Surveillance post-radiofrequency ablation for small renal masses: Recurrence and followup.

INTRODUCTION: Small renal masses (SRMs), enhancing tumors <4 cm in diameter, are suspicious for renal cell carcinoma (RCC). The incidence of SRMs have risen with the increased quality and frequency of imaging. Partial nephrectomy is widely accepted as a nephron-sparing approach for the management of clinically localized RCC, with a greater than 90% disease-specific survival for stage T1a. Radiofrequency ablation (RFA) has been emerging as an alternative management strategy, with evidence suggesting RFA as a safe alternative for SRMs. We aimed to evaluate the time to recurrence and recurrence rates of SRMs treated with RFA at our institution. METHODS: A retrospective review between October 2011 and May 2019 identified 141 patients with a single SRM treated with RFA at Hamilton Health Sciences and St. Joseph's Healthcare Hamilton. Patients with familial syndromes and distant metastases were excluded. Repeat RFAs of the ipsilateral kidney for incomplete ablation were not considered a new procedure. The primary variable measured was time from initial ablation to recurrence. A Cox proportional hazard regression model was used to identify possible prognostic variables for tumor recurrence defined a priori, including age, gender, mass size, RENAL nephrometry, and PADUA scores. RESULTS: The overall average age of our patients was 69.0±11.1 years, with 71.6% being male. Average tumor size was 2.6±0.8 cm. There were 22/154 total recurrences (15.6%) post-RFA. Median followup time was 67 (18-161) months. Those with new recurrences had median time to recurrence of 15 months and no recurrence beyond 53 months. Thirteen of 141 patients had residual disease (9.2%) and were identified within the first eight months post-RFA. The only prognostic variable identified as a predictor of residual disease was tumor size (hazard ratio 2.265; p<0.001). CONCLUSIONS: This study shows the risk of a new recurrence following RFA for SRMs is 6.4%. Most recurrences (9.2%) were a result of residual tumor at the ablation site identified within the first eight months post-RFA. No recurrences were identified beyond 53 months, with a total median followup time of 67 months. Tumor size alone, without need for complex scoring systems, may serve as a predictor of incomplete ablation following RFA and could be used to assist in shared decision-making on management strategies.

Volume Reduction in Enlarged Kidneys in Autosomal Dominant Polycystic Kidney Disease (ADPKD) Prior to Renal Transplant with Transcatheter Arterial Embolization (TAE): A Systematic Review and Meta-Analysis.

PURPOSE: Symptomatically enlarged kidneys observed in autosomal dominant polycystic kidney disease (ADPKD) patients can lead to compression symptoms and contraindications to renal transplantation. Surgical nephrectomy can be utilized to increase space in the abdomen prior to renal transplantation; however, not all individuals are appropriate candidates for this procedure. Transcatheter arterial embolization (TAE) of the renal arteries can provide a noninvasive way to reduce renal volume in ADPKD. MATERIALS AND METHODS: We performed a systematic literature review on the usage of TAE to reduce renal volume prior to kidney transplantation and to relief compression symptoms in ADPKD. PubMed, Web of Science, and Cochrane Library were searched for articles focused on the usage of TAE to reduce renal volume in symptomatic enlarged kidneys. Renal volume data were compiled, and meta-analysis was performed with three or more studies. RESULTS: Six papers satisfied the inclusion and exclusion criteria. Significant renal volume reduction was observed by 12 months in all studies. Success of TAE was measured with three clinical outcomes: removal of contraindication for renal transplant, relief of compression symptoms, and pulmonary function test. Proportionality meta-analysis of three studies measuring relief of compression symptoms showed no significant differences in heterogeneity (p = 0.4543). CONCLUSION: Current studies conclude that TAE is an effective and minimally invasive option for reduction in renal volume in order to optimize patient outcome for renal transplantation and for relief of compression symptoms. Further prospective studies involving increased sample size and multiple centers should be pursued to establish evidence-based guidelines.

Coronary artery calcification, cardiovascular events, and death: a prospective cohort study of incident patients on hemodialysis.

BACKGROUND: Coronary calcification in patients with end-stage renal disease (ESRD) is associated with an increased risk of cardiovascular outcomes and death from all causes. Previous evidence has been limited by short follow-up periods and inclusion of a heterogeneous cluster of events in the primary analyses. OBJECTIVE: To describe coronary calcification in patients incident to ESRD, and to identify whether calcification predicts vascular events or death. DESIGN: Prospective substudy of an inception cohort. SETTING: Tertiary care haemodialysis centre in Ontario (St Joseph's Healthcare Hamilton). PARTICIPANTS: Patients starting haemodialysis who were new to ESRD. MEASUREMENTS: At baseline, clinical characterization and spiral computed tomography (CT) to score coronary calcification by the Agatston-Janowitz 130 scoring method. A primary outcome composite of adjudicated stroke, myocardial infarction, or death. METHODS: We followed patients prospectively to identify the relationship between cardiac calcification and subsequent stroke, myocardial infarction, or death, using Cox regression. RESULTS: We recruited 248 patients in 3 centres to our main study, which required only biochemical markers. Of these 164 were at St Joseph's healthcare, and eligible to participate in the substudy; of these, 51 completed CT scanning (31 %). Median follow up was 26 months (Q1, Q3: 14, 34). The primary outcome occurred in 16 patients; 11 in the group above the median and 5 in the group below (p = 0.086). There were 26 primary outcomes in 16 patients; 20 (77 %) events in the group above the coronary calcification median and 6 (23 %) in the group below (p = 0.006). There were 10 deaths; 8 in the group above the median compared with 2 in the group below (p = 0.04). The hazard ratios for coronary calcification above, compared with below the median, for the primary outcome composite were 2.5 (95 % CI 0.87, 7.3; p = 0.09) and 1.7 (95 % CI 0.55, 5.4; p = 0.4), unadjusted and adjusted for age, respectively. For death, the hazard ratios were 4.6 (95 % CI 0.98, 21.96; p = 0.054) and 2.4 (95 % CI 0.45, 12.97; p = 0.3) respectively. LIMITATIONS: We were limited by a small sample size and a small number of events. CONCLUSIONS: Respondent burden is high for additional testing around the initiation of dialysis. High coronary calcification in patients new to ESRD has a tendency to predict cardiovascular outcomes and death, though effects are attenuated when adjusted for age.

CONTEXTE: La calcification de l'artère coronaire chez les patients atteints d'insuffisance rénale terminale (IRT) est associée à un risque accru de troubles cardiovasculaires et de mortalité, toutes causes confondues. Les données précédemment recueillies se limitaient à un suivi de courte durée, de même qu'à l'inclusion de séries d'accidents non liés lors de l'analyse préliminaire. OBJECTIFS: Décrire la calcification de l'artère coronaire chez les patients atteints d'IRT et déterminer si la calcification de l'artère coronaire peut prédire des accidents vasculaires et la mort. TYPE D'ÉTUDE: Sous-étude prospective de cohorte selon le mode d'installation. CADRE: Une unité de soins tertiaires en dialyse, en Ontario (St Joseph's Healthcare Hamilton). PARTICIPANTS: Des patients qui sont nouvellement atteints d'IRT et qui entament une hémodialyse. MESURES: En début de traitement, une caractérisation clinique et une tomodensitométrie (TDM) hélicoïdale qui permettent de mesurer la calcification de l'artère coronaire sur 130, selon l'échelle d'Agatston-Janowitz. L'indicateur principal des résultats comprend l'AVC, l'infarctus du myocarde ou la mort. MÉTHODES: Nous avons suivi les patients de manière prospective, afin de cibler la relation entre la calcification de l'artère coronaire et l'AVC, l'infarctus du myocarde ou la mort subséquente, en utilisant la régression de Cox. RÉSULTATS: Nous avons recruté 248 patients dans trois unités, dans le cadre de l'étude principale, qui ne requérait que des biomarqueurs chimiques. De ces patients, 164 étaient de St Joseph's Healthcare, et étaient admissibles à la sous-étude; 51 avaient effectué une tomographie par ordinateur (31 %). Le suivi médian s'étendait sur 26 mois (Q1, Q3: 14, 34). L'indicateur principal a été observé chez 16 patients; 11 dans le groupe se trouvant au-dessus de la médiane, et 5 dans le groupe inférieur (p?=?0,086). On a observé 26 indicateurs principaux chez 16 patients; 20 (77 %) accidents dans le groupe se trouvant au-dessus de la médiane en ce qui a trait à la calcification et 6 (23 %) dans le groupe inférieur (p?=?0,006). Il y a eu 10 décès; 8 dans le groupe se trouvant au-dessus de la médiane et 2 dans le groupe inférieur (p?=?0,04). Les taux de risque de calcification de l'artère coronaire se trouvant au-dessus et sous la médiane, pour les indicateurs principaux, étaient respectivement de 2,5 (95 % IC 0,98; 21,96; p?=?0,054) et 2,4 (95 % IC 0,45, 12,97; p?=?0,3). LIMITES DE L'ÉTUDE: Nous avons été limités par la taille restreinte de l'échantillon, de même que par le petit nombre d'accidents. CONCLUSION: Le fardeau du répondant repose sur des examens supplémentaires au moment de commencer la dialyse. Un fort taux de calcification de l'artère coronaire chez les patients nouvellement atteints d'IRT tend à prédire des accidents cardiovasculaires et la mort, bien que les effets soient atténués après révision en fonction de l'âge.

Active surveillance, radiofrequency ablation, or cryoablation for the nonsurgical management of a small renal mass: a cost-utility analysis.

BACKGROUND: Patients with a cortical small (≤4 cm) renal mass often are not candidates for or choose not to undergo surgery. The optimal management strategy for such patients is unclear. METHODS: A decision-analytic Markov model was developed from the perspective of a third party payer to compare the quality-adjusted life expectancy and lifetime costs for 67-year-old patients with a small renal mass undergoing premanagement decision biopsy, immediate percutaneous radiofrequency ablation or percutaneous cryoablation (without premanagement biopsy), or active surveillance with serial imaging and subsequent ablation if needed. RESULTS: The dominant strategy (most effective and least costly) was active surveillance with subsequent cryoablation if needed. On a quality-adjusted and discounted basis, immediate cryoablation resulted in a similar life expectancy (3 days fewer) but cost $3,010 more. This result was sensitive to the relative rate of progression to metastatic disease. Strategies that employed radiofrequency ablation had decreased quality-adjusted life expectancies (82-87 days fewer than the dominant strategy) and higher costs ($3,231-$6,398 more). CONCLUSIONS: Active surveillance with delayed percutaneous cryoablation, if needed, may be a safe and cost-effective alternative to immediate cryoablation. The uncertainty in the relative long-term rate of progression to metastatic disease in patients managed with active surveillance versus immediate cryoablation needs to be weighed against the higher cost of immediate cryoablation. A randomized trial is needed directly to evaluate the nonsurgical management of patients with a small renal mass, and could be limited to the most promising strategies identified in this analysis.

Self-expandable metallic biliary stents with permanent access.

OBJECTIVE: The objective of our study was to assess the safety and effectiveness of establishing a permanent access to self-expandable biliary stents in palliation of malignant biliary obstruction. CONCLUSION: Permanent access to self-expandable biliary stent provided a safe and effective means for timely reintervention in stent occlusion with acceptable stent patency.