ASCO GU 2017: Best of Journals: Renal Cell Carcinoma – Urologic Oncology - Session Highlights

Orlando, Florida USA (UroToday.com) In this session, Dr. Uzzo reviewed the important surgical literature in renal cell carcinoma (RCC) from 2016. A systematic review of the Agency for Healthcare and Research Quality demonstrated that renal mass biopsy (RMB) is a safe and important tool. Twenty studies comprising 2,797 patients and 3,113 RMBs were included in the meta-analysis. The non-diagnostic rate was 14% and repeat biopsies in these cases were diagnostic in 80%. The false positive rate was only 4%. Core biopsy sensitivity and specificity were 97.5% and 96.2% respectively. Accuracy regarding grade concordance varied from 56-76% and upgrading from low to high grade occurred in 16%. Adverse events occurred in 5-7% of patients with hematoma (4.9%) being the most common. One area of controversy in RMB is an oncocytic diagnosis. Fortunately, annual growth rates for oncocytic lesions are 0.2-0.4 cm/year. In one study, eight patients (total n = 95) elected surgery over a period of 24 months’ median follow-up and no patients died of RCC.

Dr. Uzzo cited an interesting study in which RCC histologic subtypes varied by demographic. Of 1,552 consecutive nephrectomies performed at Vanderbilt University, papillary was found to be more common in African-Americans compared to Caucasians (OR 4.15, 95% CI 2.64-6.52) and less likely in females (OR 0.60, 95% CI 0.41-0.83). Chromophobe RCC was more common among females (OR 2.32, 95% CI 1.44-3.74) and both papillary (OR 6.26, 95% CI 2.75-14.24) and chromophobe RCC (OR 7.07, 95% CI 2.13-23.46) occurred more often in patients with end stage renal disease.

In process of care surgical trials, rhabdomyolysis was found to be more common among obese patients undergoing prolonged surgeries. The overall incidence was 1 in 650 cases. However, the 90-day mortality rates among these patients were significantly higher (4.4% versus 1.02%, p < 0.05) indicating a potential for improving quality of care. An intriguing comparison of post-operative pain scores between open and laparoscopic nephrectomy was performed. Interestingly, only post-operative hour 2 scores were worse for open nephrectomy compared to laparoscopic nephrectomy. No differences were noted in acute/chronic pain scores or morphine consumption.

In the surveillance imaging literature, several studies were cited. The general themes were that there may be over-imaging for low risk recurrence and under-imaging at > 10 years’ follow-up where approximately 4.6% of patients experienced a recurrence at greater than 10 years. Regarding predictors for overall survival in patients who undergo nephrectomy, preoperative proteinuria was demonstrated to portend worse overall survival, and Dr. Uzzo recommended checking proteinuria preoperatively in patients with kidney cancer.

The impact of renal surgery on overall kidney function is frequently of concern to renal surgeons. In a study of 572 patients who underwent nephrectomy, nearly half (49%) recovered eGFR at a median of 25 months. This was best for patients with preoperative eGFR < 60 (58%) relative to patients with eGFR > 60 (44%).

Regarding adjuvant studies, Dr. Uzzo highlighted both the ASSURE and S-TRAC randomized controlled trials. Neither demonstrated overall survival benefits; however, S-TRAC did demonstrate an improvement in progression free survival. He concluded that we should keep trying in this space and outlined two current clinical trials accruing utilizing immunotherapeutic regimens (PROSPER and IMmotion).

Dr. Uzzo concluded with the following take-home messages for 2016. Renal mass biopsy is sage, effective, and often very helpful for decision making. Oncocytic lesions can be safely watched in well-selected patients. Standardized surgical pathways (e.g. ERAS and pre-emptive pain management) improve care. Preoperative proteinuria should be checked in patients undergoing renal surgery as it may predict functional outcomes. Nearly half (49%) of patient undergoing nephrectomy fully recover eGFR by 2 years. Adjuvant treatments in kidney cancer are not currently improved; therefore, patients should be enrolled in clinical trials with immunotherapy to determine whether they may derive benefit. Preoperative nutritional status is an important predictor of post-surgical outcomes in patients with metastatic RCC, and prehabilitation should be considered. Local management (resection or radiation therapy) of delayed metastatic RCC (e.g. pancreas) may improve outcomes. Lastly, transplanting kidneys with small renal masses may appears safe.

Presenter: Robert G. Uzzo, MD, Fox Chase Cancer Center, Temple University Health System

Written By: Benjamin T. Ristau, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center

at the 2017 Genitourinary Cancers Symposium - February 16 - 18, 2017 – Orlando, Florida USA
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