ORLANDO, FL, USA (UroToday.com) - In this session, Dr. John L. Gore of the University of Washington School of Medicine in Seattle was making the case for partial nephrectomy (PN) in elderly patients.
He started by saying that the aging of the US population, combined with the incidence of small renal masses found on evaluation for other complaints (other than clinical symptoms related to the mass) means that the management of these tumors among elderly patients will become a more pressing concern. The competing risk of other health concerns in elderly patients may be the most important determinant of the best course of action for elderly patients newly diagnosed with a suspicious small renal mass. PN is an excellent treatment option and the standard of care for elderly and nonelderly patients with anatomically appropriate, small kidney tumors. Both the AUA and EAU guidelines recommend PN for T1a tumors (smaller than 4 cm and localized to the kidney), but still not all masses are eligible for PN; some tumors have anatomic relationships that make them ill suited for nephron-sparing surgery (NSS).
Dr. Gore continued by stating that PN has projected benefits to patient health outcomes and overall survival compared with RN for small renal masses. The benefit of PN is thought to be related to the protection of nephron mass which leads to reduction of kidney disease and protection from higher grade of kidney cancer. This has been supported in population-based studies of renal outcomes in kidney cancer patients. However, a randomized European study (EORTC 30904) that evaluated patients with a renal mass smaller than 5 cm and normal contralateral kidney who were randomized to either PN or RN, did not support the benefit of PN over RN in this group of patients. Instead, the study showed an overall survival (OS) benefit for patients treated with RN at the 10-year follow up. But this study has been criticized for poor accrual of patients, crossover between treatment groups, and significantly more lesions > T2 in the PN group. In any case, these findings cannot be completely dismissed.
Dr. Gore went on to talk about population-based data from SEER-Medicare where Tan et al. assessed the comparative effectiveness of PN vs. RN for small renal masses. The patients who underwent PN had almost one-half the risk of death over time compared to those who underwent RN. In addition, patients treated with PN had a 5.6% survival advantage two years after surgery and a 15.5% survival advantage at eight years after surgery. PN was also an advantage in the group of patients between 65-75 years where a significant survival benefit was demonstrated, as well as in those patients with greater comorbidity. To summarize, Dr. Gore stated that treating the elderly with small renal masses can be challenging due to the risk of comorbidities, but for patients eligible for surgery, anatomy rather than age should determine surgical approach.
Presented by John L. Gore, MD, MS at the 2013 Genitourinary Cancers Symposium - February 14 - 16, 2013 - Rosen Shingle Creek - Orlando, Florida USA
Assistant Professor, Department of Urology, School of Medicine, University of Washington, Seattle, WA USA
Written by Anna Forsberg, medical reporter for UroToday.com