Partial nephrectomy (PN) is preferred for a renal mass in a solitary kidney (RMSK), although tumors with high complexity can be challenging.
To evaluate the evolution of RMSK management with a focus on achievement of PN.
Patients with nonmetastatic RMSK (n = 499) were retrospectively reviewed; 133 had high tumor complexity, including 80 in the pre-tyrosine kinase inhibitor (TKI) era (1999-2008) and 53 in the TKI era (2009-2022). After 2009, 23/53 patients received neoadjuvant TKI and 30/53 had immediate-surgery.
Functional outcomes, adverse events and complications, dialysis-free survival, and recurrence-free survival (RFS) were the measures evaluated. Mann-Whitney and χ2 tests were used to compare cohorts, and the log-rank test was applied for survival analyses.
Overall, the median RENAL score was 10 and the median tumor diameter was 5.2 cm. Demographic characteristics, tumor diameter, and RENAL scores were similar between the pre-TKI-era and TKI-era groups. In the TKI era, 23/53 patients (43%) with clear-cell histology were selected for neoadjuvant TKI. These 23 patients had a greater median tumor diameter (7.1 vs 4.4 cm; p = 0.02) and RENAL score (11 vs 10; p = 0.07). After TKI treatment, the median tumor diameter decreased to 5.6 cm and the RENAL score to 9, and tumor volume was reduced by 59% (all p < 0.05). PN was accomplished in 21/23 (91%) the TKI-treated cases and in 27/30 (90%) of the immediate-surgery cases (2009-2022). PN was only accomplished in 52/80 (65%) of the patients from the pre-TKI era (p < 0.01). The 5-yr dialysis-free survival rate was 59% in the pre-TKI-era group and 91% in the TKI-era group. The 5-yr RFS rate was lower in the TKI-era group (59% vs 74%; p = 0.21), which was mostly related to more aggressive tumor biology, as reflected by a predominance of systemic rather than local recurrences.
Management of RMSK with high tumor complexity is challenging. Selective use of TKI therapy was associated with greater use of PN, although a randomized study is needed. RFS mostly reflected aggressive tumor biology rather than failure of local management.
For complex kidney tumors in patients with a single kidney, management is challenging. Use of drugs called tyrosine kinase inhibitors before surgery was associated with reductions in tumor size and greater ability to achieve partial kidney removal for cancer control. Most recurrences were metastatic, which reflects aggressive tumor biology rather than failure of surgery.
European urology open science. 2023 Jun 10*** epublish ***
Worapat Attawettayanon, Yosuke Yasuda, Jj H Zhang, Akira Kazama, Nityam Rathi, Carlos Munoz-Lopez, Kieran Lewis, Snehi Shah, Jianbo Li, João Pedro Emrich Accioly, Rebecca A Campbell, Shetal Shah, Andrew Wood, Jihad Kaouk, Georges-Pascal Haber, Mohamad Eltemamy, Venkatesh Krishnamurthi, Robert Abouassaly, Christopher Weight, Ithaar Derweesh, Steven C Campbell
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA., Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, USA., Imaging Institute, Cleveland Clinic, Cleveland, OH, USA., Department of Urology, School of Medicine, University of California-San Diego, La Jolla, CA, USA.