The Management of a Clinical T1b Renal Tumor in the Presence of a Normal Contralateral Kidney The Case for Nephron-Sparing Surgery.

Department of Urology, University of Minnesota, Minneapolis, MN. Electronic address: .
The Journal of urology (Impact Factor: 4.47). 01/2013; 189(4). DOI: 10.1016/j.juro.2013.01.030
Source: PubMed
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Available from: Ithaar Derweesh, Jan 23, 2014
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    ABSTRACT: Background: Partial nephrectomy (PN) and radical nephrectomy (RN) are standard treatments for a small renal mass. Retrospective studies suggest an overall survival (OS) advantage, however a randomized phase 3 trial suggests otherwise. The effects of both surgical modalities on OS were evaluated compared with controls. Methods: A matched cohort study was performed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset. Individuals treated with PN or RN for localized renal cell carcinoma (RCC) measuring ≤4 cm were compared with 2 control groups (non-muscle-invasive bladder cancer (BCC) and noncancer controls (NCC). Using a greedy algorithm, RCC groups were matched with controls by demographics and comorbidities. OS for surgical groups and controls were compared. The cause of death was evaluated for cancer groups when differences in OS were noted. Results: Patients undergoing PN and RN were matched with controls. All cancer groups had >95% 10-year cancer-specific survival (CSS). Median OS was similar between RN (9.05 years) and BCC (8.67 years; P = .067) and NCC (8.77 years; P = .49). Median OS was improved for PN (10.45 years) compared with BCC (8.75 years; P<.001) and NCC controls (8.76 years; P<.001). A multivariate Cox hazards model demonstrated that PN improved OS compared with NCC (hazard ratio, 1.257; P<.001) and BCC (hazard ratio, 1.364; P<.001). Conclusions: RN patients had similar OS compared with controls, suggesting that this treatment modality does not compromise survival. Patients undergoing PN had improved OS compared with controls, suggesting possible selection bias. The apparent survival advantage conferred by PN in SEER-Medicare case series is likely the result of selection bias involving unmeasured confounders.
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    ABSTRACT: We evaluated survival outcomes of PN and RN for clinical T2 renal masses (cT2RM) controlling for RENAL score. Two-center study of 202 patients with cT2RM who underwent RN (122) or PN (80) between 7/2002-6/2012 (median follow-up 41.5 months). Kaplan-Meier analysis compared overall survival (OS), cancer specific survival (CSS) and progression free survival (PFS) among entire cohort and within categories of RENAL score≥10 and <10. Association between procedure and PFS and OS was analyzed using Cox-proportional Hazard. No significant differences between PN and RN existed in clinical T stage and RENAL nephrometry. For RN and PN, Five year-PFS was 69.8%/79.9% (p=0.115), CSS 82.5%/86.7% (p=0.407), and OS 80%/83.3% (p=0.291). Cox regression demonstrated no association between RN vs. PN and PFS; RENAL ≥10 was associated with shorter PFS (HR 6.69, p=0.002). Kaplan-Meier analysis for RN vs. PN had no difference in PFS for entire cohort or within RENAL≥10 and <10. PFS was superior for RENAL<10 vs. ≥10 (p<0.001) and for cT2a vs.cT2b tumors (p=0.012). OS was no different between cT2a and cT2b tumors; RENAL≥10 was more likely to die of disease (p<0.001) or any cause (p<0.001) vs. RENAL<10. PN may be oncologically effective for cT2RM. RENAL≥10 is negatively associated with OS among cT2RM compared to RENAL<10 and provides additional risk assessment beyond clinical T stage. Further follow-up and prospective randomized investigation is requisite to confirm efficacy of PN for cT2RM.
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