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ASCO GU 2018

ASCO GU 2018: Interpreting Data on Renal Function Preservation After Nephrectomy: Has the EORTC Trial Put the Issue to Rest?

San Francisco, CA (UroToday.com) Dr. Parikh presented renal function preservation after nephrectomy and included the following 4 goals for renal cell carcinoma (RCC) surgery:

  1. Oncologic efficacy
  2. Preservation of renal function
  3. Reduction of perioperative morbidity
  4. Cosmesis
A study published by Go et al. in the NEJM demonstrated that in the US there are over 1 million adults with chronic kidney disease (CKD).1 CKD is a significant independent risk factor for death, cardiovascular event, and hospitalization. A retrospective study published in Lancet Oncology in 2006 reviewed 662 patients with T1a renal tumors. CKD developed in 17% of patients who underwent partial nephrectomy (PN) and 70% of patients who underwent radical nephrectomy (RN).2 However, these data are retrospective, of low quality evidence, and heterogenous.

The only prospective study published comparing the oncologic outcome of PN vs. RN in low stage RCC, was the EORTC 30904, published in 2011.3 It included 541 patients randomized from 45 institutions and 17 countries between 1992-2003. The primary endpoint was overall survival (OS) and all patients had tumors smaller than 5 cm. On intention to treat (ITT) analyses there was a 10 year OS of 75.7% for PN an 81.1% for RN, with a hazard ratio (HR) of 1.5, p=0.03 (Figure 1).

The EORTC 30904 study has several known limitations. These include the low accrual rate, lack of information on the amount of parenchyma preserved, quality of PN performed, and high crossover from the PN to the RN group (15%).

An analysis of the EORTC trial 30904 study was performed in an attempt to compare renal function between PN and RN. However, the comparison was done only based on creatinine levels. The results demonstrated that PN had less incidence of moderate CKD, the incidence of advanced CKD and renal failure were the same. However, the OS was better for RN than for PN.

Dr. Parikh continued his talk and stated that the EORTC 30904 was a well intentioned but poorly accrued  randomized controlled trial. Therefore, he does not think this study provides level 1 evidence for choosing one form of therapy over the other. In treating these patients, there is always a dilemma of treating the mass or treating the patients (Figure 2).

Dr. Parikh moved on to his recommendations regarding treatment of localized RCC with a normal contralateral kidney:

  1. For T1a – PN
  2. For T1b – PN or RN and we should consider tumor/patient factors and surgeon experience
  3. For T2 – RN/PN and we should consider tumor/patients factors and surgeon experience
  4. For T3-T4 – RN
Dr. Parikh concluded his talk by summarizing the comparison between PN and RN. PN has higher complication rates with increasing tumor size and complexity. We need to take into account all patient related factors including age, comorbidities, and need for anticoagulants. Surgical CKD is probably not as harmful as initially thought and we should focus on medical CKD.

Figure – 1: Overall survival comparison between radical nephrectomy and partial nephrectomy:
OS RCC 1



Figure 2 – Treating the patient or the tumor mass:
Parikh 2



Presented by: Dipen J. Parekh, MD, University of Miami Miller School of Medicine

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, February 8-10, 2018 - San Francisco, CA

References:

1. Go  AS, Chertow  GM, Fan  D, McCulloch  CE, Hsu  C-y. Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization. New England Journal of Medicine 2004; 351(13): 1296-305.

2. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. The Lancet Oncology 2006; 7(9): 735-40.

3. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. European urology 2011; 59(4): 543-52.