Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma: population-based and single-institutional analysis.

PURPOSE: Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma is unclear. To assess whether PN provides adequate cancer control in high-risk disease (HRD), survival outcomes were compared in both a population-based cohort and an institutional cohort. METHODS: Surveillance, Epidemiology, and End Results database and a prospectively maintained institutional database were queried for patients with RCC who underwent PN or RN for a localized tumor ≤7 cm and were found to have high-grade and/or high-stage disease (HRD). Cancer-specific (CSS) or recurrence-free survival (RFS) and overall survival (OS) were primary outcomes measured and were compared between those who underwent PN and RN using multivariable Cox proportional hazards and propensity analysis. RESULTS: The population cohort consisted of 12,757 (24.9 %) patients with HRD, 85.2 and 14.8 % of which underwent RN and PN, respectively. RN was not associated with CSS (HR 1.23, p = 0.08) but was independently associated with poor OS (HR 1.16, p = 0.031). Propensity analysis showed that RN resulted in a 20 % increased risk of death from all causes (p = 0.008). In the institutional cohort, of 317 patients, 35.9 % had HRD, 56 and 52 of which underwent RN and PN, respectively. Adjusting for age-adjusted Charlson index, RN was a predictor of poor OS (OR 6.20, p = 0.041). Propensity analysis showed that RFS and OS were not related to nephrectomy type (RN HR 0.65, p = 0.627 and RN HR 1.70, p = 0.484). CONCLUSIONS: In patients with pathologic high-risk RCC, partial excision is associated with similar cancer control as compared to radical excision.

Gender disparity in kidney cancer treatment: women are more likely to undergo radical excision of a localized renal mass.

OBJECTIVE: To investigate gender effects on the type of nephrectomy performed for a stage I renal mass and differences that might account for disparity in treatment patterns according to gender. METHODS: Using a single-institution database, patients who underwent nephrectomy at a tertiary referral center for a localized, solitary tumor, ≤ 7 cm with a normal contralateral kidney were identified. Variables thought to affect selection for type of nephrectomy were compared between male and female patients. Using multivariable logistic regression, the effect of gender on the likelihood of radical vs partial nephrectomy and the likelihood of malignancy were assessed. Renal function outcomes were also compared. RESULTS: No difference between genders was seen in age, race, smoking status, body mass index, tumor size, RENAL score or operating surgeon. Only Charlson index and preoperative creatinine significantly differed with women having a more favorable comorbidity profile (Charlson >1 in 38% vs 50%; P = .027) and lower mean preoperative creatinine (0.09 ± 0.3 vs 1.1 ± 0.3; P <.001). Despite lower creatinine, women had inferior preoperative renal function with a mean estimated glomerular filtration rate of 71.4 ± 21 vs 78.9 ± 21 mL/min/1.73 m2 in men (P <.001). Multivariable analysis indicated that female patients were 2.5 times more likely to undergo radical nephrectomy compared with their male counterparts (P = .022). Women were less likely to have malignancy (odds ratio male gender 2.50; P = .013). CONCLUSION: Women are more likely than men to undergo radical vs partial excision of a localized renal mass, despite less comorbid burden, inferior renal function, and increased likelihood of benign disease.

Impact of cytoreductive nephrectomy on eligibility for systemic treatment and effects on survival: are surgical complications or disease related factors responsible?

OBJECTIVE: To understand the impact of cytoreductive nephrectomy on the ability to receive systemic therapy in patients with metastatic renal cell carcinoma. Causes of delayed eligibility and effect on overall survival (OS) were investigated. METHODS: Patients with metastatic renal cell carcinoma who underwent cytoreductive nephrectomy between 2002 and 2010 were identified. Those ineligible to receive systemic therapy>2 months after surgery were considered delayed. Reasons for delay and effect on OS were investigated, including a thorough analysis of surgical morbidity. RESULTS: Of 65 patients identified, 28% experienced delayed eligibility for systemic therapy. Reasons for delay were related to surgery in 33%, disease progression in 56%, and both in 11%. Of the entire cohort, pT4 and sarcomatoid disease predicted poor outcomes with median OS of 9.8 and 7.6 months, respectively. Comparison of the delay vs no delay groups revealed more intraoperative complications (P=.01), a trend toward more high-grade postoperative complications (17% vs 4%, P=.09), and a median OS of 4.8 vs 18.9 months. Controlling for grade and stage, delay and sarcomatoid features independently predicted poor OS (HR, 2.61; P=.01 and HR, 2.25; P=.02, respectively). CONCLUSION: Delay in eligibility for systemic therapy after cytoreductive nephrectomy adversely affects OS and is most commonly caused by disease-related factors, although high-grade complications may contribute. Those with evidence of T4 or sarcomatoid disease features may best be served by systemic therapy followed by cytoreductive nephrectomy only in those exhibiting response.