Atlanta-Two studies presented here at the AUA annual meeting suggest that new treatments could be on the horizon for the treatment of elderly patients with renal cancer and comorbid conditions. The studies are small, follow-up was relatively short, and both investigators stated emphatically that the oncologic safety of these treatments must be studied further.
W. Scott Webster, MD, examined 3-month outcomes with percutaneous image-guided cryotherapy in 27 consecutive patients with solid renal tumors (median volume, 27.1 cm3 ). Median age of patients in this study was 78 years.
Dr. Webster cautioned that this procedure is still investigational, and should be performed only at an academic center under a strict study protocol. Case selection criteria used at the Mayo Clinic for percutaneous therapy include significant medical comorbidities, advanced age, chronic renal insufficiency, a solitary kidney, previous bilateral partial nephrectomy, von Hippel-Lindau disease, tuberous sclerosis complex, symptomatic metastatic renal cancer, and patient choice.
Dr. Webster prefers percutaneous procedures to radiofrequency ablation for treatment of tumors of large diameter or those adjacent to the ureter, bowel, or adrenal gland, requiring mobilization. He observed that at 3-month follow-up in the Mayo Clinic study, percutaneous cryoablation was safe and effective in tumors between 2 and 7 cm and those proximate to the ureter, bowel, or adrenal tissue.
Asked whether either procedure had demonstrated superior safety and efficacy, Dr. Webster responded, "There is no clear winner. We need to continue to evaluate the oncologic safety of both procedures."
He believes that one, not both therapies, will become the standard of care.
In a related study performed at New York University Medical Center, researchers reported findings from a head-to-head study of 15 elderly patients who underwent either laparoscopic partial nephrectomy or laparoscopic cryoablation.
Patients were matched for age and tumor size. Average age of those undergoing laparoscopic partial nephrectomy was 75 years; the average age of those who underwent a laparoscopic cryoablative technique was 76 years. Average tumor size was similar in both groups at about 2.5 cm.
"The postoperative course was similar in the two groups, but the laparoscopic partial nephrectomy cohort did have a significantly higher estimated blood loss (222 cc vs. 59 cc, p=.007) and operative time (242 minutes vs. 152 minutes, p<.001)," lead author Rebecca O'Malley, MD, resident in urology at NYU working with Samir S. Taneja, MD, told Urology Times. "These differences didn't seem clinically significant, however, because only one patient needed transfusion, and post-op hematocrits were similar.
The researchers observed no evidence of disease in either group at a median follow-up of 11 months.
"Many of us had assumed that older patients with comorbidities cannot tolerate laparoscopic partial nephrectomy, but we found that many of these elderly patients with multiple comorbities did quite well," Dr. O'Malley explained. "In skilled hands, laparoscopic partial nephrectomies should be considered more often, even in patients between 70 and 85 years of age, if they can tolerate a significant period of anesthesia."
She added that as more laparoscopic partial nephrectomies are performed at NYU Medical Center, the conversion rate is declining.