J. Tostain

45 Chromophobe renal cell carcinoma: A comprehensive analysis of 104 cases from a multicentric European database

bjectives. To analyze the clinical behavior of chromophobe renal cell carcinoma (CRCC), we retrospecively evaluated the data from six European centers. In 1985, CRCC was identified as a new RCC histologic ubtype. Because of its low frequency, only few large CRCC series are available. ethods. We created a renal cancer database including 3228 patients who underwent surgery between 986 and 2002 in six European centers. The relevant clinical and pathologic data were extracted from the linical charts at each institution and collected into a unique database. esults. Of the 3228 patients, 104 (3.2%) affected by CRCC were identified. The mean age at diagnosis was 7.6 years (range 22 to 83). Of the 104 patients, 51 (49%) were men and 53 (51%) were women. The mean umor size was 6.4 3.6 cm. An incidental diagnosis accounted for 61.5% of the cases. Radical nephrecomy was performed in 88 patients (85%). After a median follow-up of 38 months (mean 44, range 1 to 153), o local recurrence was observed. The 5-year overall survival rate for CRCC was 81%. Of the 104 patients, (4.8%) and 9 (8.6%) died of unrelated causes and renal cancer, respectively. onclusions. Our series confirmed a favorable outcome for the CRCC subtype with little local aggressiveess and a low propensity for progression and death from cancer. UROLOGY 65: 681–686, 2005.

Intérêt de la néphrectomie partielle pour la préservation de la fonction rénale des patients ayant une tumeur rénale de plus de 4 cm

OBJECTIVEnThe objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm.nnnMETHODSnThe data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR<30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant.nnnRESULTSnSeven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors>4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004).nnnCONCLUSIONnThe renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.

Transversal European survey on testosterone deficiency diagnosis

Background: Despite being one of the relevant public health threats among ageing men, testosterone deficiency syndrome (TDS) is under-recognized and under-diagnosed. Objective: To assess current clinical practices of European physicians regarding diagnosis and management of TDS compared with current guidelines. Methods: Postal survey conducted June–November 2008 in France, Germany, Italy and Spain among urologists, endocrinologists and general practitioners to collect information regarding knowledge of TDS. Results: Among 801 respondents, the majority of endocrinologists and urologists had received training on TDS, either initially or as part of continuous medical education. TDS was recognized by 86.5% of physicians as a true clinical entity, and estimated the prevalence at 10–15% of the male population; 73.5% considered that symptoms and a low level of testosterone were required for diagnosis. Treatment preferences were quarterly intramuscular injections (26.3% of physicians), percutaneous gels (23.9%), matrix patch (21.2%), semi-monthly injections (15.4%) and oral therapy (13.4%). Adverse effects of testosterone replacement therapy, such as benign prostatic hyperplasia and prostate cancer, were a concern for physicians. Conclusions: TDS management appeared to be close to that recommended in international guidelines. Signs and symptoms of testosterone deficiency were fairly well known, but some diagnostic and treatment variations were observed.

Élargir les indications de la néphrectomie partielle induit-il un surcroît de morbidité ? ☆: Une étude multicentrique française

OBJECTIVEnTo evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study.nnnMATERIALS AND METHODSnSeven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fishers test) and Student t-test.nnnRESULTSnSix hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4).nnnCONCLUSIONnBroader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.

Quelle pratique de la néphrectomie partielle en France ? [What is the clinical practice of partial nephrectomy in France?]

OBJECTIVEnTo describe the practice of partial nephrectomy (PN) in France and assess its results in terms of morbidity and cancer control.nnnMATERIAL AND METHODnSeven French University Hospitals in which nephron sparing surgery represents at least 30% of the total number of nephrectomies for renal tumour, participated in this study. All centres included, as exhaustively as possible, all their PN cases. For each patient, 70 variables were harvested in order to characterize the patient population, the indications, the operative technique, the per- and postoperative course and complications, the tumor specificities, the carcinologic control and renal function follow-up.nnnRESULTSnSeven hundred and forty-one PN, of which 579 for malignant tumours were analysed. The mean tumour size was 3.4+/-2.1 cm (0.1-18) and 20.8% of the tumours were larger than 4 cm. In 30.1% of cases, the indication was imperative. Among the PN, 12.2% were performed laparoscopically. The mean operating time was 151+/-54.2 min (55-420). The medical and surgical complications rates were respectively 15.2 and 14.7%. At a mean 38 months follow-up, the local recurrence rate was 3.5% and the specific death rate was 4.5%.nnnCONCLUSIONnPN is nowadays getting a more and more widely used technique in France. This expansion is completely justified by its results and urologists must consider nephron sparing surgery as the gold standard treatment for renal tumours measuring less than 4 cm.

Article originalRésultats de l’aspiration cytologique à l’aiguille fine dans le diagnostic des tumeurs solides du rein de nature indéterminéeResults of fine-needle aspiration cytology (FNAC) in the diagnosis of indeterminate solid renal tumours☆

OBJECTIVEnTo evaluate the accuracy of fine-needle aspiration cytology for the diagnosis of imaging indeterminate solid renal tumours.nnnMATERIALS AND METHODSnFrom February 2003 to February 2009, 60 cytoaspirations have been performed to 20 female and 40 male patients (average age: 62.0+/-14.2 years) with an indeterminate solid renal mass by imaging. The average tumour size was 3.4+/-2.8 cm. The cytoaspiration was performed through a 22 Gauge needle under CT (n=39) or US (n=21) guidance. Papanicolaou staining was used. All slides were examined by one experienced cytologist without any clinicoradiological information. The results were given as malignant, benign, suspect or non significant. A classification of subtypes of renal cancer might be added by the cytologist.nnnRESULTSnTwenty-one cytoaspirations (35%) were non significant while 39 (65%) showed cells of interest. Among these 39 cellular cytoaspirations, the specificity for malignancy or benignity was 89.7%. The proportion of non-significant samples was the same in tumors lesser than 2 cm (38.4%) as in tumors 2-4 cm (38.8%) (p=1.000, Fishers exact test). Subtype identification was only reliable for clear cell carcinomas. No complication was observed.nnnCONCLUSIONnThe fine-needle aspiration cytology is an auxiliary technique for the diagnosis of indeterminate solid renal tumours. This simple and mini-invasive technique had a high specificity but a low sensitivity in our experience. Fine-needle aspiration is complementary to core biopsy which remains the gold standard of percutaneous sampling.

Résultats de l'aspiration cytologique à l'aiguille fine dans le diagnostic des tumeurs solides du rein de nature indéterminée

OBJECTIVEnTo evaluate the accuracy of fine-needle aspiration cytology for the diagnosis of imaging indeterminate solid renal tumours.nnnMATERIALS AND METHODSnFrom February 2003 to February 2009, 60 cytoaspirations have been performed to 20 female and 40 male patients (average age: 62.0+/-14.2 years) with an indeterminate solid renal mass by imaging. The average tumour size was 3.4+/-2.8 cm. The cytoaspiration was performed through a 22 Gauge needle under CT (n=39) or US (n=21) guidance. Papanicolaou staining was used. All slides were examined by one experienced cytologist without any clinicoradiological information. The results were given as malignant, benign, suspect or non significant. A classification of subtypes of renal cancer might be added by the cytologist.nnnRESULTSnTwenty-one cytoaspirations (35%) were non significant while 39 (65%) showed cells of interest. Among these 39 cellular cytoaspirations, the specificity for malignancy or benignity was 89.7%. The proportion of non-significant samples was the same in tumors lesser than 2 cm (38.4%) as in tumors 2-4 cm (38.8%) (p=1.000, Fishers exact test). Subtype identification was only reliable for clear cell carcinomas. No complication was observed.nnnCONCLUSIONnThe fine-needle aspiration cytology is an auxiliary technique for the diagnosis of indeterminate solid renal tumours. This simple and mini-invasive technique had a high specificity but a low sensitivity in our experience. Fine-needle aspiration is complementary to core biopsy which remains the gold standard of percutaneous sampling.

Étude anatomoclinique et de l'expression immuno-histochimique de CA9 dans les carcinomes kystiques multiloculaires du rein

OBJECTIVEnMultilocular cystic renal cell carcinoma has been considered as a distinct subtype of clear cell renal cell carcinoma according to 2004 WHO classification. CA9 has proven to be a diagnostic and prognostic marker for clear cell renal cell carcinoma, but the study has been limited to solid tumors. The aim of this article was to analyse the clinical features of multilocular cystic renal cell carcinoma with focus on CA9 expression.nnnPATIENTS AND METHODSnNine multilocular cystic renal cell carcinomas were found. Their age was from 33 to 74 years old with a median of 54 years. There were five men and four women. The computerized tomography was analyzed. There were three total nephrectomies and six partial nephrectomies. The follow-up ranged from five to 102 months with a median 56 months. Immunohistochemical staining was performed on surgical samples to detect CA9 expression.nnnRESULTSnThere were seven pT1a, one pT1b and one pT2; four grade 1 and five grade 2. The Bosniak classification was: one B2F, six B3 and two B4. In CT examination, all tumors showed a hypodense mass. Seven out of nine showed multiple intern septa, more or less thick and vascularized with an enhancement after injection of contrast. No metastasis or relapse was found during follow-up. Eight out of nine multilocular cystic renal cell carcinomas expressed strongly CA9.nnnCONCLUSIONnMultilocular cystic renal cell carcinoma was a low malignant tumor with a good prognosis. The diagnostic criteria based on the WHO classification 2004 should be adopted in routine. CA9 could be a new diagnostic marker for this tumor.

Élargir les indications de la néphrectomie partielle induit-il un surcroît de morbidité ?

OBJECTIVEnTo evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study.nnnMATERIALS AND METHODSnSeven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fishers test) and Student t-test.nnnRESULTSnSix hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4).nnnCONCLUSIONnBroader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.

156 METACHRONOUS BILATERAL RENAL CELL CARCINOMA: RISK ASSESSMENT, PROGNOSIS AND RELEVANCE OF THE PRIMARY-FREE INTERVAL

PURPOSEnWe evaluated the prognosis, risk factors and relevance of the primary-free interval in a large cohort with metachronous bilateral renal cell carcinoma.nnnMATERIALS AND METHODSnWe studied 120 patients with metachronous, bilateral renal cell carcinoma who were treated at 12 international academic centers. Logistic regression was performed to evaluate risk factors for contralateral metachronous renal cell carcinoma during followup. Disease specific survival was evaluated with univariate and multivariate analysis.nnnRESULTSnMedian age at diagnosis of the first and second renal cell carcinomas was 54 and 62 years, respectively. The most common histological subtype was bilateral clear cell renal cell carcinoma (89% of cases). Familial renal cell carcinoma was found in 14% of patients, von Hippel-Lindau disease was found in 4% and nonfamilial renal cell carcinoma was found in 81%. The 15-year disease specific survival rates for the first and second renal cell carcinomas were 66% and 44%, respectively. Logistic regression revealed von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age as independent risk factors for contralateral renal cell carcinoma after surgery for unilateral renal cell carcinoma. A longer primary-free interval was associated with a better prognosis. When calculating disease specific survival from the diagnosis of the first renal cell carcinoma, the primary-free interval was an independent prognostic factor.nnnCONCLUSIONSnLong-term survival rates of metachronous, bilateral renal cell carcinoma are moderate. von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age are independent risk factors for contralateral renal cell carcinoma. These risk factors support close and extended abdominal surveillance following nephrectomy for unilateral renal cell carcinoma. Patients with a longer primary-free interval have a more favorable prognosis.