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of the patients (79%) received postoperative systemic therapy (median disease-specific survival of 7.1 months), whereas 5 patients did not receive systemic therapy due to disease progression (median disease-specific survival of 2.5 months). The integration of massive surgical resections into the management of patients with locally advanced and or metastatic renal cancer now requires careful discussion between oncology and surgical teams. Selection factors (Motzer factors) including performance status, serum LDH 1.5x normal, high corrected Ca⫹⫹, and low hemoglobin, segregate patients into good risk, intermediate risk, and poor risk prognostic survival categories. This segregation holds true for metastatic patients receiving their initial systemic therapy, salvage therapy, and for surgical patients initially P anyN0M0 now with new metastatic disease. Surgeons tend to operate on patients in good to intermediate risk categories when performing cytoreductive nephrectomy, metastasectomy, or adjacent organ resection. Yet occasionally, despite careful clinical judgment, patients, as in this series (5/23), can develop rapidly progressive disease and are not well enough to receive the systemic therapies that may prolong survival. Now that the more effective targeted agents, sunitinib, sorafenib, and temsirolimus have been FDA approved, the timing of major surgical interventions on the primary tumor, metastatic sites, and adjacent organs may be deferred until after systemic therapies have been delivered and disease progression stabilized, maximally regressed, or when drug toxicity is reached. doi:10.1016/j.urolonc.2007.11.010 Paul Russo, M.D. Comparison of laparoscopic radical and partial nephrectomy: Effects on long-term serum creatinine. Zorn KC, Gong EM, Orvieto MA, Gofrit ON, Mikhail AA, Msezane LP, Shalhav AL, Section of Urology, Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, IL. Urology 2007;69:1035– 40 Objectives: Laparoscopic partial nephrectomy (LPN) and radical nephrectomy (LRN) have been shown to be safe and effective treatment options for renal tumors. However, limited data are available regarding the long-term effect on postoperative renal function in patients undergoing LPN and LRN who have a normal preoperative serum creatinine (sCr) less than 1.5 mg/dL and a two-kidney system. We compared the long-term sCr in patients who were treated with LPN and LRN. Methods: From October 2002 to April 2006, a total of 93 and 171 patients with a single, unilateral, sporadic renal tumor, a normal contralateral kidney, and sCr less than 1.5 mg/dL underwent LPN and LRN, respectively. Perioperative, pathologic data and sCr at least 6 months after surgery were compared between the two groups. Results: A total of 42 and 55 patients with at least 6 months of follow-up after LPN and LRN were evaluated. Tumors treated with LPN were significantly smaller (2.4 vs. 5.4 cm, P ⬍ 0.001) than those in the LRN group. The mean age, body mass index, gender, tumor location, and sCr (0.91 and 0.91 mg/dL, P ⫽ 0.93) were similar between the two groups. The mean operative time was longer for LPN (222 vs. 182 minutes, P ⫽ 0.002) with a mean warm ischemia time of 37 minutes (range 13–55). The mean 6-month sCr was significantly greater for patients undergoing LRN (1.4 vs. 1.0 mg/dL, P ⬍ 0.001). Similarly, a greater number of LRN patients developed renal insufficiency (sCr 1.5 mg/dL or greater) compared with LPN (36.4% vs. 0%, P ⬍ 0.001). Conclusions: Despite the warm ischemia and longer operative times, LPN preserves the kidney function better than LRN. In properly selected patients, LPN should be preferentially performed to prevent chronic renal insufficiency.
Commentary The authors report a four year experience with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for the treatment of renal tumors. The study patients had a normal contralateral kidney and a serum creatinine less than 1.5 mg/dL and the groups were evenly matched relative to BMI, gender, and tumor location. The mean tumor size for the LPN group of 42 patients was 2.4 cm and the mean tumor size for the LRN group of 55 patients was 5.4 cm, both well within the T1 stage of 7 cm or less. LPN was performed with a mean warm ischemia time of 37 minutes. After 6 months of follow-up, serum creatinine was significantly greater for the patients undergoing LRN (1.4 vs. 1.0) and a larger percentage of LRN patients developed renal insufficiency as defined by a serum creatinine ⬎1.5 mg/dL (36% vs. 0%). An emerging body of work from several centers over the last 5 years is changing traditional views of elective renal tumor surgery. Today, 70% of the tumors are incidentally detected with a median tumor size of less than 4 cm. Of these tumors, approximately 20% are benign, including renal oncocytoma, 25% are indolent carcinomas with limited metastasis potential including chromophobe and papillary renal cell carcinoma, and 54% represent the conventional clear cell carcinoma, which accounts for 90% of the tumors that metastasize. Many well done studies now indicate that radical and partial nephrectomy, whether performed by open or minimally invasive techniques, demonstrate equivalent oncologic tumor control with survival rates greater than 90% expected across all histological subtypes for tumors of 7 cm or less. Patients remain at a 5% lifetime risk of ipsilateral tumor recurrence if PN is done and 5% lifetime risk of contralateral tumor recurrence whether RN or PN is done, and thus all patients require lifelong surveillance. At some point, likely measured in years, the risk of metastatic disease from the index lesion is surpassed by the chance of new tumor formation. Importantly, new concerns that radical nephrectomy may cause a deleterious impact on renal function have been raised. Serum creatinine alone, as was employed in this study, is a crude indicator of renal function. Better are formulas that estimate glomerular filtration rate (eGFR), whether using the MDRD equation or the Cockcroft Gault equation. eGFR is influenced by the patient’s gender, age, and race. In a study similar to this, 26% of patients with a normal contralateral kidney and a serum creatinine
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⬍1.5 mg/dL had a eGFR ⬍60 mL/min/1.78 m2, consistent with Stage 3 chronic kidney disease (CKD) prior to kidney surgery . CKD is an independent risk factor for patient hospitalization, cardiovascular toxicity, and death, the likelihood of which increases as the eGFR decreases. Patients with small renal tumors undergoing RN are at a 36% chance of developing an eGFR ⬍45 whereas those undergoing a PN had a 5% chance. The new information utilizing eGFR, when taken together with studies such as this indicating an adverse impact on serum creatinine in patients undergoing RN vs. PN, now make partial nephrectomy, whether executed by open or laparoscopic technique, the most appropriate approach to all patients with small kidney tumors. doi:10.1016/j.urolonc.2007.11.011 Paul Russo, M.D.
Reference  Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumors: A retrospective cohort study. Lancet Oncol 2006;7:735– 40.
Disparities in treatment and outcome for renal cell cancer among older black and white patients. Berndt SI, Carter HB, Schoenberg MP, Newschaffer CJ, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. J Clin Oncol 2007;25:3589 –95 Purpose: Black patients with renal cell cancer have shorter survival compared with their white counterparts, but the causes for this disparity are unclear. To elucidate reasons for this inequality, we examined differences in treatment and survival between black and white patients. Patients and Methods: A retrospective cohort study was conducted using data from the linked Surveillance, Epidemiology and End Results (SEER) cancer registry and Medicare databases. Participants included 964 black and 10,482 white patients age ⱖ65 years who were enrolled into Medicare and diagnosed with renal cell cancer between 1986 and 1999. Information on surgical treatment was ascertained from both databases, whereas data regarding coexisting illness and survival was obtained from the Medicare database. Results: The percentage of black patients receiving nephrectomy treatment was significantly lower compared with whites (61.2% vs. 70.4%; P ⬍ 0.0001). After adjustment for age, gender, median income, cancer stage, tumor size, and comorbidity index, blacks were less likely to undergo nephrectomy treatment compared with whites (risk ratio ⫽ 0.93; 95% CI, 0.90 – 0.96). Overall survival was worse for blacks than whites even after adjustment for demographic and cancer prognostic factors (hazard ratio [HR] ⫽ 1.16; 95% CI, 1.07–1.25); however, additional adjustment for comorbidity index and nephrectomy treatment reduced the disparity substantially (HR ⫽ 1.00; 95% CI, 0.93–1.09). Conclusion: This study indicates that the lower survival rate among blacks compared with whites with renal cell cancer can be explained largely by the increased number of comorbid health conditions and the lower rate of surgical treatment among black patients.
Commentary The authors utilized the SEER cancer registry and Medicare databases to evaluate 10,482 patients ⬎65 years of age, diagnosed with renal cell carcinoma between 1986 and 1999. The percentage of black patients receiving nephrectomy treatment was significantly lower compared with white (61.2% vs. 70.4%). After adjusting for age, gender, median income, cancer stage, tumor size, and comorbidity index, blacks were less likely to undergo nephrectomy compared with whites, and overall survival was worse for blacks than whites even after adjustment for demographic and cancer prognostic factors. The lower rate of surgical treatment as well as higher frequency of comorbidities among blacks explained a large proportion of the reported survival disparity. This interesting study may shed some light on the rising incidence and declining survival characteristics reported in renal cell carcinoma over the last 20 years despite the discovery of more incidental tumors at a smaller size and more operative interventions. The American population is experiencing a rising incidence of serious medical comorbidities, including hypertension, obesity, diabetes, and cardiovascular disease, all of which may play a role in the overall survival of patients with renal cell carcinoma as they seek surgical treatment, recover from such treatment, or experience long term side effects of surgical treatment (i.e., chronic kidney disease after radical nephrectomy, as defined by eGFR ⬍60 mL/min/1.78 m2). This report suggests that within the SEER/Medicare database, black patients had an even lower survival rate than white patients most likely due to increased medical comorbidities and less access to health care. It may be that black patients with higher comorbidity burden would be less likely to be offered surgical treatment or may present at such a late stage that surgical treatment would be considered ineffective. doi:10.1016/j.urolonc.2007.11.012 Paul Russo, M.D.