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Harrison H, Stewart GD, Usher‐Smith JA. Patient experience of follow-up after surgery for kidney cancer: a focus group study. BJU Int 2023; 132:47-55. [PMID: 36726216 PMCID: PMC10952230 DOI: 10.1111/bju.15982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore patient experience of follow-up care after kidney cancer surgery and to develop recommendations for best practice. METHODS We conducted two focus groups, including 14 participants with experience of kidney cancer follow-up after surgery, to elicit patient views on current follow-up care. Thematic analysis was used to identify unifying themes to describe the patient experience of follow-up, and the results were then used to develop a set of recommendations for best practice. RESULTS We identified six themes (feelings of abandonment; uncertainty about the plan; anxiety about appointments; variation in care; a need for information; and a need for emotional support) that described current patient experience and areas in which current care could be improved. In particular, while most of the participants felt that their physical needs had been met, many had struggled with unmet emotional needs and a lack of information and resources. This was especially noted in the period immediately following surgery, when feelings of abandonment were common, and around follow-up scans and routine appointments, which were a source of anxiety. Our participants also described concerns about the lack of consistency between different hospitals and centres around the United Kingdom, with differences in the content and quality of follow-up care. Based on the results, we developed a list of recommendations to address some of the challenges described through relatively minor changes to the care pathway. CONCLUSIONS We identified gaps and variability in current follow-up care after kidney cancer surgery, and have developed a set of recommendations that, if implemented, would improve the follow-up care experience for these patients.
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Affiliation(s)
- Hannah Harrison
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Grant D. Stewart
- Department of SurgeryUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
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2
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Riveros C, Huang E, Ranganathan S, Klaassen Z, Rini B, Wallis CJD, Satkunasivam R. Adjuvant immunotherapy in renal cell carcinoma: a systematic review and meta-analysis. BJU Int 2023; 131:553-561. [PMID: 36709462 DOI: 10.1111/bju.15981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To synthesise available data regarding the disease-free survival (DFS) benefit of adjuvant immune checkpoint inhibitors (ICIs) for patients with renal cell carcinoma (RCC) and evaluate the overall safety profile of ICIs in this setting. MATERIALS AND METHODS We utilised PubMed, Embase, and relevant conference proceedings to identify phase III randomised controlled trials comparing adjuvant ICIs vs placebo/observation for RCC. The primary outcome of interest was DFS. Variables for subgroup analyses were programmed death-ligand 1 (PD-L1) expression, sarcomatoid features, nephrectomy type, and disease-risk category. Secondary outcomes included Grade ≥3 adverse events (AEs), immune-related AEs, and treatment discontinuation due to AEs. All outcomes were analysed using random-effects models owing to inter-study heterogeneity. RESULTS Among the four included studies, one demonstrated a significant DFS benefit. There was considerable clinical and statistical heterogeneity (I2 = 64%) due to differences in inclusion criteria and interventions. While pooled results across the four studies did not demonstrate a significant benefit in DFS overall (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.69-1.04) there was significant benefit among patients with positive PD-L1 expression (HR 0.72, 95% CI 0.55-0.94) and sarcomatoid features (HR 0.59, 95% CI 0.38-0.91). CONCLUSION The evidence base to date regarding ICIs as adjuvant therapy in RCC is mixed - conclusions are limited by considerable heterogeneity between studies. However, pooled analyses suggest that patients with positive PD-L1 expression or sarcomatoid features are most likely to benefit from adjuvant immunotherapy.
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Affiliation(s)
- Carlos Riveros
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Emily Huang
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | | | - Zachary Klaassen
- Division of Urology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Brian Rini
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher J D Wallis
- Division of Urology and Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Urology, University of Toronto, Toronto, ON, Canada
- Division of Urology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
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3
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Daza J, Salomé B, Okhawere K, Bane O, Meilika KN, Korn TG, Qi J, Xe H, Patel M, Brody R, Kim-Schulze S, Sfakianos JP, Lewis S, Rich JM, Zuluaga L, Badani KK, Horowitz A. Urine supernatant reveals a signature that predicts survival in clear-cell renal cell carcinoma. BJU Int 2023. [PMID: 36797809 DOI: 10.1111/bju.15989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To profile the cell-free urine supernatant and plasma of a small cohort of clear-cell renal cell carcinoma (ccRCC) patients by measuring the relative concentrations of 92 proteins related to inflammation. Using The Cancer Genome Atlas (TCGA), we then performed a targeted mRNA analysis of genes encoding the above proteins and defined their effects on overall survival (OS). SUBJECTS/PATIENTS AND METHODS Samples were collected prospectively from ccRCC patients. A multiplex proximity extension assay was used to measure the concentrations of 92 inflammation-related proteins in cell-free urine supernatants and plasma. Transcriptomic and clinical information from ccRCC patients was obtained from TCGA. Unsupervised clustering and differential protein expression analyses were performed on protein concentration data. Targeted mRNA analysis on genes encoding significant differentially expressed proteins was performed using TCGA. Backward stepwise regression analyses were used to build a nomogram. The performance of the nomogram and clinical benefit was assessed by discrimination and calibration, and a decision curve analysis, respectively. RESULTS Unsupervised clustering analysis revealed inflammatory signatures in the cell-free urine supernatant of ccRCC patients. Backward stepwise regressions using TCGA data identified transcriptomic risk factors and risk groups associated with OS. A nomogram to predict 2-year and 5-year OS was developed using these risk factors. The decision curve analysis showed that our model was associated with a net benefit improvement compared to the treat-all/none strategies. CONCLUSION We defined four novel biomarkers using proteomic and transcriptomic data that distinguish severity of prognosis in ccRCC. We showed that these biomarkers can be used in a model to predict 2-year and 5-year OS in ccRCC across different tumour stages. This type of analysis, if validated in the future, provides non-invasive prognostic information that could inform either management or surveillance strategies for patients.
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Affiliation(s)
- Jorge Daza
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bérengère Salomé
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kennedy Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Octavia Bane
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kirolos N Meilika
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Talia G Korn
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jingjing Qi
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hui Xe
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manishkumar Patel
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Brody
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Seunghee Kim-Schulze
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Lewis
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura Zuluaga
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amir Horowitz
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Nguyen MV, Walia A, Saidian A, Puri D, Meagher MF, Hakimi K, Tanaka H, Patil D, Yasuda Y, Saito K, Dhanji S, Cerrato C, Narasimhan R, Perry J, Master V, Fujii Y, Derweesh IH. Impact of worsening surgically induced chronic kidney disease (CKD-S) in preoperative CKD-naïve patients on survival in renal cell carcinoma. BJU Int 2023; 131:219-226. [PMID: 35876044 DOI: 10.1111/bju.15861] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To evaluate effects of worsening surgically induced chronic kidney disease (CKD-S) on oncological and non-oncological survival outcomes in renal cell carcinoma (RCC). PATIENTS AND METHODS We performed a retrospective analysis of patients who underwent partial (PN) or radical nephrectomy (RN) and were free of preoperative CKD (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m2 ). Patients were stratified by CKD stage at last follow-up: no CKD-S (eGFR ≥60 mL/min/1.73 m2 ), de novo CKD-S 3a (eGFR 45-59 mL/min/1.73 m2 ), CKD-S 3b (eGFR <45 and ≥30 mL/min/1.73 m2 ) and CKD-S 4 (eGFR <30 and ≥15 mL/min/1.73 m2 ). The primary outcome was all-cause mortality (ACM). Secondary outcomes included non-cancer mortality (NCM), cancer-specific mortality (CSM) and de novo CKD-S Stage 3/4. Multivariable analysis (MVA) was utilised to identify risk factors for outcomes. Kaplan-Meier analysis (KMA) was utilised to evaluate overall (OS), non-cancer (NCS), and cancer-specific survival with respect to CKD-S categories. RESULTS We analysed 3239 patients. The mean preoperative and last-follow-up eGFRs were 87.4 and 69.5 mL/min/1.73 m2 , respectively. On last follow-up, 57.9% (n = 1876) had no CKD-S, 18.7% (n = 606) had CKD-S 3a, 15.1% (n = 489) had CKD-S 3b and 8.3% (n = 268) had CKD-S 4. On MVA, de novo CKD-S 3b and 4 were independently associated with ACM (hazard ratios [HRs] 1.3-2.1, P = 0.003-0.001) and NCM (HRs 1.5-2.8, P = 0.021-0.001), but not CSM (P = 0.219-0.909); de novo CKD-S 3a was not predictive for any mortality outcomes (P = 0.102-0.81). RN was independently associated with CKD-S 3-4 (HRs 1.78-1.99, P < 0.001-0.035). Comparing no CKD-S, CKD-S 3a, CKD-S 3b and CKD-S 4, KMA demonstrated worsening outcomes with progressive CKD-S stage: 5-year OS 84% vs 78% vs 71% vs 60% (P < 0.001) and 5-year NCS 93% vs 87% vs 83% vs 72% (P < 0.001). CONCLUSION Development of CKD-S Stage 3b and 4, but not 3a, was associated with worsened ACM and NCM. The decision to proceed with nephron preservation via PN should be individualised based on oncological risk and risk of functional decline to CKD-S 3b or 4, and not CKD-S 3a.
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Affiliation(s)
- Mimi V Nguyen
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Arman Walia
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Ava Saidian
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Dhruv Puri
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Margaret F Meagher
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Kevin Hakimi
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Dattatraya Patil
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yosuke Yasuda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sohail Dhanji
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Clara Cerrato
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Rekha Narasimhan
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - John Perry
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Viraj Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ithaar H Derweesh
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
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5
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Campbell SC, Campbell JA, Munoz-Lopez C, Rathi N, Yasuda Y, Attawettayanon W. Every decade counts: a narrative review of functional recovery after partial nephrectomy. BJU Int 2023; 131:165-172. [PMID: 35835519 PMCID: PMC10087004 DOI: 10.1111/bju.15848] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies. METHODS Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off-clamp vs on-clamp cohorts. RESULTS A decade ago, 'Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri-operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on-clamp vs off-clamp PN have shown minimal impact of ischaemia on functional recovery. CONCLUSIONS The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero-ischaemia PN?
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Affiliation(s)
- Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Carlos Munoz-Lopez
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Nityam Rathi
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Yosuke Yasuda
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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6
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Usher-Smith JA, Li L, Roberts L, Harrison H, Rossi SH, Sharp SJ, Coupland C, Hippisley-Cox J, Griffin SJ, Klatte T, Stewart GD. Risk models for recurrence and survival after kidney cancer: a systematic review. BJU Int 2022; 130:562-579. [PMID: 34914159 DOI: 10.1111/bju.15673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To systematically identify and compare the performance of prognostic models providing estimates of survival or recurrence of localized renal cell cancer (RCC) in patients treated with surgery with curative intent. MATERIALS AND METHODS We performed a systematic review (PROSPERO CRD42019162349). We searched Medline, EMBASE and the Cochrane Library from 1 January 2000 to 12 December 2019 to identify studies reporting the performance of one or more prognostic model(s) that predict recurrence-free survival (RFS), cancer-specific survival (CSS) or overall survival (OS) in patients who have undergone surgical resection for localized RCC. For each outcome we summarized the discrimination of each model using the C-statistic and performed multivariate random-effects meta-analysis of the logit transformed C-statistic to rank the models. RESULTS Of a total of 13 549 articles, 57 included data on the performance of 22 models in external populations. C-statistics ranged from 0.59 to 0.90. Several risk models were assessed in two or more external populations and had similarly high discriminative performance. For RFS, these were the Sorbellini, Karakiewicz, Leibovich and Kattan models, with the UCLA Integrated Staging System model also having similar performance in European/US populations. All had C-statistics ≥0.75 in at least half of the validations. For CSS, they the models with the highest discriminative performance in two or more external validation studies were the Zisman, Stage, Size, Grade and Necrosis (SSIGN), Karakiewicz, Leibovich and Sorbellini models (C-statistic ≥0.80 in at least half of the validations), and for OS they were the Leibovich, Karakiewicz, Sorbellini and SSIGN models. For all outcomes, the models based on clinical features at presentation alone (Cindolo and Yaycioglu) had consistently lower discrimination. Estimates of model calibration were only infrequently included but most underestimated survival. CONCLUSION Several models had good discriminative ability, with there being no single 'best' model. The choice from these models for each setting should be informed by both the comparative performance and availability of factors included in the models. All would need recalibration if used to provide absolute survival estimates.
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Affiliation(s)
- Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lanxin Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Lydia Roberts
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Hannah Harrison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Carol Coupland
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Grant D Stewart
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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7
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Harrison H, Pennells L, Wood A, Rossi SH, Stewart GD, Griffin SJ, Usher-Smith JA. Validation and public health modelling of risk prediction models for kidney cancer using the UK Biobank. BJU Int 2022; 129:498-511. [PMID: 34538014 DOI: 10.1111/bju.15598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/20/2021] [Accepted: 09/04/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To externally validate risk models for the detection of kidney cancer, as early detection of kidney cancer improves survival and stratifying the population using risk models could enable an individually tailored screening programme. METHODS We validated the performance of 30 existing phenotypic models predicting the risk of kidney cancer in the UK Biobank cohort (n = 450 687). We compared the discrimination and calibration of models for men, women, and a mixed-sex cohort. Population level data were used to estimate model performance in a screening scenario for a range of risk thresholds (6-year risk: 0.1-1.0%). RESULTS In all, 10 models had reasonable discrimination (area under the receiver-operating characteristic curve >0.60), although some had poor calibration. Modelling demonstrated similar performance of the best models over a range of thresholds. The models showed an improvement in ability to identify cases compared to age- and sex-based screening. All the models performed less well in women than men. CONCLUSIONS The present study is the first comprehensive external validation of risk models for kidney cancer. The best-performing models are better at identifying individuals at high risk of kidney cancer than age and sex alone; however, the benefits are relatively small. Feasibility studies are required to determine applicability to a screening programme.
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Affiliation(s)
- Hannah Harrison
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Pennells
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Simon J Griffin
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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8
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Abu-Ghanem Y, van Thienen JV, Blank C, Aarts MJB, Jewett M, de Jong IJ, Lattouf JB, van Melick HHE, Wood L, Mulders P, Rottey S, Wagstaff J, Zondervan P, Powles T, Neven A, Collette L, Tombal B, Haanen J, Bex A. Cytoreductive nephrectomy and exposure to sunitinib - a post hoc analysis of the Immediate Surgery or Surgery After Sunitinib Malate in Treating Patients With Metastatic Kidney Cancer (SURTIME) trial. BJU Int 2021; 130:68-75. [PMID: 34706141 DOI: 10.1111/bju.15625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To analyse if exposure to sunitinib in the Immediate Surgery or Surgery After Sunitinib Malate in Treating Patients With Metastatic Kidney Cancer (SURTIME) trial, which investigated opposite sequences of cytoreductive nephrectomy (CN) and systemic therapy, is associated with the overall survival (OS) benefit observed in the deferred CN arm. PATIENTS AND METHODS A post hoc analysis of SURTIME trial data. Variables analysed included number of patients receiving sunitinib, time from randomisation to start sunitinib, overall response rate by Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1, and duration of drug exposure and dose in the intention-to-treat population of the immediate and deferred arm. Descriptive methods and 95% confidence-intervals (CI) were used. RESULTS In the deferred arm, 97.7% (95% CI 89.3-99.6%; n = 48) received sunitinib vs 80% (95% CI 66.9-88.7%, n = 40) in the immediate arm. Following immediate CN, 19.6% progressed 4 weeks after CN and the median time to start sunitinib was 39.5 vs 4.5 days in the deferred arm. At week 16, 46.0% had progressed at metastatic sites in the immediate CN arm vs 32.7% in the deferred arm. Sunitinib dose reductions, escalations and interruptions were not statistically significantly different between arms. Among patients who received sunitinib in the immediate or deferred arm the median total sunitinib treatment duration was 172.5 vs 248 days. Reduction of target lesions was more profound in the deferred arm. CONCLUSIONS In comparison to the deferred CN approach, immediate CN impairs administration, onset, and duration of sunitinib. Starting with systemic therapy leads to early and more profound disease control and identification of progression prior to planned CN, which may have contributed to the observed OS benefit.
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Affiliation(s)
- Yasmin Abu-Ghanem
- Royal Free London NHS Foundation Trust and UCL Division of Surgery and Interventional Science, London, UK
| | | | | | | | | | - Igle Jan de Jong
- University of Groningen, University Medical Center Groningen, the Netherlands
| | | | | | - Lori Wood
- QEII Health Sciences Center, Halifax, NS, Canada
| | - Peter Mulders
- Radboud University Hospital, Nijmegen, the Netherlands
| | | | - John Wagstaff
- South West Wales Cancer Centre and Swansea University College of Medicine, Swansea, UK
| | | | - Tom Powles
- Barts and Queen Mary University London, London, UK
| | - Anouk Neven
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Laurence Collette
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Bertrand Tombal
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium.,Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - John Haanen
- Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Axel Bex
- Royal Free London NHS Foundation Trust and UCL Division of Surgery and Interventional Science, London, UK.,Netherlands Cancer Institute, Amsterdam, the Netherlands
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9
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Flitcroft JG, Verheyen J, Vemulkar T, Welbourne EN, Rossi SH, Welsh SJ, Cowburn RP, Stewart GD. Early detection of kidney cancer using urinary proteins: a truly non-invasive strategy. BJU Int 2021; 129:290-303. [PMID: 34570419 DOI: 10.1111/bju.15601] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To review urinary protein biomarkers as potential non-invasive, easily obtainable, early diagnostic tools in renal cell carcinoma (RCC). METHODS A PubMed database search was performed up to the year 2020 to identify primary studies reporting potential urinary protein biomarkers for RCC. Separate searches were conducted to identify studies describing appropriate methods of developing cancer screening programmes and detection of cancer biomarkers. RESULTS Several urinary protein biomarkers are under validation for RCC diagnostics, e.g. aquaporin-1, perilipin-2, carbonic anhydrase-9, Raf-kinase inhibitory protein, nuclear matrix protein-22, 14-3-3 Protein β/α and neutrophil gelatinase-associated lipocalin. However, none has yet been validated or approved for clinical use due to low sensitivity or specificity, inconsistencies in appropriate study design, or lack of external validation. CONCLUSIONS Evaluation of biomarkers' feasibility, sample preparation and storage, biomarker validation, and the application of novel technologies may provide a solution that maximises the potential for a truly non-invasive biomarker in early RCC diagnostics.
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Affiliation(s)
- Jordan G Flitcroft
- Cavendish Laboratory, Department of Physics, University of Cambridge, Cambridge, UK
| | - Jeroen Verheyen
- Department of Surgery, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Tarun Vemulkar
- Cavendish Laboratory, Department of Physics, University of Cambridge, Cambridge, UK
| | - Emma N Welbourne
- Cavendish Laboratory, Department of Physics, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Sarah J Welsh
- Department of Surgery, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Russell P Cowburn
- Cavendish Laboratory, Department of Physics, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
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10
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Ambrosetti D, Coutts M, Paoli C, Durand M, Borchiellini D, Montemagno C, Rastoin O, Borderie A, Grepin R, Rioux-Leclercq N, Bernhard JC, Pagès G, Dufies M. Cancer-associated fibroblasts in renal cell carcinoma: implication in prognosis and resistance to anti-angiogenic therapy. BJU Int 2021; 129:80-92. [PMID: 34107167 DOI: 10.1111/bju.15506] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To investigate the role of cancer-associated fibroblasts (CAFs) in clear cell renal cell carcinoma (ccRCC) with respect to tumour aggressiveness, metastasis development, and resistance to anti-angiogenic therapy (vascular endothelial growth factor receptor-tyrosine kinase inhibitors [VEGFR-TKI]). PATIENTS AND METHODS Our study involved tissue samples from three distinct and independent cohorts of patients with ccRCC. The presence of CAFs and tumour lymphangiogenesis was investigated, respectively, by transcriptional signatures and then correlated with tumour development and prognosis. The effect of these CAFs on tumour cell migration and VEGFR-TKI resistance was analysed on co-cultures of ccRCC cells with CAFs. RESULTS Results from our cohorts and from in silico investigations showed that VEGFR-TKI significantly increase the number of CAFs in tumours. In the same populations of patients with ccRCC, the proportion of intra-tumoral CAFs correlated to shorter disease-free and overall survival. The presence of CAFs was also correlated with lymphangiogenesis and lymph node metastasis. CAFs increased the migration and decreased the VEGFR-TKI-dependent cytotoxic effect of tumour cells. CONCLUSIONS Our results show that VEGFR-TKI promote the development of CAFs, and CAFs favour tumour aggressiveness, metastatic dissemination, and resistance to treatment in ccRCC. CAFs could represent a new therapeutic target to fight resistance to treatment of ccRCC. Targeting CAF and immunotherapies combination are emerging as efficient treatments in many types of solid tumours. Our results highlight their relevance in ccRCC.
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Affiliation(s)
- Damien Ambrosetti
- Department of Pathology, CHU Nice, Université Côte d'Azur, Nice, France.,Institute for Research on Cancer and Aging of Nice (IRCAN), CNRS UMR 7284, INSERM U1081, University Côte d'Azur, Nice, France
| | - Michael Coutts
- Department of Pathology, Maidstone General Hospital, Maidstone, UK
| | - Charlotte Paoli
- Department of Pathology, CHU Nice, Université Côte d'Azur, Nice, France
| | - Matthieu Durand
- Department of Urology, CHU Nice, Université Côte d'Azur, Nice, France
| | | | - Christopher Montemagno
- Institute for Research on Cancer and Aging of Nice (IRCAN), CNRS UMR 7284, INSERM U1081, University Côte d'Azur, Nice, France.,Department of Biomedical, Centre Scientifique de Monaco, Monaco, Principality of Monaco.,LIA ROPSE, Laboratoire International Associé, Université Côte d'Azur - Centre Scientifique de Monaco, Monaco, Principality of Monaco
| | - Olivia Rastoin
- Institute for Research on Cancer and Aging of Nice (IRCAN), CNRS UMR 7284, INSERM U1081, University Côte d'Azur, Nice, France.,LIA ROPSE, Laboratoire International Associé, Université Côte d'Azur - Centre Scientifique de Monaco, Monaco, Principality of Monaco
| | - Arnaud Borderie
- Department of Pathology, CHU Nice, Université Côte d'Azur, Nice, France
| | - Renaud Grepin
- Department of Biomedical, Centre Scientifique de Monaco, Monaco, Principality of Monaco.,LIA ROPSE, Laboratoire International Associé, Université Côte d'Azur - Centre Scientifique de Monaco, Monaco, Principality of Monaco
| | | | - Jean-Christophe Bernhard
- Department of Urology, University Hospital, Bordeaux, France.,French Research Network on Kidney Cancer UroCCR, Bordeaux, France
| | - Gilles Pagès
- Institute for Research on Cancer and Aging of Nice (IRCAN), CNRS UMR 7284, INSERM U1081, University Côte d'Azur, Nice, France.,Department of Biomedical, Centre Scientifique de Monaco, Monaco, Principality of Monaco.,LIA ROPSE, Laboratoire International Associé, Université Côte d'Azur - Centre Scientifique de Monaco, Monaco, Principality of Monaco
| | - Maeva Dufies
- Department of Biomedical, Centre Scientifique de Monaco, Monaco, Principality of Monaco.,LIA ROPSE, Laboratoire International Associé, Université Côte d'Azur - Centre Scientifique de Monaco, Monaco, Principality of Monaco
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11
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Inkiläinen A, Blomqvist L, Ljungberg B, Strigård K. Patient-reported outcome measures of abdominal wall morbidity after flank incision for open partial nephrectomy. BJU Int 2021; 128:497-503. [PMID: 33825298 DOI: 10.1111/bju.15420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare patient-reported outcome measures in patients with and without abdominal wall complications after open partial nephrectomy (OPN) via flank incision. PATIENTS AND METHODS Patient-reported outcome measures were collected in 2017 from all patients operated on with OPN via flank incision between 2004 and 2016 in Västerbotten County, Sweden. Patients were mailed the ventral hernia pain questionnaire (VHPQ) and an abdominal wall asymmetry (AWA) questionnaire to evaluate postoperative AWA, attributed to bulge or incisional hernia. Demographic and follow-up data were retrieved from patient records. RESULTS A total of 198 patients were eligible for the study, and 146 questionnaires were returned (74%). Forty-five patients (31%) reported postoperative AWA and 27 (18%) reported ongoing pain. Three patients who reported AWA had a known incisional hernia. Pain and abdominal wall stiffness were more common in patients with AWA than in those without (P < 0.01 and P < 0.01, respectively). Of the 45 patients with AWA, 25 (56%) reported this as being negative cosmetically and 16 (36%) as negative regarding activities. Patients that reported AWA were younger and had a higher body mass index at surgery (P = 0.03 and 0.04, respectively). CONCLUSION Abdominal wall asymmetry is a common sequel of flank incision for OPN and is associated with a higher incidence of chronic pain and abdominal stiffness compared to absence of postoperative AWA. Some patients reported that the effect on daily activities and the cosmetic effect caused by AWA had a negative impact on their quality of life.
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Affiliation(s)
- Aapo Inkiläinen
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Lennart Blomqvist
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden.,Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Karin Strigård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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12
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Crockett MG, Giona S, Whiting D, Whitehurst L, Agag A, Malki M, Hussain M, Barber NJ. Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy. BJU Int 2021; 128:36-45. [PMID: 33001563 DOI: 10.1111/bju.15262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. RESULTS All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677). CONCLUSION This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.
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Affiliation(s)
- Matthew G Crockett
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Simone Giona
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Danielle Whiting
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Lily Whitehurst
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Ayman Agag
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Manar Malki
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Muddassar Hussain
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | - Neil J Barber
- Frimley Renal Cancer Centre, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
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13
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de Velasco G, Ruiz-Granados Á, Reig O, Massari F, Climent Duran MA, Verzoni E, Graham J, Llarena R, De Tursi M, Donskov F, Iglesias C, Pandha HS, Garcia Del Muro X, Procopio G, Oudard S, Castellano D, Albiges L. Outcomes of systemic targeted therapy in recurrent renal cell carcinoma treated with adjuvant sunitinib. BJU Int 2021; 128:254-261. [PMID: 33547860 DOI: 10.1111/bju.15356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the efficacy and tolerability of rechallenge with sunitinib and other targeted therapies (TTs) in patitents with relapsed recurrent renal cell carcinoma (RCC) in the advanced setting. METHODS In this multi-institutional retrospective study, patients with relapsed RCC were rechallenged with sunitinib or other systemic TTs as a first-line therapeutic approach after failed adjuvant sunitinib treatment. Patient characteristics, treatments and clinical outcomes were recorded. The primary endpoint was progression-free survival (PFS). Secondary endpoints were objective response rate (ORR) and overall survival (OS). RESULTS A total of 34 patients with relapses were recorded, and 25 of these (73.5%) were men. Twenty-five patients were treated with systemic TT: 65% of patients received TT against the vascular endothelial growth factor pathway (including sunitinib), 21.7% received mammalian target of rapamycin inhibitors and 13% received immunotherapy. The median (interquartile range) time to relapse was 20.3 (5.2-20.4) months from diagnosis, and 7.5 months (1.0-8.5) from the end of adjuvant suntinib treatment. At a median follow-up of 23.5 months, 24 of the 25 patients had progressed on first-line systemic therapy. The median PFS was 12.0 months (95% confidence interval [CI] 5.78-18.2). There were no statistical differences in PFS between different treatments or sunitinib rechallenge. PFS was not statistically different in patients relapsing on or after adjuvant suntinib treatment (≤ 6 or >6 months after adjuvant suntinib ending). The ORR was 20.5%. The median OS was 29.1 months (95% CI 16.4-41.8). CONCLUSIONS Rechallenge with sunitinib or other systemic therapies is still a feasible therapeutic option that provides patients with advanced or metastastic RCC with additional clinical benefits with regard to PFS and OS after failed response to adjuvant sunitinib.
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Affiliation(s)
- Guillermo de Velasco
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Álvaro Ruiz-Granados
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Oscar Reig
- Translational Genomics and Targeted Therapeutics in Solid Tumours Lab, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesco Massari
- Oncologia Medica, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia.,Division of Oncology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Elena Verzoni
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | | | - Michele De Tursi
- Department of Oncology and Neurosciences, Consorzio Interuniversitario Nazionale per la Bio-Oncologia, University G. d'Annunzio, Chieti, Italy
| | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Clara Iglesias
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Xavier Garcia Del Muro
- Department of Medical Oncology, Institut Català d'Oncologia L'Hospitalet, Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Giuseppe Procopio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stephane Oudard
- Medical Oncology Department, Georges Pompidou Hospital, University of Paris, Paris, France
| | - Daniel Castellano
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Laurence Albiges
- Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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14
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Kroeze SGC, Fritz C, Schaule J, Siva S, Kahl KH, Sundahl N, Blanck O, Kaul D, Adebahr S, Verhoeff JJC, Skazikis G, Roeder F, Geier M, Eckert F, Guckenberger M. Stereotactic radiotherapy combined with immunotherapy or targeted therapy for metastatic renal cell carcinoma. BJU Int 2020; 127:703-711. [PMID: 33113260 DOI: 10.1111/bju.15284] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the safety and efficacy of stereotactic radiotherapy (SRT) in patients with metastatic renal cell carcinoma (mRCC) concurrently receiving targeted therapy (TT) or immunotherapy. PATIENTS AND METHODS Data on patients with mRCC were extracted from a retrospective international multicentre register study (TOaSTT), investigating SRT concurrent (≤30 days) with TT/immune checkpoint inhibitor (ICI) therapy. Overall survival (OS), progression-free survival (PFS), local metastasis control (LC) and time to systemic therapy switch were analysed using Kaplan-Meier curves and log-rank testing. Clinical and treatment factors influencing survival were analysed using multivariate Cox regression. Acute and late SRT-induced toxicity were defined according to the Common Terminology Criteria for Adverse Events v.4.03. RESULTS Fifty-three patients who underwent 128 sessions of SRT were included, of whom 58% presented with oligometastatic disease (OMD). ICIs and TT were received by 32% and 68% of patients, respectively. Twenty patients (37%) paused TT for a median (range) of 14 (2-21) days. ICI therapy was not paused in any patient. A median (range) of 1 (1-5) metastatic tumour was treated per patient, with a median (range) SRT dose of 65 (40-129.4) Gy (biologically effective dose). The OS, LC and PFS rates at 1 year were 71%, 75% and 25%, respectively. The median OS and PFS were not significantly different among patients receiving TT vs those receiving ICIs (P = 0.329). New lesions were treated with a repeat radiotherapy course in 46% of patients. After 1 year, 62% of patients remained on the same systemic therapy as at the time of SRT; this was more frequent for ICI therapy compared to TT (83% vs 36%; P = 0.035). OMD was an independent prognostic factor for OS (P = 0.004, 95% confidence interval [CI] 0.035-0.528) and PFS (P = 0.004; 95% CI 0.165-0.717) in multivariate analysis. Eastern Cooperative Oncology Group performance status (ECOG-PS) was the other independent prognostic factor for OS (P = 0.001, 95% CI 0.001-0.351). Acute grade 3 toxicity was observed in two patients, and late grade 3 toxicity in one patient. No grade 4 or 5 toxicity was observed. CONCLUSION Combined treatment with TT or immunotherapy and concurrent SRT was safe, without signals of increased severe toxicity. As we observed no signal of excess toxicity, full-dose SRT should be considered to achieve optimal metastasis control in patients receiving TT or immunotherapy. Favourable PFS and OS were observed for patients with oligometastatic RCC with a good ECOG-PS, which should form the basis for prospective testing of this treatment strategy in properly designed clinical trials.
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Affiliation(s)
- Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Corinna Fritz
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Jana Schaule
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia
| | - Klaus H Kahl
- Department of Radiation Oncology, University Hospital Augsburg, Augsburg, Germany
| | - Nora Sundahl
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - David Kaul
- Department or Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, German Cancer Consortium (DKTK), Partner Site Freiburg, University of Freiburg, Freiburg, Germany
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Georgios Skazikis
- Department of Radiation Oncology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Falk Roeder
- Department of Radiation Oncology, University Hospital Munich, Munich, Germany
| | - Michael Geier
- Department of Radiation Oncology, Ordensklinikum Linz, Linz, Austria
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
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15
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Kwon Kim J, Ryu H, Kim M, Kwon EK, Lee H, Joon Park S, Byun SS. Personalised three-dimensional printed transparent kidney model for robot-assisted partial nephrectomy in patients with complex renal tumours (R.E.N.A.L. nephrometry score ≥7): a prospective case-matched study. BJU Int 2020; 127:567-574. [PMID: 33064867 DOI: 10.1111/bju.15275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/14/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of a three-dimensional (3D) printed transparent kidney model as a surgical navigator for robot-assisted partial nephrectomy (RPN) in patients with complex renal tumours, defined by a R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score of ≥7. PATIENTS AND METHODS A total of 80 patients who underwent RPN were included in the present prospective case-matched study (case group [n = 40, application of 3D-printed transparent kidney model during RPN] vs matching group [n = 40, routine protocol]). The RPNs were performed by a single experienced surgeon. The RPN procedure consisted of six steps: (i) preparation of the renal hilar vessel for clamping, (ii) tumour detection and dissection, (iii) robotic ultrasonography, (iv) tumour resection, (v) calyx repair and haemostasis, and (vi) renorrhaphy. The time for each step, console time, and warm ischaemia time were compared between the two groups as a surrogate marker for surgical effectiveness. RESULTS Both groups were well-balanced for all baseline characteristics. The use of the model reduced the console time by ~20% compared to the matched group (64.6 vs 78.5 min, P = 0.001). On multivariate logistic regression analysis, tumour radius (P < 0.001) and application of the model (P = 0.009) were identified as significant predictors of a console time of ≤70 min. CONCLUSION We established the usefulness of a personalised 3D-printed transparent kidney model for more effective RPNs. Use of the 3D-printed transparent kidney model reduced the operative time even for complex renal tumours and would be expected to broaden the indications for PN.
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Affiliation(s)
- Jung Kwon Kim
- Department of Urology, Seoul National University Bundang Hospital, Seongnam,, Korea
| | - Hoyoung Ryu
- Department of Urology, Ewha Womans University Medical Center, Seoul, Korea
| | - Myong Kim
- Department of Urology, Ewha Womans University School of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Eun-Kyung Kwon
- Department of Urology, Seoul National University Bundang Hospital, Seongnam,, Korea
| | - Hakmin Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam,, Korea
| | - Sang Joon Park
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam,, Korea.,Department of Urology, Seoul National University College of Medicine, Seoul, Korea
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16
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Ghazi A, Melnyk R, Hung AJ, Collins J, Ertefaie A, Saba P, Gurung P, Frye T, Rashid H, Wu G, Mottrie A, Costello T, Dasgupta P, Joseph J. Multi-institutional validation of a perfused robot-assisted partial nephrectomy procedural simulation platform utilizing clinically relevant objective metrics of simulators (CROMS). BJU Int 2020; 127:645-653. [PMID: 32936977 DOI: 10.1111/bju.15246] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To conduct a multi-institutional validation of a high-fidelity, perfused, inanimate, simulation platform for robot-assisted partial nephrectomy (RAPN) using incorporated clinically relevant objective metrics of simulation (CROMS), applying modern validity standards. MATERIALS AND METHODS Using a combination of three-dimensional (3D) printing and hydrogel casting, a RAPN model was developed from the computed tomography scan of a patient with a 4.2-cm, upper-pole renal tumour (RENAL nephrometry score 7×). 3D-printed casts designed from the patient's imaging were used to fabricate and register hydrogel (polyvinyl alcohol) components of the kidney, including the vascular and pelvicalyceal systems. After mechanical and anatomical verification of the kidney phantom, it was surrounded by other relevant hydrogel organs and placed in a laparoscopic trainer. Twenty-seven novice and 16 expert urologists, categorized according to caseload, from five academic institutions completed the simulation. RESULTS Clinically relevant objective metrics of simulators, operative complications, and objective performance ratings (Global Evaluative Assessment of Robotic Skills [GEARS]) were compared between groups using Wilcoxon rank-sum (continuous variables) and parametric chi-squared (categorical variables) tests. Pearson and point-biserial correlation coefficients were used to correlate GEARS scores to each CROMS variable. Post-simulation questionnaires were used to obtain subjective supplementation of realism ratings and training effectiveness. RESULTS Expert ratings demonstrated the model's superiority to other procedural simulations in replicating procedural steps, bleeding, tissue texture and appearance. A significant difference between groups was demonstrated in CROMS [console time (P < 0.001), warm ischaemia time (P < 0.001), estimated blood loss (P < 0.001)] and GEARS (P < 0.001). Six major intra-operative complications occurred only in novice simulations. GEARS scores highly correlated with the CROMS. CONCLUSIONS This perfused, procedural model offers an unprecedented realistic simulation platform, which incorporates objective, clinically relevant and procedure-specific performance metrics.
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Affiliation(s)
- Ahmed Ghazi
- Department of Urology, University of Rochester, Rochester, NY, USA.,Simulation Innovation Laboratory, University of Rochester, Rochester, NY, USA
| | - Rachel Melnyk
- Simulation Innovation Laboratory, University of Rochester, Rochester, NY, USA
| | - Andrew J Hung
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Justin Collins
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ashkan Ertefaie
- Department of Biostatistics, University of Rochester, NY, USA
| | - Patrick Saba
- Simulation Innovation Laboratory, University of Rochester, Rochester, NY, USA
| | - Pratik Gurung
- Department of Urology, University of Rochester, Rochester, NY, USA
| | - Thomas Frye
- Department of Urology, University of Rochester, Rochester, NY, USA
| | - Hani Rashid
- Department of Urology, University of Rochester, Rochester, NY, USA
| | - Guan Wu
- Department of Urology, University of Rochester, Rochester, NY, USA
| | - Alex Mottrie
- Urological Department, OLV Hospital, Aalst, Belgium.,ORSI Academy, Melle, Belgium
| | - Tony Costello
- Department Departments of Surgery and Urology, University of Melbourne and Royal Melbourne Hospital, Melbourne, Vic., Australia.,Australian Medical Robotics Academy (AMRA), Melbourne, Vic., Australia
| | - Prokar Dasgupta
- Chair of Urology, Life Sciences and Medicine, King's College London, London, UK
| | - Jean Joseph
- Department of Urology, University of Rochester, Rochester, NY, USA
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17
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Huynh MJ, Wang Y, Joshi M, Krasnow R, Yu AX, Mossanen M, Chung BI, Chang SL. Patient factors predict complications after partial nephrectomy: validation and calibration of the Preoperative Risk Evaluation for Partial Nephrectomy (PREP) score. BJU Int 2020; 127:369-374. [PMID: 32920933 DOI: 10.1111/bju.15240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop and validate the Preoperative Risk Evaluation for Partial Nephrectomy (PREP) score to predict the probability of major postoperative complications after partial nephrectomy (PN) based on patient comorbidities. PATIENTS AND METHODS The Premier Healthcare Database was used to identify patients who had undergone elective PN. Through review of International Classification of Diseases ninth revision codes, we identified patient comorbidities and major surgical complications (Clavien-Dindo Grade III-V). Multivariable logistic regression was used to identify predictors of major complications. We used half of the set as the training cohort to develop our risk score and the other half as a validation cohort. RESULTS From 2003 to 2015, 25 451 PNs were performed. The overall rate of major complications was 4.9%. The final risk score consisted of 10 predictors: age, sex, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, hypertension, obesity, and smoking. In the training cohort, the area under the receiver operating characteristic curve (AUC) was 0.75 (95% confidence interval [CI] 0.73-0.78), while the AUC for the validation cohort was 0.73 (95% CI 0.70-0.75). The predicted probabilities of major complication in the low- (≤10 points), intermediate- (11-20 points), high- (21-30 points), and very high-risk (>30 points) categories were 3% (95% CI 2.6-3.2), 8% (95% CI 7.2-9.2), 24% (95% CI 20.5-27.8), and 41% (95% CI 34.5-47.8), respectively. CONCLUSIONS We developed and validated the PREP score to predict the risk of complications after PN based on patient characteristics. Calculation of the PREP score can help providers select treatment options for patients with a cT1a renal mass and enhance the informed consent process for patients planning to undergo PN.
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Affiliation(s)
- Melissa J Huynh
- Division of Urology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ye Wang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Ross Krasnow
- Department of Urology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Alice X Yu
- Division of Urology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Matthew Mossanen
- Division of Urology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Steven L Chang
- Division of Urology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
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18
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John JB, Anderson M, Dutton T, Stott M, Crundwell M, Llewelyn R, Gemmell A, Bufacchi R, Spiers A, Campain N. Percutaneous microwave ablation of renal masses in a UK cohort. BJU Int 2020; 127:486-494. [PMID: 32871034 DOI: 10.1111/bju.15224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To report a tertiary referral centre's experience of microwave ablation (MWA) for suspected renal cell carcinoma (RCC), describing complications and oncological outcomes. PATIENTS AND METHODS Consecutive MWA procedures (n = 113) for renal masses (October 2016 to September 2019) were maintained on a prospective database. Data describing patient, disease, procedure, complications, and oncological outcomes were analysed. RESULTS The median (range) age was 68 (33-85) years, 73% were male, and the median Charlson Comorbidity Index was 0. The median (interquartile range [IQR]) tumour diameter was 25 (20-32) mm. In all, 95% had renal mass biopsy, with histologically confirmed cancer in 75%. The median (IQR) R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score was 7 (6-8). The median ablation time was 6 min and length of stay was 1 day for 95% of the patients. Clavien-Dindo complication Grades I, II, IIIb and IV occurred in 18%, 1.8%, 0.9% and 0.9%, respectively. The median follow-up was 12 months and the median (IQR) renal function change was -4 (-18 to 0)%. One patient (0.9%) had local recurrence, treated with re-ablation; two developed metastatic progression; and two (1.8%) had indeterminate findings on follow-up (one lung nodule and one possible local recurrence), managed with ongoing protocolised computed tomography surveillance. Post-procedure complications were associated with total ablation time (odds ratio [OR] 1.152/min, 95% confidence interval [CI] 1.040-1.277) and total ablation energy (OR 1.017/kJ, 95% CI 1.001-1.033). CONCLUSIONS We describe the largest UK series of MWA treatment for T1a/small T1b renal masses to date. MWA was well tolerated, with 95% discharged the following day and low complication/re-admission rates. Current follow-up demonstrates favourable disease control. MWA appears to be safe and effective and should be considered in future prospective comparisons of treatments for T1a/small T1b renal masses.
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Affiliation(s)
- Joseph B John
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Moira Anderson
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Thomas Dutton
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Mark Stott
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Rhys Llewelyn
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew Gemmell
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Rory Bufacchi
- Department of Neuroscience, Physiology and Pharmacology, University College London (UCL), London, UK
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19
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Westerman ME, Shapiro DD, Tannir NM, Campbell MT, Matin SF, Karam JA, Wood CG. Survival following cytoreductive nephrectomy: a comparison of existing prognostic models. BJU Int 2020; 126:745-753. [PMID: 32623821 DOI: 10.1111/bju.15160] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To validate models currently used to predict metastatic renal cell carcinoma (mRCC) outcomes in a cohort of patients undergoing cytoreductive nephrectomy (CN). PATIENTS AND METHODS A total of 10 RCC prognostic models (International Metastatic RCC Database Consortium [IMDC]; Memorial Sloan Kettering Cancer Center [MSKCC]; Culp; Leibovich; University of California at Los Angeles Integrated Staging System [UISS]; Stage, Size, Grade, and Necrosis [SSIGN]; Yaycioglu; Karakiewicz; Cindolo; and Margulis) were chosen based on clinical relevance and use in clinical trial design. Model validation was performed using patients who underwent CN at a single institution between 2005 and 2017, and model discrimination (ability to select patients at risk of death) was assessed. Concordance indices (c-index) were calculated and compared with originally published c-indices. RESULTS A total of 515 CN patients were stratified according to the prognostic models. A total of 387 (75%) died over the study period, with estimated 3-year survival of 46.1% (95% confidence interval [CI] 41.6-50.4%). All models' discriminatory capacity underperformed when compared to the originally published c-indices. The c-indices ranged from 0.53 (95% CI 0.50-0.56) for the Cindolo model to 0.61 (95% CI 0.58-0.64) for the Leibovich model. The MSKCC and IMDC models performed poorly with c-indices of 0.55 and 0.56, respectively. CONCLUSION Currently used prognostic models have limited discriminatory capacity when applied to a modern cohort of patients undergoing CN. They are inadequate for risk stratification and randomisation in prospective clinical trials of untreated patients with mRCC. Caution should be used when using these models for clinical decision making.
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Affiliation(s)
- Mary E Westerman
- Departments of, Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Daniel D Shapiro
- Departments of, Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nizar M Tannir
- Genitourinary Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Matthew T Campbell
- Genitourinary Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Surena F Matin
- Departments of, Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Departments of, Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Christopher G Wood
- Departments of, Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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20
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Rodriguez-Vida A, Bamias A, Esteban E, Saez MI, Lopez-Brea M, Castellano D, Caballero C, Gonzalez-Larriba JL, Calvo E, Macia S, Ravaud A, Bellmunt J. Randomised Phase II study comparing alternating cycles of sunitinib and everolimus vs standard sequential administration in first-line metastatic renal carcinoma (SUNRISES study). BJU Int 2020; 126:559-567. [PMID: 32654362 DOI: 10.1111/bju.15165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate the efficacy of alternating cycles of sunitinib and everolimus vs standard sequential treatment of sunitinib followed by everolimus in first-line metastatic renal cell carcinoma (mRCC), as alternating blockade of vascular endothelial growth factor receptor (VEGFR) and mammalian target of rapamycin (mTOR) pathways could potentially prevent the occurrence of resistance to anti-VEGFR therapy in mRCC. PATIENTS AND METHODS SUNRISES, a randomised open-label Phase II study, investigated the efficacy of alternating cycles of sunitinib and everolimus vs standard sequential treatment of sunitinib followed by everolimus upon progression. Treatment-naïve patients with clear-cell mRCC were included. Alternating treatment consisted on 12 weeks of sunitinib, followed by 12 weeks of everolimus. The primary endpoint was the progression-free survival (PFS) rate at 1 year. The secondary endpoints included the median PFS, overall survival (OS), response rate, and safety. RESULTS Accrual was low due to the advent of new-generation therapies, and the study was stopped prematurely. Only 41 patients out of the planned 102 patients were accrued, and randomised in a 2:1 ratio (15 patients to the control arm, 26 to the experimental arm). In all, 60.9% of patients had performance status (PS) 0 and 39% PS 1; 63% had a favourable prognostic risk profile, while 36% were intermediate risk. The primary endpoint was not met. The 1-year PFS rate was 49.7% (experimental arm) vs 84.62% (control arm; P = 0.11). There was a trend towards fewer Grade ≥3 adverse events with the alternating approach (50% vs 73.3%; P = 0.14). The median OS was similar in both treatment arms. The other secondary endpoints favoured the control arm. CONCLUSIONS The study failed to show any benefit of alternating cycles of sunitinib and everolimus in patients with mRCC. The alternating approach using an mTOR inhibitor does not seem to prevent the occurrence of resistance to VEGFR blockade.
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Affiliation(s)
- Alejo Rodriguez-Vida
- Hospital del Mar-Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Maria Isabel Saez
- UGCI of Medical Oncology, Hospitales Regional and Universitario Virgen de la Victoria, Málaga, Spain.,Institute of Biomedical Research (IBIMA), Málaga, Spain
| | | | | | | | | | - Emiliano Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | | | - Alain Ravaud
- Hôpital Saint André, Bordeaux University Hospital, Bordeaux, France
| | - Joaquim Bellmunt
- Hospital del Mar-Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain.,Beth Israel Deaconess Medical Center and PSMAR_IMIM Research Lab, Harvard Medical School, Boston, MA, USA
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21
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Badani KK, Kothari PD, Okhawere KE, Eun D, Hemal A, Abaza R, Porter J, Lovallo G, Ahmed M, Munver R, Stifelman MD. Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help? BJU Int 2020; 125:893-897. [PMID: 32125072 DOI: 10.1111/bju.15043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. PATIENTS AND METHODS Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. RESULTS Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. CONCLUSION In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.
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Affiliation(s)
- Ketan K Badani
- Department of Urology, Mount Sinai Medical School, New York, NY, USA
| | - Pankti D Kothari
- Department of Urology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Daniel Eun
- Department of Urology, Lewis Katz School of Medicine Temple University, Philadelphia, PA, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ronney Abaza
- Department of Urology, OhioHealth Dublin Methodist Hospital, Dublin, OH, USA
| | - James Porter
- Department of Urology, Swedish Urology, Seattle, WA, USA
| | - Gregory Lovallo
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mutahar Ahmed
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ravi Munver
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Michael D Stifelman
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
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22
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Hsu RCJ, Barclay M, Loughran MA, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Impact of hospital nephrectomy volume on intermediate- to long-term survival in renal cell carcinoma. BJU Int 2020; 125:56-63. [PMID: 31206987 PMCID: PMC6973244 DOI: 10.1111/bju.14848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the relationship between hospital volume and intermediate- and long-term patient survival for patients undergoing nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS Adult patients with RCC treated with nephrectomy between 2000 and 2010 were identified from the English Hospital Episode Statistics database and National Cancer Data Repository. Patients with nodal or metastatic disease were excluded. Hospitals were categorised into low- (LV; <20 cases/year), medium- (20-39 cases/year) and high-volume (HV; ≥40 cases/year), based on annual cases of RCC nephrectomy. Multivariable Cox regression analyses were used to calculate hazard ratios (HRs) for all-cause mortality by hospital volume, adjusting for patient, tumour and surgical characteristics. We assessed conditional survival over three follow-up periods: short (30 days to 1 year), intermediate (1-3 years) and long (3-5 years). We additionally explored whether associations between volume and outcomes varied by tumour stage. RESULTS A total of 12 912 patients were included. Patients in HV hospitals had a 34% reduction in mortality risks up to 1 year compared to those in LV hospitals (HR 0.66, 95% confidence interval 0.53-0.83; P < 0.01). Assuming causality, treatment in HV hospitals was associated with one fewer death in every 71 patients treated. Benefit of nephrectomy centralisation did not change with higher T stage (P = 0.17). No significant association between hospital volume and survival was observed beyond the first year. CONCLUSIONS Nephrectomy for RCC in HV hospitals was associated with improved survival for up to 1 year after treatment. Our results contribute new insights regarding the value of nephrectomy centralisation.
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Affiliation(s)
- Ray C. J. Hsu
- Academic Urology GroupDepartment of SurgeryCambridge Biomedical CampusUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Matthew Barclay
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Molly A. Loughran
- Transforming Cancer Services TeamNational Health ServiceLondonUK
- National Cancer Registration and Analysis ServicePublic Health EnglandLondonUK
| | - Georgios Lyratzopoulos
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) GroupDepartment of Behavioural Science and HealthUniversity College LondonLondonUK
| | - Vincent J. Gnanapragasam
- Academic Urology GroupDepartment of SurgeryCambridge Biomedical CampusUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - James N. Armitage
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
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23
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McIntosh AG, Parker DC, Egleston BL, Uzzo RG, Haseebuddin M, Joshi SS, Viterbo R, Greenberg RE, Chen DYT, Smaldone MC, Kutikov A. Prediction of significant estimated glomerular filtration rate decline after renal unit removal to aid in the clinical choice between radical and partial nephrectomy in patients with a renal mass and normal renal function. BJU Int 2019; 124:999-1005. [PMID: 31145523 PMCID: PMC7654970 DOI: 10.1111/bju.14839] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To develop a clinically applicable predictive model to quantitate the risk of estimated glomerular filtration rate (eGFR) decline to ≤45 mL/min/1.73 m2 after radical nephrectomy (RN) to better inform decisions between RN and partial nephrectomy (PN). PATIENTS AND METHODS Our prospectively maintained kidney cancer registry was reviewed for patients with a preoperative eGFR >60 mL/min/1.73 m2 who underwent RN for a localized renal mass. New baseline renal function was indexed. We used multivariable logistic regression to develop a predictive nomogram and evaluated it using receiver-operating characteristic (ROC) analysis. Decision-curve analysis was used to assess the net clinical benefit. RESULTS A total of 668 patients met the inclusion criteria, of whom 183 (27%) experienced a decline in eGFR to ≤45 mL/min/1.73 m2 . On multivariable analysis, increasing age (P = 0.001), female gender (P < 0.001), and increasing preoperative creatinine level (P < 0.001) were associated with functional decline. We constructed a predictive nomogram that included these variables in addition to comorbidities with a known association with kidney disease, but found that a simplified model excluding comorbidities was equally robust (cross-validated area under the ROC curve was 0.78). Decision-curve analysis showed the net clinical benefit at probabilities >~11%. CONCLUSIONS The decision to perform RN vs PN is multifaceted. We have provided a simple quantitative tool to help identify patients at risk of a postoperative eGFR of ≤45 mL/min/1.73 m2 , who may be stronger candidates for nephron preservation.
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Affiliation(s)
| | - Daniel C Parker
- University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
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24
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Porpiglia F, Amparore D, Checcucci E, Manfredi M, Stura I, Migliaretti G, Autorino R, Ficarra V, Fiori C. Three-dimensional virtual imaging of renal tumours: a new tool to improve the accuracy of nephrometry scores. BJU Int 2019; 124:945-954. [PMID: 31390140 DOI: 10.1111/bju.14894] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To apply the standard PADUA and RENAL nephrometry score variables to three-dimensional (3D) virtual models (VMs) produced from standard bi-dimensional imaging, thereby creating three-dimensional (3D)-based (PADUA and RENAL) nephrometry scores/categories for the reclassification of the surgical complexity of renal masses, and to compare the new 3D nephrometry score/category with the standard 2D-based nephrometry score/category, in order to evaluate their predictive role for postoperative complications. MATERIALS AND METHODS All patients with localized renal tumours scheduled for minimally invasive partial nephrectomy (PN) between September 2016 and September 2018 underwent 3D and 2D nephrometry score/category assessments preoperatively. After nephrometry score/category evaluation, all the patients underwent surgery. Chi-squared tests were used to evaluate the individual patients' grouping on the basis of the imaging tool (3D VMs and 2D imaging) used to assess the nephrometry score/category, while Cohen's κ coefficient was used to test the concordance between classifications. Receiver-operating characteristic curves were produced to evaluate the sensitivity and specificity of the 3D nephrometry score/category vs the 2D nephrometry score/category in predicting the occurrence of postoperative complications. A general linear model was used to perform multivariable analyses to identify predictors of overall and major postoperative complications. RESULTS A total of 101 patients were included in the study. The evaluation of PADUA and RENAL nephrometry scores via 3D VMs showed a downgrading in comparison with the same scores evaluated with 2D imaging in 48.5% and 52.4% of the cases. Similar results were obtained for nephrometry categories (29.7% and 30.7% for PADUA risk and RENAL complexity categories, respectively). The 3D nephrometry score/category demonstrated better accuracy than the 2D nephrometry score/category in predicting overall and major postoperative complications (differences in areas under the curve for each nephrometry score/category were statistically significant comparing the 3D VMs with 2D imaging assessment). Multivariable analyses confirmed 3D PADUA/RENAL nephrometry category as the only independent predictors of overall (P = 0.007; P = 0.003) and major postoperative complications (P = 0.03; P = 0.003). CONCLUSIONS In the present study, we showed that 3D VMs were more precise than 2D standard imaging in evaluating the surgical complexity of renal masses according to nephrometry score/category. This was attributable to a better perception of tumour depth and its relationships with intrarenal structures using the 3D VM, as confirmed by the higher accuracy of the 3D VM in predicting postoperative complications.
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Affiliation(s)
- Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Daniele Amparore
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Enrico Checcucci
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Matteo Manfredi
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
| | - Ilaria Stura
- Department of Public Health and Paediatric Sciences, School of Medicine, University of Turin, Orbassano (Turin), Italy
| | - Giuseppe Migliaretti
- Department of Public Health and Paediatric Sciences, School of Medicine, University of Turin, Orbassano (Turin), Italy
| | | | - Vincenzo Ficarra
- Urological Section, Department of Human and Paediatric Pathology, University of Messina, Messina, Italy
| | - Cristian Fiori
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano (Turin), Italy
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25
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Tran MGB, Aben KKH, Werkhoven E, Neves JB, Fowler S, Sullivan M, Stewart GD, Challacombe B, Mahrous A, Patki P, Mumtaz F, Barod R, Bex A. Guideline adherence for the surgical treatment of T1 renal tumours correlates with hospital volume: an analysis from the British Association of Urological Surgeons Nephrectomy Audit. BJU Int 2019; 125:73-81. [PMID: 31293036 DOI: 10.1111/bju.14862] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess European Association of Urology guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralisation of care. PATIENTS AND METHODS Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or partial nephrectomy (PN) in the period 2012-2016 from the British Association of Urological Surgeons Nephrectomy Audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per centre, PN rates, complication rates, and completeness of data. Descriptive analyses were performed, and confidence intervals were used to illustrate the association between hospital volume and proportion of PN. Chi- squared and Cochran-Armitage trend tests were used to evaluate differences and trends. RESULTS In total, 13 045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) complexity score was included in March 2016 and documented in 39% of cases. Missing information on postoperative complications appeared constant over the years (8.5-9%). A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [lowest volume] to 61.8% in centres performing ≥100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien-Dindo grade ≥III) complication rate decreased with increasing HV (from 12.2% and 2.9% in low-volume centres to 10.7% and 2.2% in high-volume centres, respectively), for all patients including those treated with PN. CONCLUSION Closer guideline adherence was exhibited by higher surgical volume centres. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralisation of kidney cancer specialist cancer surgical services to improve patient outcomes.
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Affiliation(s)
- Maxine G B Tran
- Division of Surgery and Interventional Science, University College London, London, UK.,Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Katja K H Aben
- Netherlands Comprehensive Cancer Centre, Utrecht, The Netherlands.,Research Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Erik Werkhoven
- Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joana B Neves
- Division of Surgery and Interventional Science, University College London, London, UK.,Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | - Mark Sullivan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Grant D Stewart
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Ahmed Mahrous
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Prasad Patki
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Faiz Mumtaz
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Ravi Barod
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Axel Bex
- Division of Surgery and Interventional Science, University College London, London, UK.,Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.,Netherlands Comprehensive Cancer Centre, Utrecht, The Netherlands.,Netherlands Cancer Institute, Amsterdam, The Netherlands
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- Netherlands Cancer Institute, Amsterdam, The Netherlands
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26
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Warren H, Fernando A, Thomas K, Austin C, Chowdhury S, O'Brien T. Surgery for high-risk locally advanced (pT3c) renal tumours: oncological outcomes and prognostic significance of a modified International Metastatic Renal Cell Cancer Database Consortium (IMDC) score. BJU Int 2019; 124:462-468. [PMID: 30908845 DOI: 10.1111/bju.14755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate contemporary oncological outcomes and long-term survival in patients undergoing surgery for urological tumours involving the peridiaphragmatic inferior vena cava up to the level of the right atrium. To apply prognostic factors developed for metastatic renal cancer to patients with very-high-risk but apparently localized tumours, and develop a scoring system. PATIENTS AND METHODS A retrospective cohort study of 54 patients referred between December 2007 and April 2018 to a single surgical and oncological team was conducted. Electronic patient records were used to obtain peri-operative data and oncological follow-up. For operated patients lost to follow-up, survival data were obtained from primary care physicians. We used Kaplan-Meier curves to estimate overall survival (OS) and disease-free survival. For the subgroup undergoing curative surgery (n = 32) the prognostic value of a renal cancer score developed at Guy's Hospital using five of the six criteria in the International Metastatic Renal Cell Carcinoma Database Consortium prognostic model (one point for each of anaemia, neutrophilia, thrombophilia, hypercalcaemia and Karnofsky performance status <80), in order to be relevant for M0 disease, was assessed using the log-rank test. RESULTS The median (interquartile range [IQR]) OS of the whole cohort was 29 (11-57) months. The median (IQR) survival of the curative subgroup (n = 32) was 32 (16-57) months, vs 11 (4-upper limit not reached) months for the cytoreductive subgroup (n = 13; P = 0.14). The median (IQR) follow-up time was 14 (1-65) months for patients alive at analysis. Disease-free survival in the curative subgroup was 10 (6-30) months. The median (IQR) OS by risk category for curative cases, as defined by the Guy's renal cancer score, was not reached in the favourable risk group (score = 0 points) because there were no patient deaths, 43 (30-61) months in the intermediate-risk group (score = 1 point), and 18 months (11-32) months in the poor-risk group (score ≥ 2 points; P = 0.005). CONCLUSION A median survival of 29 months appears to justify this type of surgery. A prognostic model, the Guy's renal cancer score, using five readily available clinical measures, appears promising in patients with very-high-risk locally advanced tumours.
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Affiliation(s)
- Hannah Warren
- Urology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | - Kay Thomas
- Urology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Conal Austin
- Cardiothoracics, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Simon Chowdhury
- Medical Oncology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Tim O'Brien
- Urology, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Ventimiglia E, Larcher A, Trevisani F, Muttin F, Cianflone F, Montorsi F, Salonia A, Bertini R, Capitanio U. Postoperative complications increase the risk of long-term chronic kidney disease after nephron-sparing surgery in patients with renal cancer and normal preoperative renal function. BJU Int 2019; 124:457-461. [PMID: 30768877 DOI: 10.1111/bju.14712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To investigate whether postoperative complications affect long-term functional outcomes of renal patients treated with nephron-sparing surgery (NSS). MATERIALS AND METHODS We performed an observational study, enrolling 596 patients with preoperative normal renal function treated with NSS for clinical T1abN0M0 renal masses. Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for chronic kidney disease (CKD) including as covariates age, comorbidity (scored according to the Charlson comorbidity index), hypertension, tumour size, preoperative estimated glomerular filtration rate (eGFR), eGFR < 60 mL/min/1.73 m2 at discharge, and ischaemia time. RESULTS A total of 137 patients (23%) developed postoperative complications. At a median (interquartile range) follow-up of 53 (26-91) months, CKD risk was 19% for patients with postoperative complications and 11% for those without complications. Patients experiencing postoperative complications (HR 1.90, 95% CI 1.26-2.86) were at increased risk of developing CKD during the follow-up at multivariable analysis, after accounting for confounders. CONCLUSIONS Our data outline how postoperative complications might have a detrimental impact on postoperative renal function in patients submitted to NSS. Improper patient selection, increasing the risk of postoperative complications, could limit the benefit in terms of renal function brought by NSS.
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Affiliation(s)
- Eugenio Ventimiglia
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Larcher
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Fabio Muttin
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Cianflone
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Salonia
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Roberto Bertini
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Umberto Capitanio
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
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Hsu RCJ, Barclay M, Loughran MA, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Time trends in service provision and survival outcomes for patients with renal cancer treated by nephrectomy in England 2000-2010. BJU Int 2018; 122:599-609. [PMID: 29603575 PMCID: PMC6175431 DOI: 10.1111/bju.14217] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe the temporal trends in nephrectomy practice and outcomes for English patients with renal cell carcinoma (RCC). PATIENTS AND METHODS Adult RCC nephrectomy patients treated between 2000 and 2010 were identified in the National Cancer Data Repository and Hospital Episode Statistics, and followed-up until date of death or 31 December 2015 (n = 30 763). We estimated the annual frequency for each nephrectomy type, the hospital and surgeon numbers and their case volumes. We analysed short-term surgical outcomes, as well as 1- and 5-year relative survivals. RESULTS Annual RCC nephrectomy number increased by 66% during the study period. Hospital number decreased by 24%, whilst the median annual hospital volume increased from 10 to 23 (P < 0.01). Surgeon number increased by 27% (P < 0.01), doubling the median consultant number per hospital. The proportion of minimally invasive surgery (MIS) nephrectomies rose from 1% to 46%, whilst the proportion of nephron-sparing surgeries (NSS) increased from 5% to 16%, with 29% of all T1 disease treated with partial nephrectomy in 2010 (P < 0.01). The 30-day mortality rate halved from 2.4% to 1.1% and 90-day mortality decreased from 4.9% to 2.6% (P < 0.01). The 1-year relative survival rate increased from 86.9% to 93.4%, whilst the 5-year relative survival rate rose from 68.2% to 81.2% (P < 0.01). Improvements were most notable in patients aged ≥65 years and those with T3 and T4 disease. CONCLUSIONS Surgical RCC management has changed considerably with nephrectomy centralisation and increased NSS and MIS. In parallel, we observed significant improvements in short- and long-term survival particularly for elderly patients and those with locally advanced disease.
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Affiliation(s)
- Ray C. J. Hsu
- Academic Urology GroupDepartment of SurgeryUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Matthew Barclay
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Molly A. Loughran
- Transforming Cancer Services TeamNational Health ServiceLondonUK
- National Cancer Registration and Analysis ServicePublic Health EnglandLondonUK
| | - Georgios Lyratzopoulos
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) GroupDepartment of Behavioural Science and HealthUniversity College LondonLondonUK
| | - Vincent J. Gnanapragasam
- Academic Urology GroupDepartment of SurgeryUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - James N. Armitage
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
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29
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Abt D, Besse A, Sedlarikova L, Kraus M, Bader J, Silzle T, Vodinska M, Slaby O, Schmid HP, Engeler DS, Driessen C, Besse L. Improving the efficacy of proteasome inhibitors in the treatment of renal cell carcinoma by combination with the human immunodeficiency virus (HIV)-protease inhibitors lopinavir or nelfinavir. BJU Int 2017; 121:600-609. [PMID: 29161753 DOI: 10.1111/bju.14083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the potential of second-generation proteasome inhibition by carfilzomib and its combination with the human immunodeficiency virus (HIV) protease inhibitors (HIV-PIs) lopinavir and nelfinavir in vitro for improved treatment of clear cell renal cell cancer (ccRCC). MATERIALS AND METHODS Cytotoxicity, reactive oxygen species (ROS) production, and unfolded protein response (UPR) activation of proteasome inhibitors, HIV-PIs, and their combination were assessed in three cell lines and primary cells derived from three ccRCC tumours by MTS assay, flow cytometry, quantitative reverse transcriptase-polymerase chain reaction and western blot, respectively. Proteasome activity was determined by activity based probes. Flow cytometry was used to assess apoptosis by annexin V/propidium iodide assay and ATP-binding cassette sub-family B member 1 (ABCB1) activity by MitoTracker™ Green FM efflux assay (Thermo Fisher Scientific, MA, USA). RESULTS Lopinavir and nelfinavir significantly increased the cytotoxic effect of carfilzomib in all cell lines and primary cells. ABCB1 efflux pump inhibition, induction of ROS production, and UPR pre-activation by lopinavir were identified as underlying mechanisms of this strong synergistic effect. Combined treatment led to unresolved protein stress, increased activation of pro-apoptotic UPR pathway, and a significant increase in apoptosis. CONCLUSION The combination of the proteasome inhibitor carfilzomib and the HIV-PIs lopinavir and nelfinavir has a strong synergistic cytotoxic activity against ccRCCin vitro at therapeutically relevant drug concentrations. This effect is most likely explained by synergistic UPR triggering and ABCB1-modulation caused by HIV-PIs. Our findings suggest that combined treatment of second-generation proteasome inhibitors and HIV-PIs should be investigated in patients with metastatic RCC within a clinical trial.
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Affiliation(s)
- Dominik Abt
- Department of Urology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Andrej Besse
- Experimental Oncology and Hematology, Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Lenka Sedlarikova
- Department of Pathological Physiology, Babak Myeloma Group, Masaryk University, Brno, Czech Republic
| | - Marianne Kraus
- Experimental Oncology and Hematology, Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Juergen Bader
- Experimental Oncology and Hematology, Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Tobias Silzle
- Experimental Oncology and Hematology, Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Martina Vodinska
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Ondrej Slaby
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Hans-Peter Schmid
- Department of Urology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Christoph Driessen
- Experimental Oncology and Hematology, Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Lenka Besse
- Experimental Oncology and Hematology, Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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30
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von Rundstedt FC, Scovell JM, Agrawal S, Zaneveld J, Link RE. Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy. BJU Int 2016; 119:598-604. [PMID: 27862866 DOI: 10.1111/bju.13712] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe our experience using patient-specific tissue-like kidney models created with advanced three-dimensional (3D)-printing technology for preoperative planning and surgical rehearsal prior to robot-assisted laparoscopic partial nephrectomy (RALPN). PATIENTS AND METHODS A feasibility study of 10 patients with solid renal masses who underwent RALPN after preoperative rehearsal using 3D-print kidney models. A single surgeon performed all surgical rehearsals and procedures. Using standard preoperative imaging and 3D reconstruction, we generated pre-surgical models using a silicone-based material. All surgical rehearsals were performed using the da Vinci® robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA) before the actual procedure. To determine construct validity, we compared resection times between the model and actual tumour in a patient-specific manner. Using 3D laser scanning in the operating room, we quantified and compared the shape and tumour volume resected for each model and patient tumour. RESULTS We generated patient-specific models for 10 patients with complex tumour anatomy. R.E.N.A.L. nephrometry scores were between 7 and 11, with a mean maximal tumour diameter of 40.6 mm. The mean resection times between model and patient (6:58 vs 8:22 min, P = 0.162) and tumour volumes between the computer model, excised model, and excised tumour (38.88 vs 38.50 vs 41.79 mm3 , P = 0.98) were not significantly different. CONCLUSIONS We have developed a patient-specific pre-surgical simulation protocol for RALPN. We demonstrated construct validity and provided accurate representation of enucleation time and resected tissue volume. This simulation platform can assist in surgical decision-making, provide preoperative rehearsals, and improve surgical training.
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Affiliation(s)
- Friedrich-Carl von Rundstedt
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.,Department of Urology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Jason M Scovell
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Smriti Agrawal
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | | | - Richard E Link
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.,Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA.,Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX, USA
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31
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Shah AY, Karam JA, Malouf GG, Rao P, Lim ZD, Jonasch E, Xiao L, Gao J, Vaishampayan UN, Heng DY, Plimack ER, Guancial EA, Fung C, Lowas SR, Tamboli P, Sircar K, Matin SF, Kimryn Rathmell W, Wood CG, Tannir NM. Management and outcomes of patients with renal medullary carcinoma: a multicentre collaborative study. BJU Int 2016; 120:782-792. [PMID: 27860149 DOI: 10.1111/bju.13705] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the management strategies and outcomes of patients with renal medullary carcinoma (RMC) and characterise predictors of overall survival (OS). PATIENTS AND METHODS RMC is a rare and aggressive malignancy that afflicts young patients with sickle cell trait; there are limited data on management to date. This is a study of patients with RMC who were treated in 2000-2015 at eight academic institutions in North America and France. The Kaplan-Meier method was used to estimate OS, measured from initial RMC diagnosis to date of death. Cox regression analysis was used to determine predictors of OS. RESULTS In all, 52 patients (37 males) were identified. The median (range) age at diagnosis was 28 (9-48) years and 49 patients (94%) had stage III/IV. The median OS for all patients was 13.0 months and 38 patients (75%) had nephrectomy. Patients who underwent nephrectomy had superior OS compared to patients who were treated with systemic therapy only (median OS 16.4 vs 7.0 months, P < 0.001). In all, 45 patients received chemotherapy and 13 (29%) had an objective response; 28 patients received targeted therapies, with 8-week median therapy duration and no objective responses. Only seven patients (13%) survived for >24 months. CONCLUSIONS RMC carries a poor prognosis. Chemotherapy provides palliation and remains the mainstay of therapy, but <20% of patients survive for >24 months, underscoring the need to develop more effective therapy for this rare tumour. In this study, nephrectomy was associated with improved OS.
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Affiliation(s)
| | | | - Gabriel G Malouf
- Groupe Hospitalier Pitié-Salpêtrière, University Pierre and Marie Curie, Paris, France
| | - Priya Rao
- MD Anderson Cancer Center, Houston, TX, USA
| | - Zita D Lim
- MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | | | | | | | | - Stefanie R Lowas
- University of Nebraska Medical Center and Children's Hospital and Medical Center, Omaha, NE, USA
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Nielsen TK, Lagerveld BW, Keeley F, Lughezzani G, Sriprasad S, Barber NJ, Hansen LU, Buffi NM, Guazzoni G, van der Zee JA, Ismail M, Farrag K, Emara AM, Lund L, Østraat Ø, Borre M. Oncological outcomes and complication rates after laparoscopic-assisted cryoablation: a European Registry for Renal Cryoablation (EuRECA) multi-institutional study. BJU Int 2016; 119:390-395. [PMID: 27488479 DOI: 10.1111/bju.13615] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess complication rates and intermediate oncological outcomes of laparoscopic-assisted cryoablation (LCA) in patients with small renal masses (SRMs). PATIENTS AND METHODS A retrospective review of 808 patients treated with LCA for T1a SRMs from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien-Dindo classification. Kaplan-Meier analyses were used to estimate 5- and 10-year disease-free survival (DFS) and overall survival (OS). RESULTS The median [interquartile (IQR)] age was 67 (58-74) years. The median (IQR) tumour size was 25 (19-30) mm. The transperitoneal approach was used in 77.7% of the patients. The median postoperative hospital stay was 2 days. In all, 514 patients with a biopsy-confirmed renal cell carcinoma (RCC) were available for survival analyses. The median (IQR) follow-up for the RCC-cohort was 36 (14-56) months. A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5-/10-year DFS was 90.4%/80.0% and 5-/10-year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥III) in 26 patients (3.2%). An American Society of Anesthesiologists score of 3 was associated with an increased risk of overall complications (odds ratio 2.85, 95% confidence interval 1.32-6.20; P = 0.005). CONCLUSIONS This large series of LCA demonstrates satisfactory long-term oncological outcomes for SRMs. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients.
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Affiliation(s)
- Tommy K Nielsen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Brunolf W Lagerveld
- Department of Urology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | - Giovanni Lughezzani
- Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Milano, Rozzano, Italy
| | | | - Neil J Barber
- Department of Urology, Frimley Park Hospital, Camberley, UK
| | - Lars U Hansen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.,Department of Urology, Odense University Hospital, Odense, Denmark
| | - Nicole M Buffi
- Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Milano, Rozzano, Italy
| | - Giorgio Guazzoni
- Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Milano, Rozzano, Italy
| | - Johan A van der Zee
- Department of Urology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | - Khaled Farrag
- Department of Urology, Darent Vally Hospital, Dartford, UK
| | - Amr M Emara
- Department of Urology, Frimley Park Hospital, Camberley, UK.,Department of Urology, Ain Shams University, Cairo, Egypt
| | - Lars Lund
- Department of Urology, Odense University Hospital, Odense, Denmark.,Department of Urology, Viborg Regional Hospital, Viborg, Denmark
| | - Øyvind Østraat
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Borre
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
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33
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Liu J, Abshire C, Carry C, Sholl AB, Mandava SH, Datta A, Ranjan M, Callaghan C, Peralta DV, Williams KS, Lai WR, Abdel-Mageed AB, Tarr M, Lee BR. Nanotechnology combined therapy: tyrosine kinase-bound gold nanorod and laser thermal ablation produce a synergistic higher treatment response of renal cell carcinoma in a murine model. BJU Int 2016; 119:342-348. [PMID: 27431021 DOI: 10.1111/bju.13590] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To investigate tyrosine kinase inhibitors (TKI) and gold nanorods (AuNRs) paired with photothermal ablation in a human metastatic clear cell renal cell carcinoma (RCC) mouse model. Nanoparticles have been successful as a platform for targeted drug delivery in the treatment of urological cancers. Likewise, the use of nanoparticles in photothermal tumour ablation, although early in its development, has provided promising results. Our previous in vitro studies of nanoparticles loaded with both TKI and AuNRs and activated with photothermal ablation have shown significant synergistic cell kill greater than each individual arm alone. This study is a translation of our initial findings to an in vivo model. MATERIALS AND METHODS Immunologically naïve nude mice (athymic nude-Foxn1nu ) were injected subcutaneously bilaterally in both flanks (n = 36) with 2.5 × 106 cells of a human metastatic renal cell carcinoma cell line (RCC 786-O). Subcutaneous xenograft tumours developed into 1-cm palpable nodules. AuNRs encapsulated in human serum albumin protein (HSA) nanoparticles were synthesised with or without a TKI and injected directly into the tumour nodule. Irradiation was administered with an 808-nm light-emitting diode laser for 6 min. Mice were humanely killed 14 days after irradiation; tumours were excised, formalin fixed, paraffin embedded, and evaluated for size and the percentage of necrosis by a genitourinary pathologist. The untreated contralateral flank tumours were used as controls. RESULTS In mice that did not receive irradiation, TKI alone yielded 4.2% tumour necrosis on the injected side and administration of HSA-AuNR-TKI alone yielded 11.1% necrosis. In the laser-ablation models, laser ablation alone yielded 62% necrosis and when paired with HSA-AuNR there was 63.4% necrosis. The combination of laser irradiation and HSA-AuNR-TKI had cell kill rate of 100%. CONCLUSIONS In the absence of laser irradiation, TKI treatment alone or when delivered via nanoparticles produced moderate necrosis. Irradiation with and without gold particles alone also improves tumour necrosis. However, when irradiation is paired with gold particles and drug-loaded nanoparticles, the combined therapy showed the most significant and synergistic complete tumour necrosis of 100% (P < 0.05). This study illustrates the potential of combination nanotechnology as a new approach in the treatment of urological cancers.
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Affiliation(s)
- James Liu
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Caleb Abshire
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Connor Carry
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Andrew B Sholl
- Department of Pathology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sree Harsha Mandava
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Amrita Datta
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Manish Ranjan
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Cameron Callaghan
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Donna V Peralta
- Department of Chemistry, University of New Orleans, New Orleans, LA, USA
| | - Kristen S Williams
- Department of Chemistry, University of New Orleans, New Orleans, LA, USA
| | - Weil R Lai
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Asim B Abdel-Mageed
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Matthew Tarr
- Department of Chemistry, University of New Orleans, New Orleans, LA, USA
| | - Benjamin R Lee
- Division of Urology, University of Arizona College of Medicine, Tucson, AZ, USA
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