Alessandro Veccia1, Ugo Falagario2, Alberto Martini3, Michele Marchioni4, Alessandro Antonelli5, Claudio Simeone6, Luigi Cormio7, Umberto Capitanio3, M Carmen Mir8, Ithaar Derweesh9, Hendrik Van Poppel10, Francesco Porpiglia11, Riccardo Autorino12. 1. Division of Urology, VCU Health System, Richmond, VA, USA; Urology Unit, ASST Spedali Civili Hospital, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Science, and Public Health, University of Brescia, Brescia, Italy. 2. Division of Urology, VCU Health System, Richmond, VA, USA; Urology and Renal Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy. 3. Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy. 4. Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy. 5. Urology Unit AUOI Verona, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy. 6. Urology Unit, ASST Spedali Civili Hospital, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Science, and Public Health, University of Brescia, Brescia, Italy. 7. Urology and Renal Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy. 8. Department of Urology, Fundación Instituto Valenciano Oncologia, Valencia, Spain. 9. Department of Urology, UCSD, San Diego, CA, USA. 10. Department of Urology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium. 11. Division of Urology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy. 12. Division of Urology, VCU Health System, Richmond, VA, USA. Electronic address: ricautor@gmail.com.
Abstract
CONTEXT: Predictors of upstaging from cT1 to pT3a renal masses are poorly inquired, and this remains an area of controversial findings. OBJECTIVE: To evaluate predictors and outcomes of upstaging from cT1 to pT3a in patients undergoing surgical removal of a renal tumor. EVIDENCE ACQUISITION: A systematic literature search was performed to identify relevant articles using three electronic engines (PubMed, Embase, and Web of Science). Only studies looking at upstaging to pT3a in patients undergoing either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1 renal tumor were included. Study selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. EVIDENCE SYNTHESIS: Thirteen studies, including 21869 patients (cT1/pT3a: 1256 [5.7%]; cT1/pT1: 20613 [93.3%]), were identified. Patients in the upstaged group were older (weighted mean difference [WMD]: 3.89; p < 0.00001) and mostly male (odds ratio [OR]: 1.23; p = 0.04). Renal tumors were larger (WMD: 0.98; p < 0.00001), more complex (OR: 2.38; p < 0.0001), and with a higher rate of cT1b masses (OR: 3.36; p < 0.00001). The cT1/pT3a group had a higher rate of other renal cell carcinoma histological subtypes (OR: 1.59; p = 0.04), as well as higher odds of Fuhrman grade ≥3 (OR: 2.57; p < 0.00001) and positive surgical margins (OR: 1.85; p = 0.007). Five-year recurrence-free survival (RFS) was worse in the upstaged group (OR: 0.31; p = 0.02). Age (OR: 1.03; p < 0.00001), tumor size (OR: 1.51; p < 0.00001), and RENAL score (OR: 2.80; p = 0.0004) were predictors of upstaging. Upstaging was associated with overall survival (hazard ratio [HR]: 1.94; p = 0.05), cancer-specific survival (HR: 2.24; p = 0.007), and RFS (HR: 2.17; p < 0.00001). CONCLUSIONS: Upstaging to pT3a in case of surgical removal of a cT1 renal tumor is an uncommon event, which however can translate into worse oncological outcomes. Both patient (older age) and tumor (larger size and higher complexity) characteristics are associated with a higher risk of upstaging. There is very limited evidence regarding whether RN would be better than PN in these cases. There remains an unmet need for tools to better characterize renal masses in the preoperative setting. PATIENTS SUMMARY: About 6% of surgically treated localized renal tumors can be found to be locally advanced on final pathology after surgery. This "upstaging" can translate into worse oncological outcomes. There are patient and tumor characteristics that are associated with an increased the risk of upstaging.
CONTEXT: Predictors of upstaging from cT1 to pT3a renal masses are poorly inquired, and this remains an area of controversial findings. OBJECTIVE: To evaluate predictors and outcomes of upstaging from cT1 to pT3a in patients undergoing surgical removal of a renal tumor. EVIDENCE ACQUISITION: A systematic literature search was performed to identify relevant articles using three electronic engines (PubMed, Embase, and Web of Science). Only studies looking at upstaging to pT3a in patients undergoing either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1 renal tumor were included. Study selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. EVIDENCE SYNTHESIS: Thirteen studies, including 21869 patients (cT1/pT3a: 1256 [5.7%]; cT1/pT1: 20613 [93.3%]), were identified. Patients in the upstaged group were older (weighted mean difference [WMD]: 3.89; p < 0.00001) and mostly male (odds ratio [OR]: 1.23; p = 0.04). Renal tumors were larger (WMD: 0.98; p < 0.00001), more complex (OR: 2.38; p < 0.0001), and with a higher rate of cT1b masses (OR: 3.36; p < 0.00001). The cT1/pT3a group had a higher rate of other renal cell carcinoma histological subtypes (OR: 1.59; p = 0.04), as well as higher odds of Fuhrman grade ≥3 (OR: 2.57; p < 0.00001) and positive surgical margins (OR: 1.85; p = 0.007). Five-year recurrence-free survival (RFS) was worse in the upstaged group (OR: 0.31; p = 0.02). Age (OR: 1.03; p < 0.00001), tumor size (OR: 1.51; p < 0.00001), and RENAL score (OR: 2.80; p = 0.0004) were predictors of upstaging. Upstaging was associated with overall survival (hazard ratio [HR]: 1.94; p = 0.05), cancer-specific survival (HR: 2.24; p = 0.007), and RFS (HR: 2.17; p < 0.00001). CONCLUSIONS: Upstaging to pT3a in case of surgical removal of a cT1 renal tumor is an uncommon event, which however can translate into worse oncological outcomes. Both patient (older age) and tumor (larger size and higher complexity) characteristics are associated with a higher risk of upstaging. There is very limited evidence regarding whether RN would be better than PN in these cases. There remains an unmet need for tools to better characterize renal masses in the preoperative setting. PATIENTS SUMMARY: About 6% of surgically treated localized renal tumors can be found to be locally advanced on final pathology after surgery. This "upstaging" can translate into worse oncological outcomes. There are patient and tumor characteristics that are associated with an increased the risk of upstaging.
Authors: Patrick O Richard; Philippe D Violette; Bimal Bhindi; Rodney H Breau; Wassim Kassouf; Luke T Lavallée; Michael Jewett; John R Kachura; Anil Kapoor; Maxine Noel-Lamy; Michael Ordon; Stephen E Pautler; Frédéric Pouliot; Alan I So; Ricardo A Rendon; Simon Tanguay; Christine Collins; Maryam Kandi; Bobby Shayegan; Andrew Weller; Antonio Finelli; Andrea Kokorovic; Jay Nayak Journal: Can Urol Assoc J Date: 2022-02 Impact factor: 1.862
Authors: Rodolfo Borges Dos Reis; Rafael Neuppmann Feres; Marcelo Cartapatti da Silva; Valdair Francisco Muglia; Antonio Antunes Rodrigues Journal: Int Braz J Urol Date: 2022 Sep-Oct Impact factor: 3.050