Urologic Oncology: Seminars and Original Investigations
Clinical-Kidney cancerUpstaging to pT3a disease in patients undergoing robotic partial nephrectomy for cT1 kidney cancer: Outcomes and predictors from a multi-institutional dataset
Introduction
The exponential increase in early detection of kidney cancer has dramatically changed its management over the past 2 decades, and partial nephrectomy (PN) has replaced radical nephrectomy as standard surgical treatment for T1 disease [1,2]. A paradigm shift towards PN was also observed in the management of T1b and T2 renal masses [3], [4], [5]. Robotic-assisted PN (RAPN) is rapidly emerging as preferred surgical approach for PN, given its potential benefits [6]. Other less invasive treatment options, such as active surveillance and kidney ablation, can be adopted for selected cases.
While surgically treated clinical T1 (cT1) kidney cancer has in general a good prognosis, there is a risk of upstaging that can potentially jeopardize the oncological outcomes of patients undergoing PN [7]. It is commonly accepted to consider “upstaged” those cT1 tumors which result as pT3a at final pathology. This because the upstaging to pT2 or pT3b could be consequence of the radiologist misjudgment of the tumor dimension or of the presence of venous thrombus [8].
Which could be the predictors as well as the impact of the upstaging on the prognosis remains unclear. The aim of the current study was to provide further evidence regarding the predictors, and the prognostic value of the upstaging to pT3a relying on one of the largest cohorts of cT1 patients who underwent RAPN at 10 high volume centers.
Section snippets
Study population
This is a retrospective international study including data of RAPN performed at 10 academic Institutions (6 European and 4 USA). Institutional review board approval and data sharing was obtained at each center involved. Data of 1,641 patients who underwent RAPN between 2005 and 2018 were collected. Among these, 74 (4%) were upstaged cases (cT1/pT3a), and they were retrospectively compared to 1,566 patients whose preoperative staging was confirmed at pathological final report (cT1/pT1).
Variable definition
Baseline
Results
Overall, 74 (4%) patients were upstaged at final histopathology (cT1/pT3a). At baseline cT1/pT3a group presented higher rate of CKD stage ≥3 (20 vs. 7%; P = 0.001), larger renal tumors (median size 4.3 vs. 2.7 cm; P < 0.001), and higher R.E.N.A.L. score (median 8 vs. 6; P = 0.004; Table 1) relative to cT1/pT1 group.
No statistically significant difference was observed in terms of operative time, and estimated blood loss, whereas cT1/pT3a group had longer median ischemia time (20 vs. 16 minutes; P
Discussion
This is a comparative analysis between non-upstaged (cT1/pT1) and upstaged (cT1/pT3a) patients after RAPN. Our results showed that only 4% of cT1 renal masses were upstaged to pT3a. We underlined some differences among the two groups which could be useful to identify preoperatively those patients who might conceal a pT3a tumor, who could require a different surgical and follow-up management.
The correlation between parenchymal renal tumor and CKD is wellestablished as neoplastic masses
Conclusions
Upstaging to pT3a in patients with cT1 renal mass undergoing RAPN represents an uncommon event, involving less than 5% of cases. One should be aware that pathologic upstaging might translate into worse oncological outcomes, and therefore strict follow-up protocols should be applied in these cases. Preoperative identification of these cases remains challenging, and it needs further investigation.
Conflict of interest
The authors declare that they have no conflicts of interest.
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Patient and tumor characteristics of histological subtypes of renal cell carcinoma and its risk of upstaging to ≥pT3
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2023, European Journal of Surgical OncologyComparison and development of preoperative systemic inflammation markers-based models for the prediction of unfavorable pathology in newly diagnosed clinical T1 renal cell carcinoma
2021, Pathology Research and PracticeCitation Excerpt :This implied that gender difference in the validation cohort might be attributed to selection bias arising from allocation process. An interesting finding was that the majority of studies assessing risk factors for pT3a upstaging, which was a component of UP, failed to demonstrate statistically significant gender differences between the groups [6,12–14,38]. This implied that more work should be done to further elucidate the true association between gender and occult adverse pathological features of cT1 renal lesions.
Predicting the risk of pT3a stage in cT1 clear cell renal cell carcinoma
2021, European Journal of Surgical OncologyUpstaging to pT3a in Patients Undergoing Partial or Radical Nephrectomy for cT1 Renal Tumors: A Systematic Review and Meta-analysis of Outcomes and Predictive Factors
2021, European Urology FocusCitation Excerpt :Statistical significance was set at p < 0.05. According to PRISMA flow chart (Supplementary Fig. 1), 13 studies met the inclusion criteria [14–26]. The level of evidence for all the studies was 3, including one of quality 5 (low) [24], one of quality 6 (medium) [25], eight of quality 7 (medium) [14–16,18,19,21–23,25], and three of quality 8 (high) [17,20,26].
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr. Veccia is an Italian Society of Urology-American Urological Association (SIU-AUA) research fellow. Funding for his fellowship is also provided by the VCU Urology Research Fund.