AUA 2018: Does Partial Nephrectomy for Biopsy Proven Fuhrman Grade 3/4 Renal Cell Carcinoma Confer Worse Outcomes Compared to Radical Nephrectomy?

San Francisco, CA ( To date, no evidence exists on whether the treatment with radical nephrectomy (RN) for non-metastatic grade 3/4 renal cell carcinoma (RCC) tumors confers better overall outcomes than treatment with partial nephrectomy (PN). In this study the authors aimed to analyze and compare results of patients with biopsy proven grade 3 / 4 RCC treated with either PN or RN. During 2006-2017 a total of 2,844 patients from the multicenter Canadian Kidney Cancer Information System (CKCIS) had undergone a biopsy for a suspicious renal mass. 

Clinical, surgical, and pathologic parameters were compared between patients who underwent PN and RN. Multivariable logistic regression analysis predicting PN was performed, after adjusting for pertinent variables.

Figure 1 demonstrates the flowchart for patient selection. Out of a total of 9222 patients, only 76 non-metastatic patients who underwent surgery were left for the analysis. None of them received adjuvant therapy. 
UroToday AUA2018 Flowchart for Study Patient selection
Table 1 demonstrates preoperative clinical characteristics, showing a higher stage T3/T4 and Grade 4 percentage among patients undergoing RN.  Postoperative data (Table 2) shows a worse stage & grade disease, and overall outcomes among RN patients. When stratifying outcomes by tumor size <7 cm, none of the PN patients died but 2/25 (8%) of the RN patients died.
UroToday AUA2018 Preoperative Post biopsy clinical charac

UroToday AUA2018 Postoperative pathological followupdata
In patients with postoperative grade 3 /4, 30% of RN compared to 12% of PN developed metastasis (p=0.1) and 19% of RN compared to none of the PN patients had died due to the disease, p=0.035 (Figure 2). Finally, multivariable logistic regression analysis showed that grade 4 compared to grade 3 (OR 0.093, 95% CI 0.01-0.871, p=0.0375), and stage T3/T4 compared to T1 disease (OR 0.09, 95% CI 0.0092-0.8961, p=0.04) significantly predict a lower odds ratio for undergoing PN (Table 3).

UroToday AUA2018 34 RCC

UroToday AUA2018 RegressionAnalysis
In summary, RN patients had worse disease resulting in worse outcomes, when compared to PN patients. However, sensitivity analyses specifically for patients with postoperative grade 3/4 or tumor size <7 cm, did not show worse outcomes for PN patients.  Despite obvious limitations of a small cohort and an inherent selection bias, PN does not appear to confer worse outcomes for biopsy proven grade 3/4 patients. Studies with larger multicenter cohorts are required to validate these results.

Presented by:  Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre

Written by:  Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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