Tag Archive for: RCC

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Residents’ Podcast: When to Perform Preoperative Chest CT for RCC Staging

Jesse Ory, Kyle Lehmann and Jeff Himmelman

Department of Urology, Dalhousie University, Halifax, NS, Canada

 

Abstract

Objectives

To provide objective criteria for preoperative staging chest computed tomography (CT) in patients diagnosed with renal cell carcinoma (RCC) because, in the absence of established indications, the decision for preoperative chest CT remains subjective.

Patients and Methods

A total of 1 946 patients undergoing surgical treatment of RCC, whose data were collected in a prospective institutional database, were assessed. The outcome of the study was presence of pulmonary metastases at staging chest CT. A multivariable logistic regression model predicting positive chest CT was fitted. Predictors consisted of preoperative clinical tumour (cT) and nodal (cN) stage, presence of systemic symptoms and platelet count (PLT)/haemoglobin (Hb) ratio.

Results

The rate of positive chest CT was 6% (n = 119). At multivariable logistic regression, ≥cT1b, cN1, systemic symptoms and Hb/PLT ratio were all associated with higher risk of positive chest CT (all P < 0.001). After 2000-sample bootstrap validation, the concordance index was found to be 0.88. At decision-curve analysis, the net benefit of the proposed strategy was superior to the select-all and select-none strategies. Accordingly, if chest CT had been performed when the risk of a positive result was >1%, a negative chest CT would have been spared in 37% of the population and a positive chest CT would have been missed in 0.2% of the population only.

Conclusions

The proposed strategy estimates the risk of positive chest CT at RCC staging with optimum accuracy and the results were statistically and clinically relevant. The findings of the present study support a recommendation for chest CT in patients with ≥cT1b, cN1, systemic symptoms or anaemia and thrombocythemia. Conversely, in patients with cT1a, cN0 without systemic symptoms, anaemia and thrombocythemia, chest CT could be omitted.

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Highlights from the Urological Association of Asia Annual Congress 2017

Having trained and worked in London throughout my urology career, I have recently relocated and joined the exciting, dynamic urology community of my birthplace, Hong Kong. Coincidentally, it so happens to be this year’s host of the Urological Association of Asia (UAA) annual congress #UAA2017.

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The beautiful and mesmerising night view of the Victoria Harbour of Hong Kong.

Established in 1990 in Fukuoka, Japan, the #UAA currently has 25 urological associations as members or affiliated members across Asia and Australasia with and over 25,000 members. This was my attendance at the #UAA and it most certainly did not disappoint. What made the conference even more special was the chance to meet up with my good friend and ex-colleague from Guy’s Hospital @nairajesh – both of us were honoured to speak at the meeting. With over 1600 delegates attending the meeting and over 500 scientific abstracts presented, the congress served as an excellent platform for knowledge exchange and the establishment of professional links with many urological greats in Asia and beyond.

 

Pre #UAA2017 Congress Activities

#UAA2017 started off with a pre-congress ‘wet-lab’ 3D laparoscopic skills and endourology workshop hosted by @HKUniversity and the European School of Urology @UrowebESU. Both transperitoneal laparoscopic and retroperitoneoscopic techniques were taught by eminent leaders and pioneers in minimally invasive urological surgery by faculties from Europe, India and China, including Professor Jens Rassweiller, Professor Christian Schwentner (@Schwenti1977), Dr Domenico Veneziano (@d_veneziano), Professor Janak Desai (@drjanajddesai), and Professor Zhang Shudong.

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Joint UAA-ESU 3D laparoscopic and endourological skills course faculties. Left to right: Dr Ada Ng (Hong Kong), Dr Wayne Lam @WayneLam_Urol (Hong Kong), Professor Janek Desai @drjanajddesai (India), Professor Jens Rassweiller (Germany), Professor MK Yiu (Hong Kong), Dr James Tsu (Hong Kong), Dr WK Ma (Hong Kong).

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Joint UAA-ESU 3D Laparoscopic skills workshop – Above: Professor Rassweiller (Germany) supervising overseas delegates. Below: Professor MK Yiu (Hong Kong) demonstrating techniques of laparoscopic suturing to delegates from China.

The renal cell carcinoma #RCC masterclass was a particular highlight. A whole day of excellent lectures and speakers entertained both local and international delegates, and was particularly popular with trainees. There were talks examining the role of percutaneous biopsy of renal tumours presented by Alessandro Volpe (@foxal72), an update of current trends and techniques in robotic and laparoscopic partial nephrectomy by Dr. Joseph Wong (Hong Kong) and Dr. Shuo Wang (China) and a fantastic discussion examining the role of non-clamping partial nephrectomy by Dr. Ringo Chu (Hong Kong). The afternoon session kicked off with @nairajesh giving a comprehensive review on the surgical management of advanced #RCC. Professor Axel Bex (Netherlands) continued with an examination of neoadjuvant and adjuvant systemic therapy in #RCC and the emerging role of #immunotherapy. Professor Alessandro Volpe (@foxal72) discussed the current #EAU guidelines and recent updates.

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Masterclass in #RCC: @foxal72 , @nairajesh , Professor Axel Bex (Netherlands), with moderators Dr Ringo Chu (Hong Kong) and Dr Joseph Wong (Hong Kong).

 

Day 1 of #UAA2017

The plenary session on day 1 of #UAA started off with Professor Zengnan Mo from China on the epidemiology of prostate cancer in Asia. There is, not surprisingly, a very diverse range of incidence of #prostatecancer rate across the largest continent in the world, inevitably effected by the presence of #PSA screening in countries such as Japan and Korea, ethnicity (East Asia vs Middle East), genetics (Israeli Jewish population), and their local healthcare system and policies. Arguably the currently available #prostatecancer screening trials may not be applicable to the Asian populations, and various on-going studies in Japan and China are going to address these issues. One in particular is an ongoing population-based study funded by the Chinese Ministry of Science and Technology, in which over 50,000 men will be recruited into the screening, early detection, localised, and advanced #prostatecancer cohorts and to be followed up with time. Obviously, we will not expect to see the results of the trial anytime soon, but will surely answers to address the behaviour of prostate cancer in the Asian population in the future.

Professor Sam Cheng (@UroCancerMD) from Vanderbilt University then gave a comprehensive review on the current status of #cystectomy. Robotic cystectomy appears to have the benefit of reduced blood loss and length of stay. However, long-term oncological outcome still remains uncertain, and certainly, patient reported outcome measures (PROMs) is lacking.

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Day 2 of #UAA2017

After early showers on day 2 of UAA, Hong Kong was heating up with temperatures over 33 degrees Celsius. So were the discussions in the plenary session in the morning. Professor Freddie Hamdy (@Freddie_Hamdy) gave the #EAU lecture on #activesurveillance for #prostatecancer. This was followed on nicely with the current status of #prostatecancer management in Hong Kong by Dr. Yau-Tung Chan and Dr. Gerhardt Attard (UK) enlightened the audience with a concise update in the management of hormone sensitive prostate cancer, an area where the landscape is ever-changing.

The advanced oncology session started off with a heated debate in the use of mass clamping (Dr Ringo Chu, Hong Kong) versus selective artery clamping in partial nephrectomy (Dr Tae-Gyun Kwon, Korea). Both speakers presented with very valid arguments and perhaps it was fair to say it ended up with all square. Professor Krishna Sethia (UK) gave a fascinating summary of the current local management of #penilecancer at centralised penile cancer centres in the UK, after which I was honoured to provide an update on current nodal management in #penilecancer from my recent experience at St George’s University Hospitals @StGeorgesTrust in the UK. It was exciting to see the centralisation of services in #penilecancer in the UK has given great opportunities to understand and optimise management of patients with such rare disease.

The Semi-live sessions entertained the audience on both days of the conference. Excellent videos were presented throughout. Professor Koon Rha of Yonsei University in South Korea gave a fantastic semi-live talk on his tricks and techniques of Retzius-space sparing Robot-assisted radical prostatectomy. Perhaps what’s even more exciting to know is that a Korean company has produced a new robot for surgery which has been well tested by Professor Rha’s group, which has just literally been licenced and approved in Korea just days before #UAA2017. Will this finally drive the cost of robotic surgery down? Time will tell.

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Associate Professor Declan Murphy (@declanmurphy) and Mr. Rajesh Nair (@nairajesh) both contributed with a beautiful video showcasing techniques in total pelvic exenteration and long-term outcomes of urinary diversion and reconstruction in this cohort of patients.

The Gala dinner in the evening was full of fun and entertainment. Following the performance of a soprano quartet formed by local Hong Kong urologists (who sang the classic My Way with a twist on prostate examination!), the rock stars of urology – Professor Jens Rassweiller, Dr Samuel Yee from Hong Kong, and Dr Domenico Veneziano (@d_veneziano) provided an energetic and electrifying live performance of some rock classics!

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Urology Rock N’ Roll! Left to right: Professor Jens Rassweiller (Germany), Dr Domenico Veneziano (Italy), Dr Samuel Yee (Hong Kong).

However, perhaps the highlight and the most touching moment of the evening the performance of a song written and sung by a young local former patient with a history of #ketaminebladder , who was successfully treated by the urology team lead by Professor Anthony Ng at the Prince of Wales Hospital in Hong Kong. His surgery and treatment has transformed his life – he is now enjoying a career as both a singer-songwriter of a rock band and as a footballer!

 

Day 3 of #UAA2017

The morning plenary session also saw the evergreen Dr Peggy Chu of Hong Kong, renown for her discovery of ketamine-associated uropathy and pioneered the management of this challenging 21st century urological disease.

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Left to right: Dr CW Man (Hong Kong), Congress President of #UAA2017, and Dr Peggy Chu (Hong Kong).

She delivered a very interesting talk on revisiting the role of #gastrocystoplasty. Interestingly, the operation was first described and carried out in human by the honourable Professor CH Leong at my current institution, Queen Mary Hospital @HKUniversity , in the 1970s following a successful animal study at the same institution. Its use has been limited due to its associated metabolic disturbances, but arguably it is still a weapon that can be used when tackling patients with tuberculosis-associated severely contracted bladder, in particular those who have already been rendered to have a single solitary kidney due to the disease. Another situation when #gastrocystoplasty can still be considered are those patients with #ketamine uropathy. Although patients are usually required to be completely abstinence from #ketamine abuse for a certain lengthy period of time before they are eligible for surgical treatment, many fear the avalanche effect of ileal re-absorption of the drug if an ileo-cystoplasty has been carried out in these patients, if they happen to resume ketamine use in the future. Hence, #gastrocystoplasty may be a better substitution tissue for cystoplasty in the management of such patients.

The meeting also provided an opportunity to catch up with fellow Guy’s Hospital urology graduates @nairajesh and @declanmurphy over a cold pint of Hong Kong locally made #MoonzenBeer, when the temperature outside the conference centre was hitting 34 degrees Celsius!

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Left to right: Dr Wayne Lam (Hong Kong), Mr Rajesh Nair (Australia/United Kingdom), A/Prof Declan Murphy (Australia).

All credits to #UAA and the local organisers’ immense effort and hard work, making this congress a valuable learning experience for everyone who participated. We very much look forward to #UAA2018. Bring on Kyoto, Japan!

 

 

Wayne Lam

Assistant Professor in Urology, Queen Mary Hospital, University of Hong Kong

Twitter: @WayneLam_Urol

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Rajesh Nair

Fellow in Robotic Surgery and Uro-Oncology

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April 2017 #urojc summary: Is SABR a viable therapeutic option for managing renal tumors in patients deemed unsuitable for surgery?

saji_author-photo5April 2017 #urojc summary: Is SABR a viable therapeutic option for managing renal tumors in patients deemed unsuitable for surgery?

In April 2017, the International Twitter-based Urology Journal Club (@iurojc) #urojc reviewed an interesting recent article by Siva et. Al reporting their experience in a prospective cohort study utilizing Stereotactic Ablative Body Radiotherapy (SABR) on inoperable primary renal cell carcinomas. The article was made freely available courtesy of BJUI for the duration of the discussion (https://onlinelibrary.wiley.com/doi/10.1111/bju.13811/full). The journal club ran for 48 hours beginning on April 2nd at 21:00 UTC. The first author of the manuscript, Dr. Shankar Siva, a radiation oncologist at the Peter MacCallum Cancer Center joined the discussion using the Twitter handle @_ShankarSiva.

The study enrolled 37 total patients (T1a n=13, T1b n=23, and T2a n=1) due to one of three reasons: (1) deemed medically inoperable (n=28 Charlson Comorbidity >6), (2) high-risk group for surgery (n=11 high risk post-surgical dialysis), (3) refused surgery (n=1). The primary outcome measured was the successful delivery of radiotherapy. Secondary outcomes included (1) adverse events of radiotherapy, (2) local progression of the disease, (3) distant progression of the disease, and (4) overall survival.

@iurojc kicked things off with a starter question

There was immediate debate regarding the validity of treating patients with inoperable tumors using alternative modalities.

@PatrickKenneyMD cited a retrospective analysis by Kutikov et. al (@uretericbud) of the SEER database on competing causes of mortality in elderly patients with localized RCC. The study reported the 5-year probability of mortality from non-cancer related etiology to be 11% while the RCC related mortality probability was 4%. The authors of the paper encourage that management decisions for localized RCC in older patients should take into account competing causes of mortality. @DrewMoghanaki argued that many patients will still suffer from the sequelae of cancer progression that could be prevented by treating with non-surgical modalities such as SABR.
@_ShankarSiva chimed in

@uretericbud questioned the comparison of two discrepant neoplasms

@_ShankarSiva explained

From Belgium, an important point was made about the question itself.

While this conversation was occurring, a lively discussion on the utility of SABR compared to other established non-surgical modalities was taking place.

@_ShankarSiva replied

Next, @CanesDavid posed a question regarding the most frequent factors of surgical disqualification in the cohort

@benchallacombe noted a limitation of the study which led to a discussion of the utility of one of the four secondary outcomes of the study- local progression.

@nickbrookMD (co-author) cited an article by Crispen et. al that characterized the growth rate of untreated solid enhancing renal masses. @Rad_Nation proposed two follow-up studies that could be conducted.

Even if these studies are conducted, there is skepticism around whether Urologists will view SBRT as a viable alternative treatment modality for RCC.

@iurojc posed an important question. What should be the overall goal of the urologist? Is it to cure cancer by all means? Or perhaps to find a balance between quality of life and management of the disease? SBRT may play a crucial role in the latter situation.

To wrap things up, @iurojc asked a summary question.

The authors of the manuscript provided a response and their thoughts on what needs to be done next.

Thank you to everyone who participated in the April 2017 #urojc. Special thanks to the authors @_ShankarSiva and @nickbrookMD for joining in on the discussion and providing further insight to their work.

Akhil Saji is a third-year medical student at New York Medical College, Valhalla, NY.

Twitter @AkhilASaji

 

References

1. Siva, Shankar, et al. “Stereotactic ablative body radiotherapy for inoperable primary kidney cancer: a prospective clinical trial.” BJU international (2017)

2. Kutikov, Alexander, et al. “Evaluating overall survival and competing risks of death in patients with localized renal cell carcinoma using a comprehensive nomogram.” Journal of Clinical Oncology 28.2 (2009): 311-317.

3. Crispen, Paul L., et al. “Predicting growth of solid renal masses under active surveillance.” Urologic Oncology: Seminars and Original Investigations. Vol. 26. No. 5. Elsevier, 2008

 

Guideline of guidelines: follow-up after nephrectomy for renal cell carcinoma

RCC folowup

 

Abstract

The purpose of this article was to review and compare the international guidelines and surveillance protocols for post-nephrectomy renal cell carcinoma (RCC). PubMed database searches were conducted, according to the PRISMA statement for reporting systematic reviews, to identify current international surveillance guidelines and surveillance protocols for surgically treated and clinically localized RCC. A total of 17 articles were reviewed. These included three articles on urological guidelines, three on oncological guidelines and 11 on proposed strategies. Guidelines and strategies varied significantly in relation to follow-up, specifically with regard to the frequency and timing of radiological imaging. Although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics.

 

Article of the week: Pneumonitis should not prevent continued mTOR inhibitor use

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Mammalian target of rapamycin (mTOR) inhibitor-associated non-infectious pneumonitis in patients with renal cell cancer: predictors, management, and outcomes

Bradley J. Atkinson, Diana H. Cauley, Chaan Ng*, Randall E. Millikan, Lianchun Xiao, Paul Corn, Eric Jonasch and Nizar M. Tannir

Departments of Pharmacy Clinical Programs, *Diagnostic Radiology, †Genitourinary Medical Oncology and ‡Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA

B.J.A. and D.H.C. are co-first authors
Supported in part by a Cancer Center Support Grant (CA016672) from the National Institutes of Health.

OBJECTIVE

• To characterise the incidence, onset, management, predictors, and clinical impact of mammalian target of rapamycin (mTOR) inhibitor-associated non-infectious pneumonitis (NIP) on patients with metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

• Retrospective review of 310 patients with mRCC who received temsirolimus and/or everolimus between June 2007 and October 2010.

• Clinical correlations were made with serial radiological imaging.

• Fisher’s exact, Wilcoxon rank-sum, and logistic regression analyses were used to evaluate the association of NIP with demographic or clinical factors.

• Log-rank and Cox proportional hazards regression analyses were used for the time-to-event analysis.

RESULTS

• NIP occurred in 6% of temsirolimus-treated and 23% of everolimus-treated patients. Symptoms included cough, dyspnoea, and fever (median of two and three symptoms per patient, respectively).

• The median National Cancer Institute Common Toxicity Criteria for Adverse Events pneumonitis grade was 2 for both groups.

• Older age and everolimus treatment were predictive of NIP.

• Patients who developed NIP had a significantly longer time on treatment (median 4.1 vs 2 months) and overall survival (OS) (median 15.4 vs 7.4 months).

• NIP was a predictor of improved OS by multivariate analysis.

CONCLUSIONS

• There was an increased incidence of NIP in everolimus-treated patients.

• Improved OS in patients who developed NIP is an intriguing finding and should be further investigated. Given the incidence, morbidity, and outcomes seen in patients on everolimus who develop NIP, management should include proactive monitoring and treatment of NIP with the goal of preserving mTOR inhibitor therapy.

 

Editorial: mTOR-related non-infectious pneumonitis: a potential biomarker of clinical benefit?

The study by Atkinson et al. [1] published in the present issue of the BJUI is the largest study to date to address the role of non-infectious pneumonitis (NIP) as a predictive biomarker in patients with RCC who are treated with mammalian target of rapamycin (mTOR) inhibitors. It is also the first article to correlate mTOR-related NIP with improved overall survival (OS). Until now, only radiological response as measured by RECIST and progression-free survival (PFS) had been correlated to the onset of NIP in two small retrospective studies [2, 3], but the results obtained in those studies were contradictory and, therefore, this correlation remains controversial.

While the predictive relationship between NIP and OS needs to be further investigated in well-designed prospective clinical trials, the implications of such a relationship may be significant because no predictive biomarkers for mTOR inhibitors have been validated to date. In the era of targeted therapies, the detection of biomarkers of treatment efficacy is crucial to differentiate the subpopulations of patients who are most likely to benefit from treatment. Several biomarkers, such as the development of arterial hypertension and hypothyroidism, have been correlated with improved outcomes in patients with advanced RCC treated with vascular endothelial growth factor pathway inhibitors [1]; however, there are currently very limited data regarding the potential predictors of the clinical efficacy of mTOR inhibitors. A recent study by Lee et al. [4] showed that greater increases in serum cholesterol levels from baseline in patients with advanced RCC treated with temsirolimus were significantly associated with longer PFS and OS. Interestingly, temsirolimus-related hypertriglyceridemia and hyperglycaemia were not associated with improved clinical outcomes. Although NIP or hypercholesterolaemia must still be validated prospectively to ascertain whether they are true surrogate biomarkers of pharmacodynamic effect or just confounding epiphenomena, these promising findings may be the first steps in the identification of predictive biomarkers in mTOR inhibitor therapy.

Other important aspects addressed by Atkinson et al. [1] are the uncertainty of the pathogenesis of mTOR-related NIP and the lack of clinical predictive factors. Older age and treatment with everolimus were the only significant predictive factors of onset of NIP in their multivariate analysis. Similarly, a retrospective study by Dabydeen et al. [2] showed a statistically nonsignificant higher incidence of NIP in patients with RCC treated with everolimus compared to those treated with temsirolimus. Interestingly, in a randomized phase II study testing three different dose levels of temsirolimus (25,75 and 250 mg/week) in patients with advanced RCC, none of the six patients diagnosed with NIP were in the highest dose group of 250 mg/week [5], suggesting that mTOR-related NIP might have a non-dose-dependent pathogenesis. Similarly, a meta-analysis of 2233 patients affected by different tumours including RCC treated with an mTOR inhibitor failed to show any relationship between median treatment duration and incidence of NIP [6]. Finally, underlying respiratory conditions before treatment, such as the presence of lung metastases [6], chronic obstructive pulmonary disease or smoking habit [2], were not shown to be predictive factors of development of mTOR-related NIP. Another study by White et al. [3] showed that the development of pneumonitis in patients with RCC treated with everolimus was not associated with more impaired baseline pulmonary function tests, indicating that pulmonary function tests may not help identify patients with an increased risk of pneumonitis nor predict its severity. At present, there are therefore very few pretreatment clinical predictive factors to help clinicians identify patients at higher risk of developing mTOR-related NIP.

In conclusion, given the potential value of NIP as a predictive biomarker of survival in patients with RCC treated with mTOR inhibitors, Atkinson et al. [1] suggest that efforts should be made to avoid dose reductions and treatment discontinuation whenever possible. However, predictive factors of the severity of lung toxicity are needed to identify those patients at risk of developing life-threatening NIP as the maintenance of dose intensity may be crucial for maximizing clinical benefit.

Alejo Rodriguez-Vida, Noan-Minh Chau and Simon Chowdhury
Department of Medical Oncology, Guy’s Hospital, London, UK

References

  1. Atkinson BJ, Pharm D, Cauley DH et al. mTOR inhibitor-associated non-infectious pneumonitis in patients with renal cell cancer: management, predictors, and outcomesBJU Int 2014; 113: 376–382
  2. Dabydeen DA, Jagannathan JP, Ramaiya N et al. Pneumonitis associated with mTOR inhibitors therapy in patients with metastatic renal cell carcinoma: incidence, radiographic findings and correlation with clinical outcomeEur J Cancer 2012; 48:1519–1524
  3. White DA, Camus P, Endo M et al. Noninfectious pneumonitis after everolimus therapy for advanced renal cell carcinomaAm J Respir Crit Care Med 2010; 182: 396–403
  4. Lee CK, Marschner IC, Simes RJ et al. Increase in cholesterol predicts survival advantage in renal cell carcinoma patients treated with temsirolimusClin Cancer Res 2012; 18: 3188–3196
  5. Atkins MB, Hidalgo M, Stadler WM et al. Randomized phase II study of multiple dose levels of CCI-779, a novel mammalian target of rapamycin kinase inhibitor, in patients with advanced refractory renal cell carcinomaJ Clin Oncol 2004; 22: 909–918
  6. Iacovelli R, Palazzo A, Mezi S, Morano F, Naso G, Cortesi E. Incidence and risk of pulmonary toxicity in patients treated with mTOR inhibitors for malignancy. A meta-analysis of published trialsActa Oncol 2012; 51: 873–879

 

Article of the week: Restored renal function after RN

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Chung discussing his paper.

If you only have time to read one article this week, it should be this one

Trends in renal function after radical nephrectomy: a multicentre analysis

Jae S. Chung1, Nak H. Son2, Seok-Soo Byun6, Sang E. Lee6, Sung K. Hong6, Chang W. Jeong6, Sang C. Lee6, Dong-Wan Chae7, Won S. Choi8, Yong H. Park3, Sung H. Hong4, Yong J. Kim9 and Seok H. Kang5

1Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 2Department of Biostatistics, Yonsei University College of Medicine, 3Department of Urology, Seoul National University Hospital, 4Department of Urology, Seoul St. Mary’s Hospital, 5Department of Urology, Korea University Anam Hospital, Seoul, 6Departments of Urology and 7Internal Medicine, Seoul National University Bundang Hospital, Seongnam, 8Choi Won Suk Urology Clinic, Yongin, and 9Department of Urology, Chungbuk National University Hospital, Cheongju, Korea

OBJECTIVE

• To evaluate serial changes in renal function by investigating various clinical factors after radical nephrectomy (RN).

PATIENTS AND METHODS

• The study population consisted of 2068 consecutive patients who were treated at multiple institutions by RN for renal cortical tumour without metastasis between 1999 and 2011.

• We measured the serial change in estimated glomerular filtration rate (eGFR) and clinical factors during a 60-month follow-up period.

• The changes in eGFR over time were analysed according to baseline eGFR (eGFR ≥60 and 15–59 mL/min/1.73m2) using a linear mixed model.

• The independent prognostic value of various clinical factors on the increase in eGFR was ascertained by multivariate mixed regression model.

RESULTS

• Overall, there was a subsequent restoration of renal function over the 60 months.

• The slope for the relationship between the eGFR and the time since RN was 0.082 (95% confidence interval [CI] 0.039–0.104; P < 0.001) and 0.053 (95% CI 0.006–0.100; P = 0.038) in each baseline group, indicating that each month after RN was associated with an increase in eGFR of 0.082 and 0.053 mL/min/1.73m2, respectively.

• When we analysed renal function based on various factors, postoperative eGFR of patients with diabetes mellitus, old age (≥70 years) or a preoperative eGFR of <30 mL/min/1.73 m2, was decreased or maintained at a certain level without any improvement in renal function.

• Preoperative predictors of an increase in eGFR after RN were young age, no DM, no hypertension, a preoperative eGFR of ≥30 mL/min/1.73m2 and time after surgery (≥36 months).

CONCLUSIONS

• Renal function recovered continuously during the 60-month follow-up period after RN.

• However, the trends in functional recovery change were different according to various clinical factors and such information should be discussed with patients when being counselled about their treatment for renal cell carcinoma (RCC).

 

Read Previous Articles of the Week

 

Editorial: Renal functional recovery after radical nephrectomy

In their publication ‘Trends in renal function after radical nephrectomy: a multicentre analysis’, Chung et al. [1] suggest that after radical nephrectomy (RN), renal functional recovery in patients who have RCC occurs even in states of baseline renal functional compromise (pre-existing stage III chronic kidney disease, CKD). These findings bolster other recent reports, which suggest that surgically induced CKD may not be associated with the same degree of renal functional decline as CKD that may be caused by medical factors [2, 3]. While the incidence of de novo stage III CKD (36.1%) and delta estimated GFR between preoperative and postoperative values are lower than reported by most other groups, which may be attributable to national and demographic trends that are different from North American and European trends [2-4], the findings are nonetheless important and show that in the short-to-intermediate term (median follow up of 33 months) continued renal functional stabilisation and recovery occurs after RN. Also, performing a RN in a patient does not sentence him or her to invariable or inevitable renal functional decline in the short-to-intermediate term. Furthermore, they establish, in the short-to-intermediate term at least, a reasonable timeline of renal functional recovery for patient counselling and physician expectations in the postoperative follow-up period. Interestingly, and perhaps more disturbingly, the authors noted minimal and no functional recovery in the elderly and diabetic groups, underlying the importance for consideration of nephron-sparing approaches in these higher risk subgroups, even in the setting of normal renal function, and particularly with a lower risk lesion, e.g. a clinical T1a renal mass [5]. What we are missing from this analysis are longer term data, and a more thorough analysis of the incidence and impact of potential metabolic and cardiovascular sequelae during this period [4, 6], and a comparative analysis that examines the timeline of renal functional recovery after partial nephrectomy. Because of these reasons, the reader should be cautioned not to over-interpret these findings, and to conclude that because RN is associated with renal functional recovery, performing a RN may not pose increased long-term risk compared with a nephron-sparing method, particularly in a patient with pre-existing medical drivers towards CKD (diabetes, obesity, hyperlipidaemia, etc.). These findings are nonetheless important and provocative, and should spur further investigation and may provide an important adjunct in the counselling of patients about the functional impact of RN.

Ithaar H. Derweesh
Department of Urology, University of California San Diego Health System, La Jolla, CA, USA

References

  1. Chung JS, Son NH, Byun SS et al. Trends in renal function after radical nephrectomy: a multicentre analysisBJU Int 2014; 113:408–415
  2. Van Poppel H, Da Pozzo L, Albrecht W et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinomaEur Urol 2011; 59:543–552
  3. Lane BR, Campbell SC, Demirjian S, Fergany AF. Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney diseaseJ Urol 2013; 189: 1649–1655
  4. Sun M, Bianchi M, Hansen J et al. Chronic kidney disease after nephrectomy in patients with small renal masses: a retrospective observational analysisEur Urol 2012; 62: 696–703
  5. Campbell SC, Novick AC, Belldegrun A et al. Guideline for management of the clinical T1 renal massJ Urol 2009; 182:1271–1279
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Video: Trends in renal function after RN

Trends in renal function after radical nephrectomy: a multicentre analysis

Jae S. Chung1, Nak H. Son2, Seok-Soo Byun6, Sang E. Lee6, Sung K. Hong6, Chang W. Jeong6, Sang C. Lee6, Dong-Wan Chae7, Won S. Choi8, Yong H. Park3, Sung H. Hong4, Yong J. Kim9 and Seok H. Kang5

1Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 2Department of Biostatistics, Yonsei University College of Medicine, 3Department of Urology, Seoul National University Hospital, 4Department of Urology, Seoul St. Mary’s Hospital, 5Department of Urology, Korea University Anam Hospital, Seoul, 6Departments of Urology and 7Internal Medicine, Seoul National University Bundang Hospital, Seongnam, 8Choi Won Suk Urology Clinic, Yongin, and 9Department of Urology, Chungbuk National University Hospital, Cheongju, Korea

OBJECTIVE

• To evaluate serial changes in renal function by investigating various clinical factors after radical nephrectomy (RN).

PATIENTS AND METHODS

• The study population consisted of 2068 consecutive patients who were treated at multiple institutions by RN for renal cortical tumour without metastasis between 1999 and 2011.

• We measured the serial change in estimated glomerular filtration rate (eGFR) and clinical factors during a 60-month follow-up period.

• The changes in eGFR over time were analysed according to baseline eGFR (eGFR ≥60 and 15–59 mL/min/1.73m2) using a linear mixed model.

• The independent prognostic value of various clinical factors on the increase in eGFR was ascertained by multivariate mixed regression model.

RESULTS

• Overall, there was a subsequent restoration of renal function over the 60 months.

• The slope for the relationship between the eGFR and the time since RN was 0.082 (95% confidence interval [CI] 0.039–0.104; P < 0.001) and 0.053 (95% CI 0.006–0.100; P = 0.038) in each baseline group, indicating that each month after RN was associated with an increase in eGFR of 0.082 and 0.053 mL/min/1.73m2, respectively.

• When we analysed renal function based on various factors, postoperative eGFR of patients with diabetes mellitus, old age (≥70 years) or a preoperative eGFR of <30 mL/min/1.73 m2, was decreased or maintained at a certain level without any improvement in renal function.

• Preoperative predictors of an increase in eGFR after RN were young age, no DM, no hypertension, a preoperative eGFR of ≥30 mL/min/1.73m2 and time after surgery (≥36 months).

CONCLUSIONS

• Renal function recovered continuously during the 60-month follow-up period after RN.

• However, the trends in functional recovery change were different according to various clinical factors and such information should be discussed with patients when being counselled about their treatment for renal cell carcinoma (RCC).

 

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