Effect of lipiodol marking before CT-guided cryoablation on the outcome of sporadic renal cell carcinoma.

PURPOSE: This retrospective study evaluates the impact of preoperative lipiodol marking on the outcomes of computed tomography (CT)-guided cryoablation for histologically diagnosed sporadic renal cell carcinoma (RCC). METHODS: This study analyzed the data of 173 patients who underwent CT-guided cryoablation for histologically proven sporadic RCC at a single institution between April 2014 and December 2020. The local control rate (LCR), recurrence-free survival rate (RFSR), overall survival rate (OSR), changes in renal function, and complications in patients with (n = 85) and without (n = 88) preoperative lipiodol marking were compared. RESULTS: The 5-year LCR and 5-year RFSR were significantly higher in patients with lipiodol marking (97.51% and 93.84%, respectively) than in those without (72.38% and 68.10%, respectively) (P value <0.01, log-rank test). There were no significant differences between the two groups regarding the 5-year OSR (97.50% vs. 86.82%) or the deterioration in chronic kidney disease stage (12.70% vs. 16.43%). Grade ≥3 complications occurred in patients with lipiodol marking (n = 2, retroperitoneal hematoma and cerebral infarction in 1 patient each) and without (n = 5; urinary fistula in 2, colonic perforation in 2, urinary infection in 1). CONCLUSION: Lipiodol marking before CT-guided cryoablation for sporadic RCC is a feasible approach to improving local control and RFS while mitigating the decline in renal function. Additionally, it may help reduce complications.

Integrating On-Treatment Modified Glasgow Prognostic Score and Imaging to Predict Response and Outcomes in Metastatic Renal Cell Carcinoma.

Importance: In the era of immuno-oncology, imaging alone seems to be insufficient to capture treatment responses, as patients with stable disease treated with immunotherapy have a wide range of clinical outcomes. There is an unmet need for complementary (ideally cost-efficient) markers that enable assessment of therapy response and outcomes in conjunction with imaging. Objectives: To examine whether longitudinal changes in the modified Glasgow prognostic score (mGPS), which is based on C-reactive protein and albumin, can predict responses and outcomes in patients with metastatic renal cell carcinoma (mRCC). Design, Setting, and Participants: This post hoc analysis, conducted from October 2022 to April 2023, evaluated the prognostic and predictive performance of on-treatment mGPS in patients with mRCC being treated with atezolizumab (plus bevacizumab) or sunitinib in 2 randomized clinical trials: the phase 3 IMmotion151 study (discovery cohort) and the phase 2 IMmotion150 study (validation cohort). Main Outcomes and Measures: Outcomes were investigator-assessed progression-free survival (PFS) per Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1 and overall survival (OS) for survival analyses. To compare the prognostic value of the on-treatment mGPS with radiologic staging, we used RECIST assessed by the Independent Review Committee (IRC-RECIST) to ensure high data quality. Results: Of the 915 patients with mRCC in the IMmotion151 discovery cohort, baseline mGPS was available for 861 patients and on-treatment mGPS for 691. The IMmotion150 validation cohort included 305 patients with mRCC, and on-treatment mGPS could be evaluated for 199. In the IMmotion150 study, on-treatment mGPS predicted outcomes as early as 6 weeks following therapy initiation, thereby opening a window for early therapy adjustments. In both clinical trials, on-treatment mGPS provided valuable prognostic information regardless of imaging-assessed treatment response at first staging. Of note, in the disease control subgroup, on-treatment mGPS exhibited superior and independent prognostic information compared with IRC-RECIST (available for 611 patients; C-index, 0.651 [95% CI, 0.588-0.714] for the mGPS during treatment vs 0.574 [95% CI, 0.528-0.619] for IRC-RECIST). Conclusions and Relevance: These data support the concept of integrating on-treatment mGPS for more holistic and patient-centered therapy monitoring in addition to radiologic staging to improve clinical care at a low cost for patients with mRCC.

Contemporary care patterns in the management of small renal masses.

OBJECTIVES: Incidental small renal masses (SRMs) now account for the majority of new diagnoses of renal cancers. Although there are established management guidelines, referral and management patterns can vary. We aimed to explore identification, practice patterns, and management of identified SRMs in an integrated health system. STUDY DESIGN: Retrospective analysis. METHODS: We identified patients with a newly diagnosed SRM measuring 3 cm or less from January 1, 2013, to December 31, 2017, at Kaiser Permanente Southern California. These patients were flagged at the time of radiographic identification to ensure adequate notification of findings. Diagnostic modality, referral, and treatment patterns were analyzed. RESULTS: Of 519 patients with SRMs, 65% were found on abdominal CT and 22% on renal/abdominal ultrasounds. Within 6 months, 70% of patients consulted with a urologist. Initial management patterns were as follows: active surveillance (60%), partial/radical nephrectomy (18%), and ablation (4%). Among 312 patients on surveillance, 14% eventually received treatment. The majority of patients (69.4%) did not receive guideline-recommended chest imaging for initial staging. Urologist visit within 6 months of SRM diagnosis was associated with increased adherence to staging (P = .003) and subsequent surveillance imaging (P < .001). CONCLUSIONS: In this contemporary analysis of an integrated health system's experience, referral to a urologist was associated with guideline-concordant staging and surveillance imaging. Frequent utilization of active surveillance with a low rate of progression to active treatment was noted in both groups. These findings shed light on care patterns upstream of urologic evaluation and support the need for clinical pathways to be implemented at the time of radiologic diagnosis.

Diagnostic accuracy of percutaneous core biopsy before cryoablation for small-sized renal cell carcinoma.

PURPOSE: To retrospectively determine the diagnostic accuracy of a percutaneous core biopsy performed before cryoablation for small-sized renal cell carcinoma. METHODS: In this study, 216 patients underwent a percutaneous core biopsy for 242 renal lesions suspected to be renal cell carcinoma on image findings before cryoablation at Kyushu University Hospital. We calculated the success rate of the histological diagnosis and investigated factors that may have contributed to the diagnostic success. Complications caused by the biopsy procedure were also evaluated. RESULTS: The histological diagnosis was successful in 203 lesions (82.8%). The success rate of the histological diagnosis was 65.4% (34/52 cases) for tumors with a diameter of ≤15 mm and 88.9% (169/190 cases) for those >15 mm. Therefore, tumor diameter was a factor contributing to the histological diagnosis success rate in both univariate and multivariable analyses (P < 0.001). For lesions with a tumor diameter ≤15 mm, the histological diagnosis success rates increased from 50.0% to 76.2% in the presence of pre-lipiodol marking and to 85.7% when the biopsy procedure was performed separately from cryoablation; the latter was statistically significant (P = 0.039). Major complications that may have been caused by the biopsy procedure were grade 3 bleeding and tract seeding (one case each). CONCLUSION: Percutaneous core biopsy in cryoablation for small-sized renal cell carcinoma had a high diagnostic rate and was safely performed. For lesions with a tumor diameter ≤15 mm, a separate biopsy procedure and pre-lipiodol marking may improve the diagnostic accuracy.

Feasibility of Computed Tomography-guided Percutaneous Renal Cryoablation Under Local Anesthesia: A Single Center Experience in Taiwan.

BACKGROUND/AIM: To survey the safety and efficacy of percutaneous cryoablation for renal tumors under local anesthesia and pain control by using the -40°C lethal isotherm of the ice ball to cover the tumor margin as well as the coaxial cryoablation technique. PATIENTS AND METHODS: All procedures were performed between February 2014 and November 2021 with computed tomography (CT) guidance. All tumors were ablated by following the aforementioned plan, according to which tumor margins were covered by the -40°C lethal isotherm. Hydrodissection and coaxial cryoablation were performed in some cases to avoid organ injury and massive bleeding. 2% xylocaine was used for local anesthesia and 50 mg of pethidine (meperidine) was injected intramuscularly for pain control and sedation. The complications were evaluated and the Kaplan-Meier method was used to estimate local recurrence-free survival (LRFS). RESULTS: Sixty-five tumors [49 renal cell carcinomas (RCC) and 16 angiomyolipomas] were ablated in 55 patients (median Charlson Comorbidity Index=5.0). Local recurrence occurred in three of the 49 RCC cases. Two received a second cryoablation. LRFS at three and five years were both 91%. LRFS at three and five years reached 100% in tumors <3 cm. A large tumor (≥3 cm) was observed in the recurrence group. Hemorrhage was the most common complication (76.9%). Two patients who needed blood transfusion did not receive coaxial cryoablation. Three (4.6%) major complications (Clavien-Dindo grade ≥3) occurred. CONCLUSION: By using -40°C as the pre-plan tumor coverage, with the aid of coaxial cryoablation and multiplanar reconstruction method, CT-guided percutaneous renal cryoablation under local anesthesia is a safe and effective procedure in patients with many comorbidities.

Selective arterial embolization of renal angiomyolipoma: comparing ethanol-lipiodol emulsion and polyvinyl alcohol particles as embolic agents.

PURPOSE: To examine the effectiveness and safety of two embolic agents, an ethanol-lipiodol emulsion and polyvinyl alcohol (PVA) particles, for selective arterial embolization (SAE) of renal angiomyolipoma (AML). METHODS: Retrospectively, we reviewed the medical records and imaging data of renal AML patients who received SAE in our hospitals between July 2007 and January 2018. Among those eligible for analysis were patients with complete medical information, preoperative and postoperative contrast-enhanced computed tomography scans, and follow-up data. An ethanol-lipiodol emulsion was used to embolize 15 AMLs, and PVA particles were used to embolize 16 AMLs. We compared the tumor responses and adverse events between the two embolization-agent groups. RESULTS: After embolization, no significant differences were observed in the shrinkage rates: 34.2% ± 3.4% for the ethanol-lipiodol emulsion group and 26.3% ± 3.0% for the PVA particles group (P = 0.090). Minor post-embolization complications were also similar between the groups, and there were no severe adverse events. The length of hospital stay after SAE was 2.5 ± 0.5 days for the ethanol-lipiodol emulsion group and 1.9 ± 0.5 days for the PVA particles group and was not significantly different (P = 0.425). CONCLUSION: The results showed that SAE with ethanol-lipiodol emulsion or PVA particles was safe and efficient in decreasing tumor size and controlling renal AML hemorrhage.

Transarterial ethiodised oil marking before CT-guided renal cryoablation: evaluation of tumour visibility in various renal cell carcinoma subtypes.

AIM: To evaluate ethiodised oil retention of transarterial embolisation using ethiodised oil (ethiodised oil marking) before computed tomography (CT)-guided percutaneous cryoablation (PCA) according to renal cell carcinoma (RCC) subtype. MATERIALS AND METHODS: Ethiodised oil marking was performed 1-3 days before PCA in 99 patients with 99 RCCs from 2016 to 2020. Ethiodised oil retention on CT images was evaluated retrospectively and CT attenuation values in the tumour were measured. Regions of interest (ROI) were placed on the tumours to calculate: average (ROI-average), maximal (ROI-max), minimum (ROI-min), and standard deviation (ROI-SD). Qualitative scores comprising a five-point scale (5, excellent; 1, poor) were evaluated for the retention scores (RS) of ethiodised oil in the tumour (ethiodised oil-RS) and the visualisation scores (VS) of the boundary between the tumour and renal parenchyma (boundary-VS). RESULTS: The histological subtypes comprised clear cell (ccRCC; n=85), papillary (pRCC; n=6), and chromophobe/oncocytoma renal cell carcinoma (chrRCC; n=8). The mean ROI-average, ROI-max, and ROI-SD were significantly higher in ccRCCs than in chrRCCs and pRCCs (p<0.05). The mean ethiodised oil-RS was significantly lower in pRCCs than in ccRCCs (p=0.039), and the mean boundary-VS was >4 in all subtypes. Even with poor intratumour ethiodised oil retention (n=6), sufficient boundary-VS was obtained due to "inverted marking." All PCA procedures were completed without additional intravenous contrast material injection at the time of PCA. CONCLUSION: Regardless of the tumour subtypes, ethiodised oil marking aids in visualising the boundary between the tumour and parenchyma on non-contrast CT in PCA.

[Metastatic Renal Cancer with Stevens-Johnson Syndrome after Nivolumab Treatment : A Case Report].

A 65-year-old male was admitted to our hospital with an abscess on his buttocks. Computed tomography (CT) on admission incidentally revealed left kidney cancer, and retroperitoneal nephrectomy was performed. Pathological examination confirmed a diagnosis of renal cell carcinoma. One month after surgery, CT showed findings suggesting primary liver cancer or liver metastasis along with retroperitoneal metastasis. Although metastatic kidney cancer was suspected, the possibility of primary liver cancer could not be ruled out. Therefore, we initiated treatment using sorafenib, which is indicated for both types of cancer, as first-line treatment for intermediate-risk based on the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk classification. After three months of sorafenib treatment, the patient showed hyponatremia, anemia, and hand-foot syndrome and was admitted to the hospital. CT showed an enlarged area that appeared to be a metastatic site, after which we suspended sorafenib. Four months after sorafenib treatment, nivolumab was initiated as a second-line treatment. However, on day 28 after the administration of nivolumab eruptions appeared all over the patient's body. The patient was diagnosed with Stevens-Johnson syndrome due to nivolumab. We initiated corticosteroid therapy, and the eruptions gradually improved. Prednisolone was gradually reduced to 5mg/day, after which the patient was discharged. Six months after discharge, the eruptions had generally become epithelialized and no metastatic lesions had grown. The patient remained under observation without proceeding to third-line treatment. It is crucial to carefully monitor the patient's condition, especially in cases involving serious immune-related adverse events.

Cone-Beam CT-Guided Transarterial Tagging of Endophytic Renal Tumors with Indocyanine Green for Robot-Assisted Partial Nephrectomy.

PURPOSE: To evaluate the safety, efficacy, and clinical impact of preoperative cone-beam computed tomography (CT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and ethiodized oil in patients undergoing robot-assisted partial nephrectomy (RAPN) using near-infrared fluorescence imaging (NIR-FI). MATERIALS AND METHODS: Patients with renal endophytic tumors eligible for RAPN and transarterial embolization with ICG and ethiodized oil were prospectively enrolled. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as ethiodized oil accumulation in the nodule, was classified as poor, moderate, good, or optimal on the basis of postembolization cone-beam CT. Surgical visibility of the tumors during RAPN with the use of NIR-FI was classified as follows: (a) not visible, (b) visible with poorly defined margins, and (c) visible with well-defined margins. RESULTS: Forty-one patients underwent preoperative selective embolization. Technical success was 100%. Ethiodized oil accumulation on cone-beam CT was poor in 2 (4.9%), moderate in 6 (14.6%), good in 25 (61.0%), and optimal in 8 (19.5%) of 41 patients. During RAPN with NIR-FI, tumors were visible with well-defined margins in 26 (63.4%), visible with blurred margins in 14 (34.1%), and not visible in 1 (2.4%) of 41 cases. There were no adverse events following endovascular embolization. CONCLUSIONS: Preoperative transarterial superselective embolization of endophytic renal tumors with ICG and ethodized oil in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

[68Ga]Ga-PSMA-11 PET/CT has potential application in predicting tumor HIF-2α expression and therapeutic response to HIF-2α antagonists in patients with RCC.

OBJECTIVE: To evaluate the efficacy of parameters derived from [68Ga]Ga-PSMA-11 PET/CT images in predicting pathological HIF-2α expression in primary tumors among patients with renal cell carcinoma (RCC). METHODS: Fifty-three RCC patients with preoperative [68Ga]Ga-PSMA-11 PET/CT scans and complete surgical specimens were retrospectively enrolled in this study. Radiographic parameters were obtained from PET/CT images, and immunohistochemistry was used to measure the expression of HIF-2α and PSMA. Continuous variables and categorical variables were analyzed by the Mann-Whitney U test and chi-square test, respectively. ROC analysis was used to test the efficacy of several preoperative parameters in identifying pathological HIF-2α expression. Univariable logistic regression analyses were performed for significant parameters to predict pathological HIF-2α expression in RCC. RESULTS: Of the 53 tumors, 29 (54.7%) had high expression of HIF-2α. The SUVmax was significantly different in the HIF-2α expression subgroups (p < 0.001). SUVmax emerged as the most significant parameter to differentiate HIF-2α expression subgroups (high vs. low), with the AUC of 0.93 (95% CI 0.85-1.00, p < 0.001), sensitivity of 90%, and specificity of 88%. Furthermore, SUVmax was confirmed as the most significant predictor of HIF-2α expression level by univariable logistic regression model analysis (odds ratio 1.39, 95% CI 1.17-1.65, p < 0.001). Consistent with the radiographic results of [68Ga]Ga-PSMA-11 PET/CT, the staining intensity of pathological PSMA was significantly higher in HIF-2α-high-expressing tumors (p = 0.003). CONCLUSIONS: [68Ga]Ga-PSMA-11 PET/CT was superior in identifying pathological HIF-2α expression in primary tumors of RCC patients, demonstrating its potential application in predicting responses to HIF-2α antagonists. KEY POINTS: • [68Ga]Ga-PSMA-11 PET/CT could potentially predict the HIF-2α expression of primary tumors among patients with RCC. • SUVmaxof [68Ga]Ga-PSMA-11 PET/CT was the most significant predictor of HIF-2α expression level. • This probability could help predict the therapeutic response of patients with RCC to HIF-2α antagonists.

Local anesthesia for percutaneous US/CT-guided bipolar radiofrequency ablation of small renal masses: A safe and feasible alternative.

PURPOSE: This study is to evaluate the safety and feasibility of local anesthesia (LA) for percutaneous ultrasound/computed tomography (US/CT)-guided bipolar radiofrequency ablation (RFA) for small renal masses (SRMs) by comparing the LA with general anesthesia. MATERIALS AND METHODS: A retrospective review was carried out between January 2018 to June 2020, 102 patients with SRMs were treated with US/CT-guided bipolar RFA. General anesthesia (GA) was performed in 42 and LA was performed in 60 patients. Demographics, tumor characteristics, peri-procedural data, pathologic and follow-up outcomes were analyzed. The factors associated with pain were also identified. RESULTS: There was no significant difference in demographics and tumor characteristics between the LA and GA group. A statistically significant difference was observed in terms of procedural time (P = 0.010) and hospital stays (P < 0.001). The maximum perceived pain in LA group comprised 60.0% (36 of 60) mild, 40.0% (24 of 60) moderate. The anxiety in LA group comprised 65.0% (39 of 60) mild, 33.3% (20 of 60) moderate, 1.7% (1 of 60) severe. On multivariate analysis, tumor diameter was a significant predictor for pain in RFA procedure (OR 1.560, 95% CI 1.233-1.974, P < 0.001). All patients were followed up for a median (range) of 12 (2-24) months. Local recurrence occurred in 8.3% (5 of 60) of the LA group and in 7.1% (3 of 42) in GA group (P = 1.000). CONCLUSION: Percutaneous bipolar RFA of SRMs using CT and ultrasound guidance under LA can be an effective and tolerable method for patients who are unfit for surgery and provide satisfactory oncologic control.

Targeted therapy in Xp11 translocation renal cell carcinoma.

BACKGROUND: Translocation renal cell carcinoma (TRCC) is a rare form of RCC affecting mostly children and young adults with the occurrence of only 1-5% of all renal cell carcinomas. These carcinomas are associated with different translocations on a short arm of chromosome X in the region 11.2, which results in genetic modification of the p arm containing the transcription factor E3 gene. METHODS: Herein we report a case of a patient who was dia-gnosed with TRCC with c-Met overexpression and was treated with multiple targeted therapy agents and immunotherapy. CASE: A 28-year old woman without a significant past medical history underwent left sided total nephrectomy for TRCC. Seven months later, she developed systemic relapse and was treated with multiple lines of targeted therapy including sunitinib, everolimus, sorafenib, crizotinib, and pazopanib as well as with anti-PD-L1 antibody nivolumab, with stable disease as a best response. The most pronounced disease stabilization was achieved with sorafenib, which lasted 18 months. The patient died 81 months after initial dia-gnosis and 74 months from the dia-gnosis of metastatic disease. CONCLUSION: Improved survival observed in our patient could be related to the effectivity of tyrosine-kinase inhibitors, but notm-TOR inhibitors, even though disease stabilisation was observed as a best response. Identification of new treatment targets are warranted in this rare disease.

Active Surveillance for Risk Stratification of All Small Renal Masses Lacking Predefined Clinical Criteria for Intervention.

PURPOSE: Despite general indolence of small renal masses and no known adversity from treatment delays, broad usage of active surveillance as a means to risk-stratify patients with small renal masses for more selective treatment has not been studied. We describe outcomes for a novel approach in which active surveillance was recommended to all patients with small renal masses lacking predefined progression criteria for intervention. MATERIALS AND METHODS: All nondialysis dependent patients with nonmetastatic small renal masses seen by 1 urologist at a comprehensive cancer center during January 2013-September 2017 were managed with active surveillance if standardized progression criteria for intervention were absent, with delayed intervention recommended only upon progression criteria for intervention development. Progression criteria for intervention were defined prospectively as small renal mass-related symptoms, unfavorable histology, cT3a stage or either of the following without benign neoplastic biopsy histology: longest tumor diameter >4 cm; growth rate >5 mm/year for longest tumor diameter ≤3 cm or >3 mm/year for longest tumor diameter >3 cm. RESULTS: In all, 96% (123/128) of patients with small renal masses lacked progression criteria for intervention at presentation and underwent active surveillance. With median/mean 31/34 months followup, none developed metastasis and 30% (37/123) developed progression criteria for intervention, 78% (29/37) of whom underwent delayed intervention. One (1%) patient crossed over to delayed intervention without progression criteria for intervention. Three-year progression criteria for intervention-free and delayed intervention-free rates were 72% and 75%, respectively. Delayed intervention resections were enriched (62%) for pT3 and/or nuclear grade 3-4 malignant pathology, with no benign resections. CONCLUSIONS: Active surveillance using predefined progression criteria for intervention in otherwise unselected patients with small renal masses allows intervention to be focused on at-risk small renal masses with common adverse pathology, avoiding treatment for most patients with small renal masses. Long-term delayed intervention and oncologic safety require study.

Complementary Role of 68Ga-Prostate-Specific Membrane Antigen and 18F-FDG PET/CT for Evaluation of Metastases and Treatment Response in Renal Cell Carcinoma.

ABSTRACT: We present a case of clear cell renal cell carcinoma, which demonstrates complementary FDG and prostate-specific membrane antigen (PSMA) uptake on metastases in PET/CT, as an example of tumor heterogeneity. The patient had non-FDG-avid lung and bone metastases with PSMA uptake, whereas metastatic cervical and axillary lymph nodes showed vice versa, and skeletal muscle metastasis to vastus lateralis, which is an unusual region for metastasis, showed both PSMA and FDG positivity. In response assessment, mix response was detected. It seems that 68Ga-PSMA and 18F-FDG may have a complementary role in demonstration of metastasis accurately and assessment of treatment response in clear cell renal cell carcinoma.

Efficacy of arterial infusion of iodized oil on CT-guided cryoablation for renal cell carcinoma.

PURPOSE: To evaluate the effectiveness of the transarterial infusion of iodized oil and gelatin particles for marking before CT-guided percutaneous cryoablation (PCA) in patients with renal cell carcinoma (RCC). MATERIAL AND METHODS: This study included ten patients (seven men, three women; mean age 53 years) with 13 RCCs between July 2016 and September 2017. The transarterial infusion of iodized oil and gelatin particles was considered successful when iodized oil accumulated in the target area on CT. CT value of the tumor before and after marking was measured and two diagnostic radiologists evaluated the visualization scores by using a five-point scale (5 = excellent to 1 = invisible). RESULTS: Preoperative marking was successful in all 13 tumors; the median visualization score was 5 post-lipiodol marking and 4 at the time of PCA. The mean CT density was 597 ± 371 Hounsfield units (HU) just after marking and 437 ± 234 HU at the time of PCA. All 13 CT-guided PCA procedures were successful. There were no significant complications. During follow-up (median 11.5 ± 7.0 months) there were no local recurrences. CONCLUSION: As the transarterial infusion of iodized oil and gelatin particles improved RCC visualization on CT, its delivery before CT-guided PCA may improve its safety and success rate in patients with RCC.

Imaging of Renal Cancer.

Renal masses are common incidental findings on cross-sectional imaging. Accurate characterization of renal masses is essential to guide management. Renal mass CT protocol comprises of a good quality noncontrast, corticomedullary and nephrographic phases, with each phase providing complementary information for diagnosis. Attenuation measurements in different phases are central to the 'golden-rules' in renal mass imaging in the characterization of renal masses. Newer modalities like dual energy CT scan obviate need for repeat imaging by generation of iodine-overlay image and also help in eliminating artifactual pseudoenhancement which can be problematic, especially in small endophytic cysts. Contrast- enhanced ultrasound (CEUS) is extremely sensitive in identification of enhancing components in indeterminate masses, especially in the setting of renal failure as the microbubbles are not excreted via the renal route. The Bosniak classification for renal cystic masses has been revised in 2019 to standardize terminology and further improve upon the original version. The current version includes CT and MRI, although CEUS is yet to be included. Image- guided biopsy of renal mass helps confirm the diagnosis and also gives information regarding the subtype and grading and is useful in avoiding overtreatment of benign entities, and in active surveillance. Multiparametric MRI can potentially help avoid needle biopsy in a subset of patients by accurate characterization through a previously validated algorithm.

[Radiotherapy of oligometastases: Sequences and interactions with systemic therapies, example of kidney cancer]. / Radiothérapie des oligométastases : interactions/séquences avec thérapies systémiques, exemple du cancer du rein.

This article is a review of the literature that aims to clarify the place of systemic and locoregional treatments, with a focus on radiotherapy and surgery in the management of patients with oligometastatic kidney cancer. We have selected articles of interest published in Medline indexed journals. We have also analysed the related guidelines: National Comprehensive Cancer Network (NCCN) 2019, European Association of Urology (EAU) 2019, European Society of Medical Oncology (ESMO) 2019, Association française d'urologie (Afu) 2018 as well as some abstracts of international congresses. The main treatments evaluated were surgery and radiotherapy. We defined the different scenarios conventionally encountered in clinical practice. The evolution of systemic therapies (increased overall survival and response rate) is likely to increase the number of patients potentially accessible to locoregional treatments. The complete analysis of the literature underlines the place of locoregional treatments whatever the scenarios mentioned. Data on stereotactic radiotherapy found a local control rate consistently above 70% in all studies with a maintained response and positive impact on overall survival and progression-free survival. The improvement of overall survival by sequential use of the various therapeutic classes confirms the need for optimization of locoregional treatments in the model of oligometastatic kidney cancer. The dogma of radioresistance must definitely be set aside with current irradiation techniques.

Patterns of Relapse and Implications for Post-Nephrectomy Surveillance in Patients with High Risk Nonclear Cell Renal Cell Carcinoma: Subgroup Analysis of the Phase 3 ECOG-ACRIN E2805 Trial.

PURPOSE: The natural history of nonclear cell renal cell carcinoma following surgery with curative intent remains poorly defined with postoperative surveillance informed by guidelines largely intended for clear cell renal cell carcinoma. We evaluated relapse patterns and potential implications for post-nephrectomy surveillance in patients with nonclear cell renal cell carcinoma enrolled in the E2805 trial, the largest randomized trial of adjuvant antiangiogenic therapy of high risk renal cell carcinoma. MATERIALS AND METHODS: We retrospectively analyzed the records of patients with completely resected nonclear cell renal cell carcinoma. Participants received up to 54 weeks of postoperative therapy with sunitinib, sorafenib or placebo and underwent surveillance imaging at standardized intervals for 10 years. For recurrence rates by site the cumulative incidence was estimated, accounting for competing risks. The adequacy of strict adherence to post-nephrectomy surveillance guidelines was evaluated. RESULTS: A total of 403 patients with nonclear cell renal cell carcinoma were enrolled in the study. During a median followup of 6.2 years 36% of nonclear cell renal cell carcinomas recurred. Five-year recurrence rates were comparable for nonclear and clear cell renal cell carcinoma in the 1,541 patients, including 34.6% (95% CI 29.8-39.4) and 39.5% (95% CI 36.9-42.1), respectively. However, patients with nonclear cell renal cell carcinoma were significantly more likely to have abdominal sites of relapse (5-year recurrence rate 26.4% vs 18.2%, p = 0.0008) and significantly less likely to experience relapse in the chest (5-year recurrence rate 13.7% vs 20.9%, p = 0.0005). Current surveillance guidelines would potentially capture approximately 90% of relapses at any site. CONCLUSIONS: Nonclear cell renal cell carcinoma may show a distinct pattern of relapse compared to clear cell renal cell carcinoma. Our findings emphasize the importance of cross-sectional, long-term imaging in patients with high risk, resected, nonclear cell renal cell carcinoma.