Purpose Treatment decisions for renal malignancies depend largely on qualitative data, including a description of tumor anatomy and the experience of the treating surgeon. Currently characterization ...of renal tumor anatomical elements is descriptive and lacks standardization. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of localized renal lesions. We have developed and propose a standardized nephrometry scoring system (R.E.N.A.L. Nephrometry Score) to quantify the anatomical characteristics of renal masses on computerized tomography/magnetic resonance imaging. Materials and Methods The nephrometry score is based on 5 critical and reproducible anatomical features of solid renal masses. Of the 5 components 4 are scored on a 1, 2 or 3-point scale with the 5th indicating the anterior or posterior location of the mass relative to the coronal plane of the kidney. We applied the R.E.N.A.L. Nephrometry Score to 50 consecutive masses resected at Fox Chase Cancer Center. Results The R.E.N.A.L. Nephrometry Score consists of (R)adius (tumor size as maximal diameter), (E)xophytic/endophytic properties of the tumor, (N)earness of tumor deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line. The suffix h (hilar) is assigned to tumors that abut the main renal artery or vein. The nephrometry scoring system accurately classified the complexity of 50 consecutive tumors undergoing excision at our institution. Conclusions Standardized reporting of renal tumor size, location and depth is essential for decision making and effective comparisons. The R.E.N.A.L. Nephrometry Score is a reproducible standardized classification system that quantitates the salient anatomy of renal masses. This novel approach for the systematic characterization of renal tumors provides a tool for meaningful comparisons of renal masses in clinical practice and in the urological literature.
Renal cell carcinoma (RCC) is the most common form of kidney cancer. It is categorized into various subtypes, with clear cell RCC (ccRCC) representing about 85% of all RCC tumors. The lack of ...sensitivity to chemotherapy and radiation therapy prompted research efforts into novel treatment options. The development of targeted therapeutics, including multi-targeted tyrosine kinase inhibitors (TKI) and mTOR inhibitors, has been a major breakthrough in ccRCC therapy. More recently, other therapeutic strategies, including immune checkpoint inhibitors, have emerged as effective treatment options against advanced ccRCC. Furthermore, recent advances in disease biology, tumor microenvironment, and mechanisms of resistance formed the basis for attempts to combine targeted therapies with newer generation immunotherapies to take advantage of possible synergy. This review focuses on the current status of basic, translational, and clinical studies on mechanisms of resistance to systemic therapies in ccRCC.
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PURPOSEThis AUA Guideline focuses on evaluation/counseling/management of adult patients with clinically-localized renal masses suspicious for cancer, including solid-enhancing tumors and Bosniak 3/4 ...complex-cystic lesions. MATERIALS/METHODSThe Renal Mass and Localized Renal Cancer guideline underwent an update literature review which resulted in the 2021 amendment. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1Table: see text). RESULTSGreat progress has been made regarding the evaluation/management of clinically-localized renal masses. These guidelines provide updated, evidence-based recommendations regarding evaluation/counseling including the evolving role of renal-mass-biopsy (RMB). Given great variability of clinical/oncologic/functional characteristics, index patients are not utilized and the panel advocates individualized counseling/management. Options for intervention (partial-nephrectomy (PN), radical-nephrectomy (RN), and thermal-ablation (TA)) are reviewed including recent data about comparative-effectiveness/potential morbidities. Oncologic issues are prioritized while recognizing the importance of functional-outcomes for survivorship. Granular criteria for RN are provided to help reduce overutilization of RN while also avoiding imprudent PN. Priority for PN is recommended for clinical T1a lesions, along with selective utilization of TA, which has good efficacy for tumors≤3.0 cm. Recommendations for genetic-counseling have been revised and considerations for adjuvant-therapies are addressed. Active-surveillance and follow-up after intervention are discussed in an adjunctive article. CONCLUSIONSeveral factors require consideration during counseling/management of patients with clinically-localized renal masses including general health/comorbidities, oncologic-considerations, functional-consequences, and relative efficacy/potential morbidities of various management-strategies.
•The “overflowing beer sign” is highly specific for angiomyolipoma vs renal carcinoma.•It frequently, but not always, co-occurs with the “angular interface sign.”•Recognizing it increases the ...sensitivity of detection of lipid-poor AML.
To validate the “overflowing beer sign” (OBS) for distinguishing between lipid-poor angiomyolipoma (AML) and renal cell carcinoma, and to determine whether it improves the detection of lipid-poor AML when added to the angular interface sign, a previously-validated morphologic feature associated with AML.
Retrospective nested case-control study of all 134 AMLs in an institutional renal mass database matched 1:2 with 268 malignant renal masses from the same database. Cross-sectional imaging from each mass was reviewed and the presence of each sign was identified. A random selection of 60 masses (30 AML and 30 benign) was used to measure interobserver agreement.
Both signs were strongly associated with AML in the total population (OBS: OR 17.4 95% CI 8.0–42.5, p < 0.001; angular interface: OR 12.6, 95% CI 5.9–29.7, p < 0.001) and the population of patients excluding those with visible macroscopic fat (OBS: OR 11.2, 95% CI 4.8–28.7, p < 0.001; angular interface: 8.5, 95% CI 3.7–21.1, p < 0.001). In the lipid-poor population, the specificity of both signs was excellent (OBS: 95.6%, 95% CI 91.9%-98%; angular interface: 95.1%, 95% CI 91.3%–97.6%). Sensitivity was low for both signs (OBS: 31.4%, 95% CI 24.0-45.4%; angular interface: 30.5%, 95% CI 20.8%-41.6%). Both signs showed high levels of inter-rater agreement (OBS 90.0% 95% CI 80.5 - 95.9; angular interface 88.6, 95% CI 78.7–94.9) Testing for AML using the presence of either sign in this population improved sensitivity (39.0%, 95% CI 28.4%–50.4%, p = 0.023) without significantly reducing specificity (94.2%, 95% CI 90%–97%, p = 0.2) relative to the angular interface sign alone.
Recognition of the OBS increases the sensitivity of detection of lipid-poor AML without significantly reducing specificity.
PURPOSEThis AUA Guideline focuses on active surveillance (AS) and follow-up after intervention for adult patients with clinically-localized renal masses suspicious for cancer, including solid ...enhancing tumors and Bosniak 3/4 complex cystic lesions. MATERIALS AND METHODSIn January 2021, the Renal Mass and Localized Renal Cancer guideline underwent additional amendment based on a current literature-search. This literature search retrieved additional studies published between July 2016 to October 2020 using the same Key Questions and search criteria from the Renal Mass and Localized Renal Cancer guideline. When sufficient evidence existed, the body of evidence was assigned strength-rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1Table: see text). RESULTSAS with potential delayed intervention should be considered for patients with solid, enhancing renal masses <2cm or Bosniak 3-4 lesions that are predominantly-cystic. Shared decision-making about AS should consider risks of intervention/competing mortality versus the potential oncologic benefits of intervention. Recommendations for renal mass biopsy and considerations for periodic clinical/imaging-based surveillance are discussed. After intervention, risk-based surveillance protocols are defined incorporating clinical/laboratory evaluation and abdominal/chest imaging designed to detect local/systemic recurrences and possible treatment-related sequelae, such as progressive renal-insufficiency. CONCLUSIONAS is a potential management strategy for some patients with clinically-localized renal masses that requires careful risk-assessment, shared decision-making and periodic-reassessment. Follow-up after intervention is designed to identify local/systemic recurrences and potential treatment-related sequelae. A risk-based approach should be prioritized with selective use of laboratory/imaging resources.
Purpose This AUA Guideline focuses on evaluation/counseling and management of adult patients with clinically localized renal masses suspicious for cancer, including solid-enhancing tumors and Bosniak ...3/4 complex-cystic lesions. Materials and Methods Systematic review utilized research from the Agency for Healthcare Research and Quality and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A/B/C (Strong/Moderate/Conditional Recommendations, respectively) with additional statements presented as Clinical Principles or Expert Opinions. Results Great progress has been made since the previous guidelines on management of localized renal masses was released (2009). The current guidelines provide updated, evidence-based recommendations regarding evaluation/counseling of patients with clinically localized renal masses, including the evolving role of renal mass biopsy. Given great variability of clinical, oncologic and functional characteristics, index patients are not utilized and the panel advocates individualized counseling/management. Management options (partial nephrectomy/radical nephrectomy/thermal ablation/active surveillance) are reviewed including recent data about comparative effectiveness and potential morbidities. Oncologic issues are prioritized while recognizing that functional outcomes are of great importance for survivorship for most patients with localized kidney cancer. A more restricted role for radical nephrectomy is recommended following well-defined selection criteria. Priority for partial nephrectomy is recommended for clinical T1a lesions, along with selective use of thermal ablation, particularly for tumors ≤3.0 cm. Important considerations for shared decision-making about active surveillance are explicitly defined. Conclusions Several factors should be considered during counseling/management of patients with clinically localized renal masses, including general health/comorbidities, oncologic potential of the mass, pertinent functional issues and relative efficacy/potential morbidities of various management strategies.
BACKGROUND:Comorbidity adjustment is an important component of health services research and clinical prognosis. When adjusting for comorbidities in statistical models, researchers can include ...comorbidities individually or through the use of summary measures such as the Charlson Comorbidity Index or Elixhauser score. We examined the conditions under which individual versus summary measures are most appropriate.
METHODS:We provide an analytic proof of the utility of comorbidity summary measures when used in place of individual comorbidities. We compared the use of the Charlson and Elixhauser scores versus individual comorbidities in prognostic models using a SEER-Medicare data example. We examined the ability of summary comorbidity measures to adjust for confounding using simulations.
RESULTS:We devised a mathematical proof that found that the comorbidity summary measures are appropriate prognostic or adjustment mechanisms in survival analyses. Once one knows the comorbidity score, no other information about the comorbidity variables used to create the score is generally needed. Our data example and simulations largely confirmed this finding.
CONCLUSIONS:Summary comorbidity measures, such as the Charlson Comorbidity Index and Elixhauser scores, are commonly used for clinical prognosis and comorbidity adjustment. We have provided a theoretical justification that validates the use of such scores under many conditions. Our simulations generally confirm the utility of the summary comorbidity measures as substitutes for use of the individual comorbidity variables in health services research. One caveat is that a summary measure may only be as good as the variables used to create it.
To determine if escalated radiation dose using hypofractionation significantly reduces biochemical and/or clinical disease failure (BCDF) in men treated primarily for prostate cancer.
Between June ...2002 and May 2006, men with favorable- to high-risk prostate cancer were randomly allocated to receive 76 Gy in 38 fractions at 2.0 Gy per fraction (conventional fractionation intensity-modulated radiation therapy CIMRT) versus 70.2 Gy in 26 fractions at 2.7 Gy per fraction (hypofractionated IMRT HIMRT); the latter was estimated to be equivalent to 84.4 Gy in 2.0 Gy fractions. High-risk patients received long-term androgen deprivation therapy (ADT), and some intermediate-risk patients received short-term ADT. The primary end point was the cumulative incidence of BCDF. Secondarily, toxicity was assessed.
There were 303 assessable patients with a median follow-up of 68.4 months. No significant differences were seen between the treatment arms in terms of the distribution of patients by clinicopathologic or treatment-related (ADT use and length) factors. The 5-year rates of BCDF were 21.4% (95% CI, 14.8% to 28.7%) for CIMRT and 23.3% (95% CI, 16.4% to 31.0%) for HIMRT (P = .745). There were no statistically significant differences in late toxicity between the arms; however, in subgroup analysis, patients with compromised urinary function before enrollment had significantly worse urinary function after HIMRT.
The hypofractionation regimen did not result in a significant reduction in BCDF; however, it is delivered in 2.5 fewer weeks. Men with compromised urinary function before treatment may not be ideal candidates for this approach.
The incidence of renal cell carcinoma is rising because of incidental detection of small renal masses (SRMs). Although surgical resection remains the standard of care, cryoablation and radiofrequency ...ablation (RFA) have emerged as minimally invasive treatment alternatives. The authors of this report performed a comparative meta-analysis evaluating cryoablation and RFA as primary treatment for SRMs.
A search of the MEDLINE database was performed reviewing the world literature for clinically localized renal masses treated by cryoablation or RFA.
Forty-seven studies representing 1375 kidney lesions treated by cryoablation or RFA were analyzed. No differences were detected between ablation modalities with regard to mean patient age (P = .17), tumor size (P = .12), or duration of follow-up (P = .53). Pretreatment biopsy was performed more often for cryoablated lesions (82.3%) than for RFA (62.2%; P < .0001). Unknown pathology occurred at a significantly higher rate for SRMs that underwent RFA (40.4%) versus cryoablation (24.5%; P < .0001). Repeat ablation was performed more often after RFA (8.5% vs 1.3%; P < .0001), and the rates of local tumor progression were significantly higher for RFA (12.9% vs 5.2%; P < .0001) compared with cryoablation. The higher incidence of local tumor progression was found to be correlated significantly with treatment by RFA on univariate analysis (P = .001) and on multivariate regression analysis (P = .003). Metastasis was reported less frequently for cryoablation (1.0%) versus RFA (2.5%; P = .06). Cryoablation usually was performed laparoscopically (65%), whereas 94% of lesions that were treated with RFA were approached percutaneously.
Ablation of SRMs is a viable strategy based on short-term oncologic outcomes. Although extended oncologic efficacy remains to be established for ablation modalities, the current data suggest that cryoablation results in fewer retreatments and improved local tumor control, and it may be associated with a lower risk of metastatic progression compared with RFA.
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