Urological Survey Urological Oncology: Adrenal, Renal, Ureteral and Retroperitoneal Tumors Re: Cytoreductive Nephrectomy in Patients with Synchronous Metastases from Renal Cell Carcinoma: Results from the International Metastatic Renal Cell Carcinoma Database Consortium D. Y. Heng, J. C. Wells, B. I. Rini, B. Beuselinck, J. L. Lee, J. J. Knox, G. A. Bjarnason, S. K. Pal, C. K. Kollmannsberger, T. Yuasa, S. Srinivas, F. Donskov, A. Bamias, L. A. Wood, D. S. Ernst, N. Agarwal, U. N. Vaishampayan, S. Y. Rha, J. J. Kim and T. K. Choueiri Tom Baker Cancer Center, Calgary, Alberta, Princess Margaret Cancer Centre and Sunnybrook Odette Cancer Centre, Toronto and London Regional Cancer Centre, London, Ontario, BCCA Vancouver Cancer Centre, Vancouver, British Columbia and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, City of Hope Comprehensive Cancer Center, Duarte and Stanford Medical Center, Stanford, California, University of Utah Huntsman Cancer Institute, Salt Lake City, Utah, Karmanos Cancer Institute, Detroit, Michigan, Sidney Kimmel Comprehensive Cancer Center at John Hopkins University, Baltimore, Maryland, Dana-Farber Cancer Institute, Boston, Massachusetts, University Hospitals Leuven, Leuven, Belgium, Asan Medical Center and Yonsei University College of Medicine, Seoul, South Korea, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan, Aarhus University Hospital, Aarhus, Denmark, and Department of Clinical Therapeutics, National and Kapodistrian University, Athens, Greece Eur Urol 2014; 66: 704e710.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.003 available at http://jurology.com/ Editorial Comment: Data reported in this retrospective analysis do not basically differ from previous reports. The only patients who benefit from cytoreductive nephrectomy (CN) are those exhibiting fewer than 3 International Metastatic Renal Cell Carcinoma Consortium risk factors at diagnosis. The strength of the study resides in the use of the Heng criteria, which are widely accepted in the era of targeted therapy, and on the size of the series. Additional data of interest are provided in the incremental benefit analysis. Based on the latter, and after adjusting for prognostic factors, the only group of patients who experience a definitive clinical benefit from CN are those who survive longer than 18 months. Only a marginal, albeit statistically significant, clinical benefit was observed in patients surviving 13 to 18 months. While valuable, these data are based on a posteriori analysis, and the relevant question, ie which patients should undergo CN and which should not, relies again on a number of factors. What is missed in the study is the use of prognostic risk groups according to Heng criteria, which are otherwise nicely validated in several data sets. Nevertheless, the present data clearly indicate that some patients in the poor prognostic group (3 or more risk factors) may still benefit from CN, while some in the intermediate group (1 to 2 risk factors) may not receive any clinical benefit based on survival data. Until randomized controlled trial data emerge, the challenge remaining for clinicians is identification of the subset of patients who will not benefit from a procedure that can be associated with morbidity and mortality. M. Pilar Laguna, MD, PhD
Suggested Reading Flanigan RC, Mickisch G, Sylvester R et al: Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis. J Urol 2004; 171: 1071. Choueiri TK, Xie W, Kollmannsberger C et al: The impact of cytoreductive nephrectomy on survival of patients with metastatic renal cell carcinoma receiving vascular endothelial growth factor targeted therapy. J Urol 2011; 185: 60.
0022-5347/15/1935-1514/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1514
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.02.003 Vol. 193, 1514-1518, May 2015 Printed in U.S.A.
ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS
Smaldone MC, Handorf E, Kim SP et al: Temporal trends and factors associated with receipt of systemic therapy in patients undergoing cytoreductive nephrectomy: an analysis of the National Cancer Database. J Urol 2014; 193: 1108. McKiernan J and Wood CG: Cytoreductive nephrectomy for metastatic renal cell carcinoma. J Urol 2013; 190: 386. You D, Jeong IG, Ahn JH et al: The value of cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy. J Urol 2011; 185: 54.
Re: Renal Tumor Contact Surface Area: A Novel Parameter for Predicting Complexity and Outcomes of Partial Nephrectomy S. Leslie, I. S. Gill, A. L. de Castro Abreu, S. Rahmanuddin, K. S. Gill, M. Nguyen, A. K. Berger, A. C. Goh, J. Cai, V. A. Duddalwar, M. Aron and M. M. Desai USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, and Department of Radiology, University of Southern California, Los Angeles, California Eur Urol 2014; 66: 884e893.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.004 available at http://jurology.com/ Editorial Comment: RENAL (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry, PADUA (Preoperative Aspects and Dimensions Used for Anatomic) score and C (centrality) index have been initially developed as tools to stratify anatomical complexity of renal tumors as a prognostic factor for complications. All of these systems highlight the increasing risk of complications associated to the increased complexity of the mass. As for other prognostic uses, encountered results have been reported. Renal tumor contact surface area (CSA) captures another dimension of complexity not yet assessed, although implied in other scores. This measure combines tumor size with an endophytic component and uses 3-dimensional image rendering software to provide the CSA of the tumor with renal parenchyma (in cm2). CSA in case of partial nephrectomy provides the ability to understand immediately that the larger the tumor, the more extensive the parenchyma line of resection, the more difficult the operation and the greater likelihood of postoperative complications. The interobserver concordance of the parameter is almost perfect, representing a strong point in the study. The weakest point is the subjective estimation of kidney preserved. However, reliable methods to assess the volume of the remnant kidney are still under development, and quality of the remaining parenchyma may be as important as volume. A last point relates to the possible generalization/diffusion of this parameter. To assess CSA, a slice thickness of 0.5 to 1 mm was used on computerized tomography. Currently computerized tomography protocols for the diagnosis/ characterization of renal masses entail a 3 mm slice, with 5 mm slice protocols still being used at a considerable percentage of community hospitals. M. Pilar Laguna, MD, PhD
Suggested Reading Lee CT, Katz J, Shi W et al: Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J Urol 2000; 163: 730. Leibovich BC, Blute M, Cheville JC et al: Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004; 171: 1066. Kutikov A and Uzzo RG: The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 2009; 182: 844. Simmons MN, Ching CB, Samplaski MK et al: Kidney tumor location measurement using the C index method. J Urol 2010; 183: 1708. Hew MN, Baseskioglu B, Barwari K et al: Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. nephrometry score in patients undergoing partial nephrectomy. J Urol 2011; 186: 42.
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Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.003 available at http://jurology.com/ Editorial Comment: Data reported in this retrospective analysis do not basically differ from previous reports. The only patients who benefit from cytoreductive nephrectomy (CN) are those exhibiting fewer than 3 International Metastatic Renal Cell Carcinoma Consortium risk factors at diagnosis. The strength of the study resides in the use of the Heng criteria, which are widely accepted in the era of targeted therapy, and on the size of the series. Additional data of interest are provided in the incremental benefit analysis. Based on the latter, and after adjusting for prognostic factors, the only group of patients who experience a definitive clinical benefit from CN are those who survive longer than 18 months. Only a marginal, albeit statistically significant, clinical benefit was observed in patients surviving 13 to 18 months. While valuable, these data are based on a posteriori analysis, and the relevant question, ie which patients should undergo CN and which should not, relies again on a number of factors. What is missed in the study is the use of prognostic risk groups according to Heng criteria, which are otherwise nicely validated in several data sets. Nevertheless, the present data clearly indicate that some patients in the poor prognostic group (3 or more risk factors) may still benefit from CN, while some in the intermediate group (1 to 2 risk factors) may not receive any clinical benefit based on survival data. Until randomized controlled trial data emerge, the challenge remaining for clinicians is identification of the subset of patients who will not benefit from a procedure that can be associated with morbidity and mortality. M. Pilar Laguna, MD, PhD
Suggested Reading Flanigan RC, Mickisch G, Sylvester R et al: Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis. J Urol 2004; 171: 1071. Choueiri TK, Xie W, Kollmannsberger C et al: The impact of cytoreductive nephrectomy on survival of patients with metastatic renal cell carcinoma receiving vascular endothelial growth factor targeted therapy. J Urol 2011; 185: 60.
0022-5347/15/1935-1514/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1514
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.02.003 Vol. 193, 1514-1518, May 2015 Printed in U.S.A.
ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS
Smaldone MC, Handorf E, Kim SP et al: Temporal trends and factors associated with receipt of systemic therapy in patients undergoing cytoreductive nephrectomy: an analysis of the National Cancer Database. J Urol 2014; 193: 1108. McKiernan J and Wood CG: Cytoreductive nephrectomy for metastatic renal cell carcinoma. J Urol 2013; 190: 386. You D, Jeong IG, Ahn JH et al: The value of cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy. J Urol 2011; 185: 54.
Re: Renal Tumor Contact Surface Area: A Novel Parameter for Predicting Complexity and Outcomes of Partial Nephrectomy S. Leslie, I. S. Gill, A. L. de Castro Abreu, S. Rahmanuddin, K. S. Gill, M. Nguyen, A. K. Berger, A. C. Goh, J. Cai, V. A. Duddalwar, M. Aron and M. M. Desai USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, and Department of Radiology, University of Southern California, Los Angeles, California Eur Urol 2014; 66: 884e893.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.004 available at http://jurology.com/ Editorial Comment: RENAL (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry, PADUA (Preoperative Aspects and Dimensions Used for Anatomic) score and C (centrality) index have been initially developed as tools to stratify anatomical complexity of renal tumors as a prognostic factor for complications. All of these systems highlight the increasing risk of complications associated to the increased complexity of the mass. As for other prognostic uses, encountered results have been reported. Renal tumor contact surface area (CSA) captures another dimension of complexity not yet assessed, although implied in other scores. This measure combines tumor size with an endophytic component and uses 3-dimensional image rendering software to provide the CSA of the tumor with renal parenchyma (in cm2). CSA in case of partial nephrectomy provides the ability to understand immediately that the larger the tumor, the more extensive the parenchyma line of resection, the more difficult the operation and the greater likelihood of postoperative complications. The interobserver concordance of the parameter is almost perfect, representing a strong point in the study. The weakest point is the subjective estimation of kidney preserved. However, reliable methods to assess the volume of the remnant kidney are still under development, and quality of the remaining parenchyma may be as important as volume. A last point relates to the possible generalization/diffusion of this parameter. To assess CSA, a slice thickness of 0.5 to 1 mm was used on computerized tomography. Currently computerized tomography protocols for the diagnosis/ characterization of renal masses entail a 3 mm slice, with 5 mm slice protocols still being used at a considerable percentage of community hospitals. M. Pilar Laguna, MD, PhD
Suggested Reading Lee CT, Katz J, Shi W et al: Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J Urol 2000; 163: 730. Leibovich BC, Blute M, Cheville JC et al: Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004; 171: 1066. Kutikov A and Uzzo RG: The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 2009; 182: 844. Simmons MN, Ching CB, Samplaski MK et al: Kidney tumor location measurement using the C index method. J Urol 2010; 183: 1708. Hew MN, Baseskioglu B, Barwari K et al: Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. nephrometry score in patients undergoing partial nephrectomy. J Urol 2011; 186: 42.
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