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Background: The CARMENA trial in patients with metastatic renal cell carcinoma (mRCC) demonstrated that treatment with sunitinib alone was noninferior to cytoreductive nephrectomy (CN) followed by sunitinib (nephrectomy⬜sunitinib)., Objective: The objective of this study was to provide updated overall survival (OS) outcomes of CARMENA and assess whether some subgroups may still benefit from upfront CN., Design, Setting, and Participants: CARMENA was a phase III trial in 450 patients with mRCC enrolled from 2009 to 2017., Intervention: Patients in the intention-to-treat population received nephrectomy⬜sunitinib (standard of care [SOC]; n = 226) or sunitinib alone (n = 224)., Outcome Measurements and Statistical Analysis: Primary endpoint was OS, assessed using an updated data cut-off (October 2018; median OS event-free follow-up, 36.6 mo). Patients were reclassified by risk using International Metastatic RCC Database Consortium (IMDC) criteria., Results and Limitations: Sunitinib alone was noninferior to nephrectomy⬜sunitinib (hazard ratio [HR], 0.97; 95% confidence interval, 0.79⬜1.19; p = 0.8) and demonstrated longer median OS (19.8 mo vs 15.6 mo, respectively). For patients with two or more IMDC risk factors, OS was significantly longer with sunitinib alone than with nephrectomy⬜sunitinib (31.2 mo vs 17.6 mo, respectively; HR, 0.65; p = 0.03). For patients with one IMDC risk factor, OS was longer for nephrectomy⬜sunitinib versus sunitinib alone although not significantly (31.4 mo vs 25.2 mo; HR, 1.30; p = 0.2). The post hoc nature of the subgroup analyses may limit their interpretation., Conclusions: Sunitinib alone was noninferior compared with nephrectomy⬜sunitinib, suggesting that CN should not be considered SOC in patients with mRCC requiring systemic treatment. Certain subgroups, including patients with one IMDC risk factor, may still benefit from upfront CN., Patient Summary: We assessed the survival of patients with metastatic kidney cancer in a clinical trial. Patients treated with sunitinib on its own had the same survival as patients who had surgery before sunitinib treatment. We conclude that surgery may not be necessary for some patients with metastatic kidney cancer., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: To report the outcomes and feasibility of active surveillance (AS) of biopsy-proven renal oncocytomas., Methods: Multicentric retrospective study (2010-2016) in 6 academic centers that included patients with biopsy-proven renal oncocytomas who were allocated to AS (imperative or elective indication) with a follow-up ≥1 year. Imaging was performed at least once a year, by CT-scan or ultrasound or MRI. Conversion to active treatment (surgical excision or ablative treatment) was at the discretion of the urologist. The primary endpoint was renal tumor growth (cm/year). Secondary outcomes included accuracy of biopsy, incidence, and reason to change AS to active treatment., Results: Eighty-nine patients were included: Median age 67 years (26-89) and median tumor size 26 mm [15-90] on diagnosis. During a mean follow-up of 43 months'' (median 36 [12-180]), mean tumor growth was 0.24 cm/year. No predictive factors (demographical, radiological or histologic) of tumor growth could be identified. Conversion from AS to active treatment occurred in 24 patients (27%) (13 surgical excisions, 11 ablative procedures), in a median time of 45 (12-76) months'' after diagnosis. Tumor growth was the main indication to convert AS to active treatment (58%) with 8% of the patients opting to discontinue AS. No patient had metastatic progression nor disease-specific death. The correlation between biopsy and surgical specimen was 92%., Conclusion: Active surveillance for biopsy-proven renal oncocytomas was oncologically safe and patient adherence was high. No predictive factor for tumor growth could be identified but the tumor growth rate was low, and biopsy efficacy was high., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To evaluate the long-term oncological and functional results of the ablative treatment of T1a kidney malignancies by percutaneous radiofrequency (RF)., Materials and Methods: Monocentric retrospective study including all patients treated for renal cell carcinoma (RCC) T1a by radiofrequency, in our center, from 2005 to 2009. All patients had a tumor biopsy before treatment. The primary endpoint was local recurrence. A total of 44 RCCs in 41 consecutive patients were treated (1 patient had 3 synchronous tumors and 1 patient had 2 tumors). There were 26 clear cell RCCs, 13 papillary RCCs and 5 chromophobe RCCs. The median age at diagnosis was 70 years [48-82]. The median American Society of Anesthesiologists (ASA) score was 2 [1-3] and the median glomerular filtration rate (GFR) was 64mL/min [26-109]. Furhman grade was defined for 39 tumors (Clear cell RCC and papillary RCC), of which 82% were grade 1-2. The median tumor size was 20mm [11-40], and the median RENAL score was 4 [4-6]. Complications were assessed according to the Clavien-Dindo classification. Overall survival, recurrence-free survival and metastasis-free survival were calculated using the Kaplan-Meier method., Results: Median follow-up was 90.5 months [17.8-145.3]. Three (7%) local recurrences were reported within a median of 26 months [12-93]. All were treated by a 2nd RF. The overall 10-year survival was 70% (95% CI [56-85]). The 10-year recurrence-free survival was 72% (95% CI [57-88]). The 10-year metastasis-free survival was 87% (95% CI [74-97]). The median GFR on the date of the last news was 51mL/min [16-98] (P=0.05). Post-RFA complications consisted in 5 (11.3%) Clavien-Dindo 1-2 complications. No high grade (Clavien ≥3)., Conclusion: Percutaneous radiofrequency for RCC T1a is an alternative. It appears to be safe with low morbidity, satisfaying long-term oncological and functional results, but a risk of reprocessing of 7%., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: We evaluated the feasibility and outcomes of immediate preoperative renal artery embolization (IPRAE) before complex nephrectomy for locally advanced RCC ± inferior vena cava thrombus (IVCT)., Methods: A comparative retrospective (2007-2017) multicenter study which included 145 patients with locally advanced RCC ± IVCT: 99 radical nephrectomies vs. 46 radical nephrectomies with IPRAE identified in the prospective UroCCR national database (CNIL DR 2013-206; NCT03293563). IPRAE was performed under local anesthesia the day of nephrectomy (< 4 h prior to nephrectomy). The primary endpoint was peroperative blood loss (mL). Secondary outcomes were: tolerance of embolization (pain visual scale), success rate of IPRAE defined by complete devascularization of the kidney, perioperative complications according to Clavien score and postoperative GFR., Results: The baseline characteristics of IPRAE and the control groups were similar. Tumor staging was 14% T2b, 41% T3a, 27% T3b, 13% T3c, 6% T4. The success rate of IPRAE was 98%. Median artery embolizated per patient was 2 (Agochukwu and Shuch in World J Urol 32:581-589, 2014; Marshall et al. in J Urol 139:1166-1172, 1988; Yap et al. in BJU Int 110:1283-1288, 2012;Gill et al. in J Urol. 194:929-938, 2015; Wang et al. in Eur Urol 69:1112-1119, 2016). No severe complications occurred after IPRAE. Postembolization syndrome was reported in 7% (Clavien I-II). Mean peroperative blood losses in the IPRAE and control groups were: 726 ± 118 ml and 1083 ± 114 ml (P = 0.03). In a multivariate analysis that included: age, Karnofsky index, IPRAE (yes vs. no), IVCT (yes vs. no), tumor size and synchronous metastasis, no IPRAE and IVCT were significantly associated with increased peroperative bleeding., Conclusion: IPRAE before nephrectomy for locally advanced and/or IVCT tumors was well tolerated, was associated with lower peroperative bleeding and did not increase the incidence or severity of postoperative complications.

Introduction: Oncocytomas are primitive kidney tumours, considered benign but their evolution is not fully established. The local progression is generally admitted but few data explain what makes a oncocytoma to grow more or less quickly. The objective of our study is to analyse the evolution of followed renal oncocytomas after histologic confirmation and to identify factors that can influence their growth., Material and Methods: This is a retrospective study in two centers (North Hospital and Hospital of the Conception of Marseille). All patients with renal oncocytoma diagnosed with percutaneous biopsy from September 2010 to April 2016 and followed for more than one year were included. Epidemiological, histological, and morphological data were collected at diagnosis, during follow-up and in case of strategy change (intervention). Statistical analysis of factors influencing oncocytomes growth was based on the Pearson correlation test., Results: Fifty-three patients were included. The median age for diagnosis was 65 years [39-85]. The sex ratio H/F was 6/5. The median follow-up was 34 months [12-180]. The average diagnosis size was 29 mm [12-90]. Thirteen patients (25%) were treated secondarily, including 70% by conservative treatment. The average growth was 0.25 (±0.23) cm/yr. The patients treated were younger and had a higher growth rate than the untreated (0.48±0.23cm/yr versus 0.18±0.18cm/yr, P<0,001). According to Pearson's analysis, there was a positive linear relationship (R=0.27, P=0.047) between velocity and initial size and a negative linear relationship (ρ=-0.44, P<0.001) between velocity and age at diagnosis. So tumor growth was faster if the patients were young and the tumor voluminous at diagnosis., Discussion: Rapid growth often leads to a cessation of surveillance in favour of an intervention strategy. For young patients, conservative treatment (partiel nephrectomy or ablative treatment) in the medium term is likely to be preferred, but for elderly patients or with important comorbidities follow-up is an alternative to an invasive attitude., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN)., Materials and Methods: A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively., Results: A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73)., Conclusion: IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Urinary tract infection (UTI) is a common complication after flexible ureteroscopy (fURS) despite technical precautions to avoid infectious complications. The aim was to investigate incidence and predictive risk factors of UTI following fURS procedure., Patients and Methods: We conducted a retrospective study including consecutive fURS performed in our center from January 2015 to March 2019. The indications were: nephrolithiasis management and diagnosis and conservative treatment of upper urinary tract urothelial carcinomas (UTUC). Since 2015, we had technical precautions to avoid postoperative infectious complications: centralized collection of preoperative urine cultures which are examined daily by an urologist and a service provider, systematic use of ureteral access sheath and application of standardized antibiotic prophylaxis measures. The primary endpoint was occurrence of UTI within 15 days following fURS., Results: Six hundred and four fURS were included for nephrolithiasis (n = 462) and UTUC management (n = 142). The median (IQR) age in the study cohort was 61(48-68) years, 268 female patients were included (44.4%), the median (IQR) Charlson score was 2(1-4) and single-use fURS were used in 186 cases (30.8%). Postoperative UTI occurred in 41 cases (6.7%). In multivariate analysis, female gender (OR 2.20 [1.02-5.02], p = 0.04), UTI within the last 6 months (OR 2.34 [1.12-5.11], p = 0.02), preoperative polymicrobial urine culture (OR 4.53 [1.99-10.56], p < 0.001) and increased operative time (OR 1.02 [1.002-1.031], p = 0.02) remain associated with postoperative UTI., Conclusions: In a large cohort study, female gender, prior UTI, increased operative time and preoperative polymicrobial urine culture were associated with the occurrence of postoperative UTI. Limiting operative time and improving our knowledge of polymicrobial urine cultures could reduce the infectious risk.

Introduction and Objective: Definitive inclusion of renal mass biopsy (RMB) in small renal mass (SRM) diagnostic algorithm remains controversial. We assessed incidence and accuracy of RMB in SRMs in the CROES Renal Mass registry and the influence of preoperative RMB on perioperative complications after SRM nephron-sparing surgery (NSS). Materials and Methods: " ad hoc " description of incidence of preoperative RMB and characteristics of SRM cases with and without RMB. Accuracy of RMB was calculated in the SRM subcohort that received extirpative treatment and complication rate after NSS compared to between the two groups. Continuous variables were compared using t -test; categorical variables were compared using the chi-square test. K-statistics was used to analyze agreement between the biopsy histology and surgical pathology. Logistic regression was used to assess the association between RMB and NSS complications. All tests were two sided, and p -values <0.05 were considered statistically significant. Results: The rate of preoperative RMB in SRMs was 11.6% (175/1597) in Europe and the United States. RMB patients were more likely to have hypertension ( p  < 0.04), be on dialysis ( p  < 0.024), or smokers ( p  = 0.005), with multiple/bilateral tumors (0.008 and 0.010) and previous other malignancy ( p  = 0.021). They underwent radical nephrectomy more frequently than non-RMB group ( p  = 0.034). RMB was nondiagnostic in 16 cases (9%). Accuracy of RMB in distinguishing malignant from benign was 89.5%. Agreement between biopsy and final surgical pathology was 93% for malignant vs benign tumors (kappa = 0.655). Upstaging to pT3a occurred more frequently in the RMB group (12.6% vs 6.25% [ p  = 0.022]). Complication rate in renal mass-NSS subcohort was 15.8%, not statistically different between RMB and non-RMB groups. On logistic regression analysis, RMB was not associated with increased risk of postoperative complication after NSS (OR: 0.9, 95% CI: 0.43-1.89). Conclusion: The practice of RMB in SRM is still scarce despite high accuracy and concordance with final pathology. RMB does not seem to increase complication rate after NSS.

Background: Cytoreductive nephrectomy has been the standard of care in metastatic renal-cell carcinoma for 20 years, supported by randomized trials and large, retrospective studies. However, the efficacy of targeted therapies has challenged this standard. We assessed the role of nephrectomy in patients with metastatic renal-cell carcinoma who were receiving targeted therapies., Methods: In this phase 3 trial, we randomly assigned, in a 1:1 ratio, patients with confirmed metastatic clear-cell renal-cell carcinoma at presentation who were suitable candidates for nephrectomy to undergo nephrectomy and then receive sunitinib (standard therapy) or to receive sunitinib alone. Randomization was stratified according to prognostic risk (intermediate or poor) in the Memorial Sloan Kettering Cancer Center prognostic model. Patients received sunitinib at a dose of 50 mg daily in cycles of 28 days on and 14 days off every 6 weeks. The primary end point was overall survival., Results: A total of 450 patients were enrolled from September 2009 to September 2017. At this planned interim analysis, the median follow-up was 50.9 months, with 326 deaths observed. The results in the sunitinib-alone group were noninferior to those in the nephrectomy-sunitinib group with regard to overall survival (stratified hazard ratio for death, 0.89; 95% confidence interval, 0.71 to 1.10; upper boundary of the 95% confidence interval for noninferiority, ≤1.20). The median overall survival was 18.4 months in the sunitinib-alone group and 13.9 months in the nephrectomy-sunitinib group. No significant differences in response rate or progression-free survival were observed. Adverse events were as anticipated in each group., Conclusions: Sunitinib alone was not inferior to nephrectomy followed by sunitinib in patients with metastatic renal-cell carcinoma who were classified as having intermediate-risk or poor-risk disease. (Funded by Assistance Publique-Hôpitaux de Paris and others; CARMENA ClinicalTrials.gov number, NCT00930033 .).

Background: The neutrophil-lymphocyte ratio (NLR) is a biological marker of inflammation with a significant prognostic value in the field of oncology., Aim: In this review, we discuss the prognostic value of the NLR in renal cell carcinoma (RCC)., Material and Method: We conducted a literature review of the PubMed database in August 2016. Initial research identified 31 publications. Following full-text screening, 15 studies were finally included: 7 studies concerning metastatic or locally advanced renal cancer, 6 studies dealing with localized renal cancer, 2 articles evaluating the NLR in renal cancer whatever the status of the disease (metastatic or localized)., Results: For localized RCC, an NLR o 3 was predictive of a reduced risk of recurrence (hazard ratio ¼ 1.63 [1.15, 2.29]). The prognostic value of the NLR was stronger for metastatic or locally advanced RCC. An NLR o 3 predicted increased overall survival (hazard ratio ¼ 1.55 [1.36, 1.76]), progression-free survivals (hazard ratio ¼ 3.19 [2.23, 4.57]), and a response to systemic treatment., Conclusion: In current practice, the NLR is a simple and inexpensive prognostic factor with potential improvement in the prognostic performance of nomograms used in renal oncology., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Results of the conservative treatment of renal cell carcinomas arising in functional renal transplants are unknown compared to transplant nephrectomy. Only small series or case reports have been reported., Methods: Data were collected from 32 transplantation centers nationwide on cases of de novo tumors in functional renal transplants presumed to be malignant between January 1988 and December 2013., Results: Among 116 de novo transplant tumors, 62 were treated conservatively including: 48 by partial nephrectomy (PN) and 14 by thermal ablation (TA). These patients were compared to 30 other patients who were treated by transplant nephrectomy. The median age of the transplanted kidneys at the time of diagnosis was 43.5 years old as calculated from the donor's age. Tumors treated by transplant nephrectomy presented more often with symptoms (pain, fever, impaired condition, hematuria) than tumors treated conservatively (P = .019). After PN, final histology showed 27 (47.5%) papillary carcinomas, 19 (32.2%) clear cell carcinomas, 1 mixed carcinoma, and 2 oncocytomas. The median tumor size treated by PN was 24 mm with no difference in comparison to the TA group. Nine patients treated by PN had postoperative complications (21%), including 4 requiring operative intervention (Clavien IIIb). None of the patients treated by TA had complications. Specific survival was 100% at the time of last follow-up (median time after treatment 37 months) for patients treated by PN or TA., Conclusion: PN proved to be efficient in the treatment of small tumors of transplanted kidneys with good long-term functional and oncologic outcomes, including avoiding return to dialysis. TA seems to be an alternative therapy with good results in selected patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The role of cytoreductive nephrectomy (CN) in the treatment of patients harboring metastatic renal cell carcinoma (mRCC) has become controversial since the emergence of effective targeted therapies. The aim of our study was to compare the overall survival (OS) between CN and non-CN groups of patients presenting with mRCC in the era of targeted drugs and to assess these outcomes among the different Memorial Sloan-Kettering Cancer Center (MSKCC) and The Eastern Cooperative Oncology Group (ECOG) performance status subgroups., Methods and Materials: A total of 351 patients with mRCC at diagnosis recruited from 18 tertiary care centers who had been treated with systemic treatment were included in this retrospective study. OS was assessed by the Kaplan-Meier method according to the completion of a CN. The population was subsequently stratified according to MSKCC and ECOG prognostic groups., Results: Median OS in the entire cohort was 37.1 months. Median OS was significantly improved for patients who underwent CN (16.4 vs. 38.1 months, P<0.001). However, subgroup analysis demonstrated that OS improvement after CN was only significant among the patients with an ECOG score of 0 to 1 (16.7 vs. 43.3 months, P = 0.03) and the group of patients with good and intermediate MSKCC score (16.8 vs. 42.4 months, P = 0.02). On the contrary, this benefit was not significant for the patients with an ECOG score of 2 to 3 (8.0 vs. 12.6 months, P = 0.8) or the group with poor MSKCC score (5.2 vs. 5.2, P = 0.9)., Conclusions: CN improves OS in patients with mRCC. However, this effect does not seem to be significant for the patients in ECOG performance status groups of 2 to 3 or poor MSKCC prognostic group., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To assess the influence of vascular clamping and ischemia time on long-term post-operative renal function following partial nephrectomy (PN) for cancer in a solitary kidney., Patients and Methods: This is a retrospective study including 259 patients managed by PN between 1979 and 2010 in 13 centers. Clamping use, technique choice (pedicular or parenchymal clamping), ischemia time, and peri-operative data were collected. Pre-operative and last follow-up glomerular filtration rates were compared. A multivariate analysis using a Cox model was performed to assess the impact of ischemia on post-operative chronic renal failure risk., Results: Mean tumor size was 4.0±2.3cm and mean pre-operative glomerular filtration rate was 60.8±18.9mL/min. One hundred and six patients were managed with warm ischemia (40.9%) and 53 patients with cold ischemia (20.5%). Thirty patients (11.6%) have had a chronic kidney disease. In multivariate analysis, neither vascular clamping (P=0.44) nor warm ischemia time (P=0.1) were associated with a pejorative evolution of renal function. Pre-operative glomerular filtration rate (P<0.0001) and blood loss volume (P=0.02) were significant independent predictive factors of long-term renal failure., Conclusion: Renal function following PN in a solitary kidney seems to depend on non-reversible factors such as pre-operative glomerular filtration rate. Our findings minimize the role of vascular clamping and ischemia time, which were not significantly associated with chronic renal failure risk in our study., Level of Evidence: 5., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Juxtaglomerular cell tumors are rare and benign tumors, occurring in young patients. The standard treatment is partial nephrectomy. We report the case of a young 22-year-old patient with a renin-secreting tumor diagnosed during an exploration of severe hypertension associated with hypokalemia that we treated by radiofrequency ablation., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objective: To describe survival data and prognostic factors in a population of renal cell carcinoma with sarcomatoid renal carcinoma., Patients and Methods: We reviewed the files of 950 patients treated for malignant renal tumor in two centers between January 2002 and December 2011. Patients with sarcomatoid renal cell carcinoma were extracted. Demographic data, treatments, histopathological and survival data as well as prognostic factors were analyzed., Results: Twenty-three patients (2.4%) with 65% of men were included with a mean age of 62.8 years (41; 82). Median ECOG PS was 1 (0; 3) and median Karnofsky PS was 80% (40-100). Median tumor size was 100mm (30; 190). Eight patients (35%) were metastatic at diagnosis. An initial surgical treatment was performed in 22 patients (95.7%). Tumors were clear cell carcinoma in 19 cases (82.6%). TNM tumor stage was greater than 2 in 81.8% of cases. Median rate of sarcomatoid component was 50% (10; 100). In univariate analysis, the existence of initial metastasis and microvascular invasion were predictors of specific survival. In multivariable analysis, the only predictor was the initial existence of metastasis. A progression was observed in metastatic mode in 78% of patients within a median of 7 months. The median disease-specific survival was 18 months., Conclusion: Sarcomatoid renal cell carcinomas were aggressive tumors with a median progression-free survival of 7 months and a median disease-specific survival of 18 months. Prognostic factors were comparable to high-risk renal cell carcinomas., Level of Evidence: 5., (Copyright © 2013. Published by Elsevier Masson SAS.)

Purpose: To assess the risk factors of metastasis relapse in pT2-3 upper tract urothelial carcinomas (UTUCs) treated by radical nephroureterectomy (RNU) without lymphadenectomy (LN)., Methods: A multicentric retrospective study was performed for pT2-3 pNx UTUCs treated by RNU between 1995 and 2010. The following criteria were retrieved: age, gender, American Society of Anaesthesiologists physical status, surgical approach, preoperative hydronephrosis, stage, grade, tumor location, surgical margin, lymphovascular invasion (LVI) status and outcomes. Metastasis-free survival (MFS) was measured by Kaplan-Meier method with the log-rank test., Results: Overall, 151 patients were included. The median follow-up was 18.5 months (IQR 9.5-37.9). The 2- and 5-year MFS were 69 % ± 4.5 and 54.1 % ± 5.8, respectively. In univariate analysis, ureteral location, pT3 stage, positive LVI status and positive surgical margin were significantly associated with worse MFS (p = 0.03; 0.02; 0.01 and 0.006, respectively). In the multivariate analysis of ureteral location and pT3 stage were independent prognostic factors (p = 0.03 and 0.03, respectively). Based on the results of the univariate analysis, we proposed a risk model predicting MFS, which classifies patients into 3 categories with different overall survival (p < 0.001)., Conclusion: In view of our data, tumor location, T stage, LVI and surgical margin status are mandatory to predict survival in case of RN without LN. Contingent upon external validation, our risk model based on these variables could be useful to provide relevant information concerning metastasis relapse probability and necessity of close follow-up for these patients.

Objective: Partial Nephrectomy (PN) in a solitary kidney is at risk of chronic kidney disease (CKD) stage V and/or haemodialysis (HD). Our objective was to determine predictive factors of CKD stage V in this population., Material & Methods: Data from 300 patients were retrospectively collected from 16 tertiary centres. Clinical and operative parameters, tumor characteristics and renal function before surgery were analyzed. Patients with and without CKD stage V (defined as MDRD<1 5 ml/min) were compared using χ2 and Student-t tests for qualitative and quantitative variables, respectively. Predictive factors of CKD stage V were evaluated with a multivariable analysis using a Cox regression model., Results: Median age and BMI were 63 years old and 26 kg/m², respectively. Most of the patients (65%) were male with an anatomic solitary kidney (88.3%). Median tumor size was 4 cm and 98% were malignant tumors. Median operative time, blood loss and clamping time were 180 min, 350 ml and 20 min respectively. Renal cooling was used in 19.3% and clamping of the pedicle was performed in 61.6%. Twenty five patients (8.5%) presented post operative CKD stage V at last follow-up and 18 underwent HD (6%) post-operatively because of acute renal insufficiency. There was no difference between CKD stage V and non CKD stage V patients concerning Charlson index, operative time (180 min vs 179 min, p = 0.39), blood loss (475 ml vs 350 ml, p = 0.51), use of renal cooling and type of clamping. Patients with CKD stage V were older (70 vs 63 years old, p = 0.005), had a lower baseline renal function (clearance MDRD 41 vs. 62 ml/min, p<0.0001) and an increased tumor size (p = 0.02). Complications occurred in 91 patients (30%) with 16% of minor (Clavien 1-2) and 14% of major (Clavien > 2) complications, respectively. In multivariable analysis, baseline MDRD, BMI, and the occurrence of a minor complication were independent predictive factors of post operative CKD stage V., Conclusion: PN in a solitary kidney is at risk of post-operative CKD stage V and HD. Pre-operative altered renal function and post operative complications are the main predictive factors of permanent CKD stage V., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: The objective was to perform a systematic review of literature concerning epidemiology, clinical and biological data, prognosis and therapy of sarcomatoid renal cell carcinomas., Material and Methods: Data on sarcomatoid renal cell carcinomas have been sought by querying the server Medline with MeSH terms following or combination of them: "renal carcinoma", "renal cell carcinoma," "renal cancer", "sarcomatoid" "sarcomatoid transformation" and "sarcomatoid differentiation." The articles obtained were selected according to their methodology, the language in English or French, the relevance and the date of publication. Twenty papers were selected., Results: According to the literature, a sarcomatoid contingent can be observed in all subtypes of renal cell carcinomas, with a frequency of 1 to 15% of cases. The median age at diagnosis was 60 years with a majority of symptomatic patients (90%), mainly with abdominal pain and hematuria. These tumors were often found in patients with locally advanced or metastatic (45-77%). The imaging was not specific for the diagnosis and biopsy had a low sensitivity for identifying a sarcomatoid contingent. The treatment was based on a combination of maximal surgical resection whenever possible and systemic therapy for metastastic disease. Pathological data often showed large tumors, Furhman 4 grades, combined biphasic carcinomatous contingent (clear cell carcinoma in most cases) and sarcomatoid. Genetically, there was no specific abnormality but a complex association of chromosomal additions and deletions. The prognosis was pejorative with a specific median survival of 5 to 19 months without any impact of the sarcomatoid contingent rate., Conclusion: Sarcomatoid renal cell carcinoma is a form not to ignore despite its rarity. Mainly symptomatic and discovered at an advanced stage, it has a poor prognosis, requiring multidisciplinary management quickly and correctly., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Purpose: To review existing literature and deduce guidelines for the management of renal disease in patients with tuberous sclerosis complex (TSC)., Patients: After review of literature, a core panel of five physicians wrote a draft that was evaluated by 14 reviewers who used a 9-level scale (1: total disagreement; 9: total agreement). The guidelines were then reformulated until each item received a median score superior or equal to 8., Results: Forty-eight to 80 % of TSC patients have significant renal involvement including angiomyolipomas (AMLs), cysts, malignant tumors and renal insufficiency. It is recommended to perform an abdominal ultrasound (and serum creatinine if abnormal ultrasound) when TSC is diagnosed. This work-up will be repeated every 3-5years if normal. Associated autosomal dominant polycystic kidney disease must be suspected in case of numerous and large cysts. After the age of 20, follow-up should use computed tomography (CT) or MRI that are more precise than ultrasound for the measurement of AMLs. Biopsy of a renal mass should be discussed in case of calcifications, necrosis or rapid growth. Females with TSC should undergo screening for pulmonary lymphangioleiomyomatosis by CT at the age of 18, and, if negative at the age of 30-40. Acute bleeding should be treated with percutaneous embolization. Asymptomatic angiomyolipomas with several risk factors (size>80mm, predominant vascular component, micro-aneurysms) should undergo prophylactic treatment, if possible using embolization. The role of mTOR inhibitors in the management of angiomyolipomas needs to be defined., Conclusion: Standardization of follow-up and treatment is necessary to improve the management of TSC renal involvement., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Despite great improvements in the management of metastatic clear cell renal carcinoma, complete responses with antiangiogenic therapies are infrequent and complete pathological responses remain anecdotal. We report the complete pathological response of a solitary bone metastasis from a clear cell renal carcinoma after sequential treatment with sunitinib and radiotherapy. In February 2009, a female patient was diagnosed with clear cell renal carcinoma of the left kidney, bearing only one metastatic site localized in the proximal extremity of the left tibia. Radical nephrectomy was performed at first. Thereafter, sunitinib was administered at standard dose level for four weeks followed by two weeks free at each cycle. The patient underwent palliative radiotherapy between the fifth and the sixth cycle. Due to stable status, a radical surgery of the left knee was then performed and pathological analysis concluded a complete response. This case highlights potential synergy between sunitinib and radiation therapy in clear cell renal carcinoma.

Incidence of small renal masses (SRM) T1a is increasing in every age group. In relation to their characteristics, treatments seem to become less invasive. This article summarizes data about Watchful Waiting. A literature review based on Pubmed and keywords "petites masses rénales", "small renal masses", "rein", "kidney", "tumeur", "tumor", "surveillance", "watchful waiting" was done. Fifty-eight english and french articles including cohort-following and meta-analysis were selected. Considering indolence and harmless of the SRM, watchful waiting is nowadays a valid therapeutic option: in most of the series is tumoral growing lower than 0.40cm per year, metastatic evolution approaches 1 to 2% (except in the Kouba et al. study with 5,7%) and disease-free survival is 100%. Nevertheless, this option seems to be appropriate after carefully selection of the patients (age, conciliance, comorbidities, imperative indications…) and the tumors (tumor size, localization, histology…). Watchful waiting is a promising alternative after selection of the SRM. Large-scale and long-term studies will precise the global cost and modalities of this therapeutic option., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: Angiomyolipoma is the most frequent benign renal solid tumor. Because of the lack of fat component on the CT scan, diagnosis of this tumor is hard and can require percutaneous biopsy of unknown renal tumor. The follow-up of the poor fat CT scan component AML (PFCT AML) is uncertain., Methods: Five hundred percutaneous renal biopsy under tomodenstitometry have been realised between 1998 and 2008. There was 41 PFCT AML on the 500 biopsy. By definition, a PFCT AML is an AML where the diagnosis is done on a percutaneous biopsy but where there was no fat component on the first CT scan. We studied and compared clinical, tomodensitometric and histologic parameters of these 41 patients (mean age: 56, 9±11.04; sexe rate M/F: 6/35) where renal AML was diagnosed on percutaneous renal biopsy but without fat component on CT scan. Average size was 26.44±14.68mm. We phone-called 16 patients for the long-term follow-up. Average follow-up was 41±28.3 months. For four patients on 16, initial diagnosis was done in front of local symptoms, for one of the 16 diagnosis was done in front of general symptoms, for one of the diagnosis was done during Bourneville tuberous sclerosis evolution and 10 of the 16 was done fortuitously., Results: After review of the initial CT scan, fat density was found on 24% of them. Ten percent was epithelioid angiomyolipoma. Four renal biopsy on 41 (10%) was epithelioid AML. No epithelioid AML had fat component after the second look of the CT scan. Among the 16 patients who were phone-called, three (19%) underwent a complication. Two had abdominal pain and was treated medically. Initial sizes were 26 and 30mm. Only one patient must be operated by radical nephrectomy for acute hemorrhage. Initial size was 45mm. No neoplasic degeneration was identified for those 16 patients., Conclusion: In our study, the PFCT AML rate was 8.2%. In 25% cases, CT scan read-through shown a fat component and could help for the diagnosis. PFCT AML evolution seems to be the same as a classic AML. Conservative treatment had a good covering because there was no death and no malignant evolution. However, we found 10% of epithelioid angiomyolipoma in which malignant risk is high. PFCT AML diagnosed on renal percutaneous biopsy of unknown renal tumor requires the same management than the classic AML., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objectives: To evaluate the results of partial nephrectomy (NP) for cancer in 60 patients selected by the biopsy of the tumor by analyzing the information, oncologic follow-up., Patients: It was a cohort study unicenter retrospective from 1994 to 2006. The biopsy was systematically done for patients who were candidates for elective NP. The criteria for elective indications NP tumors were less than 4cm, low grade Fuhrman (I and II). The tubulopapillary tumors (TBP) on biopsy were excluded from the elective indications. The parameters studied were the biopsy data, overall survival, disease-free survival., Results: The median age was 59 years (32-79 years) and 69% of tumor were fortuitous discovery. Indications of need accounted for 30% of cases (single kidney, bilateral tumors and chronic renal failure [CRF]). Biopsy allowed a diagnosis in 89% of cases. There was one death in specific postoperative immediately. A final histology was 75% of clear cell carcinoma, 13.3% of chromophobe and 11.7% of TBP, 96.6% of T1a including 86.6% of low grade and no surgical margin. The median follow-up was 49 months with 98.5% of specific survival at 5 years, one local recurrence and no general recurrence., Conclusion: The study has shown that the selection of patients by biopsy gives satisfactory carcinologic results with 98.5% specific survival at the end of follow-up; it is between 89 and 100% in the literature., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

The aim of this article is to make a synthesis of news headlines concerning the management of upper tract urinary carcinoma. For non muscle-invasive upper tract urinary tumors, ureteroscopy with biopsies is a part of the systematic diagnostic assessment in case of suspicious imaging. For muscle-invasive upper tract urinary tumors, there is low level of evidence of expert's opinion guidelines about neoadjuvant or adjuvant chemotherapy. These therapeutic strategies can be sometimes discussed, by arguing analogy with bladder tumors., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Purpose: Fuhrman grade represents a key determinant of the natural history of small renal masses that represent renal cell carcinoma. We tested whether renal mass biopsy prediction of Fuhrman grade in the nephrectomy specimen could be safely substituted for by an accurate statistical model. To date the best available model has shown poor accuracy (55.6%), which is close to flipping a coin (50%) and clearly inadequate for use in clinical practice., Materials and Methods: We identified 1,139 patients with T1aN0M0 renal cell carcinoma treated with partial or radical nephrectomy at 11 participating institutions from 1989 to 2004. This cohort was used in univariate and multivariate logistic regression models predicting high Fuhrman grade (III-IV) at nephrectomy. Predictors included age at diagnosis, gender, tumor size and symptom classification. Multivariate logistic regression coefficients were used to generate a nomogram., Results: The rate of Fuhrman grade III-IV in patients with T1aN0M0 renal cell carcinoma was 12.3%. Stratifying patients with Fuhrman grade III-IV by age, gender, histological subtypes and sample size failed to reveal statistically significant differences. On univariate analysis predicting Fuhrman grade III-IV at nephrectomy only tumor size was a statistically significant predictor (p = 0.05). The most accurate multivariate nomogram for Fuhrman grade III-IV prediction was 58.3% (95% CI 57.8-58.9) accurate. Of all tested predictors only tumor size achieved independent predictor status (p = 0.009)., Conclusions: Our analysis derived in European patients shows that statistical models cannot safely replace renal mass biopsy based prediction of Fuhrman grade III-IV at nephrectomy. Our findings corroborate a report from the United States in which a similar model had 55.6% accuracy. Jointly the studies indicate that statistical models are unreliable and cannot safely be substituted for renal mass biopsy in North American or European patients.

Purpose: Conditional survival implies that on average long-term cancer survivors have a better prognosis than do newly diagnosed individuals. We explored the effect of conditional survival in renal cell carcinoma., Materials and Methods: We studied 3,560 patients with renal cell carcinoma of all stages treated with nephrectomy. We applied conditional survival methodology to a previously reported posttreatment nomogram predicting survival after nephrectomy for patients with renal cell carcinoma stage I to IV. We used the same predictor variables that were integrated in the original multivariable Cox regression models, namely TNM stage, Fuhrman grade, tumor size and symptom classification. To validate the conditional survival nomogram we used an independent cohort of 3,560 patients from 15 institutions., Results: The 5-year survival of patients immediately after nephrectomy was 74.2%, which increased to 80.4%, 85.1%, 90.6% and 89.6% at 1, 2, 5 and 10 years after nephrectomy, respectively. The predicted probabilities varied by as much as 50% when, for example, predictions of renal cell carcinoma specific mortality at 10 years were made after nephrectomy vs 5 years later. Within the external validation cohort the accuracy of the conditional nomogram was 89.5%, 90.5%, 88.5% and 86.7% at 1, 2, 5 and 10 years after nephrectomy., Conclusions: We developed (2,530) and externally validated (3,560) a conditional nomogram for predicting renal cell carcinoma specific mortality that allows consideration of the length of survivorship. Our tool provides the most realistic prognosis estimates with high accuracy.

Antiangiogenic therapies are used for advanced clear-cell renal carcinomas (cRCC), but without curative possibilities, underlining the need for new therapeutic targets. Adrenomedullin (AM), a multifunctional peptide, is highly expressed in several tumors and plays an important role in angiogenesis and tumor growth through its receptors: calcitonin receptor-like receptor/receptor activity-modifying protein 2 and 3 (CLR/RAMP2 and CLR/RAMP3). In this study, real-time quantitative reverse-transcription-PCR showed AM mRNA levels were higher in cRCC and in chromophobe renal carcinomas (chRCC) than in normal renal tissue. Interestingly, AM mRNA expression in cRCC correlated strongly with VEGF-A mRNA expression. Immunohistochemically, AM, CLR and RAMP2 were localized in the carcinomatous epithelial compartment of cRCC. Interestingly, RAMP3 immunostaining was found only in the inflammatory cells that infiltrated tumors, suggesting a cross talk between tumor cells and the microenvironment. We also observed that cRCC cells BIZ and 786-O expressed and secreted AM into the culture medium. In vitro, exogenous AM treatment stimulated cell proliferation, migration and invasion, indicating the cell can respond to AM. The action of AM was specific and was mediated by the CLR/RAMP2 and CLR/RAMP3 receptors. Clinical data showed the prognostic value of AM. High AM mRNA levels were associated with an increased risk of relapse after curative nephrectomy for cRCC. These findings highlight the implication of the AM pathway in the metastatic process and the prognostic relevance of AM in cRCC and point to a potential new therapeutic target.

Renal epithelioid angiomyolipomas (ReAML) are rare tumors (identified in less than 0,1 per thousand in general population) and represent 8% of operated angiomolipomas (AML). The diagnostic is histological, with an epithelioid cell component among the typical AML cells. ReAML are tumors derived from perivascular epithelioid cells (PEComa). There are benign PEComas, potentially aggressive PEComas and malignant PEComas. Most malignant PEComas are ReAML. There are two ReAML clinical entities, sporadic or associated to Tuberous Sclerosis Complex (TSC). ReAML are unique, localized and sporadic solid tumors of the kidney of variable size that can be revealed as classical AML with local symptoms or a complication (hemorrhage). Revelation mode is mostly radiologic. ReAML are fat-poor on CT-scan. They can be misdiagnosed with renal cell carcinoma (RCC). (One third of ReAML are malignant with a locoregional, nodal or metastatic evolution that can lead to death. ReAML treatments are multimodal depending of histology, clinical-radiological entity, evolution and the patient. Partial nephrectomy or follow-up are the benign entity treatment. Radical nephrectomy eventually followed by doxorubicine or rapamycine treatments are recommended for potentially aggressive and malignant entities.

The most innovating studies presented at the 2008 international conferences in the field of kidney cancer were selected. In localized kidney cancer, contrast-enhanced ultrasonography could be a new diagnostic tool. Many communications dealed with positive surgical margins and their consequences, and predictive factors of chronic kidney disease after nephrectomy. Robot-assisted laparoscopic nephrectomy seems to be a safe and effective technique. Mini-invasive treatments are promising. In metastatic kidney cancer, sunitinib was compared to IFN-alpha in first line treatment and survival data are now available. Everolimus could become the new standard after tyrosine kinase inhibitor failure.

Objective: To quantify the survival disadvantage related to the presence of exclusive nodal metastases (eNM) in patients with otherwise non-metastatic (M0) renal cell carcinoma (RCC)., Patients and Methods: Data were retrieved from 12 institutional databases and yielded 3507 patients with T1-3N1-2M0 RCC treated with partial or radical nephrectomy. Cox regression analyses relied on T stage, Fuhrman grade and presence of eNM. Data were analysed using univariable, multivariable and stratified analyses., Results: Overall 165 (4.7%) patients had eNM; of 2023 patients of stage T1, 23 (1.1%) had eNM, vs 20 of 448 (4.5%) for T2 and 122 of 993 (12.3%) for T3. In univariable analyses the presence of eNM increased the rate of cancer specific mortality (CSM) by 7.1 times. After adjusting for T stage and Fuhrman grade, in all patients eNM increased the rate of CSM by 3.2 times. In stratified analyses adjusted for Fuhrman grade, the increase in CSM related to the presence of eNM was 28.9, 4.3 and 2.5 times (all P < 0.001) for stages T1, T2 and T3, respectively., Conclusions: From the prognostic perspective, staging lymphadenectomy appears of most value in patients with T1-2 RCC, but the low prevalence of eNM questions the practical applicability of nodal staging in those patients. Conversely, in patients with T3 RCC, the prevalence and the prognostic impact of eNM might make a staging lymphadenectomy worthwhile.

Objective: To identify, in a large multicentre series of incidental renal tumours, the key factors that could predict cancer-related deaths, as such tumours have a better outcome than symptomatic tumours and selected patients are increasingly being included in watchful-waiting protocols., Patients and Methods: Data from 3912 patients were extracted from three international kidney-cancer databases. Age, gender, Eastern Cooperative Oncology Group (ECOG) performance status (PS), Tumour-Node-Metastasis (TNM) stage, tumour size, Fuhrman grade, and final pathology were recorded. Benign tumours and malignant lesions with incomplete information were excluded from final analysis., Results: The mean (SD) age of the patients was 60.6 (12.2) years and the mean tumour size 5.5 (3.5) cm. Most tumours were malignant (90.2%) and of low stage (T1-T2, 71.7%) and low grade (G1-G2, 72.4%). There were nodal and distant metastases in 5.7% and 13% of the patients. In all, 525 (14.4%) patients died from cancer; in this group, tumours were >4 cm in 88.2% and had nodal or distant metastases in 20.2% and 49.3%, respectively. Multivariable analysis showed that tumour size >4 cm, ECOG PS >or=1, TNM stage and Fuhrman grade were independent predictors of cancer-related death., Conclusion: A significant proportion of incidental renal tumours can lead to the death of the patient. Standard prognostic variables for renal cell carcinoma appear to remain valid for this subset of patients. A watchful-waiting strategy should not be recommended if the tumour diameter is >4 cm, if biopsy confirms high-grade tumours, or if there is an impaired ECOG PS, or computed tomography findings suggest the presence of advanced T stage.

The most innovating studies presented at the 2007 international conferences in the field of kidney cancer were selected. The notable topics presented covered diagnostic biopsies and the growing place of conservative surgery and laparoscopy in kidney cancer management. For cases with poor prognosis, the new anti-angiogenic therapies were thoroughly evaluated.

Objectives: To compare cancer-specific mortality in patients with unclassified renal cell carcinoma (URCC) vs clear cell RCC (CRCC) after nephrectomy, as URCC is a rare but very aggressive histological subtype., Patients and Methods: Eighty-five patients with URCC and 4322 with CRCC were identified within 6530 patients treated with either radical or partial nephrectomy at 18 institutions. Of 85 patients with URCC, 55 were matched with 166 of 4322 for grade, tumour size, and Tumour, Node and Metastasis stages. Kaplan-Meier and life-table analyses were used to address RCC-specific survival. Subsequently, multivariate Cox regression analyses were used to test for differences in RCC-specific survival in unmatched samples., Results: Of patients with URCC, 80% had Fuhrman grades III or IV, vs 37.8% for CRCC. Moreover, 36.5% of patients with URCC had pathologically confirmed nodal metastases, vs 8.6% with CRCC. Finally, 54.1% of patients with URCC had distant metastases at the time of nephrectomy, vs 16.8% with CRCC. Despite these differences in the overall analyses, after matching for tumour characteristics, the URCC-specific mortality rate was 1.6 times higher (P = 0.04) in matched analyses and 1.7 times higher (P = 0.001) in multivariate analyses., Conclusions: These findings indicate that URCC presents with a higher stage and grade, and even after controlling for the stage and grade differences, predisposes patients to 1.6-1.7 times the mortality of CRCC.

Objectives: Collecting duct renal cell carcinoma (CDRCC) is a rare but reportedly aggressive histologic subtype. We assessed the stage and histologic features of patients with CDRCC and compared cancer-specific mortality in CDRCC and matched patients with clear-cell renal cell carcinoma (CRCC)., Methods: Forty-one (0.6%) patients with CDRCC and 5246 CRCC patients were identified within a cohort of 6608 patients treated with either radical or partial nephrectomy for renal cancer. Within the 5246 CRCC cases, 105 were matched with CDRCC cases for grade, tumour size, and T, N, and M stages. Kaplan-Meier and life table analyses addressed RCC-specific survival., Results: Of all CDRCC patients, 76% had pT3 disease at nephrectomy versus 37% for those with CRCC. The predominant Fuhrman grades were III (56%) and IV (22%) in CDRCC versus II (42%) and III (28%) for CRCC. Moreover, 49% of CDRCC patients were pN1-2 versus 8% for CRCC. Of CDRCC patients 19% had distant metastases at nephrectomy versus 14% for CRCC. Finally, 73% of CDRCC patients had either local or systemic symptoms versus 56% for CRCC. After matching, the RCC-specific mortality of CDRCC patients was no different from that for CRCC patients (RR=1.1; p=0.8). One- and 5-yr CDRCC-specific survival rates were 86% and 48%, respectively, versus 86% and 57% for matched CRCC controls., Conclusions: CDRCC patients present with more advanced stage and with more aggressive disease compared with CRCC patients. After nephrectomy, when CDRCC cases were matched with CRCC, the same cause-specific survival was seen.

The use of mTOR inhibitors started about 30 years ago following the discovery of rapamycin, a macrolide derived from a soilborne microorganism Streptomyces hygroscopicus that exerts antibiotic, immunosuppressive and antiproliferative properties. Initially intended to be used as an antibiotic, a more detailed understanding of the mechanism of action of this class of drugs has rationalized and validated its use in the field of transplantation and oncology. Many clinical trials on mTOR inhibitors have been conducted in these two fields, in which urologists are actively involved. This review summarizes the current knowledge on the mechanism of action and clinical applications of mTOR inhibitors in renal transplantation and oncology.

Objectives: To analyse the influence of age at diagnosis on tumour characteristics and cancer-specific survival in renal cell carcinoma (RCC)., Methods: Data on age, tumour characteristics, and survival for 4774 patients from 12 European RCC databases were recorded. Patients were divided into four groups according to age at diagnosis: < or =40, >40 and <60, > or =60 and <80, and > or =80 yr. The following variables were analysed: TNM stage, Fuhrman grade, tumour size, symptoms at diagnosis, ECOG performance status (PS), and cancer-specific survival. The groups were compared for usual clinical and pathologic variables, and cancer-specific survival., Results: The four groups accounted for 288 (6%), 1839 (38.5%), 2499 (52.3%), and 148 cases (3.2%), respectively. Differences were found among groups for tumour stage, symptoms at diagnosis, ECOG PS, Fuhrman grade (p<0.001), tumour size, M stage, and histologic subtype (p: 0.02). Patients < or =40 yr were more likely to have papillary or chromophobe RCCs and less likely to have clear-cell RCCs. No significant difference was found among groups for N stage (p: 0.15). The 5-yr cancer-specific survival rates for the four age categories were 85%, 74%, 70%, and 69%, respectively. In multivariate analysis age category remained an independent prognostic parameter (p<0.001)., Conclusions: Renal tumours diagnosed in younger age are characterized by lower tumour stages and grades as well as favourable histologic patterns compared with tumours in older patients. Basic research is required for explaining such a relationship between age, tumour aggressiveness, and therefore tumour biology.

Purpose: We tested the hypothesis that the prediction of renal cancer-specific survival can be improved if traditional predictor variables are used within a prognostic nomogram., Patients and Methods: Two cohorts of patients treated with either radical or partial nephrectomy for renal cortical tumors were used: one (n = 2,530) for nomogram development and for internal validation (200 bootstrap resamples), and a second (n = 1,422) for external validation. Cox proportional hazards regression analyses modeled the 2002 TNM stages, tumor size, Fuhrman grade, histologic subtype, local symptoms, age, and sex. The accuracy of the nomogram was compared with an established staging scheme., Results: Cancer-specific mortality was observed in 598 (23.6%) patients, whereas 200 (7.9%) died as a result of other causes. Follow-up ranged from 0.1 to 286 months (median, 38.8 months). External validation of the nomogram at 1, 2, 5, and 10 years after nephrectomy revealed predictive accuracy of 87.8%, 89.2%, 86.7%, and 88.8%, respectively. Conversely, the alternative staging scheme predicting at 2 and 5 years was less accurate, as evidenced by 86.1% (P = .006) and 83.9% (P = .02) estimates., Conclusion: The new nomogram is more contemporary, provides predictions that reach further in time and, compared with its alternative, which predicts at 2 and 5 years, generates 3.1% and 2.8% more accurate predictions, respectively.

This review was designed to determine whether patients with renal cell carcinoma (RCC) present an increased risk of developing a second cancer. Cancers statistically associated with RCC were determined by a review of epidemiological publications and the aetiological factors of these associations were then studied. The clinical implications of the results of this review are discussed at the end of this study. This review of the literature demonstrates an increased risk of bladder cancer and prostate cancer in patients with RCC, particularly in the case of the tubulopapillary subtype. The pathophysiology of these associations has not been clearly elucidated, but probably involves common genetic alterations. These epidemiological associations should be taken into account in the follow-up of patients with RCC.

Objective: Renal oncocytoma is a benign tumour that is usually diagnosed postoperatively. Its natural history is poorly defined. We studied the outcome of patients with renal oncocytoma diagnosed by percutaneous biopsy and not operated., Material: From January 1998 to April 2004, on a series of 148 renal tumour biopsies performed in our centre, 15 showed oncocytoma. The initial treatment was non-surgical. We report the follow-up of these patients and the course of these oncocytomas. The mean follow-up was 404 +/- 20.9 months., Results: The mean age of these patients at diagnosis was 57.6 +/- 14.4 years and the mean tumour diameter was 3.49 +/- 2.43 cm with a mean volume of 62.3 +/- 135.4 cm3. Six of these 15 patients were operated: 4 total nephrectomies and 2 partial nephrectomies. The indications for surgery were the initial tumour volume (n = 1), tumour growth > 0.5 cm/year (n = 4) and the patient's preference (n = 1). Operated patients were younger (45.5 +/- 11.1 years vs 65.6 +/- 10.3 years) and had larger tumours at diagnosis (50 +/- 30.1 mm vs 27.3 +/- 10.5 mm). All 9 patients treated by watchful waiting were asymptomatic., Conclusion: The natural history of oncocytomas appears to be a more or less rapid increase in size. Treatment can be conservative. The initial tumour volume or rapid tumour growth are indications for resection. Partial nephrectomy, when allowed by the size and site of the tumour is currently the technique of choice.

Due to its nonspecific clinical and radiological features, renal oncocytoma is usually diagnosed on the operative specimen. Histological confirmation of the diagnosis is based on the distinction between oncocytoma and renal cell carcinoma (RCC), which can be difficult. Description of cases in which RCC and oncocytoma are present in the same tumour and the hypothesis of a link between oncocytoma and RCC further complicate the diagnosis of this tumour by the urologist. The authors reviewed the management of tumours suspected to be oncocytoma based on a review of the international literature concerning the diagnosis, natural history and treatment of renal oncocytoma.

Objective: The reference treatment for filling defects of the upper urinary tract is nephroureterectomy with excision of a perimeatal bladder segment. The authors evaluated the role of endoscopy and laser in the management of filling defects of the upper urinary tract., Material and Methods: Filling defects of the upper urinary tract were evaluated by biopsies performed during ureteroscopy followed by 10 Watt Holmium-YAG laser vaporisation. High-grade or incompletely vaporised tumours or multifocal tumours or tumours more than 2 cm in diameter received complementary treatment. Low-grade and completely vaporised tumours were followed by ureteroscopy at 3 months and then every 6 months. The authors conducted a prospective study from March 2002 to September 2004. Fifteen consecutive patients were managed according to this protocol. The mean age was 70 years (range: 53 to 85 years). Thirty nine tumours were treated. The mean tumour diameter was 1.05 cm (range: 0.3 to 2.5 cm)., Results: In this series of 15 patients treated according to this protocol, 39 tumours were diagnosed and treated. The grade was determined by biopsy in 66% of cases. Seven patients have a median recurrence-free survival of 18 months (range: 12 to 34 months). Overall, conservative management was able to be performed in twelve patients, corresponding to a 22-month kidney preservation rate of 80%. Two patients died during follow-up, one from prostatic cancer and the other from invasive urothelial bladder tumour. One patient who had had recurrence ans had been re-treated was lost for report., Conclusion: Filling defects of the upper urinary tract can be investigated by ureteroscopy to obtain a histological diagnosis and to perform treatment by laser vaporisation. Complementary treatment is then performed depending on the histological results, either by complementary vaporisation or by nephroureterectomy. Laser treatment ensures a high kidney preservation rate but with a recurrence risk. Conservative endoscopic treatment, which is considered to be acceptable in cases of necessity, may also be useful in the context of small, unifocal, minimally invasive tumours with a normal contralateral kidney.

Objective: The purpose of this study was to demonstrate the prognostic value of subdivision of tubulopapillary tumours into 2 histological subtypes and to discuss the therapeutic implications., Materials and Methods: This was a single-centre retrospective study of 58 cases from a series of 414 patients operated for renal cancer between 1988 and 2001 based on review of histology slides (biopsies and operative specimens). The radiological assessment was based on ultrasound reports and review of CT scans. Karyotypes were described by cytogenetic analysis., Results and Discussion: Tubulopapillary tumours represented 14% of all kidney tumours with a male prevalence of 77% and a mean age of 56.5 years. The overall mean follow-up was 62.6 months. Treatment consisted of 25 right radical nephrectomies, 29 left radical nephrectomies and 4 partial nephrectomies. 84% of tumours were low-grade and 80% were low stage T1 or T2. Multifocal lesions were observed in 31% of cases. Synchronous bilateral lesions were observed in 12% of cases. The 5-year survival was 95% and the 10-year survival was 87%, correlated with stage, grade, tumour diameter, presence of necrosis and low enhancement. According to the data reported by Delahunt, 2 subtypes can be distinguished: Type I tumours (75%) with low grade and low stage were correlated with a high rate of multifocal lesions (30%) with a genetic predisposition. Type 2 tumours (25%), usually unifocal, were correlated with a higher grade and stage, confirmed by their poorer prognosis. Biopsy allows a distinction of the type and grade of the tumour., Conclusions: In our series, for equivalent mean tumour diameters (55 mm), tubulopapillary tumours treated by radical nephrectomy had a good prognosis regardless of their subtype. Classification of the tumour by biopsy prior to surgery could have implications for therapeutic management. For type 1 tubulopapillary tumours identified on preoperative biopsy, we propose radical nephrectomy due to the high risk of multifocal lesions (30%). Although partial nephrectomy may be indicated for type 1 tubulopapillary tumours less than 4 cm, the patient must be informed about the risk of recurrence and the importance of long-term follow-up. Studies including a larger number of patients must be conducted to compare the survival associated with type 2 tumours compared to that of the classical histological subtype.

Objectives: To evaluate the outcome of patients with oncocytoma of the kidney diagnosed in our center by percutaneous biopsy and treated with watchful waiting., Methods: From January 1998 to April 2004, of 148 solid renal tumors biopsied in our center, 15 were renal oncocytomas. The mean (+/- standard deviation) follow-up was 30 +/- 19.8 months. We report on the outcome of these patients., Results: The mean age at diagnosis was 57.6 +/- 14.4 years, and mean tumor size was 3.49 +/- 2.43 cm, corresponding to a mean tumor volume of 62.3 +/- 135.4 cm3. During follow-up, 6 of 15 patients needed surgery: two partial and four total nephrectomies. Indications for surgery were initial tumor burden, greater than 0.5 cm/yr tumor growth, and patient's preference in 1 case, 4 cases, and 1 case, respectively. The patients who received surgical treatment were significantly younger (45.5 +/- 11.1 years versus 65.6 +/- 10.3 years) and had more bulky tumors at diagnosis (50 +/- 30.1 mm versus 27.3 +/- 10.5 mm). In 1 patient, a chromophobic renal cell carcinoma was associated with the oncocytoma. All 9 patients who did not receive surgical treatment remained asymptomatic., Conclusions: The evolution of renal oncocytoma seems to be increase of tumor size with variable velocity. Treatment must be conservative. Initial management might be nonsurgical with close follow-up. Monitoring should not miss the time of conservative surgery. Initial tumor volume or fast tumor growth are indications for surgery. Partial nephrectomy, if the tumor size and localization are reasonable, is currently the technique of choice.

Renal oncocytoma is a benign tumour that can be associated with renal cell carcinoma in rare genetic syndromes. The authors report the case of a 62-year-old patient with no medical history, in whom assessment of low back pain in 1999 demonstrated a 40 mm tumour of the lower pole of the left kidney. Percutaneous needle biopsy of the tumour demonstrated oncocytoma confirmed by Hale's stain. Follow-up ultrasound demonstrated an increase in size (88 mm) and a nine-fold increase in volume over four years (210 cm3 in April 2003). Surgery was indicated in view of the rapid increase of the tumour volume. Histological examination of the operative specimen demonstrated a combination of oncocytoma and Fuhrman grade III renal cell carcinoma.

Background: The 10-year risk of developing a solid malignancy is 20% for kidney transplant recipients. The goal of the current study was to investigate the epidemiology and the diagnostic and prognostic parameters associated with de novo malignancies of the native kidney among transplant recipients at the authors' institution (Department of Urology and Renal Transplantation, Hôpital Salvator, Marseille, France)., Methods: The authors reexamined the follow-up of 933 consecutive transplant recipients at their institution between 1987 and 2003. Immunossupressive therapy was not modified in the event of malignant disease, nor was systematic radiologic monitoring of native kidneys performed. All de novo malignancies of the native kidney were included in the current analysis., Results: Among the 933 patients examined, a combined total of 12 malignancies of the native kidney were diagnosed in 11 individuals. For these 11 individuals, the average ages at transplantation and diagnosis were 42.5 and 49.1 years, respectively. Ten malignancies were discovered fortuitously, whereas two were symptomatic. Among the 10 renal echographies performed, there was 1 false-negative result. Tomodensitometry was performed in 11 cases and yielded no false-negative results. The average tumor size was 37 mm. Nephrectomy was performed in 10 cases, and biopsy was performed in 1. Among the 12 kidney malignancies encountered in the current study, there were 7 conventional cell carcinomas, 3 basophilic papillary carcinomas, and 2 chromophobic renal cell carcinomas. Half of all tumors were Furhman Grade 3 lesions, and pT1aN0M0 tumors (2003 TNM staging system) also accounted for half of all malignancies in the current cohort. Two affected transplant recipients died (one due to disease), and the remaining nine are alive without recurrence and with normal renal functioning (median follow-up, 39 months)., Conclusions: There appears to be an increased risk of malignancy of the native kidney in renal transplant recipients, with high-grade and papillary tumors being particularly common. Consequently, systematic radiologic follow-up of native kidneys must be performed for individuals who undergo kidney transplantation., ((c) 2004 American Cancer Society.)

Purpose: We evaluated the accuracy and clinical role of fine needle percutaneous biopsy of solid renal masses 4.0 cm or smaller with helical computerized tomography (CT) guidance., Materials and Methods: In 88 consecutive patients (mean age 61 years) 88 biopsies were performed. Median tumor size was 2.8 cm. Tumor biopsy was performed with an 18 gauge needle using helical CT guidance in an outpatient setting. At least 2 whole cores per tumor were obtained., Results: Biopsy material was insufficient for analysis in 3 (3.4%) procedures. Median tumor size of failed biopsies was 3.0 cm. There were 5 (5.6%) biopsies which revealed fibrosis and were considered inconclusive. A benign lesion was found in 14 (15.9%) biopsies. In the 66 biopsies positive for malignancy there were 65 cases of renal cell carcinoma and 1 lymphoma. A total of 62 patients underwent surgery. Biopsy changed tumor management in 42 (47.8%) patients who avoided radical nephrectomy, 13 of whom had a lesion which did not require surgery, 1 with a lymphoma and 28 who were treated with partial nephrectomy. Biopsy accuracy for histopathological tumor type and Fuhrman nuclear grade was 92% and 69.8%, respectively. No substantial morbidity occurred., Conclusions: Fine needle biopsy of small renal masses could select benign lesions for which observation might be an alternative to surgery. The accuracy of fine needle biopsy in identifying histological tumor type was high. However, biopsy was less accurate in evaluating Furhman grade. Biopsy with helical CT guidance could be a key point in tailored management of small solid renal masses and provide important information to those patients harboring renal masses.

Development of cancer on a kidney transplant is a rare complication of renal transplantation. In the light of a case of cancer on a kidney transplant, in a series of 729 consecutive renal transplantations performed between January 1987 and December 2000, the authors discuss the epidemiology, pathophysiology, prognosis, treatment and prevention of this disease and emphasize the importance of regular and prolonged periodic ultrasound surveillance of kidney transplants. The reference treatment is transplantectomy with discontinuation of immunosuppression and resumption of haemodialysis. Under certain conditions, partial transplantectomy could appear be an alternative to the reference treatment.