ESOU 2019: Debate: T2 Renal Tumors Best Surgical Treatment: Partial Nephrectomy

Prague, Czech Republic (UroToday.com) As part of the localized kidney cancer session, a debate discussing the optimal surgical treatment of T2 renal tumors. Dr. Karim Bensalah from Rennes, France presented the position that the best treatment is partial nephrectomy.

A recent systematic review published in European Urology assessed outcomes of partial nephrectomy and radical nephrectomy in cases of large renal tumors (≥cT1b)1. Overall there were 21 case-control studies assessing 11,204 patients, and specific to T2 patients, there were four studies with 212 patients undergoing partial nephrectomy and 1,792 patients undergoing radical nephrectomy. Importantly, both the recurrence rate (RR 0.61, p=0.004) and cancer-specific mortality (RR 0.65, p=0.03) favored partial nephrectomy among T2 patients. A study published last year using NCDB data assessed patients with cT1bN0M0 and cT2N0M0 and the likelihood of receiving a partial nephrectomy2. There were 6,072 patients that underwent partial nephrectomy, which was associated with better OS among patients with T2 tumors (cT2 n=538), however, the result was not statistically significant (HR 0.8, 95%CI 0.62-1.04).

With regards to surgical outcomes, partial nephrectomy for T2 renal masses is associated with higher blood loss (+ 107 mL) compared to radical nephrectomy, but as Dr. Bensalah notes, this is a clinically insignificant volume1. In three studies assessing complication rates, partial nephrectomy was associated with a higher complication rate (RR 2.0; p <0.001)1, with the most common complication reported being urinary fistulae3.

Data from the ROSULA cohort sheds light on the outcomes of patients with cT2 tumors undergoing robotic partial nephrectomy [4]. Among 298 patients, median tumor size was 7.6 (range 7-8.5) cm, median ischemia time was 25 (range 20-32) min, and the median estimated blood loss was 150 (range 100-300) ml. The intraoperative complication rate was 5.4%, whereas the postoperative complication rate was 22% (5% Clavien grade ≥3). Pathological pT2 stage (OR 0.51, 95%CI 0.12-0.86) was protective against postoperative complications. A total of 243 lesions (82%) were malignant and 8% of patients had positive surgical margins. Over a median follow-up of 12 months (range 5-35), 10 deaths and 25 recurrences/metastases occurred. In a French Committee of Urologic Oncology collaborative effort comparing robotic and open partial nephrectomy outcomes (n=1,800), the complication rate was significantly higher in the open group (28.6 vs 18%, p<0.001). Not surprisingly, both declines in eGFR and onset of CKD favored patients undergoing partial vs radical nephrectomy1.

Dr. Bensalah concluded his presentation advocating for partial nephrectomy in patients with cT2 renal masses with the following statements:
  • Partial nephrectomy is an option for T2 tumors, considering there are similar oncological outcomes, improved renal function, and acceptable morbidity
  • Partial nephrectomy should be considered whenever feasible, particularly in imperative situations and patients with chronic kidney disease

Presented by: Karim Bensalah, MD, Ph.D., Rennes University Hospital, Rennes, France

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

References:

  1. Mir MC, Derweesh I, Porpiglia F, et al. Partial nephrectomy versus radical nephrectomy for clinical T1b and T2 renal tumors: A systematic review and meta-analysis of comparative studies. Eur Urol 2017 Apr;71(4):606-617.
  2. Venkatramani V, Koru-Sengul T, Miao F, et al. A comparison of overall survival and perioperative outcomes between partial and radical nephrectomy for cT1b and cT2 renal cell carcinoma: Analysis of a national cancer registry. Urol Oncol 2018 Mar;36(3):90,e9-e90.e14.
  3. Nahar B, Gonzalgo ML. What is the current role of partial nephrectomy for T2 tumors? Can J Urol 2017 Apr;24(2):8698-8704.
  4. Bertolo R, Autorino R, Simone G, et al. Outcomes of robot-assisted partial nephrectomy for clinical T2 renal tumors: A multicenter analysis (ROSULA Collaborative Group). Eur Urol 2018 Aug;74(2):226-232.
  5. Peyronnet B, Seisen T, Oger E, et al. Comparison of 1800 Robotic and Open Partial Nephrectomies for Renal Tumors. Ann Surg Oncol 2016 Dec;23(13):4277-4283.







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