Ahmet Bindayi

Neoadjuvant therapy for localized and locally advanced renal cell carcinoma

Neoadjuvant Targeted Molecular Therapy in the setting of localized and locally advanced renal cell carcinoma has emerged as a strategy to render primary renal tumors amenable to planned surgical resection in settings where radical resection or nephron-sparing surgery was not thought to be safe or feasible. Presurgical tumor reduction has been demonstrated in a number of studies including a recently published randomized double-blind placebo-controlled study, and an expanding body of literature suggests benefit in select patients. Nonetheless, most reports are small phase II clinical trials or retrospective reports. Thus, large randomized clinical trial data are not present to support this approach, and guidelines for use of presurgical therapy have not been promulgated. The advent of immunomodulation through checkpoint inhibition represents an exciting horizon for neoadjuvant strategies. This article reviews the current status and future prospects of neoadjuvant therapy in nonmetastatic renal cell carcinoma.

Utilization and quality outcomes of cT1a, cT1b and cT2a partial nephrectomy: analysis of the national cancer database

To describe the utilization and compare quality outcomes of partial nephrectomy (PN) for cT1a, cT1b and cT2a renal masses using a large national database.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group)

BACKGROUNDnWhile partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented worldwide.nnnOBJECTIVEnTo analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass).nnnINTERVENTIONnRobotic-assisted PN.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPatients demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival.nnnRESULTS AND LIMITATIONSnA total of 298 patients were analyzed. Median tumor size was 7.6 (7-8.5) cm. Median RENAL score was 9 (8-10). Median ischemia time was 25 (20-32) min. Median estimated blood loss was 150 (100-300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12-0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5-35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design.nnnCONCLUSIONSnRAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication.nnnPATIENT SUMMARYnThis report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.

Comparison of functional outcomes of robotic and open partial nephrectomy in patients with pre-existing chronic kidney disease: a multicenter study

BackgroundWe compared renal functional outcomes of robotic (RPN) and open partial nephrectomy (OPN) in patients with chronic kidney disease (CKD), a definite indication for nephron-sparing surgery.MethodsA multicenter retrospective analysis of OPN and RPN in patients with baseline ≥u2009CKD Stage III [estimated glomerular filtration rate (eGFR) <u200960xa0mL/min/1.73xa0m2] was performed. Primary outcome was change in eGFR (ΔeGFR, mL/min/1.73xa0m2) between preoperative and last follow-up with respect to RENAL nephrometry score group [simple (4–6), intermediate (7–9), complex (10–12)]. Secondary outcomes included eGFR decline >u200950%.Results728 patients (426 OPN, 302 RPN, mean follow-up 33.3xa0months) were analyzed. Similar RENAL score distribution (pu2009=u20090.148) was noted between groups. RPN had lower median estimated blood loss (pu2009<u20090.001), and hospital stay (3 vs. 5xa0days, pu2009<u20090.001). Median ischemia time (OPN 23.7 vs. RPN 21.5xa0min, pu2009=u20090.089), positive margin (pu2009=u20090.256), transfusion (pu2009=u20090.166), and 30-day complications (pu2009=u20090.208) were similar. For OPN vs. RPN, mean ΔeGFR demonstrated no significant difference for simple (0.5 vs. 0.3, pu2009=u20090.328), intermediate (2.1 vs. 2.1, pu2009=u20090.384), and complex (4.9 vs. 6.1, pu2009=u20090.108). Cox regression analysis demonstrated that decreasing preoperative eGFR (OR 1.10, pu2009=u20090.001) and complex RENAL score (OR 5.61, pu2009=u20090.03) were independent predictors for eGFR decline >u200950%. Kaplan–Meier analysis demonstrated 5-year freedom from eGFR decline >u200950% of 88.6% for OPN and 88.3% for RPN (pu2009=u20090.724).ConclusionsRPN and OPN demonstrated similar renal functional outcomes when stratified by tumor complexity group. Increasing tumor age and tumor complexity were primary drivers associated with functional decline. RPN provides similar renal functional outcomes to OPN in appropriately selected patients.

Renal Functional Outcome of Partial Nephrectomy for Complex R.E.N.A.L. Score Tumors With or Without Neoadjuvant Sunitinib: A Multicenter Analysis

Background Sunitinib might optimize the feasibility of partial nephrectomy (PN) for complex renal tumors with imperative indications. We compared the renal functional outcomes of patients with complex renal masses who had undergone sunitinib before PN with those of patients who had not required neoadjuvant sunitinib before PN. Patients and Methods We performed a multicenter retrospective analysis of patients with renal cell carcinoma who had undergone PN for a complex renal mass (R.E.N.A.L. nephrometry score, 10‐12) and imperative indications from January 2012 to July 2014. Neoadjuvant sunitinib was used in cases for which PN was not considered feasible. The cohort was divided into those patients who had undergone PN without neoadjuvant sunitinib and those who had undergone PN after sunitinib (no‐neoadjuvant vs. neoadjuvant). The change in tumor size and R.E.N.A.L. score were assessed. The primary outcome was the change in the estimated glomerular filtration rate (&Dgr;eGFR) from preoperatively to the last postoperative follow‐up visit. Results The data from 125 consecutive patients were analyzed (47 neoadjuvant and 78 no‐neoadjuvant; median follow‐up, 21 months). The neoadjuvant plus PN patients had had a greater median tumor size preoperatively (7.2 vs. 6 cm; P = .045). Sunitinib caused a significant decrease in the median tumor size (from 7.2 to 5.8 cm [19.4%]; P = .012) and R.E.N.A.L. score (from 11 to 9; P = .001). No significant differences were found between the neoadjuvant and no‐neoadjuvant groups in the ischemia time (P = .413) or incidence of complications (P = .728). The median &Dgr;eGFR was similar (neoadjuvant, 6.4; no‐neoadjuvant, 6.1; P = .534). Linear regression analysis for factors associated with an increasing &Dgr;eGFR demonstrated increasing age (estimate, −0.074; P = .009) increasing body mass index (estimate, −0.087; P = .043), and decreasing baseline eGFR (estimate, −0.104; P = .02) as significant factors. Conclusion The use of neoadjuvant sunitinib might facilitate complex PN and result in renal functional outcomes similar to those of patients with a complex renal mass who had not required neoadjuvant sunitinib. Micro‐Abstract Neoadjuvant sunitinib might facilitate partial nephrectomy (PN) in imperative indications. We performed a retrospective comparison of functional outcomes in patients who had and had not received neoadjuvant sunitinib before PN for imperative indications. We noted similar renal functional outcomes between the 2 groups. To the best of our knowledge, these findings represent the first such reported comparison.

Can multiphase CT scan distinguish between papillary renal cell carcinoma type 1 and type 2

OBJECTIVEnTo investigate the utility of multiphase computed tomography (CT) and percutaneous renal mass biopsy (PRMB) in differentiating between papillary renal cell carcinoma (pRCC)-Type 1 and -Type 2, as emerging data have suggested differential enhancement patterns in different renal tumor histologies.nnnMATERIAL AND METHODSnRetrospective analysis of 51 patients (23 pRCC-Type 1/28 pRCC-Type 2) who underwent multiphase CT followed by surgery from July 2011 to April 2016 was performed. Data were analyzed between subgroups based on histology. Multiphase CT was analyzed for tumor size, and attenuation [Hounsfield Units (HU)]. Change in HU (ΔHU) was calculated between noncontrast (NC), corticomedullary (CM), nephrographic (N), and delayed (D) phases. Subset analysis was carried out on patients who underwent PRMB prior to surgery.nnnRESULTSnThere was no difference in median tumor size (pRCC-Type 1 2.8 vs. pRCC-Type 2 2.6 cm, p=0.832). In addition to tumor size being similar between groups, distribution of tumor stages between groups was also similar (p=0.651). Greater proportion of high-grade tumors (III/IV) was noted in pRCC-Type 2 (42.9% vs. 8.7%) (p=0.011). There was no difference in HU values for NC (p=0.961), CM (p=0.118), N (p=0.277), and D (p=0.256) phases, and in ΔHU between CM-NC (p=0.278), N-NC (p=0.316), and D-NC (p=0.103). Thirteen patients underwent percutaneous biopsy, 11 of whom had diagnostic samples. Examination of 10/11 (90.9%) samples accurately predicted correct histology, and of 6/11 (54.5%) samples correctly identified high-vs. low-grade histology.nnnCONCLUSIONnOur findings suggest substantial overlap of CT findings, despite pRCC-Type 2 having greater proportion of high-grade tumors. Utility of CT is limited in the differentiation between pRCC subtypes. Patients with suggested pRCC on CT imaging being considered for a non-extirpative strategy should undergo PRMB for risk stratification.