CU专题推送（七）| Advances in Renal Cell Carcinoma Management 文章合集

Abstract 

Background: There are various alternative fifirst-line therapeutic options besides tyrosine kinase inhibitors (TKIs) for metastatic renal cell carcinoma (mRCC). To inform therapeutic decision-making for such patients, this study aimed to identify predictive factors for resistance to TKI. 

Materials and methods: A total of 239 cases of mRCC patients who received fifirst-line TKI therapy were retrospectively studied. Patients with a radiologic diagnosis of progressive disease within 3months after initiating therapy were classifified as primary refractory cases; the others were classifified as non-primary refractory cases. The association between primary refractory cases and age, gender, pathology fifindings, serum c-reactive protein (CRP) level, metastatic organ status, and 6 parameters defifined by the International Metastatic Renal Cell Carcinoma Database Consortium were analyzed. 

Results: Of 239 cases, 32 (13.3%) received a radiologic diagnosis of progressive disease within 3months after initiating therapy. The rates of sarcomatoid differentiation, hypercalcemia, a serum CRP level of 0.3mg/dL or higher, presence of liver metastasis, anemia, and time from diagnosis to treatment interval of less than a year were signifificantly higher in the primary refractory group. Multivariate analysis showed that sarcomatoid differentiation, hypercalcemia, a serum CRP level of 0.3mg/dL or higher, and liver metastasis were independently associated with primary refractory disease. A risk-stratifified model based upon the number of patients with these factors indicated rates of primary refractory disease of 4.0%, 10.1%, and 45.0% for patients with 0, 1, and 2 or more factors, respectively. 

Conclusions: Sarcomatoid differentiation, hypercalcemia, an elevated serum CRP level, and presence of liver metastasis were associated with primary refractory disease in mRCC patients receiving fifirst-line TKI therapy. These results provide clinicians with useful information when selecting a fifirst-line therapeutic option for mRCC patients.

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Teishima J, Murata D, Inoue S, Hayashi T, Mita K, Hasegawa Y, Kato M, Kajiwara M, Shigeta M, Maruyama S, Moriyama H, Fujiwara S, Matsubara A. Prediction of early progression of metastatic renal cell carcinoma treated with first-line tyrosine kinase inhibitor. Curr Urol 2021;15(4):187–192. doi: 10.1097/ CU9.0000000000000042

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Abstract 

Background: In patients with high-risk bladder cancer and concomitant upper urinary tract malignancies, simultaneous cystectomy and nephroureterectomy is the principle oncological procedure of choice. Nevertheless, there are still not many reports of simultaneous robot-assisted radical cystectomy (RARC) and nephroureterectomy. Therefore, the aim of this study was to evaluate outcomes and complications of simultaneous RARC and laparoscopic nephroureterectomy in our institution. 

Materials and methods: This case series evaluated our initial clinical results of 3 patients who underwent simultaneous laparoscopic unilateral nephroureterectomy and RARC with the da Vinci Xi system between 2019 and 2020 at our hospital. Demographic data, preoperative parameters, and postoperative parameters were retrospectively analyzed. 

Results: All 3 patients were men whose median age was 75 years (range 73–89 years). The median total operative time was 435 minutes (range 429–484 minutes), median estimated blood loss was 377mL (range 125–410mL), and median hospital stay was 26 days (range 21–36 days). In all 3 cases, each trocar was used in 7 ports. The postoperative complications were stratifified according to the Clavien-Dindo Classifification system, and a grade 3B complication developed in 1 patient: trocar site herniation of the small bowel. 

Conclusions: We reported our initial experience of simultaneous laparoscopic nephroureterectomy and RARC. A large-scale prospective, randomized, controlled trial will be required to prove the feasibility and safety of simultaneous laparoscopic nephroureterectomy and RARC.

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Yajima S, Nakanishi Y, Matsumoto S, Tanabe K, Masuda H. Simultaneous laparoscopic nephroureterectomy and robot-assisted radical cystectomy: Lessons learned from our initial experience. Curr Urol 2021;15(4):193–197. doi: 10.1097/ CU9.0000000000000043

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Abstract 

Background: We investigated the characteristics and outcomes of patients who underwent open partial nephrectomy (OPN) in the minimally invasive approach era. 

Materials and methods: We retrospectively reviewed 52 patients (55 cases) who underwent OPN from May 2009 to March 2016. We assessed perioperative change in estimated glomerular fifiltration rate (eGFR), complications, and oncological outcomes. Tumor complexity was evaluated using the R.E.N.A.L nephrometry score (NS) and the modifified NS. 

Results: Fifteen cases (27%) had imperative indications and 40 (73%) had elective indications. The elective cases were more likely to have adverse tumor complexity based on NS. The perioperative complication rate defifined as a Clavien-Dindo grade ≥IIIa was 11%. The rate of postoperative decline in eGFR at 1month, 1 year, and 2 years was 22%, 20%, and 21%, respectively. Multivariate analysis revealed that male gender (odds ratio [OR] 11.8, p=0.03), NS ≥9 (OR 13.9, p=0.02), modifified NS ≥11 (OR 13.5, p=0.01), and cold ischemic time ≥40 minutes (OR 7.9, p=0.04) were signifificantly associated with worsening eGFR at 1 year after surgery. During a median follow-up period of 52months, the 5-year overall survival and recurrence-free survival rates were 93% and 84%, respectively. 

Conclusions: OPN is acceptable with regard to oncological outcomes and complications in the minimally invasive surgery era. We propose that OPN should be the preferred approach in cases in which it is technically diffificult to preserve maximum renal function via a minimally invasive approach.

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Shibamori K, Hashimoto K, Shindo T, Tabata H, Kyoda Y, Kobayashi K, Tanaka T, Masumori N. Outcomes of open partial nephrectomy for renal cell carcinoma in the minimally invasive approach era. Curr Urol 2021;15(4):198–203. doi: 10.1097/ CU9.0000000000000046

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Abstract 

Introduction: Minimally invasive partial nephrectomy is standard of care treatment for small renal masses. We evaluated the relationship between subcutaneous and visceral obesity with high-grade postoperative 30-day complications in patients undergoing minimally invasive partial nephrectomy. 

Methods: We retrospectively identifified 98 patients at our institution from 2014 to 2017 who underwent laparoscopic or roboticassisted partial nephrectomy due to suspected renal cell carcinoma. Patients were stratifified based on presence or absence of highgrade (Clavien ≥ IIIa) 30-day postoperative complications. Means were compared with the independent t test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of high-grade 30-day complications. 

Results: Mean nephrometry score was 6.7 with 21 (21.4%) patients having hilar tumors. Mean estimation of blood loss was 207mL, mean operating time was 223min, and mean warm ischemia time was 23min. The majority of patients had clear renal cell carcinoma (n=83, 84.7%) and pT1a disease (n=76, 77.6%) with negative margins (n=89, 90.8%) on pathology. There were 5 (5.1%) patients who experienced a high-grade postoperative 30-day complication. Mean visceral fat index was an independent predictor of highgrade 30-day complications (odds ratio: 1.02; 95% confifidence interval: 1.002–1.03; p=0.027). 

Conclusions: Visceral obesity should be considered as a prognostic indicator of outcomes in patients undergoing surgical treatment for a small renal mass.

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Nesbitt K, Sharma P. Visceral fat is associated with high-grade complications in patients undergoing minimallyinvasive partial nephrectomy for small renal masses. Curr Urol 2021;15(1):52–58. doi: 10.1097/CU9.0000000000000001

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Abstract 

Background: Renal cell carcinoma (RCC) has traditionally been considered to be radioresistant. Response rates are believed to be improved by a high dose of stereotactic body radiotherapy (SBRT). A retrospective analysis was conducted of patients treated with SBRT for metastatic disease from RCC. 

Materials and methods: We reviewed records from 20 patients who underwent SBRT for a total of 30 RCC metastases from 2015 to 2020. Patients were included who had a confirmed primary RCC and radiographic evidence of metastasis, either synchronous or metachronous. The most common SBRT fractionation was 30 Gy in 3 fractions. 

Results: Median age was 60 years (range, 40–77 years) and 60% were male. After a median follow-up of 18 months (range, 3–36 months), overall survival was estimated to be 85% and 70%, at 1 and 2 years, respectively, and local control at 2 years was 83.33%. Only 5 patients had documented progression of disease, all of whom received biologically effective dose inferior to 100 Gy, and no patients treated with a higher biologically effective dose had disease, which progressed. The most common acute toxicity was grade 1 fatigue (20%). No grade 3 or higher acute toxicity occurred. 

Conclusions: Treatment with SBRT in patients with RCC metastases yielded a high local control rate, promising survival rate, and low toxicity.

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Rida H, Zaine H, Jouhadi H, Benider A, Samlali H, Samlali R. Stereotactic body irradiation for metastasis from renal carcinoma: a retrospective study. Curr Urol 2023;00(00):00–00. doi: 10.1097/ CU9.0000000000000191

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