Michael Daugherty

Renal Cell Carcinoma in Young Patients: a Review of Recent Literature

Renal cell carcinoma is most common in patients in the seventh decade of life. However, renal cell carcinoma (RCC) patients under the age of 40 represent 3–7xa0% of all renal tumors. These young patients develop RCC from a variety of mechanisms including genetic syndromes, heritable mutations, and sporadic mutations. This population encompasses a distinct clinical entity that requires early identification and adjustments in standard practices including sometimes-aggressive surgical measures in order to improve oncologic management.

Compared with radical nephrectomy, nephron-sparing surgery offers a long-term survival advantage in patients between the ages of 20 and 44 years with renal cell carcinomas (≤4 cm): An analysis of the SEER database

PURPOSEnCompared with radical nephrectomy (RN), partial nephrectomy (PN) decreases the risk of developing chronic kidney disease. Although numerous studies have demonstrated the survival advantage of PN in older patients, they have been criticized by selection bias toward the procedure owing to comorbidities. We hypothesized that long-standing effects of renal preservation would manifest in a survival advantage of a younger patient population, where selection bias owing to comorbidities is minimized.nnnMATERIALS AND METHODSnThe Surveillance, Epidemiology, and End Results 18-registries database was queried for patients aged 20 to 44 years surgically treated between 1993 and 2003 for renal cell carcinoma (RCC) ≤ 4 cm with known grade and histology. Patients with prior RCC, multiple tumors, and metastatic or locally advanced disease were excluded. The final cohorts consisted of 222 and 494 subjects treated with PN and RN, respectively. The chi-square and log-rank analyses compared patient and tumor characteristics and patient survival, respectively.nnnRESULTSnThere were no differences between the groups in demographics or tumor characteristics. Additionally, there was no difference in cancer-specific survival at 5 or 10 years (P = 0.34 and P = 0.1, respectively). Although there was no difference in 5-year overall survival (P = 0.07), PN offered an advantage in 10-year overall survival (P = 0.025).nnnCONCLUSIONSnPresent Surveillance, Epidemiology, and End Results analyses demonstrate that compared with RN, PN improved overall survival in patients with small, localized RCC. As expected, the survival advantage is observed late and supports the importance of long-term renal functional preservation. Although our study is limited by lack of comorbidities, the results suggest that detrimental effects of RN may have implications on overall survival in younger patients with RCC.

The metastatic potential of renal tumors: Influence of histologic subtypes on definition of small renal masses, risk stratification, and future active surveillance protocols

OBJECTIVEnThe influence of histology in metastatic potential is often overlooked when discussing the management options of small renal masses (SRM), with size or growth rate often serving as the triggers for the intervention. We aim to re-examine the definition of a SRM by evaluating the metastatic potential of renal masses incorporating tumor size and histology to create metastatic risk tables.nnnMATERIALS AND METHODSnSurveillance Epidemiology and End Results (SEER)-18 registries database was queried for all cases of clear cell, papillary, and chromophobe renal cell carcinoma (RCC) diagnosed between 2004 and 2012. There were 55,478 cases identified that included 43,783, 8,587, and 3,208 cases of clear cell, papillary, and chromophobe, respectively. Tumors were stratified using 1-cm increments to determine the metastatic potential by calculating the metastatic rate at presentation for different size intervals in histologic categories.nnnRESULTSnFor all 3 histologies, tumors measuring 5cm or less had a rate of metastatic RCC at presentation of less than 4%. The metastatic potential was highest for clear cell, followed by papillary and then chromophobe tumors. Setting a cutoff of no more than 3% for metastatic potential to be called a SRM, makes clear cell carcinoma and papillary carcinoma a SRM up to 4cm, whereas the chromophobe RCC would be considered a SRM up to 7cm.nnnCONCLUSIONnAlthough clinical staging and tumor size have been the key determinants in decision-making of patients with solid renal tumors, the histology-specific risks of metastatic potential are different for each mass. The definition of a SRM should be based on the metastatic potential and not on tumor size alone. This information could be helpful for counseling and managing patients with SRMs as well as for modifying active surveillance protocols.

Adjuvant Radiation Improves Survival in Older Women Following Breast-Conserving Surgery for Estrogen Receptor-Negative Breast Cancer.

PURPOSEnPublished prospective trials have questioned the role of post-lumpectomy radiotherapy in older women with early-stage, estrogen receptor-positive (ER+) breast cancer. As the population with ER- tumors may be at greater risk for relapse, particularly given that endocrine therapy is not effective, we hypothesize the addition of radiation would be of benefit in patients agexa0≥xa070.nnnMETHODS AND MATERIALSnThe Surveillance, Epidemiology, and End Results database was queried from 1998 to 2011 for patients agexa0≥ 70 years receiving breast-conserving surgery for T1, ER- invasive ductal carcinoma. Patients were separated into 2 cohorts: those treated with and without adjuvant radiotherapy. Chi-square analysis, unpaired t test and Kaplan-Meier log-rank were used to compare patient and tumor characteristics as well as overall and cancer-specific survival between the cohorts.nnnRESULTSnOverall, 3685 patients received radiation and 1493 patients received lumpectomy alone. Patients treated with adjuvant radiation were younger (median age 76 vs. 78 years, Pxa0< .0001). Patients who received radiation had improved overall survival, with 5-year survival rates of 81.0% versus 61.7% without radiation (Pxa0< .0001). Cancer-specific survival was also improved with radiotherapy, with 5-year cancer-specific survival rates of 93.1% versus 85.0% (Pxa0< .0001).nnnCONCLUSIONSnThis analysis of the SEER database demonstrates that women ages 70 and older treated with lumpectomy and radiotherapy for ER-, early-stage breast cancer have improved overall survival and breast cancer-specific survival compared with patients treated with lumpectomy alone. This information may help in the decision-making process for this patient population.

Chromophobe Renal Cell Carcinoma is the Most Common Nonclear Renal Cell Carcinoma in Young Women: Results from the SEER Database.

PURPOSEnThe renal cell cancer incidence is relatively low in younger patients, encompassing 3% to 7% of all renal cell cancers. While young patients may have renal tumors due to hereditary syndromes, in some of them sporadic renal cancers develop without any family history or known genetic mutations. Our recent observations from clinical practice have led us to hypothesize that there is a difference in histological distribution in younger patients compared to the older cohort.nnnMATERIALS AND METHODSnWe queried the SEER (Surveillance, Epidemiology and End Results) 18-registry database for all patients 20 years old or older who were surgically treated for renal cell carcinoma between 2001 and 2008. Patients with unknown race, grade, stage or histology and those with multiple tumors were excluded from study. Four cohorts were created by dividing patients by gender, including 1,202 females and 1,715 males younger than 40 years old, and 18,353 females and 30,891 males 40 years old or older. Chi-square analysis was used to compare histological distributions between the cohorts.nnnRESULTSnWhile clear cell carcinoma was still the most common renal cell cancer subtype across all genders and ages, chromophobe renal cell cancer was the most predominant type of nonclear renal cell cancer histology in young females, representing 62.3% of all nonclear cell renal cell cancers (p <0.0001). In all other groups papillary renal cell cancer remained the most common type of nonclear renal cell cancer.nnnCONCLUSIONSnIt is possible that hormonal factors or specific pathway dysregulations predispose chromophobe renal cell cancer to develop in younger women. We hope that this work provides some new observations that could lead to further studies of gender and histology specific renal tumorigenesis.

Comparison of survival for partial vs. radical nephrectomy in young patients with T1a renal cell carcinoma treated at commission on cancer-accredited facilities and influence of comorbidities on treatment choice

PURPOSEnThere is a paucity of data comparing effects of partial nephrectomy (PN) vs. radical nephrectomy (RN) on overall survival in young patients. In this study, the National Cancer Database was used to evaluate the survival outcomes of those treated with PN and RN, and influence of comorbidities on surgical treatment (PN vs. RN) in young patients while accounting for Charlson-Deyo Comorbidity Score (CDCS).nnnMATERIALS AND METHODSnPatients between 20 and 44 years old (n = 9,849) surgically treated for pT1a renal cell carcinoma between 2004 and 2013 were identified from the National Cancer Database. Kaplan-Meier log-rank analysis and Cox proportional hazards model were performed to compare overall survival and calculate the hazard ratio between those undergoing RN and PN. Binary logistic regression was used to calculate odds ratios for receiving RN compared to PN. The effect measures in all models were adjusted for potential confounding factors.nnnRESULTSnAfter adjusting for comorbidities, PN offered an overall survival advantage over RN (P<0.001, hazard ratio = 0.464, 95% CI: 0.359-0.601) at a mean follow-up of 48.4 months (0-130.96), including young patients with no comorbidities (P<0.001). Compared to those with a CDCS = 0, patients were more likely to be treated with RN if they had a CDCS>1 (odds ratios = 2.049, 95% CI: 1.527-2.750).nnnCONCLUSIONSnYoung patients treated with PN demonstrate an overall survival advantage. This survival advantage is observed after an early follow-up even in those without comorbidities. It is still not clear if the survival advantage seen is due to treatment itself or selection bias.

Surgical Techniques in the Management of Small Renal Masses

This article provides a review and outline of the various surgical techniques for small renal masses. It covers surgical approaches and compares outcomes of open versus minimally invasive surgery. The article discusses renal nephrometry scoring and renal ischemia at time of resection. Techniques for controlling the renal hilum and controlling blood flow to the kidney are described. Extirpative techniques for small renal masses are reviewed along with a comparison of outcomes. With careful adherence to key oncologic and surgical principles, negative margins, no complications, and no or minimal decline in renal functional outcomes can be achieved.

Are we underestimating the rates of incontinence after prostate cancer treatment? Results from NHANES

PurposeLocal therapy for prostate cancer (PCa) includes radical prostatectomy (RP) and radiotherapy (XRT), both of which share a complication of urinary incontinence. Post-treatment incontinence has been reported to occur 6–69%, yet no truly patient-centered report has been compiled. We evaluated patient-reported incontinence rates and bother scores after treatment for prostate cancer.MethodsThe NHANES database was queried for all men who reported a diagnosis and treatment of PCa from 2001 to 2010. A control arm of men without a diagnosis of PCa age 60–80xa0years was constructed for baseline incontinence rates. Incontinence was patient-reported and obtained through questionnaires. Three additional cohorts were created for patients treated with RP, XRT or combination RP and XRT.ResultsWe identified 316 men treated for prostate cancer, of which 136 reported RP and 125 reported XRT, who were compared to 3534 controls. Men that underwent RP experience significant incontinence rates of 23% compared to 12% of those patients treated with XRT, whereas those patients with combined therapy had incontinence rates of 52% (pxa0<xa00.0001). Bother scores did not significantly vary, but were increased compared to baseline. Urge incontinence did not differ between treatment groups, but stress incontinence was significantly higher in surgical patients.ConclusionThese data from a nationwide sample of patient-reported urinary outcomes have limited interviewer bias and report significantly higher incontinence rates, which may impact prostate cancer discussions. This further underscores the importance of patient-reported outcomes in the evaluation of treatment success and counseling for patients with prostate cancer.

Clinical and Patient-reported Outcomes of 1-sided Anterior Urethroplasty for Long-segment or Panurethral Strictures

OBJECTIVEnTo evaluate clinical and patient-reported urinary and sexual outcomes after a long-segment stricture repair using the 1-sided urethral dissection, penile invagination, and dorsal buccal mucosa graft onlay technique described by Kulkarni etxa0al.nnnMETHODSnPatients from 4 institutions after single-stage repairs for long-segment urethral strictures (>8u2009cm) from January 2002 to April 2016 were reviewed. Technique described by Kulkarni etxa0al was used in all cases. Clinical outcomes included uroflowmetry (Qmax) and post-void residuals. Patient-reported outcome measures included International Prostate Symptom Score survey, Sexual Health Inventory for Men, Male Sexual Health Questionnaire, and Global Response Assessment questionnaire to measure voiding, sexual, ejaculatory symptoms, and overall improvement, respectively.nnnRESULTSnSeventy-three patients with a minimum of 12 months follow-up were included. The mean age and stricture length were 56 (21-80) years and 13.6 (8-21) cm, respectively. At a mean follow-up of 44 (12-162) months, 9 of 73 (12%) strictures recurred. The mean baseline International Prostate Symptom Score of 23 (7-24) decreased to 10 (1-17) on follow-up (Pu2009<.001). Eight of 42 patients (21.4%) reported an increase, and 6 of 42 patients (14.3%) decreased in Sexual Health Inventory for Men following urethroplasty. Ejaculatory function on Male Sexual Health Questionnaire improved after urethroplasty from 8 preoperatively to 11 postoperatively (Pu2009<.004). All patients reported improvement after urethroplasty on Global Response Assessment questionnaire. Post-void dribbling and chordee occurred in 45% and 25% of patients, respectively.nnnCONCLUSIONnDurable patency in most patients is demonstrated in this study. PROMs indicate an improvement in urinary function and moderate effect on sexual function. Transient penile chordee was evident in 25% of patients.

Hypoandrogenism is Prevalent in Males With Urethral Stricture Disease and is Associated with Longer Strictures

OBJECTIVEnTo assess the association of hypoandrogenism (HA) with urethral stricture disease in a series of patients undergoing urethroplasty at 2 institutions. HA has recently been associated with increased urethral atrophy in artificial sphincter failures and decreased androgen receptors and periurethral vascularity. HA might be an etiologic factor in urethral stricture disease.nnnMETHODSnWe reviewed the charts in 202 men with anterior urethral strictures between 2011 and 2017. We excluded patients with radiation-induced stricture, previous prostatectomy, previous urethroplasty, pelvic fracture-related strictures, or those on testosterone replacement. We defined HA by a total testosterone of less than 300u2009ng/dL. We used as age-matched cohort from a national database (National Health and Nutrition Examination Survey), as a reference. Stricture characteristics, such as length, location, and etiology were compared in HA and eugonadal groups.nnnRESULTSnOf 202 men with anterior urethral strictures, we excluded 45. Of the remaining 157 patients, 115 (73%) had preoperative testosterone measurements. Overall, hypoandrogenism (HA) was found in 65 of 115 (57%) men in the urethral stricture group compared with 28% of age-matched men in the national database. Mean stricture length in HA and eugonadal men was 7.2u2009cm and 4.8u2009cm, respectively (Pu2009=u2009.02).nnnCONCLUSIONnHA may be more prevalent and associated with increased disease severity in men with anterior urethral strictures. The relationship between HA and stricture formation and its potential impact on therapeutic outcomes merit further prospective investigation.