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GLOMERULAR FILTRATION RATE AND PERIOPERATIVE OUTCOMES AFTER PARTIAL NEPHRECTOMY FOR MULTIPLE IPSILATERAL RENAL MASSES
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
1231 GLOMERULAR FILTRATION RATE AND PERIOPERATIVE OUTCOMES AFTER PARTIAL NEPHRECTOMY FOR MULTIPLE IPSILATERAL RENAL MASSES Miguel A Mercado*, Alana M Murphy, Gregory W Hruby, Jaime Landman, Mitchell C Benson, James M McKiernan, New York, NY INTRODUCTION AND OBJECTIVES: Historically, patients with multiple renal masses in one kidney underwent radical nephrectomy. The development and refinement of nephron-sparing techniques has provided a novel therapeutic option for patients who have multiple ipsilateral renal masses, with or without contralateral disease. We review our experience with open and laparascopic partial nephrectomy in the management of two or more ispilateral renal masses and the subsequent preservation of renal function. METHODS: The Columbia Urologic Oncology Database was reviewed and 1,244 patients who underwent partial or radical nephrectomy from 1988-2008 were identified. A total of 31 patients underwent partial nephrectomy for multiple ipsilateral renal masses. Pre-operative and post-operative glomerular filtration rate (GFR) was calculated using the MDRD (modification of diet in renal disease) formula. RESULTS: The majority of patients (n=27) underwent open partial nephrectomy and 4 patients underwent laparoscopic partial nephrectomy. The mean follow-up time was 43.9 months. The indication for partial nephrectomy was elective in 19 patients (61.3%) and presence of contralateral renal masses in 12 patients (38.7%). The mean number of renal masses was 2.6 (range 2-6), mean diameter of the largest mass was 2.8 cm (range 0.2-6.3 cm), and mean diameter of the second largest mass was 1.5 cm (range 0.1-3.0 cm). The mean ischemic time was 25 minutes (range 15-40 minutes, data available for 15 patients). A total of 7 perioperative complications were noted (ileus (n=2), hypoxemia (n=1), EKG changes (n=1), respiratory failure (n=1), hyponatremia (n=1)). Final pathologic examination revealed papillary renal cell carcinoma (RCC) in 23 patients (74.2 %), chromophobe RCC in 3 patients (9.7%), oncocytomas in 3 patients (9.7%), angiomyolipomas in one patient (3.2%) and one patient was found to have benign cystic renal disease (3.2%). The overall positive surgical margin rate was 12.9% (4/31). Four patients experienced disease recurrence at a median of 23.3 months. Mean preoperative GFR was 76.1 mL/min (32-132) and mean postoperative GFR was 68.2 mL/min (19-99). CONCLUSIONS: Nephron sparing surgery allows for the preservation of renal function, especially in patients with prior contralateral radical nephrectomy or contralateral disease. At our institution, either open or laparoscopic partial nephrectomy for multiple ipsilateral masses is viable option. Source of Funding: NA
1232 RACIAL DIFFERENCES IN CLEAR CELL RENAL CELL CARCINOMA PRESENTATION AND SURVIVAL Heinric Williams*, Ishai Ross, Mihailo Popovic, Zachary Posey, Isaac J Powell, Detroit, MI INTRODUCTION AND OBJECTIVES: Data from the National Cancer Institute SEER database have demonstrated that African Americans have a higher incidence and mortality rates from renal cell carcinoma (RCC) as compared to other ethnic groups. However, it is unclear which RCC histological subtypes are contributing to this disparity. In this study, we evaluated the patterns of disease presentation and outcomes among both African Americans and Caucasians with a clear cell RCC diagnosis. METHODS: We retrospectively reviewed the charts of 1862 patients who were diagnosed with RCC between 1980 and 2007. We analyzed race, age, gender, stage at diagnosis differences on the incidence and survival among 1239 patients with clear cell RCC. Incidence trends were analyzed by linear regression models and Cox proportional hazard models was used to determine overall survival of patients by race, gender and stage.
439
RESULTS: The median age of 61 at diagnosis was similar for both African Americans and Caucasians. Localized disease accounted for much of the incidence of clear cell RCC with African Americans having a higher incidence rate as compared to Caucasians (p<0.001). Overall, females also had a higher incidence of localized disease as compared to males (p<0.05). With respect to survival, African Americans with localized disease had a poorer survival rate compared to Caucasians (p<0.05). There was no survival difference between the racial groups with respect to regional or distant disease at diagnosis. CONCLUSIONS: Higher incidence rates and lower survival rates were observed for African Americans with localized clear cell RCC at diagnosis. The clear cell RCC subtype is the most common subtype among RCC and thus may explain some of the disparity seen between African Americans and Caucasians with RCC. However, further studies with the other histological subtypes are warranted. Source of Funding: None
1233 THE INCIDENCE OF BENIGN RENAL MASS NEGATIVELY CORRELATES WITH TUMOR SIZE IN MEN ONLY AND IS INFLUENCED BY SURGICAL APPROACH - A MULTICENTRIC STUDY Amnon Zisman*, Zrifin, Israel; Jean-Jacques Patard, Rennes, France; Orit Raz, Zrifin, Israel; Tobias Klatte, Los Angeles, CA; Sonia Mendelovic, Arie Lindner, Zrifin, Israel; Arie S. Belldegrun, Allan J. Pantuck, Los Angeles, CA INTRODUCTION AND OBJECTIVES: The aim of this study is to define preoperative independent predictors for renal mass to harbor benign histology. METHODS: 1664 T1-2N0M0 patients with unilateral renal mass underwent nephrectomy. Study population was divided into 5 groups based on tumor size distribution. Univariate analysis and multivariable analysis were performed in order to determine independent variables predictive of malignant versus benign histology. RESULTS: Surgical approach (OR=2.9, p=0.0001), gender (OR=1.97, p=0.0001) and age (OR=1.01, p=0.007) were found to be independent pre-operative predictors for the malignant-benign distinction. Malignant tumors were more abundant in men (878/1009, 87%) versus women (515/651, 79%, p<0.001). There is a relationship between tumor size and risk of malignancy in men but not in women, (ROC AUC 0.602 versus 0.448 respectively): age adjusted odds ratio (OR): tumor size 0-2.5 cm: 82% in men and 83% in women, 2.5-4.0 cm: 84% (OR-1.09) and 81% (OR-0.87), respectively, 4.1-5 cm: 88% (OR-1.5) and 76% (OR-0.61),respectively, 5.1-7.6 cm: 94% (OR-3.12) and 82% (OR-0.93), respectively and q7.6 cm: 91% (OR-3.12) and 72% (OR-0.58), respectively. High grade RCC were more prevalent in men, 31% grade 3 or 4 versus 21% in women (p=0.001) despite of similar T stage distribution. Histological tumor types distribute differently: 8% papillary RCC in women versus 16% in males, 86% and 78% CCRCC, respectively, 33% and 57% oncocytomas and 40% versus 12% angimyolipomas, respectively. The pre-operative decision on surgical approach based on patient pre-operative consultation resulted in patient selection: 90% malignant tumors for radical nephrectomy versus only 75% for partial nephrectomy (p=0.001) and 31% versus 20% high grade tumors, respectively (p=0.0001). CONCLUSIONS: Renal tumors are benign in 20% of women regardless of size, whereas in men the chance of benign mass decreases with increasing tumor size. Surgeons’ pre-operative decision to perform NSS also appears to cause a selection bias in favor of benign lesions regardless of sex. Our findings justify pre-operative biopsy in women at large and in men with smaller lesions, especially if NSS is pre-operatively believed to be feasible. Such changes could alter current practice and limit the treatment of histologically proven benign lesions to surveillance or ablation only. Source of Funding: None
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
1231 GLOMERULAR FILTRATION RATE AND PERIOPERATIVE OUTCOMES AFTER PARTIAL NEPHRECTOMY FOR MULTIPLE IPSILATERAL RENAL MASSES Miguel A Mercado*, Alana M Murphy, Gregory W Hruby, Jaime Landman, Mitchell C Benson, James M McKiernan, New York, NY INTRODUCTION AND OBJECTIVES: Historically, patients with multiple renal masses in one kidney underwent radical nephrectomy. The development and refinement of nephron-sparing techniques has provided a novel therapeutic option for patients who have multiple ipsilateral renal masses, with or without contralateral disease. We review our experience with open and laparascopic partial nephrectomy in the management of two or more ispilateral renal masses and the subsequent preservation of renal function. METHODS: The Columbia Urologic Oncology Database was reviewed and 1,244 patients who underwent partial or radical nephrectomy from 1988-2008 were identified. A total of 31 patients underwent partial nephrectomy for multiple ipsilateral renal masses. Pre-operative and post-operative glomerular filtration rate (GFR) was calculated using the MDRD (modification of diet in renal disease) formula. RESULTS: The majority of patients (n=27) underwent open partial nephrectomy and 4 patients underwent laparoscopic partial nephrectomy. The mean follow-up time was 43.9 months. The indication for partial nephrectomy was elective in 19 patients (61.3%) and presence of contralateral renal masses in 12 patients (38.7%). The mean number of renal masses was 2.6 (range 2-6), mean diameter of the largest mass was 2.8 cm (range 0.2-6.3 cm), and mean diameter of the second largest mass was 1.5 cm (range 0.1-3.0 cm). The mean ischemic time was 25 minutes (range 15-40 minutes, data available for 15 patients). A total of 7 perioperative complications were noted (ileus (n=2), hypoxemia (n=1), EKG changes (n=1), respiratory failure (n=1), hyponatremia (n=1)). Final pathologic examination revealed papillary renal cell carcinoma (RCC) in 23 patients (74.2 %), chromophobe RCC in 3 patients (9.7%), oncocytomas in 3 patients (9.7%), angiomyolipomas in one patient (3.2%) and one patient was found to have benign cystic renal disease (3.2%). The overall positive surgical margin rate was 12.9% (4/31). Four patients experienced disease recurrence at a median of 23.3 months. Mean preoperative GFR was 76.1 mL/min (32-132) and mean postoperative GFR was 68.2 mL/min (19-99). CONCLUSIONS: Nephron sparing surgery allows for the preservation of renal function, especially in patients with prior contralateral radical nephrectomy or contralateral disease. At our institution, either open or laparoscopic partial nephrectomy for multiple ipsilateral masses is viable option. Source of Funding: NA
1232 RACIAL DIFFERENCES IN CLEAR CELL RENAL CELL CARCINOMA PRESENTATION AND SURVIVAL Heinric Williams*, Ishai Ross, Mihailo Popovic, Zachary Posey, Isaac J Powell, Detroit, MI INTRODUCTION AND OBJECTIVES: Data from the National Cancer Institute SEER database have demonstrated that African Americans have a higher incidence and mortality rates from renal cell carcinoma (RCC) as compared to other ethnic groups. However, it is unclear which RCC histological subtypes are contributing to this disparity. In this study, we evaluated the patterns of disease presentation and outcomes among both African Americans and Caucasians with a clear cell RCC diagnosis. METHODS: We retrospectively reviewed the charts of 1862 patients who were diagnosed with RCC between 1980 and 2007. We analyzed race, age, gender, stage at diagnosis differences on the incidence and survival among 1239 patients with clear cell RCC. Incidence trends were analyzed by linear regression models and Cox proportional hazard models was used to determine overall survival of patients by race, gender and stage.
439
RESULTS: The median age of 61 at diagnosis was similar for both African Americans and Caucasians. Localized disease accounted for much of the incidence of clear cell RCC with African Americans having a higher incidence rate as compared to Caucasians (p<0.001). Overall, females also had a higher incidence of localized disease as compared to males (p<0.05). With respect to survival, African Americans with localized disease had a poorer survival rate compared to Caucasians (p<0.05). There was no survival difference between the racial groups with respect to regional or distant disease at diagnosis. CONCLUSIONS: Higher incidence rates and lower survival rates were observed for African Americans with localized clear cell RCC at diagnosis. The clear cell RCC subtype is the most common subtype among RCC and thus may explain some of the disparity seen between African Americans and Caucasians with RCC. However, further studies with the other histological subtypes are warranted. Source of Funding: None
1233 THE INCIDENCE OF BENIGN RENAL MASS NEGATIVELY CORRELATES WITH TUMOR SIZE IN MEN ONLY AND IS INFLUENCED BY SURGICAL APPROACH - A MULTICENTRIC STUDY Amnon Zisman*, Zrifin, Israel; Jean-Jacques Patard, Rennes, France; Orit Raz, Zrifin, Israel; Tobias Klatte, Los Angeles, CA; Sonia Mendelovic, Arie Lindner, Zrifin, Israel; Arie S. Belldegrun, Allan J. Pantuck, Los Angeles, CA INTRODUCTION AND OBJECTIVES: The aim of this study is to define preoperative independent predictors for renal mass to harbor benign histology. METHODS: 1664 T1-2N0M0 patients with unilateral renal mass underwent nephrectomy. Study population was divided into 5 groups based on tumor size distribution. Univariate analysis and multivariable analysis were performed in order to determine independent variables predictive of malignant versus benign histology. RESULTS: Surgical approach (OR=2.9, p=0.0001), gender (OR=1.97, p=0.0001) and age (OR=1.01, p=0.007) were found to be independent pre-operative predictors for the malignant-benign distinction. Malignant tumors were more abundant in men (878/1009, 87%) versus women (515/651, 79%, p<0.001). There is a relationship between tumor size and risk of malignancy in men but not in women, (ROC AUC 0.602 versus 0.448 respectively): age adjusted odds ratio (OR): tumor size 0-2.5 cm: 82% in men and 83% in women, 2.5-4.0 cm: 84% (OR-1.09) and 81% (OR-0.87), respectively, 4.1-5 cm: 88% (OR-1.5) and 76% (OR-0.61),respectively, 5.1-7.6 cm: 94% (OR-3.12) and 82% (OR-0.93), respectively and q7.6 cm: 91% (OR-3.12) and 72% (OR-0.58), respectively. High grade RCC were more prevalent in men, 31% grade 3 or 4 versus 21% in women (p=0.001) despite of similar T stage distribution. Histological tumor types distribute differently: 8% papillary RCC in women versus 16% in males, 86% and 78% CCRCC, respectively, 33% and 57% oncocytomas and 40% versus 12% angimyolipomas, respectively. The pre-operative decision on surgical approach based on patient pre-operative consultation resulted in patient selection: 90% malignant tumors for radical nephrectomy versus only 75% for partial nephrectomy (p=0.001) and 31% versus 20% high grade tumors, respectively (p=0.0001). CONCLUSIONS: Renal tumors are benign in 20% of women regardless of size, whereas in men the chance of benign mass decreases with increasing tumor size. Surgeons’ pre-operative decision to perform NSS also appears to cause a selection bias in favor of benign lesions regardless of sex. Our findings justify pre-operative biopsy in women at large and in men with smaller lesions, especially if NSS is pre-operatively believed to be feasible. Such changes could alter current practice and limit the treatment of histologically proven benign lesions to surveillance or ablation only. Source of Funding: None