Nephron-sparing Surgery Is Equally Effective to Radical Nephrectomy for T1BN0M0 Renal Cell Carcinoma: A Population-based Assessment

doi:10.1016/j.urology.2009.04.098

Urology

Volume 75, Issue 2, February 2010, Pages 271-275

https://doi.org/10.1016/j.urology.2009.04.098 Get rights and content

Objectives

To test the effect of nephron-sparing surgery (NSS) vs radical nephrectomy (RN) on cancer-specific mortality (CSM) in patients with T1bN0M0 renal cell carcinoma (RCC) in a population-based cohort. To date, only few series from tertiary care centers supported the use of NSS for T1bN0M0 (range 4-7 cm) RCC.

Methods

The Surveillance, Epidemiology, and End Results database allowed us to identify 275 NSS (5.3%) and 4866 RN (94.7%) patients treated for T1bN0M0 RCC between 1988 and 2004. Analyses matched for age, year of surgery, tumor size, and Fuhrman grade addressed the effect of nephrectomy type (NSS vs RN) on CSM.

Results

Five years after surgery, the surviving proportions of NSS and RN patients matched for age, tumor size, and year of surgery were respectively 91.4 and 95.3% and 90.1 and 93.8% in the cohort, where additional matching for Fuhrman grade was performed. Neither of the matched analyses resulted in statistically significant CSM difference (P = .1 and .4) between NSS and RN. Similarly, competing-risks regression analyses based on both matching schemes also failed to reveal statistically significant CSM differences (P = .3 and .3).

Conclusions

Our study represents the largest and the only population-based analysis of cancer control efficacy of NSS vs RN in T1bN0M0 RCC. It indicates that NSS does provide equivalent cancer control relative to RN. In consequence, based on cancer control equivalence, NSS should be given equal consideration to RN in patients with T1bN0M0 lesions.

Section snippets

Material and Methods

Patients diagnosed with primary invasive kidney cancer between 1988 and 2004 were identified within 9 SEER cancer registries. The registries include the Atlanta, Detroit, San Francisco-Oakland, and Seattle-Puget Sound Metropolitan areas, as well as the states of Connecticut, Hawaii, Iowa, New Mexico, and Utah. Characteristics of the SEER population are comparable with that of the general population of the United States. The 2 kidney cancer diagnostic codes (International Classification of

Results

The selection criteria resulted in the identification of 5141 patients with T1bN0M0 RCC, aged ≥ 18 years, who had malignant renal cortical tumors sized between 4 and 7 cm. Of those patients, 275 (5.4%) underwent NSS and 4866 (94.6%) had a RN.

The 275 NSS patients were matched with 1100 of 4866 available (22.6%) RN cases. Matching was made for age, tumor size, and year of surgery. When Fuhrman grade was added to the other 3 matching variables, 163 (56.5%) of 275 NSS patients could be matched with

Comment

We hypothesized that NSS would result in the same cancer control rate as RN. Our results confirmed our hypothesis and demonstrated a virtual equivalence of CSM after NSS vs RN in 2 distinct analytic approaches: in Cox and in competing-risks regression models. Therefore, based on cancer control outcomes, our findings suggest that in patients with T1bN0M0 lesions, NSS should be given equal consideration as RN.

The current study focused on 275 NSS cases. The sample size substantially exceeds the

Conclusions

In conclusion, despite its limitations, our study strongly suggests that in patients with T1bN0M0 RCC, NSS does provide equivalent cancer control relative to RN. In consequence, NSS should be given equal consideration as RN when surgical treatment options are considered for T1bN0M0 lesions.

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Partial nephrectomy (PN) for clinical stage T3 tumors is controversial. Radical nephrectomy (RN) has been associated with a greater rate of chronic kidney disease, an increased risk of cardiovascular disease, and increased mortality compared with PN. We present our long-term 2-center experience with PN for stage pT3a tumors and compare the oncologic outcomes with those of similar patients treated with RN.
We reviewed the data from all patients who had undergone nephrectomy for renal cell carcinoma from 1987 to 2015 in 2 medical centers. The study included 134 patients with pathologic stage T3a tumors, of whom 48 and 86 underwent PN and RN, respectively. We compared the 2 groups (PN and RN) using univariate and multivariate analyses.
The tumors of all patients with pathologic stage T3a who had undergone PN had been pathologically upstaged from clinical stage T1 or T2. Univariate and multivariate analyses revealed tumor size was significantly different statistically between the study groups (median, 7.0 cm in RN group vs. 4.0 cm in PN group; P < .001). Surgery type was not a predictor of local recurrence (P = .978), metastatic progression (P = .972), death from renal cancer (P = .626), or death from all causes (P = .974) at the 5-year follow-up point.
The results of the present study have shown similar oncologic outcomes between 48 patients with stage pT3a renal cancer who underwent PN and 86 patients who underwent RN. Although PN was not performed on clinical T3a tumors, our findings suggest that PN can also be considered for these tumors and, thus, avoid the long-term complications of RN. However, strict follow-up protocols are mandatory.
Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-analysis of Comparative Studies
2017, European Urology
Partial nephrectomy (PN) is the reference standard of management for a cT1a renal mass. However, its role in the management of larger tumors (cT1b and cT2) is still under scrutiny.
To conduct a meta-analysis assessing functional, oncologic, and perioperative outcomes of PN and radical nephrectomy (RN) in the specific case of larger renal tumors (≥cT1b). The primary endpoint was an overall analysis of cT1b and cT2 masses. The secondary endpoint was a sensitivity analysis for cT2 only.
A systematic literature review was performed up to December 2015 using multiple search engines to identify eligible comparative studies. A formal meta-analysis was performed for studies comparing PN to RN for both cT1b and cT2 tumors. In addition, a sensitivity analysis including the subgroup of studies comparing PN to RN for cT2 only was conducted. Pooled estimates were calculated using a fixed-effects model if no significant heterogeneity was identified; alternatively, a random-effects model was used when significant heterogeneity was detected. For continuous outcomes, the weighted mean difference (WMD) was used as summary measure. For binary variables, the odds ratio (OR) or risk ratio (RR) was calculated with 95% confidence interval (CI). Statistical analyses were performed using Review Manager 5 (Cochrane Collaboration, Oxford, UK).
Overall, 21 case-control studies including 11 204 patients (RN 8620; PN 2584) were deemed eligible and included in the analysis. Patients undergoing PN were younger (WMD −2.3 yr; p < 0.001) and had smaller masses (WMD −0.65 cm; p < 0.001). Lower estimated blood loss was found for RN (WMD 102.6 ml; p < 0.001). There was a higher likelihood of postoperative complications for PN (RR 1.74, 95% CI 1.34–2.2; p < 0.001). Pathology revealed a higher rate of malignant histology for the RN group (RR 0.97; p = 0.02). PN was associated with better postoperative renal function, as shown by higher postoperative estimated glomerular filtration rate (eGFR; WMD 12.4 ml/min; p < 0.001), lower likelihood of postoperative onset of chronic kidney disease (RR 0.36; p < 0.001), and lower decline in eGFR (WMD −8.6 ml/min; p < 0.001). The PN group had a lower likelihood of tumor recurrence (OR 0.6; p < 0.001), cancer-specific mortality (OR 0.58; p = 0.001), and all-cause mortality (OR 0.67; p = 0.005). Four studies compared PN (n = 212) to RN (n = 1792) in the specific case of T2 tumors (>7 cm). In this subset of patients, the estimated blood loss was higher for PN (WMD 107.6 ml; p < 0.001), as was the likelihood of complications (RR 2.0; p < 0.001). Both the recurrence rate (RR 0.61; p = 0.004) and cancer-specific mortality (RR 0.65; p = 0.03) were lower for PN.
PN is a viable treatment option for larger renal tumors, as it offers acceptable surgical morbidity, equivalent cancer control, and better preservation of renal function, with potential for better long-term survival. For T2 tumors, PN use should be more selective, and specific patient and tumor factors should be considered. Further investigation, ideally in a prospective randomized fashion, is warranted to better define the role of PN in this challenging clinical scenario.
We performed a cumulative analysis of the literature to determine the best treatment option in cases of localized kidney tumor of higher clinical stage (T1b and T2, as based on preoperative imaging). Our findings suggest that removing only the tumor and saving the kidney might be an effective treatment modality in terms of cancer control, with the advantage of preserving the kidney function. However, a higher risk of perioperative complications should be taken into account when facing larger tumors (clinical stage T2) with kidney-sparing surgery.
Partial vs Radical Nephrectomy for T1-T2 Renal Masses in the Elderly: Comparison of Complications, Renal Function, and Oncologic Outcomes
2017, Urology
To compare outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in patients 65 years and older.
Our institutional renal mass registry was queried for patients 65 and older with solitary cT1-T2 renal mass resected by PN or RN. Clinicopathologic features and perioperative outcomes were compared between groups. Renal function outcomes measured by change in estimated glomerular filtration rate (eGFR) and freedom from eGFR< 45 mL/min/1.73 m² were analyzed. Multivariate Cox proportional hazard models for overall survival and cancer-specific survival were analyzed.
Overall, 787 patients met inclusion criteria. Of these, 437 (55.5%) underwent PN and 350 (44.5%) underwent RN. Median follow-up was 36 months. Patients in the PN cohort were younger (median age 70.3 years vs 71.9 years, P < .001), had lower American Society of Anesthesiologists scores (2.6 vs 2.8, P = .001), smaller tumors (tumor diameter 2.8 cm vs 5.0 cm, P < .001), and lower proportion of renal cell carcinoma (76.7% vs 87.4%, P < .001). Perioperative outcomes were similar between PN and RN groups as were complications (37.8% vs 38.9%). Estimated change in eGFR was less in PN vs RN (6.4 vs 19.7, P < .001) at last follow-up. Overall survival and cancer-specific survival were equivalent between modalities.
Because the renal functional benefit of PN is realized over many years and the procedure has a higher historical complication rate than RN, some suspected elderly patients might benefit more from RN over PN. However, these data suggest that elderly patients are not harmed and may potentially benefit from PN. Age alone should not be a contraindication to nephron-sparing surgery.
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: Pierre I. Karakiewicz is partially supported by the University of Montreal Health Center Urology Associates, Fonds de la Recherche en santé du Quebec, the University of Montreal Department of Surgery and the University of Montreal Health Center (CHUM) Foundation.

: Maxime Crépel is partially supported by the Association Française d'urologie.

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Renal CancerNephron-sparing Surgery Is Equally Effective to Radical Nephrectomy for T1BN0M0 Renal Cell Carcinoma: A Population-based Assessment

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

Lancet Oncol

J Urol

J Urol

J Urol

Eur Urol

Urology

J Urol

J Urol

Eur Urol

J Urol

Renal Cancer
Nephron-sparing Surgery Is Equally Effective to Radical Nephrectomy for T1BN0M0 Renal Cell Carcinoma: A Population-based Assessment