The Experts below are selected from a list of 41103 Experts worldwide ranked by ideXlab platform
Houston R Thompson - One of the best experts on this subject based on the ideXlab platform.
-
comparative effectiveness for survival and renal function of partial and radical Nephrectomy for localized renal tumors a systematic review and meta analysis
The Journal of Urology, 2012Co-Authors: Simon P Kim, Christopher J Weight, Houston R Thompson, Nathan D Shippee, Brian A Costello, Stephen A Boorjian, Leona C Han, Hassan M Murad, Patricia J Erwin, George K ChowAbstract:Purpose: The relative effectiveness of partial vs radical Nephrectomy remains unclear in light of the recent phase 3 European Organization for the Research and Treatment of Cancer trial. We performed a systematic review and meta-analysis of partial vs radical Nephrectomy for localized renal tumors, considering all cause and cancer specific mortality, and severe chronic kidney disease.Materials and Methods: Cochrane Central Register of Controlled Trials, MEDLINE®, EMBASE®, Scopus and Web of Science® were searched for sporadic renal tumors that were surgically treated with partial or radical Nephrectomy. Generic inverse variance with fixed effects models were used to determine the pooled HR for each outcome.Results: Data from 21, 21 and 9 studies were pooled for all cause and cancer specific mortality, and severe chronic kidney disease, respectively. Overall 31,729 (77%) and 9,281 patients (23%) underwent radical and partial Nephrectomy, respectively. According to pooled estimates partial Nephrectomy correl...
-
contemporary trends in Nephrectomy for renal cell carcinoma in the united states results from a population based cohort
The Journal of Urology, 2011Co-Authors: Simon P Kim, Nilay D Shah, Christopher J Weight, Houston R Thompson, James P Moriarty, Nathan D Shippee, Brian A Costello, Stephen A Boorjian, Bradley C. LeibovichAbstract:Purpose: Despite benefits in functional renal outcome and the similar oncological efficacy of partial Nephrectomy for renal cell carcinoma, previous studies show marked underuse of partial Nephrectomy. We describe national trends in partial and radical Nephrectomy using a contemporary, population based cohort.Materials and Methods: Using the 2003 to 2008 Nationwide Inpatient Sample we identified 188,702 patients treated with partial or radical Nephrectomy for renal cell carcinoma at a total of 1,755 hospitals. Multivariate logistic regression was used to assess the independent associations of patient and hospital characteristics with partial Nephrectomy. Post-estimations from multivariate logistic regression were done to ascertain the annual predicted probability of partial Nephrectomy by hospital feature.Results: Overall 149,636 (79.3%) and 39,066 patients (20.7%) underwent radical and partial Nephrectomy for renal cell carcinoma, respectively. Partial Nephrectomy use increased each year from 16.8% in 20...
-
renal function outcomes in patients treated with partial Nephrectomy versus percutaneous ablation for renal tumors in a solitary kidney
The Journal of Urology, 2011Co-Authors: Christopher R Mitchell, Bradley C. Leibovich, Stephen A Boorjian, Adam J Weisbrod, Thomas D Atwell, Houston R ThompsonAbstract:Purpose: Partial Nephrectomy is the recommended management for small renal masses. Percutaneous ablation is safe and effective with comparable short-term cancer specific survival. Currently to our knowledge data are lacking on the impact of thermal ablation on renal function preservation. We examined the impact on renal function of partial Nephrectomy vs percutaneous ablation in patients with a solitary kidney.Materials and Methods: We performed a retrospective review to identify patients with a solitary kidney who underwent partial Nephrectomy or percutaneous ablation at Mayo Clinic Rochester between 2003 and 2009. Preoperative characteristics and 3-month posttreatment renal function were compared using the Wilcoxon rank sum, chi-square and Fisher exact tests.Results: During the study period 50 patients underwent percutaneous ablation and 62 underwent partial Nephrectomy. At partial Nephrectomy no ischemia was used in 30 cases (48%), a median of 28 minutes of cold ischemia was used in 26 (42%) and a medi...
-
sunitinib prior to planned cytoreductive Nephrectomy is this the new litmus test for metastatic renal cell carcinoma
European Urology, 2011Co-Authors: Simon P Kim, Houston R ThompsonAbstract:There is currently a paucity of high-level evidence regarding the role of cytoreductive Nephrectomy in the era of targeted therapy. Patients diagnosed with metastatic renal carcinoma are confronted with difficult treatment decisions regarding the optimal treatment strategy and the timing of surgery in relation to targeted therapy. Level 1 evidence from two randomized trials has demonstrated improved overall survival with cytoreductive Nephrectomy in the immunotherapy era [1–3]. Current clinical guidelines recommend cytoreductive Nephrectomy followed by systemic therapy for patients presenting with metastatic renal carcinoma in which the primary tumor is surgically resectable and where the treatment is individualized based on symptoms and extent of metastatic disease [4]. In this issue of the Platinum Journal, Powles et al report a pooled analysis of two single-arm, phase 2 prospective trials and evaluate the efficacy and outcomes of sunitinib prior to cytoreductive Nephrectomy [5]. Although the authors previously reported safety with neoadjuvant sunitinib prior to cytoreductive Nephrectomy [6], this investigation describes the outcomes for the 66 patients who received two or three cycles of sunitinib prior to surgery. Two principal findings from this study help inform the debate regarding the optimal treatment strategy of targeted therapy and cytoreductive Nephrectomy. First, patients who are in the Memorial Sloan-Kettering Cancer Center (MSKCC) intermediate risk group can achieve a lasting response with a median overall survival >2 yr compared with patients harboring poor-risk disease, for whom a markedly shorter median overall survival of 9 mo was observed. These results suggest that patient selection, particularly by MSKCC risk stratification, is paramount in identifying those patients who are most likely to benefit from targeted therapy prior to cytoreductive Nephrectomy. Second, the authors also observed that interruptions of sunitinib in preparation for surgery were associated with a high rate of disease progression. Although the study attempted to apply a rigorous protocol to minimize the time off of targeted therapy by reinitiating sunitinib within 2–3 wk following cytoreductive Nephrectomy, there was considerable variation in the amount of time off of therapy following surgery. Consequently, 36% of the patients had disease progression by RECIST criteria and eight patients had new metastatic sites during the perioperative convalescence interval without sunitinib. Thus patients treated with sunitinib who plan to stop treatment for surgical intervention should be informed about the risk of disease progression. Although the authors acknowledge the need to validate their findings with a randomized trial, the results of this study suggest that cytoreductive Nephrectomy may have limited efficacy in patients who experience disease progression following initiation of sunitinib or in patients with poor MSKCC risk. To date, no level 1 evidence has evaluated the efficacy of cytoreductive Nephrectomy and targeted therapy, whether neoadjuvant or adjuvant, in patients presenting with metastatic renal carcinoma. Proponents of cytoreductive Nephrectomy have extrapolated the results from randomized trials of sunitinib and immunotherapy in patients who underwent previous Nephrectomy and then developed metastatic disease and from the two randomized trials that set the current treatment paradigm of cytoreductive Nephrectomy [1–3,7,8]. Currently, an ongoing phase 3 trial is recruiting patients presenting with metastatic renal carcinoma to be randomized to immediate cytoreductive Nephrectomy followed by sunitinib or three cycles of sunitinib (4 wk of sunitinib and then 2 wk off) followed by
-
partial versus radical Nephrectomy for 4 to 7 cm renal cortical tumors
The Journal of Urology, 2009Co-Authors: Bradley C. Leibovich, Christine M Lohse, Houston R Thompson, Paul Russo, Sameer Siddiqui, Michael L. BluteAbstract:Purpose: Recent observations suggest that partial Nephrectomy for small renal tumors may be associated with improved survival compared with radical Nephrectomy. We evaluated survival in patients with 4 to 7 cm renal tumors in a bi-institutional collaboration.Materials and Methods: By combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering Cancer Center we identified 1,159 patients with 4.1 to 7.0 cm sporadic, unilateral, solitary, localized renal masses who underwent radical or partial Nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models.Results: Of the 1,159 patients 873 (75%) and 286 (25%) were treated with radical and partial Nephrectomy, respectively. Patients treated with partial vs radical Nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%) and chronic kidney disease (15% vs 7%, each p <0.001). Median followup in survivors was 4.8 years (range 0 to 19). There was no significant differen...
Inderbir S. Gill - One of the best experts on this subject based on the ideXlab platform.
-
10 year oncologic outcomes after laparoscopic and open partial Nephrectomy
The Journal of Urology, 2010Co-Authors: Brian R. Lane, Steven C. Campbell, Inderbir S. GillAbstract:Purpose: Open partial Nephrectomy has proven long-term oncologic efficacy. Laparoscopic partial Nephrectomy outcomes at 5 to 7 years of followup appear comparable to those of the open approach. We present the 10-year outcomes of patients who underwent laparoscopic or open partial Nephrectomy for a single clinical stage cT1 7 cm or less renal cortical tumor.Materials and Methods: Of 1,541 patients treated with partial Nephrectomy for a single cT1 tumor between 1999 and 2007 with a minimum 5-year followup, an actual followup of 10 years or greater was available in 45 and 254 after laparoscopic and open partial Nephrectomy, respectively.Results: Median followup after laparoscopic and open surgery was 6.6 and 7.8 years, respectively. At 10 years the overall survival rate was 77.2%. The metastasis-free survival rate was 95.2% and 90.0% after partial Nephrectomy for clinical T1a and T1b renal cell carcinoma, respectively (p <0.0001). Baseline differences between patients treated with laparoscopic and open parti...
-
7 year oncological outcomes after laparoscopic and open partial Nephrectomy
The Journal of Urology, 2010Co-Authors: Brian R. Lane, Inderbir S. GillAbstract:Purpose: Open partial Nephrectomy has proven long-term oncologic efficacy. Laparoscopic partial Nephrectomy outcomes at 5 to 7 years of followup appear comparable to those of the open approach. We present the 10-year outcomes of patients who underwent laparoscopic or open partial Nephrectomy for a single clinical stage cT1 7 cm or less renal cortical tumor.Materials and Methods: Of 1,541 patients treated with partial Nephrectomy for a single cT1 tumor between 1999 and 2007 with a minimum 5-year followup, an actual followup of 10 years or greater was available in 45 and 254 after laparoscopic and open partial Nephrectomy, respectively.Results: Median followup after laparoscopic and open surgery was 6.6 and 7.8 years, respectively. At 10 years the overall survival rate was 77.2%. The metastasis-free survival rate was 95.2% and 90.0% after partial Nephrectomy for clinical T1a and T1b renal cell carcinoma, respectively (p <0.0001). Baseline differences between patients treated with laparoscopic and open parti...
-
halving ischemia time during laparoscopic partial Nephrectomy
The Journal of Urology, 2008Co-Authors: Mike M Nguyen, Inderbir S. GillAbstract:Purpose: Laparoscopic partial Nephrectomy has demonstrated renal functional and 5-year oncological outcomes equivalent to those of open partial Nephrectomy. A remaining critique of laparoscopic partial Nephrectomy is its 10-minute longer ischemia time compared to open surgery. We present an early unclamping laparoscopic partial Nephrectomy technique that decreases ischemia time by more than 50%.Materials and Methods: During standard laparoscopic partial Nephrectomy renal reconstruction is completely performed under ischemic conditions. In our early unclamping technique only the initial parenchymal suturing is performed under ischemia with the remainder of bolstered renorrhaphy performed in the revascularized kidney. Of 100 consecutive nonrandomized patients the initial 50 underwent standard laparoscopic partial Nephrectomy (group 1) and the subsequent 50 underwent early unclamping laparoscopic partial Nephrectomy (group 2).Results: Baseline demographics (body mass index, mean tumor size and central/hilar ...
-
positive surgical parenchymal margin after laparoscopic partial Nephrectomy for renal cell carcinoma oncological outcomes
The Journal of Urology, 2006Co-Authors: Sompol Permpongkosol, Inderbir S. Gill, Jose R Colombo, Louis R KavoussiAbstract:Purpose: The oncological efficacy of partial Nephrectomy is related to obtaining a negative surgical margin intraoperatively. This study assesses the oncological outcomes of patients undergoing laparoscopic partial Nephrectomy for a renal tumor who had positive surgical margin on final pathology.Materials and Methods: The experiences of 2 surgeons with 511 patients with a pathological diagnosis of renal cell carcinoma treated with laparoscopic partial Nephrectomy were reviewed. Patients with a positive surgical margin were identified retrospectively. Oncological outcomes were assessed by followup with chest x-ray and computerized tomography every 6 to 12 months for 5 years.Results: There were 9 patients (1.8%) with a positive margin on final pathology. Mean tumor size was 2.8 cm (range 1.7 to 4.0). Two patients underwent secondary completion radical Nephrectomy, one at 4 days and the other at 2 months following laparoscopic partial Nephrectomy. No residual tumor was identified in the Nephrectomy specimen ...
-
laparoscopic nephron sparing surgery for two or more ipsilateral renal tumors
Urology, 2004Co-Authors: Andrew P Steinberg, Jihad H Kaouk, Mete Kilciler, Sidney C Abreu, Anup P Ramani, Mihir M Desai, Inderbir S. GillAbstract:Abstract Objectives To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor. Methods Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial Nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses. Results A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial Nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial Nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial Nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic Nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites. Conclusions Laparoscopic partial Nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial Nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.
Bradley C. Leibovich - One of the best experts on this subject based on the ideXlab platform.
-
contemporary trends in Nephrectomy for renal cell carcinoma in the united states results from a population based cohort
The Journal of Urology, 2011Co-Authors: Simon P Kim, Nilay D Shah, Christopher J Weight, Houston R Thompson, James P Moriarty, Nathan D Shippee, Brian A Costello, Stephen A Boorjian, Bradley C. LeibovichAbstract:Purpose: Despite benefits in functional renal outcome and the similar oncological efficacy of partial Nephrectomy for renal cell carcinoma, previous studies show marked underuse of partial Nephrectomy. We describe national trends in partial and radical Nephrectomy using a contemporary, population based cohort.Materials and Methods: Using the 2003 to 2008 Nationwide Inpatient Sample we identified 188,702 patients treated with partial or radical Nephrectomy for renal cell carcinoma at a total of 1,755 hospitals. Multivariate logistic regression was used to assess the independent associations of patient and hospital characteristics with partial Nephrectomy. Post-estimations from multivariate logistic regression were done to ascertain the annual predicted probability of partial Nephrectomy by hospital feature.Results: Overall 149,636 (79.3%) and 39,066 patients (20.7%) underwent radical and partial Nephrectomy for renal cell carcinoma, respectively. Partial Nephrectomy use increased each year from 16.8% in 20...
-
renal function outcomes in patients treated with partial Nephrectomy versus percutaneous ablation for renal tumors in a solitary kidney
The Journal of Urology, 2011Co-Authors: Christopher R Mitchell, Bradley C. Leibovich, Stephen A Boorjian, Adam J Weisbrod, Thomas D Atwell, Houston R ThompsonAbstract:Purpose: Partial Nephrectomy is the recommended management for small renal masses. Percutaneous ablation is safe and effective with comparable short-term cancer specific survival. Currently to our knowledge data are lacking on the impact of thermal ablation on renal function preservation. We examined the impact on renal function of partial Nephrectomy vs percutaneous ablation in patients with a solitary kidney.Materials and Methods: We performed a retrospective review to identify patients with a solitary kidney who underwent partial Nephrectomy or percutaneous ablation at Mayo Clinic Rochester between 2003 and 2009. Preoperative characteristics and 3-month posttreatment renal function were compared using the Wilcoxon rank sum, chi-square and Fisher exact tests.Results: During the study period 50 patients underwent percutaneous ablation and 62 underwent partial Nephrectomy. At partial Nephrectomy no ischemia was used in 30 cases (48%), a median of 28 minutes of cold ischemia was used in 26 (42%) and a medi...
-
outcome of stage t2 or greater renal cell cancer treated with partial Nephrectomy
The Journal of Urology, 2010Co-Authors: Rodney H Breau, Michael L. Blute, Christine M Lohse, Paul L Crispen, Rafael E Jimenez, Bradley C. LeibovichAbstract:Purpose: Partial Nephrectomy for stage T1 renal cell carcinoma is oncologically efficacious and safe, and may have survival advantages. We describe our experience with partial Nephrectomy for T2 or greater renal cell cancer.Materials and Methods: Between 1970 and 2008 approximately 2,300 partial nephrectomies were done at our institution, including 69 for sporadic unilateral advanced stage tumors (pT2 in 32, pT3a in 28 and pT3b in 9). We reviewed outcomes in these patients compared to those in 207 treated with radical Nephrectomy matched 3:1 for stage, tumor size, baseline renal function, age and gender.Results: The risk of cancer specific (HR 0.80, 95% CI 0.43–1.50, p = 0.489) and overall (HR 1.11, 95% CI 0.72–1.71, p = 0.642) death was similar for partial Nephrectomy. At a median of 3.2 years of followup 15 patients (22%) with partial Nephrectomy had metastatic disease vs 69 (33%) with radical Nephrectomy (HR 0.74, 95% CI 0.42–1.29, p = 0.29). Four patients (6%) with partial Nephrectomy had isolated loc...
-
partial versus radical Nephrectomy for 4 to 7 cm renal cortical tumors
The Journal of Urology, 2009Co-Authors: Bradley C. Leibovich, Christine M Lohse, Houston R Thompson, Paul Russo, Sameer Siddiqui, Michael L. BluteAbstract:Purpose: Recent observations suggest that partial Nephrectomy for small renal tumors may be associated with improved survival compared with radical Nephrectomy. We evaluated survival in patients with 4 to 7 cm renal tumors in a bi-institutional collaboration.Materials and Methods: By combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering Cancer Center we identified 1,159 patients with 4.1 to 7.0 cm sporadic, unilateral, solitary, localized renal masses who underwent radical or partial Nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models.Results: Of the 1,159 patients 873 (75%) and 286 (25%) were treated with radical and partial Nephrectomy, respectively. Patients treated with partial vs radical Nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%) and chronic kidney disease (15% vs 7%, each p <0.001). Median followup in survivors was 4.8 years (range 0 to 19). There was no significant differen...
-
radical Nephrectomy for pt1a renal masses may be associated with decreased overall survival compared with partial Nephrectomy
The Journal of Urology, 2008Co-Authors: Houston R Thompson, Eugene D Kwon, Bradley C. Leibovich, Christine M Lohse, John C Cheville, Stephen A Boorjian, Michael L. BluteAbstract:Purpose: We reviewed our surgical experience with small renal tumors, comparing overall survival in patients treated with radical and partial Nephrectomy.Materials and Methods: Using our Nephrectomy registry we identified patients with sporadic, unilateral, solitary and localized renal masses 4 cm or less who underwent radical or partial Nephrectomy between 1989 and 2003. Patients with a solitary kidney or impaired renal function at presentation were excluded, leaving 648 available for analysis. Overall survival was estimated using the Kaplan-Meier method and associations with death were evaluated using Cox proportional hazards regression.Results: At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial Nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical Nephrectomy was not significantly associated with death from any cause compared with partial Nephrectomy (RR 1.12, p = 0.52). However, there was a significant...
Michael L. Blute - One of the best experts on this subject based on the ideXlab platform.
-
outcome of stage t2 or greater renal cell cancer treated with partial Nephrectomy
The Journal of Urology, 2010Co-Authors: Rodney H Breau, Michael L. Blute, Christine M Lohse, Paul L Crispen, Rafael E Jimenez, Bradley C. LeibovichAbstract:Purpose: Partial Nephrectomy for stage T1 renal cell carcinoma is oncologically efficacious and safe, and may have survival advantages. We describe our experience with partial Nephrectomy for T2 or greater renal cell cancer.Materials and Methods: Between 1970 and 2008 approximately 2,300 partial nephrectomies were done at our institution, including 69 for sporadic unilateral advanced stage tumors (pT2 in 32, pT3a in 28 and pT3b in 9). We reviewed outcomes in these patients compared to those in 207 treated with radical Nephrectomy matched 3:1 for stage, tumor size, baseline renal function, age and gender.Results: The risk of cancer specific (HR 0.80, 95% CI 0.43–1.50, p = 0.489) and overall (HR 1.11, 95% CI 0.72–1.71, p = 0.642) death was similar for partial Nephrectomy. At a median of 3.2 years of followup 15 patients (22%) with partial Nephrectomy had metastatic disease vs 69 (33%) with radical Nephrectomy (HR 0.74, 95% CI 0.42–1.29, p = 0.29). Four patients (6%) with partial Nephrectomy had isolated loc...
-
partial versus radical Nephrectomy for 4 to 7 cm renal cortical tumors
The Journal of Urology, 2009Co-Authors: Bradley C. Leibovich, Christine M Lohse, Houston R Thompson, Paul Russo, Sameer Siddiqui, Michael L. BluteAbstract:Purpose: Recent observations suggest that partial Nephrectomy for small renal tumors may be associated with improved survival compared with radical Nephrectomy. We evaluated survival in patients with 4 to 7 cm renal tumors in a bi-institutional collaboration.Materials and Methods: By combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering Cancer Center we identified 1,159 patients with 4.1 to 7.0 cm sporadic, unilateral, solitary, localized renal masses who underwent radical or partial Nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models.Results: Of the 1,159 patients 873 (75%) and 286 (25%) were treated with radical and partial Nephrectomy, respectively. Patients treated with partial vs radical Nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%) and chronic kidney disease (15% vs 7%, each p <0.001). Median followup in survivors was 4.8 years (range 0 to 19). There was no significant differen...
-
radical Nephrectomy for pt1a renal masses may be associated with decreased overall survival compared with partial Nephrectomy
The Journal of Urology, 2008Co-Authors: Houston R Thompson, Eugene D Kwon, Bradley C. Leibovich, Christine M Lohse, John C Cheville, Stephen A Boorjian, Michael L. BluteAbstract:Purpose: We reviewed our surgical experience with small renal tumors, comparing overall survival in patients treated with radical and partial Nephrectomy.Materials and Methods: Using our Nephrectomy registry we identified patients with sporadic, unilateral, solitary and localized renal masses 4 cm or less who underwent radical or partial Nephrectomy between 1989 and 2003. Patients with a solitary kidney or impaired renal function at presentation were excluded, leaving 648 available for analysis. Overall survival was estimated using the Kaplan-Meier method and associations with death were evaluated using Cox proportional hazards regression.Results: At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial Nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical Nephrectomy was not significantly associated with death from any cause compared with partial Nephrectomy (RR 1.12, p = 0.52). However, there was a significant...
-
a scoring algorithm to predict survival for patients with metastatic clear cell renal cell carcinoma a stratification tool for prospective clinical trials
The Journal of Urology, 2005Co-Authors: Bradley C. Leibovich, Eugene D Kwon, Jaime R Merchan, Horst Zincke, Igor Frank, Christine M Lohse, John C Cheville, Michael L. BluteAbstract:ABSTRACTPurpose: We developed a clinically useful scoring algorithm to predict cancer specific survival for patients with clear cell metastatic renal cell carcinoma (RCC).Materials and Methods: We studied 727 patients treated with radical Nephrectomy for clear cell RCC from 1970 to 2000 who had distant metastases at Nephrectomy (285) or in whom metastases subsequently developed (442). A scoring algorithm to predict cancer specific survival was developed using the regression coefficients from a Cox proportional hazards model.Results: There were 606 deaths from clear cell RCC at a median of 1.0 years (range 0 to 14) following metastatic RCC. Constitutional symptoms at Nephrectomy (+2), metastases to the bone (+2) or liver (+4), metastases in multiple simultaneous sites (+2), metastases at Nephrectomy (+1) or within 2 years of Nephrectomy (+3), complete resection of all metastatic sites (-5), tumor thrombus level I to IV (+3), and the primary pathological features of nuclear grade 4 (+3) and histological tum...
-
outcome of isolated renal cell carcinoma fossa recurrence after Nephrectomy
The Journal of Urology, 2000Co-Authors: Nancy B Itano, Michael L. Blute, Bruce E Spotts, Horst ZinckeAbstract:Purpose: Local recurrence of renal cell carcinoma in the renal fossa after complete radical Nephrectomy is uncommon. We characterize and determine outcome in a small subset of patients.Materials and Methods: From 1970 to 1998 the incidence of isolated renal bed recurrence among 1,737 T1-3N0M0 unilateral Nephrectomy cases was 1.8% (standard error [SE] 0.4) at 5 years. There were 30 patients in whom isolated local fossa carcinoma recurred after complete radical Nephrectomy without evidence of metastatic disease. Patients with any nodal involvement at radical Nephrectomy were excluded from study as were those who had undergone any form of partial Nephrectomy. Patient charts were reviewed for clinical presentation, stage, treatment, development of metastatic disease and survival. Pathological stage was assigned according to the 1997 TNM staging system. Recurrence was identified in 12 (40%) patients during routine followup and the remaining 18 (60%) presented with symptoms related to the recurrent tumor. Patie...
Paul Russo - One of the best experts on this subject based on the ideXlab platform.
-
Cytoreductive Nephrectomy and Nephrectomy/complete metastasectomy for metastatic renal cancer. Scientifi c World J 2007; 7: 768–78
2020Co-Authors: Paul Russo, Varuni Kondagunta, Mark Snyder, Andrew Vickers, Robert J MotzerAbstract:The objective of this study was to determine our institutional experience with cytoreductive Nephrectomy alone or in conjunction with Nephrectomy complete metastasectomy. Between July 1989 and September 2003, we queried our department's renal tumor database for patients undergoing cytoreductive Nephrectomy alone or in conjunction with complete metastasectomy. Clinical and pathological factors analyzed included primary tumor size, stage and histological subtype, age, gender, Karnofsky Performance Status (KPS) prior to Nephrectomy, number and location of metastatic sites, and the presence or absence of any systemic therapy. Preoperative laboratory values analyzed included hemoglobin (HGB), calcium (CA), albumin (ALB), lactose dehydrogenase (LDH), alkaline phosphatase (ALP), and corrected calcium. Corrected calcium was defined as follows: corrected calcium = total calcium -0.707*(albumin -3.4). During this time frame,1628 patients underwent Nephrectomy (partial or radical) for renal masses, 91 (5.6%) of whom had metastatic disease. In this group, 71% of patients were male, 88% of patients had a KPS of 80% or greater, and 92% had conventional clear cell histology. Sixty-four percent of patients had a single site of metastatic disease, with lung the most common, followed by bone, adrenal, brain, and liver. Sixty-one patients (67%) had Nephrectomy with removal of all metastatic sites (Nephrectomy/complete metastasectomy) and 30 (33%) had cytoreductive Nephrectomy alone. Median survival for patients undergoing Nephrectomy/complete metastasectomy was 30 months. Median survival for patients undergoing cytoreductive Nephrectomy alone was 12 months. Perioperative complications occurred in 13% of patients and four patients died within 30 days of their operation. For patients with metastatic renal cell carcinoma, surgical resection of the primary tumor alone (cytoreductive Nephrectomy) or in conjunction with metastasectomy can be accomplished with acceptable perioperative morbidity and mortality. This surgical experience provides a contemporary foundation as new targeted therapeutic agents are integrated into the neoadjuvant or adjuvant treatment of locally advanced and metastatic renal cancer. KEYWORDS: renal cancer, cytoreductive Nephrectomy, metastasectomy Russo et al.: Surgery for Metastatic Renal Cancer TheScientificWorldJOURNAL (2007) 7, 768-778 769 INTRODUCTION In the year 2006, there will be an estimated 38,890 new cases and 12,840 deaths from kidney cancer in the U.S. Operative management of small RCT today consists of open or laparoscopic partial Nephrectomy and radical Nephrectomy when partial Nephrectomy is not technically feasible, to achieve the concomitant goals of local tumor control and maintenance of maximal renal function The role of surgical resection of the renal tumor primary and synchronous or asynchronous metastatic sites (Nephrectomy complete metastasectomy), or the resection of the renal tumor primary alone in the face of unresectable metastatic disease (cytoreductive Nephrectomy), has long been controversial with data insufficient to determine if survival following operation was a therapeutic effect or simply related to patient selection factors and disease natural history. It was the purpose of the present report to review the rationale for surgical intervention in the face of metastatic disease as well as to report a contemporary experience at our center with both procedures relative to survival and perioperative complications. PATIENTS AND METHODS AND MATERIALS Patients After receiving approval from our Institutional Review Board, we queried our departmental renal tumor surgical database, which has been prospectively updated since its inception in 1989, for patients who underwent a Nephrectomy in the face of metastatic disease between July 1989 and September 2003. The database was also queried to identify patients who underwent a complete metastasectomy prior to, during, or subsequent to the Nephrectomy. Nephrectomy/complete metastasectomy were defined as the surgical resection of all clinically evident metastatic disease sites and the tumor-bearing kidney. Patients with unresectable metastatic disease or those patients in whom an incomplete or palliative resection of metastatic sites was performed were classified as having undergone a cytoreductive Nephrectomy. Russo et al.: Surgery for Metastatic Renal Cancer TheScientificWorldJOURNAL (2007) 7, 768-778 770 Clinical and pathological factors analyzed included primary tumor size, stage and histological subtype, age, gender, KPS prior to Nephrectomy, number and location of metastatic sites, and the presence or absence of any systemic therapy. KPS was taken from preNephrectomy evaluations or assigned retrospectively by one of us (PR) for 37 patients who were missing that information. Multiple metastatic deposits in one location were classified as involvement of a single site. For example, bilateral lung nodules counted as one metastatic site location, the lungs. Preoperative laboratory values analyzed included hemoglobin (HGB), calcium (CA), albumin (ALB), lactose dehydrogenase (LDH), alkaline phosphatase (ALP), and corrected calcium. Corrected calcium was defined as follows: corrected calcium = total calcium -0.707*(albumin -3.4). Statistical Analysis Overall survival for patients who underwent a cytoreductive Nephrectomy with complete metastasectomy and cytoreductive Nephrectomy alone (including cytoreductive Nephrectomy plus incomplete or palliative metastasectomy) were determined. The endpoint in these studies was death from any cause, with survival probabilities estimated by Kaplan-Meier methods RESULTS Between July 1989 and September 2003, 1628 patients underwent Nephrectomy (partial or radical) for renal cortical masses. The focus of this study was the 91 (5.6%) patients with metastatic disease treated in this time frame Patient and surgical characteristics for the patients undergoing Nephrectomy/complete metastasectomy and cytoreductive Nephrectomy alone are given in There were 74 deaths. Median follow-up for survivors was 43 months. Median survival for patients undergoing Nephrectomy/metastasectomy was 30 months DISCUSSION The role of operative intervention in patients with metastatic renal cancer has long been controversial. In 1939, Barney and Churchill first reported a patient that underwent both Nephrectomy for a renal cancer and excision of a solitary pulmonary metastasis only to die 23 years later of coronary artery disease 773 The role of radical Nephrectomy in patients with extensive metastatic renal cancer where complete metastasectomy is not possible is also controversial. The rationale for cytoreductive radical Nephrectomy relates to the theoretical purpose of removing a large, potentially immunosuppressive tumor burden that could serve as a potential source for tumor-related factors that facilitate the metastatic process, enhance tumor neovascularity, and allow tumor cells to escape immune recognition. Rarely, cytoreductive Nephrectomy is performed to treat complications from the primary tumor during systemic therapy, such as unremitting gross hematuria or flank pain not relieved by conservative measures, such as angioinfarction. Russo et al.: Surgery for Metastatic Renal Cancer TheScientificWorldJOURNAL (2007) 7, 768-778 Radical Nephrectomy should not be done in order to induce spontaneous remission, a phenomena observed only in 4/474 patients (0.8%) so treated in an important study reported from the Cleveland Clinic 774 In an attempt to address this important clinical issue of the role of Nephrectomy in patients with widely metastatic renal cancer, in 2001, two randomized and prospective clinical trials were completed in the U.S. (Southwest Oncology Group, SWOG, 246 patients) Despite the apparent survival benefit of the cytoreductive Nephrectomy as described above, the impact of referral patterns, surgical judgment, and patient selection was reported by Bromwich and colleagues The extent to which the patient selection factors described by Motzer and colleagues at MSKCC[8,9] (KPS, serum corrected calcium >10 mg/dl, hemoglobin less than the sex-specific lower limit of normal, and LDH >1.5× the upper limit of normal) and validated externally For over 30 years, extensive clinical research with systemic cytokines, chemotherapeutic agents, hormonal manipulations, and vaccines have been largely unsuccessful in treating metastatic renal cancer, leading many investigators to conclude that this disease is resistant to systemic therapy Two oral multitargeted kinase inhibitors, sorafenib and sunitinib, have undergone extensive clinical trials in previously cytokine-treated patients with metastatic renal cancer as second-line therapy and have been effective in this setting of inducing partial remissions, disease stabilization, and delay in time to progression of up to 8.7 months in patients previously without a therapeutic option. Of interest is the observation in some cases of substantial regression of the primary kidney tumor during targeted therapy. Regression of primary and metastatic sites has been associated with qualitative changes in imaging contrast uptake, suggesting an effect on the vascular perfusion by the systemic agents In our dataset, which spanned a 14-year period, operations in the face of metastatic renal cancer represented a small percentage of the overall surgical experience (<6%) at our center. The 61 patients that underwent a Nephrectomy and metastasectomy differed from the 30 patients undergoing cytoreductive Nephrectomy by only the preoperative selection factor of serum hemoglobin (12.6 vs. 11.7g/dl). However, the more limited extent of disease that allowed for these carefully selected patients to undergo metastasectomy likely explains their enhanced survival compared to patients undergoing cytoreductive Nephrectomy in which metastasectomy was not possible (30 vs. 12 months). For the entire group, perioperative complications were acceptable (13%), but four patients died of disease progression within 30 days. We cannot necessarily ascribe the observed differences in outcome to differences in surgical approach. Selection bias may take place preoperatively, in terms of a surgeon's or patient's willingness to undergo a potentially complex radical Nephrectomy when overall anticipated survival is limited. Perhaps more critically, selection bias acts intraoperatively, as patients seen to have widespread or unresectable disease will receive only cytoreductive Nephrectomy. As new and possibly more effective systemic agents are introduced for the treatment of metastatic renal cancer, shifting surgical strategies may be required. Future clinical trial design for patients with widely metastatic renal cancer will likely integrate pretreatment with effective systemic targeted agents with surgical intervention as a means of consolidation, either in the form of cytoreductive Nephrectomy and/or metastasectomy, followed with the possibility for long-term maintenance of the systemic agents. Surgical debulking of the primary and, if possible, complete metastasectomy, coupled with effective systemic targeted agents, may convert metastatic renal cancer from a progressive disease to a chronic disease. Our study provides a baseline of expectations and perioperative complications in a contemporary series of patients undergoing operative resection in the face of metastatic renal cancer. CONCLUSIONS Patients with RCC that either present with or later develop metastatic disease represent approximately 30% of the patients with RCT. Operative intervention in patients with metastatic renal cancer has long been controversial and subjected to extensive selection biases. Our 14-year experience with 91 patients undergoing operative intervention either as a Nephrectomy/metastasectomy (n = 61) or as a cytoreductive Nephrectomy (n = 30) is presented. Survival differences, median of 30 months in the former group and 12 months in the latter, are likely associated with the extent of disease at the time of intervention and patient selection factors. As new, recently FDA-approved targeted agents, such as sunitinib and sorafenib, with specific activity in metastatic renal cancer, are integrated into the treatment of locally advanced and metastatic renal cancer, the role of the surgical intervention is likely to evolve with cytoreductive Russo et al.: Surgery for Metastatic Renal Cancer TheScientificWorldJOURNAL (2007) 7, 768-778 778 Nephrectomy and metastasectomy will be utilized to achieve complete surgical remission. Our data also indicate that operative intervention in the face of metastatic renal cancer can be done with acceptable surgical morbidity
-
solitary isolated metastatic disease to the kidney memorial sloan kettering cancer center experience
BJUI, 2011Co-Authors: Ari Adamy, Melanie Bernstein, Christian Von Bodman, Tarek Ghoneim, Ricardo L Favaretto, Paul RussoAbstract:OBJECTIVE: • To analyse the clinical characteristics and outcomes of patients who underwent Nephrectomy for solitary, isolated metastatic disease to the kidney. PATIENTS AND METHODS: • From July 1989 to July 2009, we identified 13 patients who underwent Nephrectomy for solitary metastasis to the kidney. Patients' demographics, intra-operative variables and outcomes are reported. RESULTS: • The median age at Nephrectomy was 52 years (range 33-79). Eleven patients (85%) had an incidentally discovered renal mass, whereas two patients (15%) presented with gross haematuria. • Median time from initial surgery at the primary site to development of metastatic disease to the kidney was 63 months (range 9-136). No patient had evidence of disease at other sites at the time of Nephrectomy. In seven patients (54%), the kidney was the first site of recurrence. • The most common primary site was the lung in five patients (38%), followed by the colon in two (15%), chest wall in two (15%) and bone, brain, breast and salivary gland in one patient each (8%). • Of the 14 procedures performed, eight (57%) were partial Nephrectomy (PN) and six (43%) were radical Nephrectomy (RN). • Four patients died after progression from the primary tumour, all within 2 years of Nephrectomy. One patient with a primary chondrosarcoma had no evidence of disease at last follow-up and died from other causes 50 months after Nephrectomy. The median follow-up for the eight patients who were alive at last follow-up was 30 months after Nephrectomy. Four of these patients had no evidence of disease and four patients were alive with metastatic disease. CONCLUSION: • Kidney involvement by metastatic disease can occur as isolated solitary lesions. Some patients will also have the kidney as the first and only site of metastatic involvement. The presence of an isolated renal metastasis should not be considered an end-stage disease, and Nephrectomy can be offered for highly selected patients as a therapeutic option.
-
partial versus radical Nephrectomy for 4 to 7 cm renal cortical tumors
The Journal of Urology, 2009Co-Authors: Bradley C. Leibovich, Christine M Lohse, Houston R Thompson, Paul Russo, Sameer Siddiqui, Michael L. BluteAbstract:Purpose: Recent observations suggest that partial Nephrectomy for small renal tumors may be associated with improved survival compared with radical Nephrectomy. We evaluated survival in patients with 4 to 7 cm renal tumors in a bi-institutional collaboration.Materials and Methods: By combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering Cancer Center we identified 1,159 patients with 4.1 to 7.0 cm sporadic, unilateral, solitary, localized renal masses who underwent radical or partial Nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models.Results: Of the 1,159 patients 873 (75%) and 286 (25%) were treated with radical and partial Nephrectomy, respectively. Patients treated with partial vs radical Nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%) and chronic kidney disease (15% vs 7%, each p <0.001). Median followup in survivors was 4.8 years (range 0 to 19). There was no significant differen...
-
contemporary use of partial Nephrectomy at a tertiary care center in the united states
The Journal of Urology, 2009Co-Authors: Houston R Thompson, Andrew J Vickers, Matthew Kaag, Shilajit Kundu, Melanie Bernstein, William T Lowrance, David J Galvin, Guido Dalbagni, Karim Touijer, Paul RussoAbstract:Purpose: The use of partial Nephrectomy for renal cortical tumors appears unacceptably low in the United States according to population based data. We examined the use of partial Nephrectomy at our tertiary care facility in the contemporary era.Materials and Methods: Using our prospectively maintained Nephrectomy database we identified 1,533 patients who were treated for a sporadic and localized renal cortical tumor between 2000 and 2007. Patients with bilateral disease or solitary kidneys were excluded from study and elective operation required an estimated glomerular filtration rate of 45 ml per minute per 1.73 m2 or greater. Predictors of partial Nephrectomy were evaluated using logistic regression models.Results: Overall 854 (56%) and 679 patients (44%) were treated with partial and radical Nephrectomy, respectively. In the 820 patients treated electively for a tumor 4 cm or less the frequency of partial Nephrectomy steadily increased from 69% in 2000 to 89% in 2007. In the 365 patients treated electi...
-
partial Nephrectomy versus radical Nephrectomy in patients with small renal tumors is there a difference in mortality and cardiovascular outcomes
The Journal of Urology, 2009Co-Authors: William C Huang, Elena B Elkin, Andrew S Levey, Thomas L Jang, Paul RussoAbstract:Purpose: Compared with partial Nephrectomy, radical Nephrectomy increases the risk of chronic kidney disease, which is a significant risk factor for cardiovascular events and death. Given equivalent oncological efficacy in patients with small renal tumors, radical Nephrectomy may result in overtreatment. We analyzed a population based cohort of patients to determine whether radical Nephrectomy is associated with an increase in cardiovascular events and mortality compared with partial Nephrectomy.Materials and Methods: Using Surveillance, Epidemiology and End Results cancer registry data linked with Medicare claims we identified 2,991 patients older than 66 years who were treated with radical or partial Nephrectomy for renal tumors 4 cm or less between 1995 and 2002. The primary end points of cardiovascular events and overall survival were assessed using Kaplan-Meier survival estimation, Cox proportional hazards regression and negative binomial regression.Results: A total of 2,547 patients (81%) underwent ...
