Michael Leveridge

Imaging renal cell carcinoma with ultrasonography, CT and MRI

The increased use of abdominal imaging techniques for a variety of indications has contributed to more-frequent detection of renal cell carcinoma (RCC). Ultrasonography has been used to characterize the solid versus cystic nature of renal masses. This modality has limitations, however, in further characterization of solid tumors and in staging of malignancy, although contrast-enhanced ultrasonography has shown promise. Cross-sectional imaging with multiplanar reconstruction capability via CT or MRI has become the standard-bearer in the diagnosis, staging and surveillance of renal cancers. The use of specific protocols and the exploitation of different imaging characteristics of RCC subtypes, including variations in contrast agent timing, MRI weighting and digital subtraction, have contributed to this diagnostic capability. Cystic renal masses are a special case, evaluation of which can require multiple imaging modalities. Rigorous evaluation of these lesions can provide information that is crucial to prediction of the likelihood of malignancy. Such imaging is not without risk, however, as radiation from frequent CT imaging has been implicated in the development of secondary malignancies, and contrast agents for CT and MRI can pose risks, particularly in patients with compromised renal function.

Renal Cell Carcinoma in the Native and Allograft Kidneys of Renal Transplant Recipients

PURPOSE Renal cell carcinoma develops in renal transplant recipients 30 or more times more commonly than in the general population. We assessed the prevalence, histology and outcome of renal cell carcinoma in a large, single center recipient population. MATERIALS AND METHODS We examined outcomes in patients who underwent renal transplantation at our center to determine the prevalence, histology and outcome of those in whom renal cell carcinoma developed. RESULTS A total of 3,568 patients received a renal allograft at our institution between 1966 and 2009. A total of 45 renal cell carcinomas were diagnosed in the native kidney of 39 patients (1.1%) and in 8 (0.2%) renal cell carcinoma developed in the allograft kidney. Mean age at diagnosis was 51.6 and 48.2 years in patients with native kidney and allograft tumors, respectively. The mean interval between transplantation and the native or allograft renal cell carcinoma diagnosis was 10.6 and 12.1 years, respectively. Clear cell renal cell carcinoma was the most common tumor histology in native kidneys, diagnosed in 21 cases, while papillary renal cell carcinoma was diagnosed in 20. Five allograft tumors were papillary renal cell carcinoma and 3 were clear cell renal cell carcinoma. Native kidney tumors were managed by radical nephrectomy in 44 or by observation after biopsy. Allograft tumors were managed by transplant nephrectomy in 3 cases, radio frequency ablation in 3 and partial nephrectomy in 2. At a mean 6.6-year followup 32 patients with native kidney renal cell carcinoma were alive while 7 with allograft tumors were alive at a mean 3.6-year followup. CONCLUSIONS Renal cell carcinoma is more prevalent in patients with renal transplantation than the general population, although the subtype distribution differs. Excellent survival is seen at more than 6 years after treatment.

Assessing Outcomes in Probe Ablative Therapies for Small Renal Masses

The increasing incidence of renal-cell carcinoma can be largely attributed to the increased detection of small renal masses (SRMs) via abdominal imaging. These lesions tend to have a slow rate of growth and low malignant potential, and hence, minimally invasive treatments and active surveillance have been developed for these low-risk tumors to minimize treatment-related morbidity. Radiofrequency ablation and cryotherapy are the principal less-invasive approaches, and their initial oncologic efficacy and complication profiles have been favorable. Suboptimal definition of the relevant outcomes of treatment, a dearth of prospective and randomized data, and relatively short follow-up in the context of the natural history of SRMs pose challenges in the assessment of the efficacy and outcomes of thermal ablation of renal-cell carcinoma. Better pretreatment characterization of the biology of these tumors, more effective real-time treatment monitoring, and standardization of outcome definitions and follow-up are needed to better clarify the effectiveness and role of these treatments. This review highlights these potential pitfalls in the assessment of outcomes of probe ablation of SRMs.

Renal colic: current protocols for emergency presentations.

Flank pain caused by renal colic is a common presentation to emergency departments. This paper reviews the acute clinical assessment of these patients, outlines appropriate diagnostic strategies with labwork and imaging and updates the reader on conservative treatments, suitable choices for analgesia and indications for surgical intervention. Prompt diagnosis and appropriate treatment instituted in the Emergency Department can rapidly and effectively manage this excruciatingly painful condition.

CUA guideline on the management of cystic renal lesions

and titles screened (n=1963) Full-text articles assessed for eligibility (n=108) Studies included (n=77) Records excluded (n=1855) Reasons: non-English or French articles, case reports; studies limited to children; animal studies; basic science studies; acquired/congenital cystic disease Records excluded (n=31) Reasons: basic science studies; acquired/congenital cystic disease; imaging characteristics alone Supplementary Fig. 1. Flow diagram: Search and study selection process.

MP5-02 PARTIAL CYSTECTOMY FOR UROTHELIAL CARCINOMA OF THE BLADDER: PRACTICE PATTERNS AND OUTCOMES IN THE GENERAL POPULATION

bladder cancer is limited. Understanding the drivers of bladder cancer morbidity and mortality can help increase global awareness and guide policy. Our objective is to determine geographic and temporal trends in morbidity and mortality in bladder cancer worldwide and examine potential associated factors. METHODS: Age-adjusted sex-specific mortality rates (deaths per 100,000 people) and disease burden (disability adjusted life years) for each country and region were obtained for the years 1990, 2005 and 2010 from the 2010 Global Burden of Disease Project. Data from 187 countries were available and univariate ordinary least squares regression models were developed for each country. Disease burden was assessed using mortality rates and disease adjusted life years (DALYs). Potential associated metrics examined for each country include Human Development Index (HDI), Gross Domestic Product (GDP) per capita, and smoking rates. RESULTS: From 1990 to 2010, across all countries, each 0.1 unit increase in HDI is associated with a decrease in 0.0049 annual mortality rate of bladder cancer (p<0.0028). Over 20 years, each 0.1 unit increase in HDI is associated with a 0.98 decrease in mortality. Every

Solidifying prognosis after surgery for renal cell carcinoma

10,000 increase in per capita GDP was associated with a 0.277 decrease in bladder cancer mortality rate over 20 years (p<0.0001). Across all countries, each percent increase in smoking rate (percentage of population over age 15) was associated with a 2.01 increase in bladder cancer mortality rate (p< 0.0001). Over 20 years, each 0.1 unit increase in HDI is associated with a decrease in 22.5 DALYs (p1⁄40.0011). Every

An analysis of the readability of patient information materials for common urological conditions.

10,000 increase in per capita GDP is associated with a 5.74 decrease in DALYs over 20 years (p<0.001). Increasing smoking rates were not associated with an increase in DALYs (p1⁄40.7478). CONCLUSIONS: Bladder cancer mortality is decreasing globally. In the past 20 years countries with higher GDP per capita, higher HDI, and those with lower smoking rates have experienced a decline in bladder cancer deaths. Countries with higher HDI and GDP per capita have also experiences an associated decrease in morbidity from bladder cancer. Global policy and initiatives to improve outcomes of bladder cancer worldwide should take into account the effects that a country’s economic status has on bladder cancer morbidity and mortality.

821 SMALL RENAL MASS NEEDLE CORE BIOPSY: OUTCOMES OF NON-DIAGNOSTIC PERCUTANEOUS BIOPSY AND ROLE OF REPEAT BIOPSY

Dason and colleagues from Dublin, Ireland have added an interesting series to the canon of nephrectomy outcomes, and have further validated and solidified the prognostic implications of stage, grade and histology in renal cell carcinoma (RCC). 1 Newer series such as this one have renewed value in that they may provide a window into RCC outcomes in an era when the peculiarities of the small renal mass (SRM) have gained prominence. 2 The increasing incidence of RCC, attributed in large part to increased abdominal imaging, has typically accompanied a downward stage migration, with smaller incident masses and the expectation of lower stage and grade. Surgical series of SRM pathology have confirmed that a decreasing size of tumour is associated with increased benign diagnosis, and lower markers of aggressiveness. 3 These expectations are not met here, as the increasing surgical volume is accompanied by unchanged tumour size and stage, while grade decreased as might be expected. This finding stirs the mind into seeking a biological rationale to explain it, and indeed the authors concede that reasons are not particularly obvious. The tertiary care environment may play a role here, as referral patterns might distill more challenging cases toward these centres, while smaller or more favourable masses are handled outside. The preponderance of SRMs has also paralleled the introduction of thermal ablation techniques, active surveillance and watchful waiting due to competing risks, so smaller or more indolent-behaving masses may be