Platinum Priority – Kidney CancerEditorial by Alexander Kutikov, Marc C. Smaldone and Robert G. Uzzo on pp. 260–261 of this issueComparison of Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses
Introduction
Radical nephrectomy has historically been the standard of care for management of renal masses. Initially reserved for imperative situations, partial nephrectomy (PN) has been increasingly used after observations suggested that oncologic control was similar when compared with radical nephrectomy, with the additional benefits of renal preservation [1], [2], [3], [4], [5]. Consistent with this situation, the American Urological Association (AUA) guidelines state that PN should be strongly considered for healthy patients with cT1a renal masses and should be discussed as an alternate standard for cT1b patients, particularly when there is a need to preserve renal function [5]. Other treatment options, including thermal ablation and active surveillance, represent further management strategies that should be discussed, though with appropriate levels of discretion depending on the clinical scenario [5]. Accordingly, the European Association of Urology guidelines state that thermal ablation should be considered predominately in patients with small tumors who are unfit for surgery with the understanding that local progression rates are higher [6].
In the last 10–15 yr, we have amassed significant experience with percutaneous cryoablation and radiofrequency ablation (RFA) for renal masses. Ablative options, initially reserved for patients who were poor candidates for surgery, now have expanded indications and are routinely discussed. Nevertheless, direct comparisons of cancer-related outcomes among PN, RFA, and cryoablation patients are lacking, especially from institutions that routinely perform all the aforementioned nephron-sparing options [7]. Thus, we evaluated our experience with management of cT1 renal masses to compare oncologic outcomes among patients treated with PN, percutaneous RFA, and percutaneous cryoablation.
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Patient selection
Following institutional review board approval, we queried the Mayo Clinic Renal Tumor Registry to identify patients treated with PN, percutaneous RFA, or percutaneous cryoablation for sporadic, localized (N0M0), cT1 solid renal masses between 2000 and 2011. Patients with a history of prior renal cell carcinoma (RCC) or genetic syndromes were excluded. In total, there were 1424 patients treated with PN (n = 1057), RFA (n = 180), or cryoablation (n = 187) for cT1aN0M0 renal masses and 379 patients
Patients with cT1a tumors
Clinical and pathologic features for the 1424 patients with cT1a tumors are depicted in Table 1. Patients treated with PN were significantly younger (p < 0.001) and had lower Charlson scores (p < 0.001) compared with patients treated with RFA and cryoablation. Median tumor size was 2.4 cm, 1.9 cm, and 2.8 cm for patients treated with PN, RFA, and cryoablation, respectively (p < 0.001). As expected, the percentage of patients with benign or unknown histology was higher for those treated with ablation
Discussion
We compared local recurrence-free, metastases-free, and overall survival among patients treated with PN, percutaneous RFA, and percutaneous cryoablation for sporadic and localized solid renal masses. For patients with cT1a renal masses, we observed that local control was similar among the three treatment groups, metastases-free survival was inferior for RFA, and overall survival was superior for PN. For patients with cT1b renal masses, we further observed that local control and metastases-free
Conclusions
In a large cohort of sporadic cT1 renal masses, we observed that recurrence-free survival was similar for PN and percutaneous ablation patients. Metastases-free survival was superior for PN and cryoablation patients when compared with RFA for cT1a patients. Overall survival was superior after PN, likely because of selection bias. If validated, these data suggest that an update to clinical guidelines would be warranted.
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