Should patients with low risk renal cell carcinoma be followed differently after nephron-sparing surgery versus radical nephrectomy?

To investigate whether pT1-renal cell carcinoma (RCC) should be followed differently after partial (PN) or radical nephrectomy (RN) based on a retrospective analysis of a multi-centre database (RECUR).

Retrospective study of 3380 patients treated for nonmetastatic RCC between January-2006 and December-2011 across 15 centres from 10 countries, as part of the RECUR-database project. For patients with pT1 clear-cell RCC (ccRCC), patterns of recurrence were compared between RN and PN according to recurrence site. Univariate and multivariate models were used to evaluate the association between surgical approaches and recurrence-free survival (RFS) and cancer-specific mortality (CSM).

From the database 1995 patients were identified as low-risk patients (pT1,pN0,pNx), of whom 1055 (52.9%) underwent PN. On multivariate analysis, features associated with worse RFS included tumour size (HR1.32, 95%CI 1.14-1.39,p<0.001), nuclear grade (HR 2.31, 95% CI 1.73-3.08, p<0.001), tumour necrosis (HR 1.5, 95%CI 1.03-2.3, p=0.037), vascular invasion (HR: 2.4 95%CI 1.3-4.4, p=0.005) and positive surgical margins (HR 4.4, 95%CI 2.3-8.5, p<0.001). Kaplan-Meier analysis of CSM revealed that the survival of patients with recurrence after PN was significantly better than those recurring after RN (p=0.02). While the above-mentioned risk factors were associated with prognosis, the type of surgery alone was not an independent prognostic variable for RFS nor CSM. Limitations include the retrospective nature of the study.

Our results showed that follow-up protocols should not rely solely on stage and type of primary surgery. An optimized regimen should also include validated risk factors rather than the type of surgery alone, to select the best imaging modality and to avoid unnecessary imaging. A follow-up of more than three years should be considered in patients with pT1 tumours after RN. A novel follow-up strategy is proposed.

BJU international. 2021 Apr 01 [Epub ahead of print]

Y Abu-Ghanem, T Powles, U Capitanio, C Beisland, P Järvinen, G D Stewart, E Gudmundsson, Tbl Lam, L Marconi, S Fernandéz-Pello, H Nisen, R P Meijer, A Volpe, B Ljungberg, T Klatte, Karim Bensalah, S Dabestani, A Bex

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, UCL Division of Surgical and Interventional Science, London, UK., Barts Cancer Institute, Mary University of London, Queen, London, UK., Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy., Department of Urology, Haukeland University Hospital, Department of Clinical Medicine, University of Bergen, Norway., Abdominal Center, Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland., Department of Surgery, University of Cambridge, Cambridge, UK., Department of Urology, Landspitali University Hospital, Reykjavik, Iceland., Academic Urology Unit, University of Aberdeen, Aberdeen, UK., Department of Urology, Coimbra University Hospital, Coimbra, Portugal., Department of Urology, Cabueñes University Hospital, Gijón, Spain., Department of Oncological Urology, University Medical Centre Utrecht, Utrecht, The Netherlands., Department of Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy., Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden., Department of Urology, University Hospital of Rennes, Rennes, France., Dept. of Translational Medicine, Division of Urological Cancers, Central Hospital Kristianstad, Lund University, Lund, Sweden.