Andrew Wagner, MD, presents the take home messages on kidney cancer from the AUA annual meeting in San Diego.
Presented by Andrew A. Wagner, MD
Harvard Medical School, Boston
• In patients with kidney tumors, the total number of specific chromosomal aberrations detected using interface FISH technology, as well as tumor grade and tumor size, were independent predictors of metastatic disease and overall survival.
• Both platelet derived growth factor beta-receptor and plasma fibrogenic levels were found to be specific indicators of renal cell carcinoma (RCC) progression and overall survival, suggesting possible future use as tumor markers and for categorizing risk.
• HIF-2 alpha, a nuclear transcription factor, may be an important tumor promotor in patients with clear cell RCC. After adjustment for various co-variants, including stage, performance status, and grade, HIF-2 alpha in the cytoplasm remained a significant predictor of cancer-specific survival.
• New nomograms that incorporate C-reactive protein (CRP) appear effective in predicting overall and RCC-specific mortality. CRP had its largest effect on preoperative and postoperative survival nomograms, and concordance was superior to that of existing prediction models.
• Lymphovascular invasion (LVI) was found to be a significant predictor of disease-free and cancer-specific survival in patients with organ-confined clear cell RCC. T1-2 patients with LVI had similar disease-free and cancer-specific survival as T3-4 patients.
• In RCC patients with preoperative lymphadenopathy on cross-sectional imaging, 60% of patients were negative on final pathology, pointing to the need for aggressive lymphadenectomy during surgery.
• Patients undergoing open partial nephrectomy had significantly more superficial wound infections, organ space infections, urinary tract infections, and bleeding events requiring transfusion than those having minimally invasive partial nephrectomy.
• Improved training and simulation is needed for partial nephrectomy. Surgeries conducted with residents and fellows had an increased morbidity rate versus those with attending-only involvement. Complication rates were higher among PGY 6 residents and fellows versus surgeries done with the help of more junior residents.
• Among patients undergoing partial or radical nephrectomy, those at low-volume hospitals were 28% more likely to have an adverse outcome. For every 18 nephrectomies that were redirected to high-volume hospitals, one postoperative complication could be potentially avoided.
• In a large series of kidney cancer biopsies, there was a 22% non-diagnostic rate (63% for cystic lesions), but there was a 92% concordance with RCC subtype. Authors recommended against using biopsy for renal masses <2 cm and those with cystic changes.
• A prospective multicenter registry of patients with small renal masses includes a scoring system that may help differentiate patients suitable for active surveillance from those suitable for surgery.
• Ultimate renal function primarily correlated with parenchymal volume preservation during partial nephrectomy, while warm ischemia time played a secondary role.
• In one comparison of zero-ischemia versus typical clamped robotic partial nephrectomy, less decrease in glomerular filtration rate (GFR) was seen in patients undergoing the zero-ischemia technique. Another group found no demonstrable differences in kidney function between patients having unclamped or clamped partial nephrectomy.
• A comparison of zero-ischemia and short warm ischemia time during minimally invasive partial nephrectomy found no significant difference in GFR between the two groups.
• At 15 years of follow-up, average creatinine concentration remained approximately stable in a nephron-sparing arm and decreased by .25 mg/dL in a radical nephrectomy arm, suggesting that radical nephrectomy patients do slightly better than expected.
• Patients who underwent radical nephrectomy had a higher incidence of de novo hyperlipidemia than partial nephrectomy patients. Those receiving statins after nephrectomy had improved overall and disease-specific survival.UT