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Resumen: Objetivo: Evaluar la asociación entre la exposición al radón y el cáncer genitourinario en población minera a través de una revisión sistemática de la literatura científica. Método: Se realizó una revisión sistemática de la literatura científica en MEDLINE (PubMed) combinando términos MeSH (Medical Subject Heading) y términos libres. Se realizó una escala específica de valoración de la calidad de los estudios incluidos. Resultados: Se incluyeron 17 estudios. Todos fueron estudios de cohortes, excepto uno que fue un pool de datos. Todos los estudios incluían análisis de la relación entre la exposición al radón y el cáncer genitourinario. Los resultados son ambiguos: unos estudios apuntan hacia una asociación entre la exposición y el cáncer genitourinario, especialmente de riñón, y otros no encuentran asociación. Conclusión: Los estudios incluidos presentan una gran heterogeneidad metodológica. No puede concluirse que exista una asociación entre la exposición al radón y el cáncer genitourinario. Es necesaria más investigación sobre el tema, con estudios que tengan más potencia estadística y mejor control de las variables confusoras, y preferentemente que sean prospectivos. Abstract: Objective: To assess the association between exposure to radon and genitourinary cancer in a mining population through a systematic review of the scientific literature. Method: A systematic review of the scientific literature was carried out in MEDLINE (PubMed), combining MeSH (Medical Subject Heading) terms and free terms. We applied a specific scale to assess the quality of the included studies. Results: We included 17 studies; all were cohort studies with the exception of one which was a pooling of data. All studies included analysed the relationship between exposure to radon and genitourinary cancer. While some studies point towards an association between radon exposure and genitourinary cancer, especially kidney cancer, others do not find such association. Conclusions: The included studies showed great heterogeneity. It cannot be concluded that there is an association between exposure to radon and genitourinary cancer. More research is needed on this topic, designing studies with higher statistical power, better control of confounders, and preferably prospective.

CONTEXT: The optimal ischemia technique at partial nephrectomy (PN) for renal masses is yet to be determined. OBJECTIVE: To summarize and analyze the current evidence about surgical, oncological, and functional outcomes after different ischemia techniques (cold, warm, and zero ischemia) at PN. EVIDENCE ACQUISITION: A computerized systematic literature search was performed by using PubMed (MEDLINE) and Science Direct. Identification and selection of the studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Outcomes of interest were estimated blood loss (EBL), overall complications, positive surgical margins, local tumor recurrence, and renal function preservation. Meta-analysis and forest-plot diagrams were performed. Overall pooled estimates, together with 95% confidence intervals (CIs), of the incidence of all parameters were obtained using a random effect model (RE-Model) on the log transformed means (MLN), proportion, or standardized mean change, as deemed appropriate. EVIDENCE SYNTHESIS: One hundred and fifty-six studies were included. No clinically meaningful differences were found in terms of EBL after cold (mean: 215.5; 95% CI: 154.2-276.8m), warm (mean: 201.8; 95% CI: 175.0-228.7ml), or zero (mean: 261.2; 95% CI: 171.0-351.3ml) ischemia technique. Overall, postoperative complications were recorded in 14.1% (95% CI: 6.7-27.4), 11.1% (95% CI: 10.0-12.3), and 9.7% (95% CI: 7.7-12.2) of patients after cold, warm, and zero ischemia (p

Background: A non-negligible proportion of individuals diagnosed with cT1 renal cell carcinoma (RCC) are upstaged to pT3a at final pathology. Few data on oncological outcomes for these patients are available to determine whether partial nephrectomy (PN) might jeopardise cancer control. Objective: To assess, within an international multi-institutional collaboration, whether PN might undermine cancer control relative to radical nephrectomy (RN) in RCC patients with unexpected pT3a disease. Design, setting, and participants: International multi-institutional collaboration including patients with cT1abN0M0-pT3a RCC. Intervention: PN or RN. Outcome measurements and statistical analysis: We used Kaplan-Meier analyses, before and after propensity-score matching, to evaluate differences in metastatic progression (MP) and cancer-specific mortality (CSM) rates during follow-up. Univariable and multivariable Cox regression analyses were used to assess predictors of MP and CSM. Results and limitations: Overall, 309 patients with cT1abN0M0 RCC (cT1aN0M0, n = 107, 34.6%; cT1bN0M0, n = 202, 65.4%) had pT3a disease according to final pathology. Patients were treated with either PN (n = 71, 23%) or RN (n = 238, 77%). MP at 1, 2, and 5 yr was detected in 9.1%, 13.3%, and 24.1% of patients, respectively. CSM was 3.5%, 10.7%, and 18.4% at 1, 2, and 5 yr, respectively. After matching, no difference in terms of MP or CSM was observed between the PN and RN cohorts (both p>0.3). On multivariable analysis, type of surgery (PN vs RN) was not an independent predictor of either MP (p = 0.3) or CSM (p = 0.4). Limitations include the retrospective design. Conclusions: In patients with unexpected pT3a RCC at final pathology, PN does not appear to jeopardise cancer control with regard to MP and CSM. Patient summary: Cancer control is similar between patients treated with removal of the entire kidney and those with only partial removal, even if the final histology examination demonstrates a tumour that is unexpectedly not confined within the kidney. Partial nephrectomy does not undermine cancer control when unexpected pT3a renal cancer is identified at final pathology.

Enhanced recovery after surgery protocols (ERAS) have been developed and implemented as of 2001. However, no previous analyses targeted length of stay (LOS) changes over time after major surgical oncological procedures (MSOPs).Between 2003 and 2013, we retrospectively identified patients, who underwent prostatectomy, colectomy, cystectomy, mastectomy, gastrectomy, hysterectomy, nephrectomy, oophorectomy, lung resection or pancreatectomy within the Nationwide Inpatient Sample. A total of 3 431 602 assessable patients were identified. We examined temporal trends of LOS after ten MSOPs, as well as LOS determinants and the impact of LOS on total hospital charges (THCGs). Univariable and multivariable linear, log-linear, logistic (MLR) and Poisson regression (MPR) analyses were used.Mean and median LOS were respectively 6 and 4 days (IQR 2-7). During the study span, LOS decreased [Estimated annual percentage change (EAPC): -1.89%, p = 0.0002]. Of the ten examined MSOPs, nine showed a decrease that ranged from -4.47% in prostatectomy to -0.7% in mastectomy. Conversely, no decrease in LOS was recorded for colectomy (EAPC:+0.37, p = 0.015). In MPR analyses, robotic [Relative risk (RR):0.68, p = 0.0003] and laparoscopic (RR: 0.90, p 0.0001) surgical approaches were associated with shorter LOS. LOS was directly related to THCGs.Since the implementation of ERAS protocols, LOS has decreased for nine out of ten MSOPs in a significant fashion. Although these gains may appear marginal on an annual basis, their cumulative effect, over the study span, ranges for 7.7%-49.2%, which can hardly be interpreted as marginal. LOS decrease directly translates in THCGs savings.

Primary glomus tumors of the kidney are rare with only 33 cases reported in the literature. We present a 59-year-old lady with abdominal pain and dyspepsia with a provisional diagnosis of renal cell carcinoma on imaging. Pathological examination revealed a mesenchymal pericytic tumor with morphology and immunohistochemistry being most consistent with malignant glomus tumor. We believe this is the first case of glomus tumor of the kidney in the Indian literature. We report this case given its rarity and to add to the existing published data.

Background Local tumour ablation (LTA) may yield better perioperative outcomes than partial nephrectomy (PN), however the impact of each treatment on perioperative mortality and health care expenditures is unknown. The aim of the study was to compare mortality, morbidity and health care expenditures between LTA and PN. Patients and methods A population-based assessment of 2471 patients with cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009, in the SEER-Medicare database was performed. After propensity score matching, 30-day mortality, overall and specific complication rates, length of stay, readmission rates and health care expenditures according to LTA or PN were estimated. Multivariable logistic and linear models addressed the effect of each specific LTA approach on overall complication rates, length of stay, readmission rates and health care expenditures. Results The 30-day mortality was

INTRODUCTION AND OBJECTIVES: To analyze postoperative complications and to assess for significant predictive factors during partial nephrectomy (PN) using a large multicenter dataset. METHODS: Patients who underwent PN for clinical T1 renal tumors at 19 urological Italian centers (Registry of Conservative Renal Surgery [RECORd] project) were evaluated between 2009 and 2012. Anthropometric data, comorbidities and perioperative outcomes were analyzed. Complications were divided as intra- and postoperative, medical and surgical, as appropriate. The severity of postoperative complications was graded according to the modified Clavien classification system. Patients who experienced intraoperative complications were excluded from the analyses for the potential confounding effect in the evaluation of predicting factors for postoperative complications. RESULTS: Overall, 979 patients were analyzed: open, laparoscopic and robot-assisted (available since 2011) surgical approaches were used in 522 (56.4%), 286 (30.9%) and 117 (12.6%) cases, respectively. Surgical postoperative complications were reported in 121 (13.1%) cases (32 (3.5%) were Clavien 3), medical were reported in 52 (5.6%) cases (3 (0.3%) were Clavien 3). No Clavien 4 complications were reported. At multivariable analysis, ECOG score ≥1 (OR 1.98; p = 0.002), lower preoperative hemoglobin (OR 0.71; p < 0.0001) and open surgical approach (2.91; p = 0.02) were significant predictive factors of overall surgical postoperative complications, ECOG score ≥1 (OR 1.93; p = 0.04) and surgical approach (p = 0.05) were significant predictive factors of Clavien 3 either surgical or medical postoperative complications. CONCLUSIONS: Comorbidities and surgical approach should be considered in preoperative evaluation of patients undergoing PN, as they resulted to play a significant role in the occurrence of postoperative complications.

Pleomorphic Hyalinizing Angiectatic Tumor (PHAT) is a rare benign lesion characterized by slow growth, infiltrative behavior and high rate of local recurrences. Only one case has been described in retroperitoneum, at renal hilum, but not involving pelvis or parenchyma. Here we present the first case of PHAT arising in the renal parenchyma. A nodular lesion in right kidney lower pole was diagnosed to a 61 year old woman. The patient underwent right nephrectomy. Microscopically, the lesion showed solid and pseudo-cystic components with hemorrhagic areas characterized by aggregates of ectatic blood vessels. Pleomorphic cells were characterized by large eosinophilic cytoplasm with irregular and hyperchromatic nuclei. Immunohistochemistry was performed and the lesion was classified as a Pleomorphic Hyalinizing Angiectatic Tumor (PHAT). Due to the clinical behavior of this tumor, in spite of its benign nature, review of the surgical margins and close follow up after partial nephrectomy are mandatory.

Background Previous studies have demonstrated that elevated neutrophil-to-lymphocyte ratios and platelet-to-lymphocyte ratios (PLRs) are associated with the presence of various malignancies. The present study evaluated various hematologic parameters and their association with renal tumor biopsy pathology. Materials and Methods The clinical, hematologic, and pathologic parameters were obtained through a retrospective review of 475 diagnostic biopsy specimens of small renal masses from January 2001 to December 2013. The complete blood counts closest to and before the biopsies were obtained. The biopsy pathologic findings were divided into 3 groups: benign, primary renal malignancy, and nonrenal malignancy. The hematologic parameters were compared among the 3 groups. Receiver operating characteristic curves were constructed for the parameters that were significantly different among the groups. Multiple logistic regression models were used to assess whether the clinical and hematologic parameters were associated with benign or malignant pathologic findings. Results Hematologic parameters were available for 462 cases (97%). Pathologic examination of the biopsy specimens demonstrated benign, primary renal malignancy, and nonrenal malignancy in 114 (25%), 337 (73%), and 11 (2%) patients, respectively. The PLR was significantly ( P = .010) different among the 3 groups and was significantly ( P = .013) greater in those with nonrenal malignancies than in those with primary renal malignancies. Using a cutoff for the PLR of 202.9 gave a sensitivity of 63.6% and specificity of 82.2% for detecting a nonrenal malignancy. Conclusion The hematologic parameters did not differ significantly between benign and primary renal malignant masses undergoing biopsy. The PLR might be useful as a simple and inexpensive marker to help distinguish nonrenal malignancies in the workup of a small renal mass.

ResumenA nivel mundial, el carcinoma de células renales representa el 3% de todas las neoplasias malignas. Los sitios más frecuentes de metástasis son pulmón, ganglios linfáticos, hígado, hueso y las glándulas suprarrenales. Las metástasis a lengua o músculo son verdaderamente inusuales y en la literatura han sido reportados casos anecdóticos aislados. El objetivo de presentar este caso consiste en describir las manifestaciones clinicopatológicas, así como el diagnóstico y el tratamiento de las metástasis a 2 sitios muy poco frecuentes en el carcinoma renal de células claras. Además, se muestran algunos datos de diferentes revisiones a fin de comparar este caso con otros similares que han sido reportados. Presentamos el caso de un paciente masculino de 61 años de edad, de nacionalidad mexicana, con antecedentes de carcinoma renal de células claras en riñón izquierdo tratado con nefrectomía, y que presentó 2 metástasis sincrónicas 19 años después: una a la base de la lengua y otra al músculo bíceps braquial izquierdo. Actualmente, el tratamiento de las metástasis del carcinoma renal de células claras es fundamentalmente paliativo; sin embargo, existen nuevos agentes moleculares dirigidos que han demostrado resultados prometedores como tratamiento adyuvante.AbstractRenal cell carcinoma accounts for 3% of all malignancies worldwide. The most frequent sites of metastases include the lung, lymph nodes, liver, bone and adrenal glands. Tongue or muscle metastases are unusual, and only single anecdotal cases have been reported. The main purpose of presenting this case is to describe the clinical-pathological manifestations, as well as the diagnosis and treatment of metastases in two very uncommon sites for clear-cell renal carcinoma. In addition, some data from different reviews are presented, in order to compare this case with other similar reported cases. The case is described of a 61-year old male Mexican patient with a history of clear-cell renal carcinoma in the left kidney treated with nephrectomy, and who presented 19 years later with two synchronous metastases: one at the base of the tongue, and the other in the left biceps brachii muscle. Currently, the treatment of metastatic clear-cell renal carcinoma is mainly palliative; nevertheless, there are new molecular targeted agents that have shown promising results in the adjuvant setting.

Background: A new edition of the TNM was recently released that includes modifications for the staging system of kidney cancers. Specifically, T2 cancers were subclassified into T2a and T2b ( 10 cm), tumors with renal vein involvement or perinephric fat involvement were classified as T3a cancers, and those with adrenal involvement were classified as T4 cancers. Objective: Our aim was to validate the recently released edition of the TNM staging system for primary tumor classification in kidney cancer. Design, setting, and participants: Our multicenter retrospective study consisted of 5339 patients treated in 16 academic Italian centers. Intervention: Patients underwent either radical or partial nephrectomy. Measurements: Univariable and multivariable Cox regression models addressed cancer-specific survival (CSS) after surgery. Results and limitations: In the study, 1897 patients (35.5%) were classified as pT1a, 1453 (27%) as pT1b, 437 (8%) as pT2a, 153 (3%) as pT2b, 1059 (20%) as pT3a, 117 (2%) as pT3b, 26 (0.5%) as pT3c, and 197 (4%) as pT4. At a median follow-up of 42 mo, 786 (15%) had died of disease. In univariable analysis, patients with pT2b and pT3a tumors had similar CSS, as did patients with pT3c and pT4 tumors. Moreover, both pT3a and pT3b stages included patients with heterogeneous outcomes. In multivariable analysis, the novel classification of the primary tumor was a powerful independent predictor of CSS (p for trend < 0.0001). However, the substratification of pT1 tumors did not retain an independent predictive role. The major limitations of the study are retrospective design, lack of central pathologic review, and the small number of patients included in some substages. Conclusions: The recently released seventh edition of the primary tumor staging system for kidney tumors is a powerful predictor of CSS. However, some of the substages identified by the classification have overlapping prognoses, and other substages include patients with heterogeneous outcomes. The few modifications included in this edition may have not resolved the most critical issues in the previous version. (C) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Mixed epithelial and stromal tumour of the kidney (MESTK) is a rare kidney neoplasm that occurs almost exclusively in perimenopausal women. Long-term oestrogen replacement appears to play a major role in its pathogenesis. Around 70 cases have been described in the international literature, none of which involve male children. Herein, we describe an atypical case of MESTK diagnosed in a 12-year-old prepubertal boy who presented with hematuria. Pathology and immunohistochemistry revealed a typical MESTK. The child was free of disease at 2-year follow up after a partial nephrectomy and tumour excision.

Aim The aim of this study was to characterize the morphology of renal tumor vessels. Methods Twenty-two patients with kidney neoplasm underwent three-dimensional reconstruction prior to surgery. The vascular cast of kidney specimens was obtained after surgery. Results The vascular cast revealed proliferation, thickening, compression, displacement, and arteriovenous fistulae in tumor vessels, which were consistent with the findings from 3-D ultrasound ( χ 2 =12.60, P Conclusion Most renal cellular carcinomas are rich blood-supplied tumors with distinctive vasculature in the tumor region.

Renal-cell carcinoma is considered to be a radioresistant tumour, but this notion might be wrong. If given in a few (even single) fractions, but at a high fraction dose, stereotactic body radiotherapy becomes increasingly important in the management of renal-cell carcinoma, both in primary settings and in treatment of oligometastatic disease. There is an established biological rationale for the radiosensitivity of renal-cell carcinoma to stereotactic body radiotherapy based on the ceramide pathway, which is activated only when a high dose per fraction is given. Apart from the direct effect of stereotactic body radiotherapy on renal-cell carcinoma, stereotactic body radiotherapy can also induce an abscopal effect. This effect, caused by immunological processes, might be enhanced when targeted drugs and stereotactic body radiotherapy are combined. Therefore, rigorous, prospective randomised trials involving a multidisciplinary scientific panel are needed urgently. © 2014 Elsevier Ltd.

Purpose of the study The aim of the study was to assess the efficacy, safety and effectiveness of percutaneous image-guided microwave ablation (MWA) in Bosniak category III or IV cystic renal lesions after 24 months follow-up duration. Methods Between May 2008 and December 2012, computed tomography (CT)- or ultrasound (US)-guided MWA was performed in 6 patients with 7 cystic renal lesions (range 13.8–27 mm, mean 17.02 mm, SD 8.5 mm) Bosniak catgegory III or IV. The number of treatment sessions, treatment results, lesion size changes and complications were evaluated. Technical success (TS), technical effectiveness (TE), local tumor progression rate (LTPR), cancer-specific survival rate (CSSR) and overall survival rate (OSR) were computed. Main findings TS was 100% (7/7) and TE was 100%; LTPR was 0%; CSSR and OSR were 100%. No major complications were observed. Conclusion Our preliminary experience with MWA shows a potential role for US/CT-guided percutaneous MWA in treating Bosniak category III or IV cystic renal lesions, as a safe approach to treat selected patients not suitable for surgery.

Treatment options for a suspicious renal mass in a renal allograft include radical nephrectomy or nephron-sparing surgery (NSS). To our knowledge robotic-assisted laparoscopic partial nephrectomy (RPN) as treatment for a renal mass in a transplant kidney has not been previously reported. We report the case of RPN for a 7-cm renal mass in a transplanted kidney. A 35-year-old female with reflux nephropathy received a living-related donor kidney transplant in 1986. At 24 years after transplantation she had a 7-cm Bosniak III cystic mass of the allograft detected on computerized tomography (CT) scan. Preoperative creatinine was 2.2 mg/dL with an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m(2) . RPN was performed with bulldog clamping of the renal vessels, the graft was left in situ and immunosuppression was maintained postoperatively. Tumor diameter was 7.3 cm with a nephrometry score of 10a. Warm ischemia time (WIT) was 26.5 min. Estimated blood loss was 100 mL. There was no change between pre- and postoperative eGFR. There were no operative complications. Histology was papillary renal cell carcinoma type 1, nuclear grade 2. Margins were negative. RPN is a technically feasible treatment option for a suspicious renal mass in renal allografts.

To analyze the clinical behavior of chromophobe renal cell carcinoma (RCC) in Korean patients.A total of 657 patients with conventional RCC and 71 with chromophobe RCC were included in the analysis. The median follow-up for all patients was 44 months (95% confidence interval, 10 to 126).Patients with chromophobe RCC differed significantly from those with conventional RCC on the following parameters: a greater female ratio (P = 0.019), less advanced TNM stage (P = 0.004), and higher Fuhrman nuclear grade (P0.001). There was no statistical difference with regard to age and tumor diameter. The 5- and 10-year disease-specific survival rates in patients with chromophobe RCC (92.9% and 92.9%) were higher than in patients with conventional RCC (84.9% and 79.8%). When patients were divided according to T stage, Fuhrman's grade, and tumor size for the subgroup analysis, disease-specific survival probabilities of chromophobe RCC were higher in only tumors with a high Fuhrman's grade (G3/G4) (P = 0.002) and larger than 4 cm (P = 0.025). The multivariate analysis showed that the histologic type was not an independent predictor of disease-specific survival.Although Korean patients with chromophobe RCC had a better survival probability than patients with conventional RCC, the histologic type was not an independent predictor of survival probability. In addition, our findings suggest that chromophobe RCC has a better survival probability than conventional RCC in patients with Fuhrman's grade 3 to 4 or with a tumor diameter4.0 cm.

Most newly diagnosed kidney cancers present at localized stages. With appropriate treatments, the cancer-specific survival rates of such patients are extremely high, which makes patients' health-related quality of life (HRQoL) a relevant issue. To date, most of the available studies on HRQoL have been biased by the absence of baseline HRQoL assessments and by retrospective designs.To evaluate the baseline HRQoL of patients with kidney cancer, comparative HRQoL during the first year after surgery, and the prognostic factors predictive of HRQoL recovery.We prospectively collected the data of all patients undergoing surgery for kidney tumors at a tertiary academic referral center from February 2006 to September 2007.Patients underwent nephron-sparing surgery (NSS) or radical nephrectomy (RN).Patients were invited to self-complete the validated, Italian version of the RAND 36-Item Health Survey 1.0 (SF-36) before surgery, 6 mo after surgery, and 12 mo after surgery.Overall, 129 consecutive patients were evaluated. No significant differences were found between the baseline scores of our patients and age- and sex-matched normative data for the Italian general population. Comparing the baseline SF-36 scores to those at 6 mo and 12 mo, there was statistically significant worsening in the physical domains and improvement in the emotional domains (all p0.05). About 50-80% of patients returned to baseline scores 6 mo and 12 mo after surgery. Age, body mass index (BMI), educational level, occupational status, New York Heart Association (NYHA) functional class, tumor mode of presentation, pathologic stage, size, and histologic subtype were associated with 6-mo and 12-mo return to the baseline HRQoL scores. The main limitation of the study was the lack of a disease-specific questionnaire.Most patients returned to preoperative HRQoL within 12 mo after RN or NSS. Several patient features, clinical variables, and pathologic tumor variables predict the return of HRQoL.

In recent years molecular biologists and pathologists have described new entities of renal cell cancer (RCC) with a totally different morphology and biology among the histotypes of renal carcinoma, but always referring to the same renal cancer disease. The evidence of a distinct biological behavior and long-term prognosis among these makes the correct pathological diagnosis of renal cancer critically important for the clinician. Advances in understanding of the pathogenesis, behavior, and importance of prognostic factors for RCC have paved the way for a revision of its classification and staging. We reviewed the role of histological classification, microscopic tumor necrosis, microscopic venous invasion, lymph node involvement and, particularly, pathological stage. In our series of patients who underwent renal surgery for neoplasm, a retrospective study established the predictive role of tumor size on recurrence rate, compared with other known prognostic factors, and we conclude that histological grade, pathological stage and tumor size remain relevant prognosticators in early stage RCC patients. In order to optimize the management of patients with RCC it is necessary to develop an interdisciplinary approach (surgeon, radiologist, pathologist, oncologist) and find new prognostic parameters at molecular and cellular levels. Many efforts are ongoing to integrate molecular data (from tissue microarrays) and clinical data (traditional prognosticators) into a molecular integrated staging system. In the postgenomic era, new tumor-associated antigens and molecules can be identified at the protein level using proteomics, providing a major opportunity for screening and finding novel targets that are the basis of new emerging therapies for RCC.

Purpose We characterized CT findings of collecting duct carcinoma of the kidney and correlated these with the histopathologic findings. Materials and methods CT scans of 18 patients with pathologically proven collecting duct carcinoma of the kidney were retrospectively reviewed. We analyzed CT findings of collecting duct carcinoma and also correlated CT findings with the histopathologic findings. Results The mean size of the tumors was 6.9 cm and all cases were solid. Seventeen (94%) tumors had a medullary location. Nine (69%) and 11 (85%) cases showed weak and heterogeneous enhancement, respectively. A cystic component (50%) was frequently seen within the tumors. Lymphadenopathy and metastasis were noted in 10 (56%) and 6 (33%) cases, respectively. Perinephric stranding and vascular invasion were present in 10 (56%) and 5 (28%) cases, respectively. In 17 (94%) of the 18 cases, involvement of the renal sinus was present. Infiltrative growth (67%) and preservation of the renal contour (61%) were more common than expansile growth (33%) and exophytic configuration (39%), respectively. These CT features were well correlated with the histopathologic findings. Conclusion Medullary location, weak and heterogeneous enhancement, involvement of the renal sinus, infiltrative growth, preserved renal contour, and a cystic component are CT findings frequently seen in patients with collecting duct carcinoma of the kidney. CT findings are nevertheless nonspecific and do not allow collecting duct carcinoma to be easily differentiated from the other subtypes of renal cell carcinoma. However, when CT demonstrates a renal tumor with these findings, collecting duct carcinoma can be considered in the differential diagnosis.

Introduction Primary renal carcinoid tumor is a rare tumor of the kidney. Less than 40 cases of primary and metastatic renal carcinoids have been reported. There is a strong association of renal carcinoid tumors with horseshoe kidneys [1, 2]. The radiographic appearance is non-specific and overlaps that of renal cell carcinoma. Histopathologic differentiation between these two entities is essential because the treatment and prognosis are entirely different. We report a unique case of multifocal carcinoid tumor within a horseshoe kidney with metastases to the thyroid gland. It has been postulated that the renal carcinoid horseshoe subtype carried a more favorable prognosis; however, our case with multifocal involvement and distant metastases suggests the possibility for a more aggressive course.

Objective The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period. Methods From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery. Results Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was S$4,943 compared with S$4,479 for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (S$7,500 versus S$7,907). Conclusion The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.

Objective: Incidence of multifocality in Renal Cell Carcinoma (RCC) is estimated at between 5 and 25%. Multifocality has been largely studied because of the growing interest in conservative surgery which is a risk of local recurrence. The aim of this study is to evaluate the relationship between multifocality and other prognostic parameters and whether it is an independent prognostic factor. Material and methods: From 1980 to 1990, 255 patients (median age: 60.9 years) were treated by radical nephrectomy for pT1 to pT3b N0M0 RCC. The median follow-up time was 183 months. Multifocality was defined as the existence of at least one other tumoral localization, macroscopically and microscopically diagnosed as renal cell carcinoma, in the same kidney. Studied parameters were: age, sex, side, size, stage, Fuhrman's grade, capsular invasion, renal vein involvement and microvascular invasion. Survival was assessed with Kaplan–Meier and Cox models. Results: 37 cases of multifocal RCC were diagnosed (14.5%). There was only a significant correlation with stage ( p =0.002) and with capsular invasion ( p =0.002). No other factor was correlated with multifocality. It had no influence on the risk of metastatic progression, overall or specific survival. Conclusion: There is a significant correlation between capsular invasion and multifocality that has to be considered before proposing conservative surgery for a localized RCC. Multifocality has no influence on survival or metastatic progression in case of radical nephrectomy.

Summary Mesoblastic nephroma (MN) is a neoplasm originating from the kidney, which usually occurs during the first 6 months of life and mostly benign. In most cases, the total excision without postoperative adjuvant therapy can cure the disease completely. Rarely, however, the cellular variant may occur in adulthood and behave aggressively in contrast to the classical one. Owing to its highly rare metastasis to the lung, the chest physicians are not familiar with its clinical features and treatment modalities. We report a case of a 42-year-old woman with a metastatic lung mass of cellular MN along with a review of the literature.

Given recent epidemiological and practice trends, small kidney cancers are poised to become a focus of modern-day surgical care provided by urologists and urologic oncologists. For the past decade, partial nephrectomy has been viewed as preferable to radical nephrectomy for the treatment of many patients with early-stage kidney cancer, partly because observational studies suggest a survival benefit with nephron sparing. More recently, European Organisation for Research and Treatment of Cancer 30904--a phase 3 randomized control trial--demonstrated better survival for patients treated with radical vs. partial nephrectomy. Shortly thereafter, an instrumental variable analysis reported a survival advantage with partial nephrectomy. Although seemingly contradictory, these studies are potentially reconcilable when considering methodological differences and other empiric work.

Although kidney cancer incidence and nephrectomy rates have risen in tandem, clinical advances have generated new uncertainty regarding the optimal management of patients with small renal tumors, especially the elderly. To clarify existing practice patterns, we assessed contemporary trends in the incidence and management of patients with early-stage kidney cancer.Using Surveillance, Epidemiology, and End Results data, we identified adult patients diagnosed with T1aN0M0 kidney cancer from 2000 to 2010. We determined age-adjusted and age-specific incidence and management rates (i.e., nonoperative, ablation, partial nephrectomy [PN], and radical nephrectomy) per 100,000 adults and determined the average annual percent change (AAPC). Finally, we compared management groups using multinomial logistic regression accounting for patient characteristics, cancer information, and county-level measures for health.From 2000 to 2010, we identified 41,645 adults diagnosed with T1aN0M0 kidney cancer. Overall incidence increased from 3.7 to 7.0 per 100,000 adults (AAPC = 7.0%, P0.001). Over the study interval, rates of PN (AAPC = 13.1%, P0.001) increased substantially, becoming the most used treatment by 2010. Among the elderly, rates of nonoperative management and ablation approached nephrectomy rates for those aged 75 to 84 years and became the predominant strategy for patients older than 84 years. Adjusting for clinical, oncological, and environmental factors, older patients less frequently underwent PN and more often received ablative or nonoperative management (P0.001).As the incidence of early-stage kidney cancer rises, patients are increasingly treated with nonoperative and nephron-sparing strategies, especially among the most elderly. The broader array of treatment options suggests opportunities to better personalize kidney cancer care for seniors.

Objectives: Variability in survival after surgical treatment is observed in patients with renal cell carcinoma (RCC), thereby affirming the heterogeneity of the disease. The aim of our study was to provide a clinically relevant and detailed assessment of survival following surgical excision in patients with RCC of all stages according to age, stage, and grade. Materials and methods: A retrospective population-based analysis of 42,090 patients in the United States who were treated with partial nephrectomy (PN) or radical nephrectomy (RN) for RCC of all stages between the years 1988 and 2008 was performed. Competing-risks Poisson regression analyses focusing on cancer-specific mortality (CSM) or other-cause mortality (OCM) were executed. Stratification was performed according to age groups (≤59, 60-69, 70-79, and ≥80. y), the American Joint Committee on Cancer stage (I, II, III, and IV), and the Fuhrman grade (I-II and III-IV). Results: Increasing stage was associated with higher CSM rates (from 2%-9% to 54%-79% for stage I and IV), regardless of age. Similarly, high tumor grade was associated with higher CSM rates (from 2%-64% to 6%-79% for low and high grade). However, OCM was nonnegligible amongst persons aged 70 to 79 years (11%-24%) and ≥80 years (17%-44%), regardless of stage and grade. In subanalyses focusing on stage I RCC, CSM (3%-10%) rates were slightly higher for RN-treated patients, regardless of age and grade. However, in individuals aged 70 to 79 years with high-grade RCC, OCM rates were slightly higher for PN relative to RN (25.5% vs. 23.5%). In those aged ≥80 years, OCM rates were higher for PN compared with RN, both for low-grade (39.4% vs. 32.7%) and high-grade disease (52.0% vs. 42.8%). Conclusions: Tumor grade and American Joint Committee on Cancer stage represent important prognostic factors for the prediction of CSM, despite adjustment for patient age. However, OCM rates were nonnegligible in elderly individuals (≥70. y) with low-grade and stage I to III RCC. © 2014.

Five cases in which computed tomography (CT) detected a hypernephroma that had been missed by one or more of the other imaging modalities are reported here. Computed tomography may have an important role in the diagnosis of radiologically occult hypernephroma.

Aim: Renal medullary carcinoma (RMC) is a rare, highly aggressive renal neoplasm. In absence of prospective trials, a systematic review of RMC publications was performed in order to characterize clinical features and treatment. Methods: We found 68 articles on RMC in Pubmed from 1987 to January 2014 (key words “Carcinoma, renal cell” OR “kidney neoplasm” AND “medullary”). Results: 123/135 cases were analysed (12 missing data). Median age was 21.9y (10-69). Male/female ratio was 2:1. Afro-Americans represented 83% of pts, Caucasians, Arabs / Brazilians were 8.7% and 2.6% respectively. Cases related to sickle cell trait accounted 89% while homozygous form and hemoglobinopathy free status were 8% and 3% respectively. Common initial symptoms were hematuria (49%), flank pain (55%) and weight loss (14%). Time from symptoms to diagnosis had a mean of 4.7 m. At diagnosis, only 2% had localized tumor while 98% were metastatic: secondary lymph node involvement (62.5%), lung (48%), liver (33%), bone (32%), pleura (16%) and brain (16%). Right kidney was involved in 74% of cases. Survival data was available in 82 pts (66%). Ten pts (12%) were alive at the moment of publication. Median overall survival was 9 m (0-92). Patients with visceral metastasis (96%) had the worst mean survival (6.3m) while pts with isolated-lymph-node involvement (12%) showed better outcome (OS = 14m). No responses were detected with immunotherapy (OS = 3m). Best outcomes were displayed with chemotherapy combination regimens based on platinum derivatives, gemcitabine, paclitaxel (n = 9) or based on MVAC (n = 14), with median survivals of 10 and 15 months respectively. High-dose chemotherapy followed by autologous stem cell transplantation seems useful but not sufficiently explored (n = 1, OS = 22m). Anecdotal cases of targeted therapy included: Bortezomib (n = 2, OS= 27 m and 6 m), Thalidomide (n = 2, OS = 52 m and 2 m), Sunitinib (n = 10, OS = 2 m), Imatinib (n = 1, OS = 1m). Loss of immunoexpression and gene inactivation of SMARCB1/INI were the only molecular alterations constantly found (n = 28/28). Conclusions: RMC, a rare subtype of renal cell carcinoma with poor outcome, mainly affects a particular population of young afro-Americans with hemoglobinopathy. Better biological understanding and molecular characterization of RMC will facilitate improving the treatment and survival of these patients. Disclosure: All authors have declared no conflicts of interest.