pT3a RCCa from cT1. In particular, patients who had undergone PNx show a significantly improved OS. If PNx is available, we recommend performing PNx for all cT1 RCCa, even in patients with upstaging potential. However, due to the low level of evidence, large-scale randomized trials are required.

The critical impact of tumor size in predicting cancer special survival for T3aM0M0 renal cell carcinoma: A proposal of an alternative T3aN0M0 stage

OBJECTIVE

Based on the eighth TNM staging system, T3a renal cell carcinoma (RCC) is identified as an anatomical extrarenal invasion and does not consider the size of the tumor; however, it may not fully predict the prognosis of the patient. The objective of this study was to evaluate the prognostic value of tumor size effects on prognosis in T3a RCC and propose an alternative tumor stage system combined with T1-2.

METHODS

Data relating to T1-3aN0M0 RCC (n = 49586) were obtained from the Surveillance, Epidemiology, and End Results database (2004-2015). Survival analyses were conducted by Cox regression and Fine and Gray regression. Harrell's concordance index (c-index) was used to assess the discriminatory ability of the prognostic factors.

RESULTS

A 1-cm increase in T3a RCC resulted in an 8% increase in all-cause mortality (hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 1.06-1.10, p < 0.001) and 14% increase in the risk of RCC-specific mortality (sub-distribution HR [sHR]: 1.14; 95% CI: 1.11-1.16, p < 0.001). T3a tumor size stratified by the cutoff of 4 cm and 7 cm showed a better prediction of RCC-special survival (c-index: 0.644), compared with a cutoff just by 4 cm (c-index: 0.571) or by 7 cm (c-index: 0.602). Compared with T1b tumors, T3a RCC ≤4 cm showed no differences in terms of all-cause mortality (HR: 0.93; 95% CI: 0.79-1.09; p = 0.37) and mortality caused by RCC (sHR: 0.91; 95% CI: 0.70-1.19; p = 0.50). Last, the alternative T-staging system (T1a, a combination of T1b and T3a [≤4 cm], T2a, T2b, T3a [4-7 cm], and T3a [>7] cm) demonstrated good RCC-special survival predictive accuracy (c-index: 0.729), which was higher than that shown by the current eighth edition T-staging system (c-index: 0.720).

CONCLUSION

Tumor size should be taken into consideration for T3aN0M0 RCC rather than based on anatomical features alone.

Predicting the risk of pT3a stage in cT1 clear cell renal cell carcinoma

We hypothesized that pT3a stage at nephrectomy can be accurately predicted in cT1N0M0 clear cell-renal cell carcinoma (cc-RCC) patients. Of 236 patients, treated with either partial or radical nephrectomy (2005-2019), 25 (10.6%) harbored pT3a stage. Multivariable logistic regression models predicting pT3a were fitted using age, tumor size, tumor location and exophytic rate. The new model was 81% accurate. In calibration plots, minimal departures from ideal prediction were recorded. In decision curve analyses, a net-benefit throughout all threshold probabilities was recorded relative to the treat-all or treat-none strategies. Using a probability cut-off of 21% for presence of pT3a stage, 38 patients (16.1%) were identified, in whom pT3a rate was 36.8%. Conversely, in 198 patients (83.9%) below that cut-off, the rate of pT3a was 5.6%. Alternative user-defined cut-offs may be selected. The new model more accurately identifies a subgroup of cT1N0M0 cc-RCC patients with substantially higher risk of pT3a stage than average.

Does renal tumor biopsies for small renal carcinoma increase the risk of upstaging on final surgery pathology report and the risk of recurrence?

BACKGROUND

Renal tumor biopsies (RTB) have been proposed as a means to diminish overtreatment of small renal masses. A potential concern of RTB is tumor seeding along the biopsy tract leading to worse clinical outcomes.

OBJECTIVES

To evaluate whether RTB was associated with greater upstaging to pT3a compared to patients without a biopsy and to determine if pathologic upstaging affects the risk of recurrence.

DESIGN, SETTING AND PARTICIPANTS

The Canadian Kidney Cancer information system was used to identify patients who underwent radical or partial nephrectomy for malignant renal tumors ≤ 4cm (cT1a) between January 1, 2011 and July 2, 2019.

INTERVENTION

RTB prior to nephrectomy or nephrectomy without biopsy.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

Upstaging to pT3a and cancer recurrence were compared between subjects that had a RTB compared to those who did not. A multivariable analysis was used to evaluate factors associated with disease upstaging and recurrence.

RESULTS AND LIMITATIONS

The cohort consisted of 1993 cT1a patients, followed for a median of 17.5 months. Of these patients, 502 (25%) had a preoperative RTB. There was no difference in the proportion with tumor upstaging to pT3a between patients that had RTB compared to those who did not (7.2% vs. 6.3%; P = 0.5). On multivariable analysis, RTB was not associated with pathological upstaging (Odds Ratio 0.90; 95% Confidence Interval 0.61-1.34) or recurrence (Odds Ratio 1.04; 95% Confidence Interval 0.57-1.89). The main limitation is that the study is underpowered to detect small differences between groups.

CONCLUSIONS

In this large, multi-institution cohort, RTB was not associated with increased risk of tumor upstaging or recurrence. Hence, tumor tract seeding, although possible, should not be a clinical deterrent to using RTBs as a means of personalizing renal masses management and diminishing overtreatment.

PATIENT SUMMARY

Recent evidence suggests that tumor seeding following RTB may be more common than initially perceived. Our results have demonstrated that RTB was not associated with an increased risk of tumor upstaging or disease recurrence.

Upstaging to pT3a in Patients Undergoing Partial or Radical Nephrectomy for cT1 Renal Tumors: A Systematic Review and Meta-analysis of Outcomes and Predictive Factors

CONTEXT

Predictors of upstaging from cT1 to pT3a renal masses are poorly inquired, and this remains an area of controversial findings.

OBJECTIVE

To evaluate predictors and outcomes of upstaging from cT1 to pT3a in patients undergoing surgical removal of a renal tumor.

EVIDENCE ACQUISITION

A systematic literature search was performed to identify relevant articles using three electronic engines (PubMed, Embase, and Web of Science). Only studies looking at upstaging to pT3a in patients undergoing either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1 renal tumor were included. Study selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.

EVIDENCE SYNTHESIS

Thirteen studies, including 21869 patients (cT1/pT3a: 1256 [5.7%]; cT1/pT1: 20613 [93.3%]), were identified. Patients in the upstaged group were older (weighted mean difference [WMD]: 3.89; p < 0.00001) and mostly male (odds ratio [OR]: 1.23; p = 0.04). Renal tumors were larger (WMD: 0.98; p < 0.00001), more complex (OR: 2.38; p < 0.0001), and with a higher rate of cT1b masses (OR: 3.36; p < 0.00001). The cT1/pT3a group had a higher rate of other renal cell carcinoma histological subtypes (OR: 1.59; p = 0.04), as well as higher odds of Fuhrman grade ≥3 (OR: 2.57; p < 0.00001) and positive surgical margins (OR: 1.85; p = 0.007). Five-year recurrence-free survival (RFS) was worse in the upstaged group (OR: 0.31; p = 0.02). Age (OR: 1.03; p < 0.00001), tumor size (OR: 1.51; p < 0.00001), and RENAL score (OR: 2.80; p = 0.0004) were predictors of upstaging. Upstaging was associated with overall survival (hazard ratio [HR]: 1.94; p = 0.05), cancer-specific survival (HR: 2.24; p = 0.007), and RFS (HR: 2.17; p < 0.00001).

CONCLUSIONS

Upstaging to pT3a in case of surgical removal of a cT1 renal tumor is an uncommon event, which however can translate into worse oncological outcomes. Both patient (older age) and tumor (larger size and higher complexity) characteristics are associated with a higher risk of upstaging. There is very limited evidence regarding whether RN would be better than PN in these cases. There remains an unmet need for tools to better characterize renal masses in the preoperative setting.

PATIENTS SUMMARY

About 6% of surgically treated localized renal tumors can be found to be locally advanced on final pathology after surgery. This "upstaging" can translate into worse oncological outcomes. There are patient and tumor characteristics that are associated with an increased the risk of upstaging.

A preoperative model to predict pT3 upstaging in clinically localized renal cell carcinoma

Introduction

Patients upstaged to pT3 after partial nephrectomy (PN) may be at an increased risk of disease progression compared to those patients submitted to radical nephrectomy (RN). We sought to identify preoperative factors predicting pT3 upstaging in localized renal cell carcinoma.

Material and methods

Patients submitted to nephrectomy for clinically localized (cT1–cT2) renal cell carcinoma between 2011 and 2016 were identified from a prospective registry, those presenting with locally advanced or metastatic disease were excluded. Clinical factors, laboratory, and imaging using RENAL score, were analyzed. A multivariate analysis was performed looking for stage pT3a predictors.

Results

Two hundred and nine patients were included, 66% were men, with a mean age of 57 years. Mean tumor size was 49 ±31 mm. 19% were staged as pT3a. Of this group, 10% underwent a PN. Age, hypertension, presence of hematuria, creatinine levels, size and RENAL score were statistically associated with locally advanced stage. The variables of the RENAL score that were associated to pT3a stage were size, nearness to renal sinus/collector system and contact with main renal vessels. On the multivariate analysis, only age, size, and contact with renal vessels were found to predict upstaging. A model was developed which was able to predict stage pT3a with an area under the curve (AUC) of 0.864 in the ROC curve.

Conclusions

Upstaging to pT3a is fairly common in clinically localized tumors. A formula that includes tumor size, age and contact with the main vessels on imaging, can help predict it. This should be considered when deciding if the patient is a candidate for nephron sparing surgery.

Clinical Significance of Tumor Size, Pathological Invasion Sites Including Urinary Collecting System and Clinically Detected Renal Vein Thrombus as Predictors for Recurrence in pT3a Localized Renal Cell Carcinoma

The recent eighth tumor-node-metastasis (TMN) staging system classifies renal cell carcinoma (RCC) with perirenal fat invasion (PFI), renal sinus fat invasion (SFI), or renal vein invasion (RVI) as stage pT3a. However, limited data are available on whether these sites have similar prognostic value or recurrence rate. We investigated the recurrence rate based on tumor size, pathological invasion sites including urinary collecting system invasion (UCSI), and clinically detected renal vein thrombus (cd-RVT) with pT3aN0M0 RCC. We retrospectively reviewed 91 patients with pT3aN0M0 RCC who underwent surgical treatment. Patients with tumor size > 7 cm, UCSI, three invasive sites (PFI + SFI + RVI), and cd-RVT showed a significant correlation with high recurrence rates (hazard ration (HR) 2.98, p = 0.013; HR 8.86, p < 0.0001; HR 14.28, p = 0.0008; and HR 4.08, p = 0.0074, respectively). In the multivariate analysis, tumor size of >7 cm, the presence of UCSI, and cd-RVT were the independent predictors of recurrence (HR 3.39, p = 0.043, HR 7.31, p = 0.01, HR 5.06, p = 0.018, respectively). In pT3a RCC, tumor size (7 cm cut-off), UCSI, and cd-RVT may help to provide an early diagnosis of recurrence.

Survival Analysis of Pathological T3a Upstaging in Clinical T1 Renal Cell Carcinoma

AIM

To evaluate the oncological outcomes of pathological T3a upstaging from clinical T1 renal cell carcinoma.

PATIENTS AND METHODS

We retrospectively studied patients who underwent radical or partial nephrectomy for clinical T1 renal tumors.

RESULTS

The median follow-up period was 44 months. At three and five years, the respective overall survival rate was 88.7% and 82.4% in pT3a disease, 95.7% and 93.4% in pT1 (p=0.008), the cancer-specific survival rate, 93.9% and 90.8% in pT3a, 99% and 97.7% in pT1 (p=0.001), and the recurrence-free survival rate, 79.7% and 71.0% in pT3a, and 95.5 and 94.3% in pT1 (p<0.001).

CONCLUSION

Patients with pathological T3a upstaging tumors were associated with a significantly decreased survival rate, along with a higher recurrence rate when compared to those with pathological T1 disease.

Predictive factors for recurrence after partial nephrectomy for clinical T1 renal cell carcinoma: a retrospective study of 1227 cases from a single institution

OBJECTIVE

Identifying the predictive factors for tumor recurrence after partial nephrectomy (PN) is useful to determine patients who require careful observation after surgery. Therefore, we investigated recurrence after partial nephrectomy (PN) in patients with clinical T1 renal cell carcinoma (RCC) and analyzed predictive factors for recurrence-free survival (RFS).

METHODS

This study included 1227 patients who underwent PN for clinical T1 RCC and retrospectively investigated patients' characteristics and tumor factors that are associated with tumor recurrence.

RESULTS

The median patient age was 59 years, and the median tumor size was 30 mm. Although 970 (74%) and 319 (26%) patients had clinical T1a and T1b RCCs, respectively, 20 patients (1.6%) were upstaged to pathological T3a. A positive surgical margin was found in 19 (1.5%) patients. The distribution of surgical approaches was open surgery in 428 (35%) patients and minimally invasive surgery in 799 (65%) patients. With a median follow-up of 35 months (Interquartile range 19-55 months), 39 (3.2%) patients, including ten with local recurrence, five with recurrence in the ipsilateral kidney, and 28 with other organs or lymph-nude, developed recurrence. The 3-year RFS was 99%, and the median recurrence time from PN was 19 months (interquartile range: 11-37 months). Multivariate analysis identified high grade tumor and upstaging to pT3a as significant predictors for worse RFS.

CONCLUSION

Patients with high grade tumors and tumors upstaged to pT3 had a high risk of worse RFS, which suggested that careful monitoring is required for such patients after PN, even if a good prognosis is achieved in patients with clinical T1 RCC.

Prognostic significance of the sub-classification of stage pT3a renal tumors by perinephric and sinus fat invasion

In the current Tumor-Node-Metastasis (TNM) classification system for renal cell carcinoma (RCC), both perinephric fat invasion (PFI) and renal sinus fat invasion (SFI) are classified at the T3a stage. However, their associated prognoses are clinically controversial. The present study proposes a new sub-classification criterion for pathological T3a (pT3a) RCC with SFI or PFI to resolve this dispute. Data were collected from consecutive records of 2,765 patients with T1a renal cancer, who had undergone partial nephrectomy (PN) between 2001 and 2015 at one of four hospitals. Among these patients, 127 cases were diagnosed with stage pT3a RCC with SFI or PFI, according to final pathological examination. The pathological characteristics, clinical data and follow-up observations were analyzed. Of the 127 patients, with an average follow-up duration of 56 months (range, 15–60 months), 17 cases of tumor recurrence were found. After analysis of the pathological findings, the following new sub-classification criteria was proposed for pT3a RCC with SFI or PFI: i) Type A, renal tumor invades the pseudo-capsule and contacts with the perinephric adipose tissues directly (3 recurrences out of 57 patients); ii) type B, tumor protrudes into the perinephric adipose tissues like a tongue (4 recurrences out of 29 patients); and iii) type C, tumor nodules distribute in perinephric adipose tissues (10 recurrences out of 41 patients). There was statistically significant difference between the three subtypes in terms of recurrence rate (P=0.023). In conclusion, controversies remain in the current TNM classification system for pT3a RCC. The present study added to the available data and found that pT3a RCC with tumor nodules in perinephric adipose or/and with an irregular tumor protruding into adipose tissues showed a higher recurrence rate. Thus, it is recommended that pT3a RCC should be carefully analyzed and should be considered differently to other stages of RCC.

Impact of pathological T3a upstaging on oncological outcomes of clinical T1 renal cell carcinoma: a meta-analysis

Objective: The study aims to assess the prognostic impact of pathological T3a upstaging in clinical T1 renal cell carcinoma (RCC) on clinical outcomes. Methods: We performed a systematic literature search of PMC, Embase, Web of Science, and Cochrane library from inception to April 2019 for studies that investigated the prognostic significance of pathological T3a upstaging in clinical T1 RCC after surgery and conducted a standard meta-analysis on survival outcomes. Results: Overall, nine studies including 101,505 clinical T1 RCC patients were identified, in which 5,560 (5.5%) patients were upstaged to T3a after surgical treatment. Meta-analysis results showed that pT3a upstaging from clinical T1 RCC was significantly associated with poor recurrence-free survival (RFS; pooled hazard ratio [HR] 2.16, 95% confidence interval [CI] 1.70-2.75; P<0.001), overall survival (OS; pooled HR 1.36, 95% CI 1.24-1.50; P<0.001), and cancer-specific survival (CSS; pooled HR 2.11, 95% CI 1.58-2.83; P<0.001). Subgroup analyses by surgical type demonstrated that pT3a upstaging remains a significant prognostic factor for RFS and OS in RCC patients who underwent different surgical treatments. Conclusions: Current available evidence strongly supported that postoperative pT3a upstaging has a significant negative impact on RFS, OS, and CSS in clinical T1 RCC patients. Clinical T1 RCC patients with pT3a upstaging after surgery should be closely monitored by clinician and should receive close follow-up for their poor prognosis.

The Preoperative Predictive Factors for Pathological T3a Upstaging of Clinical T1 Renal Cell Carcinoma

We aimed to determine the oncological outcomes of patients with clinical T1 renal cell carcinoma (RCC) upstaged to pathological T3a and to identify the preoperative predictive factors for upstaging. We retrospectively reviewed 272 patients with clinical T1 RCC who underwent surgical treatment. Thirty-three patients (12%) were upstaged to pathological T3a. These patients had a significantly larger tumor size on computed tomography (p < 0.0001), a higher aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (p = 0.037), and an elevated c-reactive protein (CRP) level (p = 0.014) preoperatively compared with those with pathological T1 RCC. On multivariate analysis, tumor diameter was the only significant preoperative predictive factor for upstaging [hazard ratio (HR), 3.61; 95% confidence interval (CI), 1.32-9.84; p = 0.01]. The AST/ALT ratio tended to be a preoperative predictive factor for upstaging, although it was not significant (HR, 2.14; 95% CI, 0.97-4.73; p = 0.06). Pathological T3a upstaging occurred in 25% of those with a tumor diameter ≥30 mm and a preoperative AST/ALT ratio ≥1.1. There was a significant correlation between pathological T3a upstaging and the number of preoperative risk factors (p = 0.0002). The preoperative tumor diameter and serum AST/ALT ratio can be predictive factors for pathological T3a upstaging in patients with clinical T1 RCC.

Oncological outcomes and pathological characteristics of cT1 upstaging to pT3a renal cell carcinoma compared with de novo pT3a tumors

INTRODUCTION

The significance of upstaging of cT1 renal tumors to pT3a is not clear. We evaluate the incidence of upstaging, identify predictors and analyze oncological outcomes of these patients versus those who did not upstage. We also compared the oncological outcomes of cT1 upstaging to pT3a with de novo pT3a renal tumors.

METHODS

From a database of 1021 renal tumors with complete available follow-up data, 517 patients had cT1. Patients upstaging to pT3a were compared to those who did not. Baseline clinical, perioperative, histopathologic features and oncological outcomes were analysed.

RESULTS

Out of 517 cT1 patients, 105 (20.3%) upstaged to pT3a and 412 (79.7%) did not. Proportion of patients in each group undergoing partial and radical nephrectomy, postoperative tumor size, histology, margin status and lymph node involvement were similar. Among upstaged, 9 patients (8.6%) developed first recurrence as compared to only 3 (0.7%) in those not upstaging (P <0.001). The median time to recurrence (57 vs. 107 months; P <0.001) was lesser in de novo pT3a renal tumors.

CONCLUSIONS

Pathological upstaging from cT1 to pT3a and necrosis on histopathology were associated with recurrence. Advanced age, smoking, necrosis on histopathology, clear cell histology and higher Fuhrman grades contributed to pathological upstaging of cT1 tumors. De novo pT3a RCC had worse survival when compared to cT1 patients upstaging to pT3a RCC.

Multi-institutional Survival Analysis of Incidental Pathologic T3a Upstaging in Clinical T1 Renal Cell Carcinoma Following Partial Nephrectomy

OBJECTIVE

To evaluate whether incidental pathologic T3a (pT3a) upstaging after partial nephrectomy (PN) for clinical T1 disease results in inferior oncologic outcomes compared to pT1a-b disease.

MATERIALS AND METHODS

Retrospective chart review was completed at the University of Michigan and Moffitt Cancer Center to identify patients undergoing PN for clinical T1 masses between 1995 and 2015. A total of 1955 patients were identified, of which 95 had pT3a upstaging. Median follow-up was 38.2 months. Patients with pT3a disease were individually matched by clinicopathologic features with patients undergoing PN with pT1a-b disease in a 1:2 ratio. Kaplan-Meier analysis and univariate and multivariable Cox proportional hazards regression analysis were performed. Primary endpoint was recurrence-free survival (RFS). Secondary endpoints were all-cause mortality, cancer-specific survival (CSS), and rates of local and distant recurrence.

RESULTS

Recurrence rates were significantly higher in pT3a disease compared to pT1a-b controls (P <.01). In those patients with pT3a upstaging, 3- and 5-year RFS were 81% and 58%, compared to 86% and 75% in pT1a-b controls (P = .01). CSS at 3 and 5 years were 91% and 90% in pT3a disease and 100% and 97% in pT1a-b controls (P <.01). All-cause mortality at 3 and 5 years were 82% and 71% in pT3a disease and 93% and 80% in pT1a-b controls (P = .04). Univariate and multivariable analysis of pT3a disease demonstrated no association between demographic or pathologic characteristics and RCC recurrence.

CONCLUSION

Patients with pT3a upstaging following PN experience a significantly reduced RFS and CSS when compared to pT1 disease.