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Re: Partial Nephrectomy for the Treatment of Renal Cell Carcinoma (RCC) and the Risk of End-Stage Renal Disease (ESRD)
Urological Survey Urological Oncology: Adrenal, Renal, Ureteral and Retroperitoneal Tumors Re: Partial Nephrectomy for the Treatment of Renal Cell Carcinoma (RCC) and the Risk of End-Stage Renal Disease (ESRD) S. A. Yap, A. Finelli, D. R. Urbach, G. A. Tomlinson and S. M. Alibhai Department of Urology, University of California Davis, Sacramento, California, and Division of Urologic Oncology, Princess Margaret Hospital and Department of Surgery, Institute of Health Policy/Management and Department of Medicine, University of Toronto, Toronto, Ontario, Canada BJU Int 2015; 115: 897e906.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.039 available at http://jurology.com/ Editorial Comment: The risk of ESRD requiring renal replacement therapy is low following surgery for RCC. This epidemiological study from Canada provides additional level 3 evidence of the protective effect of partial nephrectomy (PN) in preventing ESRD requiring renal replacement therapy compared to radical nephrectomy. Using a large, population based, administrative cohort (1995 to 2010), and after adjusting for comorbidities that directly influence long-term renal function, the authors did not find a protective effect of PN on preventing ESRD. However, when a modern subgroup (2003 to 2010) was analyzed, PN decreased the risks of ESRD and chronic kidney disease. Several sensitivity analyses to control for confounders and propensity scores were conducted in an effort to minimize biases, all of which supported the results in the modern cohort. The methods and results of the study are robust enough to support the conclusions. Because ESRD occurs rarely following surgery for RCC (2.5% in the current study), the number needed to treat is high (108 PNs to prevent 1 case of ESRD at 5 years). However, the economical, social and psychological burden justifies prevention when possible. While not devoid of limitations, ie the lack of laboratory values required the authors to rely on inpatient and outpatient diagnoses of chronic kidney disease, and despite the relatively short followup of the subcohort, the value of the study undoubtedly lies in the analysis of a modern cohort that likely reflects more accurately the incidence of and current indications for PN. While the authors should be commended for their transparency in presenting the results of the entire cohort, the findings of the oldest cohort may be irrelevant. Although followup data on the modern cohort are not yet mature, it seems sensible to keep those results in mind when considering treatment options. M. Pilar Laguna, MD, PhD
Suggested Reading Clark MA, Shikanov S, Raman JD et al: Chronic kidney disease before and after partial nephrectomy. J Urol 2011; 185: 43. Huang WC, Elkin EB, Levey AS et al: Partial nephrectomy versus radical nephrectomy in patients with small renal tumorsdis there a difference in mortality and cardiovascular outcomes? J Urol 2009; 181: 55. Patel SG, Penson DF, Pabla B et al: National trends in the use of partial nephrectomy: a rising tide that has not lifted all boats. J Urol 2012; 187: 816. Shuch B, Hanley JM, Lai JC et al: Adverse health outcomes associated with surgical management of the small renal mass. J Urol 2014; 191: 301.
0022-5347/15/1945-1226/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1226
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.08.039 Vol. 194, 1226-1233, November 2015 Printed in U.S.A.
ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS
Demirjian S, Lane BR, Derweesh IH et al: Chronic kidney disease due to surgical removal of nephrons: relative rates of progression and survival. J Urol 2014; 192: 1057. Lane BR, Campbell SC, Demirjian S et al: Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney disease. J Urol 2013; 189: 1649. Thompson RH, Boorjian SA, Lohse CM et al: Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 2008; 179: 468.
Re: Evaluation of the Prognostic Significance of Perirenal Fat Invasion and Tumor Size in Patients with pT1-pT3a Localized Renal Cell Carcinoma in a Comprehensive Multicenter Study of the CORONA Project. Can we Improve Prognostic Discrimination for Patients with Stage pT3a Tumors? S. D. Brookman-May, M. May, I. Wolff, R. Zigeuner, G. C. Hutterer, L. Cindolo, L. Schips, O. De Cobelli, B. Rocco, C. De Nunzio, A. Tubaro, I. Coman, M. Truss, O. Dalpiaz, nchez-Chapado, M. del C. Santiago Martin, B. Feciche, R. S. Figenshau, K. Madison, M. Sa L. Salzano, G. Lotrecchiano, S. Zastrow, M. Wirth, P. Sountoulides, S. Shariat, R. Waidelich, C. Stief and S. Gunia; CORONA Project; European Association of Urology Young Academic Urologists Renal Cancer Group Departments of Urology, Ludwig Maximilians University, Munich, St. Elisabeth Hospital Straubing, Straubing, Carl Thiem Klinikum, Cottbus, Klinikum Dortmund, Dortmund and Carl Gustav Carus University, Dresden and Department of Pathology, Johanniter Hospital Stendal, Stendal, Germany, Janssen Pharma Research and Development, Beerse, Belgium, Departments of Urology, Medical University of Graz, Graz and Vienna General Hospital, Medical University of Vienna, Vienna, Austria, Department of Urology, Pio Da Pietrelcina Hospital, Vasto, Division of Urology, European Institute of Oncology and Department of Urology, Ospedale Maggiore Policlinico, Universita degli Studi di Milano, Milan, Department of Urology, Faculty of Health Sciences, University La Sapienza, Rome and Department of Urology, G. Rummo Hospital, Benevento, Italy, Departments of Urology, Clinical Municipal Hospital, Cluj-Napoca and Emergency Hospital Satu Mare, Satu Mare, Romania, Department of Urology, Hospital Universitario Principe de Asturias, Madrid, Spain, and Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Eur Urol 2015; 67: 943e951.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.040 available at http://jurology.com/ Editorial Comment: This series is a retrospective evaluation of the prognostic significance of perirenal fat invasion (PFI) and renal vein invasion (RVI) in an international pT1 to pT3a clear cell renal cell carcinoma cohort. Estimated 5 and 10-year cancer specific survival differed between patients with pT3a and PFI alone (86%) and those with RVI with or without PFI (75%). Based on these results, the authors propose introduction of a size cutoff of 7 cm in pT3a tumors for further prognostic discrimination. Others have indicated this prognostic size for pT3a tumors even before implementation of the 2009 TNM classification,1 although the present sample is by far the largest. When comparing the prognostic discrimination of the current TNM and alternative stages, including the size cutoff of 7 cm, concordance index increased in 0.5% without CI overlapping, meaning that their proposal is statistically supported. The 2009 TNM version has a slightly increased prognostic discrimination compared to previous versions. Certainly overlap exists for some substages. Recognition that prospective data are scarcely available to support future changes in the TNM does not preclude careful scrutiny of the retrospective data. Current TNM stage T3a classification includes perirenal fat invasion, sinus fat invasion and gross extension of the tumor into the renal vein or its segmental branches. Unfortunately sinus fat invasion was not reported in the present series, and thus questions remain regarding its prognostic value. In addition, the definition of RVI is imprecise in the present study. Accepting that the TNM formulation is somewhat imprecise regarding how to stage possible invasion of the renal vein wall, most uropathologists will label this finding as pT3c when this information is available in retrospective studies. For future reports it might be more appropriate to reserve the word “invasion” for “ingrowth” in the wall of the vein and to use “extension” for anatomical thrombus extension. M. Pilar Laguna, MD, PhD 1. S€uer E, Baltaci S, Burgu B et al: Significance of tumor size in renal cell cancer with perinephric fat infiltration: is TNM staging system adequate for predicting prognosis? Urol J 2013; 10: 774.
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IMAGING
Suggested Reading Siemer S, Lehmann J, Loch A et al: Current TNM classification of renal cell carcinoma evaluated: revising stage T3a. J Urol 2005; 173: 33. Leibovich BC, Cheville JC, Lohse CM et al: Cancer specific survival for patients with pT3 renal cell carcinomadcan the 2002 primary tumor classification be improved? J Urol 2005; 173: 716. Thompson RH, Leibovich BC, Cheville JC et al: Is renal sinus fat invasion the same as perinephric fat invasion for pT3a renal cell carcinoma? J Urol 2005; 174: 1218. Siddiqui SA, Frank I, Leibovich BC et al: Impact of tumor size on the predictive ability of the pT3a primary tumor classification for renal cell carcinoma. J Urol 2007; 177: 59. Gofrit ON, Shapiro A, Pizov G et al: Does stage T3a renal cell carcinoma embrace a homogeneous group of patients? J Urol 2007; 177: 1682. Margulis V, Tamboli P, Matin SF et al: Location of extrarenal tumor extension does not impact survival of patients with pT3a renal cell carcinoma. J Urol 2007; 178: 1878. Terrone C, Gontero P, Volpe A et al: Proposal of an improved prognostic classification for pT3 renal cell carcinoma. J Urol 2008; 180: 72. Yoo C, Song C, Hong JH et al: Prognostic significance of perinephric fat infiltration and tumor size in renal cell carcinoma. J Urol 2008; 180: 486.
Imaging Re: Utility of Apparent Diffusion Coefficients in the Evaluation of Solid Renal Tumors at 3T H. Sasamori, M. Saiki, J. Suyama, Y. Ohgiya, M. Hirose and T. Gokan Department of Radiology, Showa University School of Medicine, Tokyo, Japan Magn Reson Med Sci 2014; 13: 89e95.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.055 available at http://jurology.com/ Editorial Comment: This study evaluates 31 patients with renal tumors. All patients were examined using a 3 T magnet and the apparent diffusion coefficient (ADC) values of the masses were calculated. Of the 4 angiomyolipoma cases 1 was a classic fat containing angiomyolipoma and 2 were specifically stated to be fat poor angiomyolipomas. Mean SD ADC values were 0.719 0.172 103 mm2 per second (range 0.606 to 0.817). These ADC values were slightly lower than (but showed some overlap with) the clear cell renal cell carcinoma range of 0.749 to 1.881 103 mm2 per second. Although there were only 31 lesions in this study, with a small number of individual clear cell, papillary and urothelial carcinomas and angiomyolipomas, these results provide further evidence that diffusion weighted imaging at 3 T will be beneficial and yield additional information in evaluating the indeterminate renal mass. Further research and larger studies are needed. Cary Siegel, MD
Re: Renal Masses Measuring under 2 cm: Pathologic Outcomes and Associations with MRI Features A. B. Rosenkrantz, N. E. Wehrli, J. Melamed, S. S. Taneja and M. B. Shaikh Departments of Radiology and Pathology, and Division of Urologic Oncology, Department of Urology, NYU Langone Medical Center, New York, New York Eur J Radiol 2014; 83: 1311e1316.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.056 available at http://jurology.com/ Editorial Comment: This article examines 86 patients with 92 renal masses 2 cm or smaller with a pathological diagnosis. The authors have shown data that are different from prior pathology studies,
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.039 available at http://jurology.com/ Editorial Comment: The risk of ESRD requiring renal replacement therapy is low following surgery for RCC. This epidemiological study from Canada provides additional level 3 evidence of the protective effect of partial nephrectomy (PN) in preventing ESRD requiring renal replacement therapy compared to radical nephrectomy. Using a large, population based, administrative cohort (1995 to 2010), and after adjusting for comorbidities that directly influence long-term renal function, the authors did not find a protective effect of PN on preventing ESRD. However, when a modern subgroup (2003 to 2010) was analyzed, PN decreased the risks of ESRD and chronic kidney disease. Several sensitivity analyses to control for confounders and propensity scores were conducted in an effort to minimize biases, all of which supported the results in the modern cohort. The methods and results of the study are robust enough to support the conclusions. Because ESRD occurs rarely following surgery for RCC (2.5% in the current study), the number needed to treat is high (108 PNs to prevent 1 case of ESRD at 5 years). However, the economical, social and psychological burden justifies prevention when possible. While not devoid of limitations, ie the lack of laboratory values required the authors to rely on inpatient and outpatient diagnoses of chronic kidney disease, and despite the relatively short followup of the subcohort, the value of the study undoubtedly lies in the analysis of a modern cohort that likely reflects more accurately the incidence of and current indications for PN. While the authors should be commended for their transparency in presenting the results of the entire cohort, the findings of the oldest cohort may be irrelevant. Although followup data on the modern cohort are not yet mature, it seems sensible to keep those results in mind when considering treatment options. M. Pilar Laguna, MD, PhD
Suggested Reading Clark MA, Shikanov S, Raman JD et al: Chronic kidney disease before and after partial nephrectomy. J Urol 2011; 185: 43. Huang WC, Elkin EB, Levey AS et al: Partial nephrectomy versus radical nephrectomy in patients with small renal tumorsdis there a difference in mortality and cardiovascular outcomes? J Urol 2009; 181: 55. Patel SG, Penson DF, Pabla B et al: National trends in the use of partial nephrectomy: a rising tide that has not lifted all boats. J Urol 2012; 187: 816. Shuch B, Hanley JM, Lai JC et al: Adverse health outcomes associated with surgical management of the small renal mass. J Urol 2014; 191: 301.
0022-5347/15/1945-1226/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1226
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.08.039 Vol. 194, 1226-1233, November 2015 Printed in U.S.A.
ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS
Demirjian S, Lane BR, Derweesh IH et al: Chronic kidney disease due to surgical removal of nephrons: relative rates of progression and survival. J Urol 2014; 192: 1057. Lane BR, Campbell SC, Demirjian S et al: Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney disease. J Urol 2013; 189: 1649. Thompson RH, Boorjian SA, Lohse CM et al: Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 2008; 179: 468.
Re: Evaluation of the Prognostic Significance of Perirenal Fat Invasion and Tumor Size in Patients with pT1-pT3a Localized Renal Cell Carcinoma in a Comprehensive Multicenter Study of the CORONA Project. Can we Improve Prognostic Discrimination for Patients with Stage pT3a Tumors? S. D. Brookman-May, M. May, I. Wolff, R. Zigeuner, G. C. Hutterer, L. Cindolo, L. Schips, O. De Cobelli, B. Rocco, C. De Nunzio, A. Tubaro, I. Coman, M. Truss, O. Dalpiaz, nchez-Chapado, M. del C. Santiago Martin, B. Feciche, R. S. Figenshau, K. Madison, M. Sa L. Salzano, G. Lotrecchiano, S. Zastrow, M. Wirth, P. Sountoulides, S. Shariat, R. Waidelich, C. Stief and S. Gunia; CORONA Project; European Association of Urology Young Academic Urologists Renal Cancer Group Departments of Urology, Ludwig Maximilians University, Munich, St. Elisabeth Hospital Straubing, Straubing, Carl Thiem Klinikum, Cottbus, Klinikum Dortmund, Dortmund and Carl Gustav Carus University, Dresden and Department of Pathology, Johanniter Hospital Stendal, Stendal, Germany, Janssen Pharma Research and Development, Beerse, Belgium, Departments of Urology, Medical University of Graz, Graz and Vienna General Hospital, Medical University of Vienna, Vienna, Austria, Department of Urology, Pio Da Pietrelcina Hospital, Vasto, Division of Urology, European Institute of Oncology and Department of Urology, Ospedale Maggiore Policlinico, Universita degli Studi di Milano, Milan, Department of Urology, Faculty of Health Sciences, University La Sapienza, Rome and Department of Urology, G. Rummo Hospital, Benevento, Italy, Departments of Urology, Clinical Municipal Hospital, Cluj-Napoca and Emergency Hospital Satu Mare, Satu Mare, Romania, Department of Urology, Hospital Universitario Principe de Asturias, Madrid, Spain, and Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Eur Urol 2015; 67: 943e951.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.040 available at http://jurology.com/ Editorial Comment: This series is a retrospective evaluation of the prognostic significance of perirenal fat invasion (PFI) and renal vein invasion (RVI) in an international pT1 to pT3a clear cell renal cell carcinoma cohort. Estimated 5 and 10-year cancer specific survival differed between patients with pT3a and PFI alone (86%) and those with RVI with or without PFI (75%). Based on these results, the authors propose introduction of a size cutoff of 7 cm in pT3a tumors for further prognostic discrimination. Others have indicated this prognostic size for pT3a tumors even before implementation of the 2009 TNM classification,1 although the present sample is by far the largest. When comparing the prognostic discrimination of the current TNM and alternative stages, including the size cutoff of 7 cm, concordance index increased in 0.5% without CI overlapping, meaning that their proposal is statistically supported. The 2009 TNM version has a slightly increased prognostic discrimination compared to previous versions. Certainly overlap exists for some substages. Recognition that prospective data are scarcely available to support future changes in the TNM does not preclude careful scrutiny of the retrospective data. Current TNM stage T3a classification includes perirenal fat invasion, sinus fat invasion and gross extension of the tumor into the renal vein or its segmental branches. Unfortunately sinus fat invasion was not reported in the present series, and thus questions remain regarding its prognostic value. In addition, the definition of RVI is imprecise in the present study. Accepting that the TNM formulation is somewhat imprecise regarding how to stage possible invasion of the renal vein wall, most uropathologists will label this finding as pT3c when this information is available in retrospective studies. For future reports it might be more appropriate to reserve the word “invasion” for “ingrowth” in the wall of the vein and to use “extension” for anatomical thrombus extension. M. Pilar Laguna, MD, PhD 1. S€uer E, Baltaci S, Burgu B et al: Significance of tumor size in renal cell cancer with perinephric fat infiltration: is TNM staging system adequate for predicting prognosis? Urol J 2013; 10: 774.
1227
1228
IMAGING
Suggested Reading Siemer S, Lehmann J, Loch A et al: Current TNM classification of renal cell carcinoma evaluated: revising stage T3a. J Urol 2005; 173: 33. Leibovich BC, Cheville JC, Lohse CM et al: Cancer specific survival for patients with pT3 renal cell carcinomadcan the 2002 primary tumor classification be improved? J Urol 2005; 173: 716. Thompson RH, Leibovich BC, Cheville JC et al: Is renal sinus fat invasion the same as perinephric fat invasion for pT3a renal cell carcinoma? J Urol 2005; 174: 1218. Siddiqui SA, Frank I, Leibovich BC et al: Impact of tumor size on the predictive ability of the pT3a primary tumor classification for renal cell carcinoma. J Urol 2007; 177: 59. Gofrit ON, Shapiro A, Pizov G et al: Does stage T3a renal cell carcinoma embrace a homogeneous group of patients? J Urol 2007; 177: 1682. Margulis V, Tamboli P, Matin SF et al: Location of extrarenal tumor extension does not impact survival of patients with pT3a renal cell carcinoma. J Urol 2007; 178: 1878. Terrone C, Gontero P, Volpe A et al: Proposal of an improved prognostic classification for pT3 renal cell carcinoma. J Urol 2008; 180: 72. Yoo C, Song C, Hong JH et al: Prognostic significance of perinephric fat infiltration and tumor size in renal cell carcinoma. J Urol 2008; 180: 486.
Imaging Re: Utility of Apparent Diffusion Coefficients in the Evaluation of Solid Renal Tumors at 3T H. Sasamori, M. Saiki, J. Suyama, Y. Ohgiya, M. Hirose and T. Gokan Department of Radiology, Showa University School of Medicine, Tokyo, Japan Magn Reson Med Sci 2014; 13: 89e95.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.055 available at http://jurology.com/ Editorial Comment: This study evaluates 31 patients with renal tumors. All patients were examined using a 3 T magnet and the apparent diffusion coefficient (ADC) values of the masses were calculated. Of the 4 angiomyolipoma cases 1 was a classic fat containing angiomyolipoma and 2 were specifically stated to be fat poor angiomyolipomas. Mean SD ADC values were 0.719 0.172 103 mm2 per second (range 0.606 to 0.817). These ADC values were slightly lower than (but showed some overlap with) the clear cell renal cell carcinoma range of 0.749 to 1.881 103 mm2 per second. Although there were only 31 lesions in this study, with a small number of individual clear cell, papillary and urothelial carcinomas and angiomyolipomas, these results provide further evidence that diffusion weighted imaging at 3 T will be beneficial and yield additional information in evaluating the indeterminate renal mass. Further research and larger studies are needed. Cary Siegel, MD
Re: Renal Masses Measuring under 2 cm: Pathologic Outcomes and Associations with MRI Features A. B. Rosenkrantz, N. E. Wehrli, J. Melamed, S. S. Taneja and M. B. Shaikh Departments of Radiology and Pathology, and Division of Urologic Oncology, Department of Urology, NYU Langone Medical Center, New York, New York Eur J Radiol 2014; 83: 1311e1316.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.056 available at http://jurology.com/ Editorial Comment: This article examines 86 patients with 92 renal masses 2 cm or smaller with a pathological diagnosis. The authors have shown data that are different from prior pathology studies,