Molecular Imaging for Renal Cell Carcinoma. History of Renal Surgery for Cancer. Role of Lymphadenectomy. Outcomes Prognostic Factors Models and Algorithms. Role for Radiation Therapy in Renal Cancer. Rationale for Partial Nephrectomy. Of the deaths observed during the study period, deaths Nephron-sparing surgery was associated with a lower risk of death from kidney cancer compared with nonsurgical management, controlling for patient and disease characteristics adjusted HR, 0. Compared with nonsurgical management, radical nephrectomy did not have a significantly different effect on cancer-specific survival.
The results of the competing-risk analysis were similar to those of the standard proportional hazards regression model eTable in the Supplement. The presentation and management of kidney cancer has evolved substantially since the turn of the century. With increased use of diagnostic imaging, the incidence of kidney cancer has risen, largely owing to small localized masses that are diagnosed incidentally on imaging for unrelated conditions.
This downward size and stage migration has engendered a change in the treatment paradigm for localized kidney cancers. With an improved understanding of the biological behavior of these small cancers as well as a growing appreciation of the effect of renal surgery on oncologic and nononcologic outcomes, the treatment options for small kidney cancers have evolved.
Radical nephrectomy, which was the standard treatment for all renal tumors regardless of size, has been replaced by partial nephrectomy at tertiary referral centers for the treatment of clinical T1a renal masses whenever technically feasible owing to the functional benefits with equivalent oncologic outcomes. This paradigm shift has been slower to occur in community practices and, for unclear reasons, in some patient subgroups, particularly women and the elderly population.
Nonetheless, our analysis demonstrates that radical nephrectomy is no longer the treatment of choice for small kidney cancers. Expert guidelines for the management of small renal masses, such as those published by the American Urological Association in , 8 appear to have bolstered the paradigm shift away from radical nephrectomy toward nephron-sparing options for such tumors.
Nonsurgical management has become an acceptable treatment approach for a variety of malignant neoplasms, including small kidney cancers. In low-risk prostate cancer, for example, primary surgical treatment has been associated with treatment-related morbidity but not a clear survival advantage, resulting in increasing adoption of active surveillance for low-risk disease in elderly patients and those with comorbid illness. The survival benefit of surgery for small, localized kidney cancers remains unclear.
In our study, surgery was associated with an overall survival advantage compared with nonsurgical management. However, because most of the deaths were unrelated to kidney cancer, it is likely that observed differences in overall survival reflect patient selection rather than a direct benefit of surgery. This difference is highlighted by the greater risk of mortality observed soon after diagnosis in the cohort whose treatment was managed nonsurgically. In the context of an observational study, it is impossible to draw a causal inference, particularly when there are many factors that could confound the association between treatment approach and all-cause mortality.
Without a randomized trial, large observational cohorts may be the best available source of information on the comparative effectiveness of the different strategies for managing small kidney cancers overall as well as in specific patient subgroups. Although cancer-specific deaths recorded in the SEER registry are based on state death certificates that may be subject to misattribution, prior studies 24 , 25 support the use of information from death certificates to identify cancer-specific mortality. In our population-based cohort of older adults, 4.
Controlling for patient and disease characteristics, we only observed a cancer-specific survival advantage associated with nephron-sparing surgery, but not radical nephrectomy, compared with nonsurgical management. Because of the small number of cases treated with ablation, we were unable to independently analyze the outcomes of ablation and partial nephrectomy vs nonsurgical management. The paradoxical oncologic advantage of partial nephrectomy has been found in other observational studies 26 but not in the only randomized trial 13 comparing radical nephrectomy with partial nephrectomy, supporting the notion that the findings are likely related to patient selection.
Although our findings support nonsurgical management as an acceptable treatment option for small kidney tumors in elderly patients or those with limited life expectancy, it appears that nonsurgical management of small kidney cancers remains uncommon and stable over time. It is possible, however, that with heightened awareness of outcomes from studies such as ours, the use of nonsurgical management may increase.
Several limitations of the present study should be noted. Despite controlling for numerous potential confounders in the absence of randomized treatment assignment, inferences about the association between treatment strategy and outcomes must be made cautiously.
Selection bias owing to the omission of important characteristics, such as functional status, cannot be ruled out. To some degree, our findings might also reflect appropriate selection of patients for each treatment strategy based on observed characteristics and others that are not available in the SEER-Medicare data set. Our analysis was limited to adults 66 years or older with pathologically confirmed cancers, and our results may not be generalizable to younger patients or those with small kidney tumors identified by imaging alone without a tissue diagnosis.
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We also cannot extrapolate beyond the time horizon of our available follow-up. Some small proportion of patients, should they survive long enough, could experience metastatic disease and death from kidney cancer. Until such potentially lethal tumors can be accurately identified at the time of diagnosis, surgery remains the standard treatment option for patients with a normal life expectancy. In the future, advances in imaging, coupled with percutaneous biopsy and tumor-specific molecular characterization, may improve our ability to appropriately select patients for the various treatment options.
The presentation and management of kidney cancer have evolved considerably in the past decade. Surgery remains the treatment of choice for most small kidney cancers; however, radical nephrectomy is no longer the most commonly used approach.
Contemporary management of small renal tumors
In this population-based cohort, surgery was associated with a cancer-specific and overall survival benefit compared with nonsurgical management, although these associations likely reflect some degree of patient selection, particularly in the case of overall survival. Nonsurgical management appears to be a reasonable treatment strategy for elderly patients or those with limited life expectancy, yet utilization rates remain low and stable over time.
Corresponding Author: William C. Published Online: May 27, Author Contributions: Drs Huang and Elkin had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported.
The interpretation and reporting of these data are the sole responsibility of the authors. All Rights Reserved. Figure 1.
Renal Cancer - Contemporary Management | John A Libertino | Springer
View Large Download. Treatment Trends of Small Kidney Cancers Table 1. Characteristics of the Cohort by Initial Management Strategy. Competing Risk Model. Cancer statistics, CA Cancer J Clin.
PubMed Google Scholar Crossref. Rising incidence of renal cell cancer in the United States. New York, NY: Springer; Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst. The incidence of kidney cancer in the United States is rising because the increased use of cross-sectional imaging is resulting in more tumors being detected and because the population is aging. In addition, a stage migration in kidney cancer has been observed, again because of improved detection, with an increase in stage T1 tumors and a concomitant decrease in the number of stage T2 to T4 tumors.
These findings raise the question of what the optimal management of SRTs should be.
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Radical nephrectomy, the traditional, most aggressive, and still most frequently used extirpative surgery, has been shown to increase the risk of chronic kidney disease.