Cytoreductive nephrectomy in metastatic renal cell carcinoma: outcome of patients treated with a multidisciplinary, algorithm-driven approach.

PURPOSE: Metastatic renal cell carcinoma (mRCC) represents a significant and rising burden of disease, with rapidly evolving treatment modalities. The role of cytoreductive nephrectomy (CN) is controversial in this setting. As such, London Cancer has pursued a multidisciplinary team (MDT) approach when assessing suitability for surgery. METHODS: A retrospective analysis of treatment-naive synchronous mRCC patients, managed via a renal-specialist MDT, was conducted between January 2015 and December 2018. An MDT selection algorithm for CN-using the International Metastatic Renal Cell Carcinoma Database Consortium score (IMDC), performance status and metastatic disease burden-was developed. RESULTS: 87 treatment-naive synchronous mRCC patients received either CN (n = 18), Systemic therapy (ST) alone (n = 43) or Best supportive care (BSC) (n = 26). Progression free survival (PFS) and overall survival (OS) were assessed. 51% and 39% were IMDC intermediate and poor risk. Median PFS was 28.6 months and 4.5 months in the CN group and ST alone group, respectively, Hazard Ratio for death was 3.63 [(95% CI 1.68-7.83) p < 0.05]. OS remains immature for the CN group, but a median OS of 12.8 months was observed in the ST group and 5.0 months for BSC. 1-year OS rate for CN, ST and BSC groups was 77.8%, 55.8% and 23.10%, respectively. CONCLUSION: These findings describe outcomes of an unselected series of patients treated via an MDT-driven, protocolised treatment pathway. MDT pathway-based decision making may improve patient selection for CN. Further research is needed to evaluate the role of CN amongst a growing landscape of treatment strategies, including immune checkpoint inhibitors and combination therapies. Multi-disciplinary team, pathway-based treatment strategy may improve patient selection for cytoreductive nephrectomy in patients with metastatic renal cell carcinoma.

Adjuvant therapy in renal cell carcinoma: the perspective of urologists.

BACKGROUND: Until recently, there was no approved adjuvant therapy (AT) for renal cell carcinoma (RCC) unless sunitinib was approved in the US. We evaluated clinical opinion and estimated use regarding different treatment options and patient selection of AT in RCC patients based on current scientific data and individual experience in Germany. METHODS: We conducted an anonymous survey during a national urology conference in 01/2017. Answers of 157 urologists treating RCC patients could be included. Questions were related to practice setting, treatment of RCC, follow-up strategy, physicians' personal opinion and individually different important parameters regarding S-TRAC and ASSURE-trial. RESULTS: 82% were office based. 67% were located in larger cities. 83% reported that nephron-sparing surgery (NSS) was performed in tumors with diameter < 4 cm. Follow-up was done mainly in concordance with guideline recommendations. 68% treated an average of 2.9 patients/year with systemic therapy. Therapy was predominantly advocated using sunitinib (94%). Urologists were informed about S-TRAC and ASSURE-trial. For 47%, reported hazard ratio is the most important parameter to understand trial results followed by overall survival (OS) in 46%, disease-free survival in 38%, and results of other trials in 34%. The most convincing parameter to decide on AT is OS (69%). 62% placed their confidence in ASSURE over STRAC-trial. 44% would use AT for 12 months. Nodal involvement was the most common denominator for use of AT. 82% favor sunitinib as AT. CONCLUSIONS: A minority of urologists would use AT and are more confident in ASSURE-trial. Reluctance of prescribing AT mainly is based on lack of OS data and conflicting trial results.

Clinical Usage of Different Guidelines in Routine Management, Therapy and Follow-Up of Patients with Renal Cell Cancer in Germany.

OBJECTIVES: To evaluate the usage of different guidelines and to estimate the impact of changed recommendation in routine management, therapy and follow-up of patients with renal cell cancer (RCC). METHODS: An anonymous questionnaire was sent to 600 urologists in Germany. Twenty-seven percent of them were included in the analysis. The questions were about the practice setting, surgical and medical treatment of RCC, follow-up modalities, knowledge and usage of RCC guidelines. Results were correlated with the recommendations of the EAU-guideline. RESULTS: Sixty-eight percent of the urologists were office based. Sixty percent were located in bigger cities. Ninety-eight percent of the colleagues reported to be knowledgeable about the EAU-guidelines, 62% reported to know the American Urological Association, 59% DGU/AWMF, 19% National Comprehensive Cancer Network, 19% European Society for Medical Oncology, 13% Onkopedia, and 3% British Association of Urological Surgeons-guidelines. Eighty-seven percent reported that partial nephrectomy (Nx) was performed in tumours with diameter <4 cm. Forty-one percent performed a radical Nx for tumours that were 4-7 cm. Follow-up of RCC was done in 99%. Fifty-nine percent underwent an abdominal CT scan after 6 months. Thirty-nine percent got a chest X-ray done. Among those with metastatic RCC, only 84% were offered systemic therapy. First-line therapy was predominantly advocated using sunitinib. CONCLUSION: Almost all urologists know and use the EAU-guidelines. Other guidelines are rarely used. Follow-up is performed in discordance with the EAU-recommendations. Interestingly, only 84% with metastatic disease are introduced to systemic therapy.

Prognostic significance of absolute lymphocyte count in patients with metastatic renal cell carcinoma receiving first-line combination immunotherapies: results from the International Metastatic Renal Cell Carcinoma Database Consortium.

BACKGROUND: Lymphocytes are closely linked to mechanisms of action of immuno-oncology (IO) agents. We aimed to assess the prognostic significance of absolute lymphocyte count (ALC) in patients with metastatic renal cell carcinoma (mRCC). PATIENTS AND METHODS: Using the International mRCC Database Consortium (IMDC), patients receiving first-line IO-based combination therapy were analysed. Baseline patient characteristics, objective response rates (ORRs), time to next treatment (TTNT), and overall survival (OS) were compared. RESULTS: Of 966 patients included, 195 (20%) had lymphopenia at baseline, and they had a lower ORR (37% versus 45%; P < 0.001), shorter TTNT (10.1 months versus 24.3 months; P < 0.001), and shorter OS (30.4 months versus 48.2 months; P < 0.001). Among 125 patients with lymphopenia at baseline, 52 (42%) experienced ALC recovery at 3 months, and they had longer OS (not reached versus 30.4 months; P = 0.012). On multivariable analysis for OS, lymphopenia was an independent adverse prognostic factor (hazard ratio 1.68; P < 0.001). Incorporation of lymphopenia into the IMDC criteria improved OS prediction accuracy (C-index from 0.688 to 0.707). CONCLUSIONS: Lymphopenia was observed in one-fifth of treatment-naive patients with mRCC and may serve as an indicator of unfavourable oncologic outcomes in the contemporary IO era.

[Follow-up of renal cell carcinoma in a nonmetastatic stage]. / Nachsorge beim Nierenzellkarzinom im nicht fernmetastasierten Stadium.

Postoperative follow-up care after curative surgery or ablative treatment is the standard of care in patients with nonmetastatic renal cell carcinoma. The goal is to identify and treat postoperative complications and local recurrences early on. Follow-up investigations and their relevance are widely acknowledged and validated and patients undergoing follow-up seem to benefit from a longer survival in nonmetastatic renal cell carcinoma. Hence there is no consensus on a standardized follow-up strategy. The most disputed question is around the frequency of the investigations and the duration of the follow-up. Without an evidence-based follow-up protocol, urologists should carry out an individualized, potentially lifelong follow-up regimen, which also includes the patients' needs and perspectives.

[Epidemiology and diagnostic assessment of small renal masses]. / Epidemiologie und Diagnostik kleiner Nierentumoren.

BACKGROUND: The incidence of small renal masses has been rising over the last few decades. At the same time, mortality of renal cell carcinoma (RCC) is decreasing. These trends can be explained by the availability of improved therapeutic measures and the good prognosis of small renal masses (SRM) turning out to be histopathologically benign or of low malignancy in many cases. OBJECTIVES: The aim of this article is to present epidemiology and diagnostic assessment of SRM. MATERIALS AND METHODS: Statistics, basic research, guidelines. RESULTS: The incidence of SRM is rising due to the widespread use of imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and contrast-enhanced ultrasound (CEUS). Sensitivity is excellent for CEUS and for CECT in the characterization of SRM, while good specificity values can be reached by MRI. For characterization of complex cystic renal masses, CEUS has good diagnostic accuracy. CONCLUSIONS: Due to improved diagnostic possibilities, SRMs can be diagnosed in early asymptomatic stages. As SRM have a good prognosis and often are of low malignancy therapy, options should be carefully considered; especially in older patients, active surveillance should considered.

[Scrotal space-occupying lesions]. / Skrotale Raumforderungen.

Palpable scrotal masses are common scenarios in any clinical practice. These tumors can be painful or painless, can be intratesticular or extratesticular and be cystic or solid. The distinction between benign and malignant tumors is of utmost importance to enable an adequate and differentiated therapy of patients. In clinical diagnostics besides the medical history, examination of the inguinoscrotal region, laboratory diagnostics and ultrasound examination of the inguinoscrotal area play a decisive role. During the last few years the increased use of contrast-enhanced ultrasound has helped clinicians in differentiating scrotal tumors. Malignant tumors are of particular importance because this entity is the most frequent malignant disease among younger men and according to the Robert Koch Institute there are approximately 3900 new patients in Germany each year (Robert Koch Institute, Krebs in Deutschland 2007/2008 and 2012).

IgE levels of infants with complications after pertussis vaccination.

IgE levels of 31 infants who had severe complications after whooping cough vaccination, were determined by RIST. The patients had convulsions, encephalitis or anaphylactic shock symptoms. All but two had elevated IgE levels for their age. It is suggested that, in certain genetically predisposed human beings, pertussis antigen can also induce IgE synthesis, as has already been established in rodents.