American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy

PURPOSE

To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014.

METHODS

Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used.

RESULTS

We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter.

CONCLUSION

Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Assessment of Treatment Patterns for Metastatic Renal Cell Carcinoma in Brazil

Background

Although multiple therapies have emerged for the treatment of metastatic renal cell carcinoma (mRCC), it is unclear whether application of these agents is consistent in developed and developing countries. We sought to determine patterns of care for mRCC in Brazil as a representative developing country.

Material and Methods

A commercial database was used to acquire information pertaining to patients with mRCC receiving treatment at private or public hospitals in Brazil between March 2013 and October 2016. Basic clinical and demographic criteria were available, as well as information to ascertain the International Metastatic Renal Cell Carcinoma Database Consortium risk. Treatment-related data across multiple lines of therapy were collected.

Results

Of 4,379 patients assessed, 3,990 (91%) had metastatic disease, and 26%, 48%, and 26% of patients had good, intermediate, and poor International Metastatic Renal Cell Carcinoma Database Consortium risk disease, respectively. Although 3,149 patients (79%) received first-line therapy, only 641 (20%) and 152 (5%) received second- and third-line therapy, respectively. In the first-line setting, vascular endothelial growth factor–directed agents represented the most commonly used therapy, whereas in the second-line setting, vascular endothelial growth factor– and mammalian target of rapamycin–directed agents were used with similar frequency. Marked differences were seen in receipt of systemic therapy on the basis of treatment in private or public hospitals.

Conclusion

Relative to developed countries, marked attrition is noted between each subsequent line of therapy in Brazil. Patterns of care also vary greatly in private and public settings, pointing to financial constraints as a potential cause for discordances in treatment.

Complete metastasectomy in renal cell carcinoma: a propensity-score matched by the International Metastatic RCC Database Consortium prognostic model

Introduction

We evaluated overall survival (OS) benefit of complete metastasectomy (CM) in metastatic renal cell carcinoma (mRCC) using a propensity score-matched (PSM) analysis to balance groups by age, gender and by the International Metastatic RCC Database Consortium prognostic model (IMDC).

Methods

We included patients (pts) treated at the AC Camargo Cancer Center between 2007 and 2016. Pairs were matched by age, gender and IMDC. Kaplan–Meier survival estimates and Cox proportional hazard models were used to evaluate OS on CM and no-CM group.

Results

We found 116 pts with clear cell mRCC. After PSM, the number was reduced to 74 (37 CM, 37 no-CM). The median OS for CM and no-CM was 98.3 months and 40.5 months, respectively (hazard ratio 0.24 95%CI 0.11–0.53 p < 0.001). The OS benefit of CM was confirmed on favourable and intermediate IMDC but was absent on poor IMDC. The CM group received less systemic therapy than the no-CM group. Ten pts in the CM group still have no evidence of disease (NED).

Conclusion

After matching for age, gender and IMDC, we found CM impacts on OS and also diminishes the need for systemic treatment. Survival benefit was confirmed for favourable/intermediate IMDC but not for the poor IMDC prognostic model. Further studies correlating IMDC and metastasectomy are needed to guide clinical decision-making.

Treatment of Localized and Locally Advanced, High-Risk Prostate Cancer: A Report From the First Prostate Cancer Consensus Conference for Developing Countries

PURPOSE

To generate and present survey results on important issues relevant to treatment and follow-up of localized and locally advanced, high-risk prostate cancer (PCa) focusing on developing countries.

METHODS

A panel of 99 PCa experts developed more than 300 survey questions of which 67 questions concern the main areas of interest of this article: treatment and follow-up of localized and locally advanced, high-risk PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up of localized and locally advanced, high-risk PCa in areas of limited resources discussed in this article.

RESULTS

The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion and not on a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations considered cost-effectiveness as well as the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. Results were tabulated in real time.

CONCLUSION

The voting results and recommendations presented in this article can guide physicians managing localized and locally advanced, high-risk PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment of localized and locally advanced, high-risk PCa in developing countries have not been defined, this article will serve as a point of reference when confronted with this disease.

Recommendations on robotic-assisted radical prostatectomy: a Brazilian experts' consensus

Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.

Características Clínicas dos Pacientes Submetidos à Nefrectomia Parcial e Presença de Carcinoma Renal

Introdução: Existem poucos relatos correlacionando dados clínicos com a presença de carcinoma renal após o diagnóstico do tumor no exame de imagem. Objetivos: Analisar as características clínicas de pacientes submetidos à nefrectomia parcial (NP); correlacionar dados clínicos e da evolução no pós-operatório com a presença de carcinomas renais. Método: Estudo clínico observacional, retrospectivo, com 178 pacientes submetidos à NP entre 2009 a 2013. Foram avaliadas as características demográficas; morbidades: diabetes mellitus, hipertensão, doença cardiovascular; complicações do intra e pós-operatório e evolução. Os dados foram descritos em porcentagens, médias e desvio-padrão e significância estatística se p<0,05. Resultados: Foram analisados 178 pacientes de 54,0±13,4 anos, 61,2% do sexo masculino, 18,6% com tumores benignos e 81,4% com carcinomas renais. Entre os carcinomas, 69,7% foram de células claras e, entre os tumores benignos, 72,7% eram oncocitomas. A NP aberta foi realizada em 55,9% das vezes e em 44,1% por via laparoscópica. Após a cirurgia, 31,4 % necessitaram de unidade de terapia intensiva; 13,4 % apresentaram lesão renal aguda; 2,3 % alguma infecção; e 1,8% (n=3) foram a óbito após a alta. Entre as características, somente a obesidade e a redução do ritmo de filtração glomerular estimado (eRFG) em sete dias foi significativamente maior nos pacientes com carcinomas. Conclusões: Pacientes submetidos à NP eram predominantemente do sexo masculino e portadores de carcinomas de células claras. Pacientes com carcinomas eram mais obesos e tiveram maior redução do eRFG em sete dias do pós-operatório.

Abstract 3097: Patient-derived renal cell carcinoma xenografts engraftment identifies patients at risk of disease relapse, progression and death

Renal cell carcinoma (RCC) represents up to 90% of all kidney tumors, with 30% of patients presenting metastasis at diagnosis while 20-50% of those treated for curable localized disease experience recurrence. A better understanding of RCC biology is necessary to define the most efficient and personalized treatment or develop better antineoplastic drugs. Patient-derived xenografts (PDX) have emerged as one of the most promising approaches for that. This tool was generated by using surgical specimens of 87 patients implanted in immunodeficient NOD/SCID/gamma (NSG) mice, 17 of those subcutaneously and 70 at the renal subcapsular space. A total of 19 PDX developed only after orthotopic implantation and included 15 cases of clear cell RCC subtype, 3 cases of papillary subtype, and one unclassifiable tumor. One case of a PDX of a clear cell RCC recapitulated the phenotype of vena cava tumor thrombus extension that had been diagnosed in the source patient. The overall take rate was 27%, and the time to observed tumor growth varied from 5 to 13 months. An association between tumor growth and take rate was suggested by increasing take rates of 18%, 36%, and 100% among pT1 (pT1a + pT1b), pT3a, and pT3b stage tumors, respectively. PDX take rate was unrelated to tumor size (p =0.071). Patients whose tumor fragments engrafted experienced worse overall survival (OS) than those whose tumor fragments did not engraft (p = 0.003). Data also suggested a similar trend of association with metastasis-free survival (MFS) (p = 0.063). The median MFS for patients with successful PDX was 21.6 months (95% CI: 14.9, 28.3;), compared to a median of 34.4 months (95% CI: 30.4, 38.5 p = 0.003) among PDX engraftment-negative patients. PDX characterization by immunohistochemistry and targeted sequencing of the 21 most frequently mutated genes in the kidney indicated that all PDXs preserved RCC identity and major molecular alterations. From 19 PDX, the sequences of 13 patients’ tumor samples were compared with their respective PDX. In most patients (92% - 11/12), at least one mutation in patients’ tumor was identified in the PDX and in one case, no alterations were mapped. The most frequently mutated genes were VHL (50% - 6/12) and PBRM1 (41.7% - 5/12), followed by SETD2 (25% - 3/12), BAP1 and KDM5C (both 16.7% - 2/12), and ARID1A (8.3% - 1/12), indicating that all PDXs preserved RCC identity and major molecular alterations. These findings suggest that tumor engraftment capacity can identify patients at increased risk of relapse or death. Furthermore, pT1 stage tumors with the ability to engraft could also facilitate the identification of risk factors related to the rare pT1 cases with disease progression. These results suggest that the orthotopic xenograft model of RCC represents a suitable tool to study RCC biology, identify biomarkers, and test therapeutic candidates.

Citation Format: Vilma Regina Martins, Adriano Beserra, Ethiene C. Estevan, Stephania Bezerra, Giovana T. Torrezan, Amanda Ikegani, Dellê Humberto, Isabela V. Cunha, Isabella T. Meira, Dirce M. Carraro, Primo N. Lara, Stenio Zequi, Tiago G. Santos. Patient-derived renal cell carcinoma xenografts engraftment identifies patients at risk of disease relapse, progression and death [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3097.