Kendrick Yim

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.

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.