title: Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Large prospective investigation of meat intake, related mutagens, and risk of renal cell carcinoma. Active surveillance of small renal masses: progression patterns of early stage kidney cancer. A preoperative prognostic model for patients treated with nephrectomy for renal cell carcinoma. Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. Temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. Diagnostic accuracy of computed tomography-guided percutaneous biopsy of renal masses. Improved prognostication of renal cell carcinoma using an integrated staging system. Body size and risk of renal cell carcinoma in the European Prospective Investigation into Cancer and Nutrition (EPIC). Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy. EAU guidelines on renal cell carcinoma: the 2010 update.
abstract: BACKGROUND Besides clinical tumour size , other anatomical aspects of the renal tumour are routinely considered when evaluating the feasibility of elective nephron-sparing surgery ( NSS ) . OBJECTIVE To propose an original , st and ardised classification of renal tumours suitable for NSS based on their anatomical features and size and to evaluate the ability of this classification to predict the risk of overall complications result ing from the surgery . DESIGN , SETTING , AND PARTICIPANTS We enrolled prospect ively 164 consecutive patients who underwent NSS for renal tumours at a tertiary academic referral centre from January 2007 to December 2008 . INTERVENTION Open partial nephrectomy without vessel clamping . MEASUREMENTS All tumours were classified by integrating size with the following anatomical features : anterior or posterior face , longitudinal , and rim tumour location ; tumour relationships with renal sinus or urinary collecting system ; and percentage of tumour deepening into the kidney . We generated an algorithm evaluating each anatomical parameter and tumour size ( the preoperative aspects and dimensions used for an anatomical [ PADUA ] score ) to predict the risk of complications . RESULTS AND LIMITATIONS Overall rates of complication were significantly correlated to all the evaluated anatomical aspects , excluding clinical size and anterior or posterior location of the tumour . By multivariate analysis , PADUA scores were independent predictors of the occurrence of any grade complications ( hazard ratio [ HR ] for score 8 - 9 vs 6 - 7 : 14.535 ; HR for score ≥10 vs 6 - 7 : 30.641 ) . Potential limitations were the limited number of patients with T1b tumours included in the study and the lack of laparoscopically treated patients . Further external validation of the PADUA score is needed . CONCLUSIONS The PADUA score is a simple anatomical system that can be used to predict the risk of surgical and medical perioperative complications in patients undergoing open NSS . The use of an appropriate score can help clinicians stratify patients suitable for NSS into subgroups with different complication risks and can help research ers evaluate the real comparability among patients undergoing NSS with different surgical approaches BACKGROUND The evidence for meat intake and renal cell carcinoma ( RCC ) risk is inconsistent . Mutagens related to meat cooking and processing , and variation by RCC subtype may be important to consider . OBJECTIVE In a large US cohort , we prospect ively investigated intake of meat and meat-related compounds in relation to risk of RCC , as well as clear cell and papillary RCC histologic subtypes . DESIGN Study participants ( 492,186 ) completed a detailed dietary assessment linked to a data base of heme iron , heterocyclic amines ( HCA ) , polycyclic aromatic hydrocarbons ( PAHs ) , nitrate , and nitrite concentrations in cooked and processed meats . Over 9 ( mean ) y of follow-up , we identified 1814 cases of RCC ( 498 clear cell and 115 papillary adenocarcinomas ) .  HRs and 95 % CIs were estimated within quintiles by using multivariable Cox proportional hazards regression . RESULTS Red meat intake [ 62.7 g ( quintile 5 ) compared with 9.8 g ( quintile 1 ) per 1000 kcal ( median ) ] was associated with a tendency toward an increased risk of RCC [ HR : 1.19 ; 95 % CI : 1.01 , 1.40 ; P-trend = 0.06 ] and a 2-fold increased risk of papillary RCC [ P-trend = 0.002 ] . Intakes of benzo(a)pyrene ( BaP ) , a marker of PAHs , and 2-amino-1-methyl-6-phenyl-imidazo[4,5-b]pyridine ( PhIP ) , an HCA , were associated with a significant 20 - 30 % elevated risk of RCC and a 2-fold increased risk of papillary RCC . No associations were observed for the clear cell subtype . CONCLUSIONS Red meat intake may increase the risk of RCC through mechanisms related to the cooking compounds BaP and PhIP . Our findings for RCC appeared to be driven by strong associations with the rarer papillary histologic variant . This study is registered at clinical trials.gov as NCT00340015 BACKGROUND Most early stage kidney cancers are renal cell carcinomas ( RCCs ) , and most are diagnosed incidentally by imaging as small renal masses ( SRMs ) . Indirect evidence suggests that most small RCCs grow slowly and rarely metastasize . OBJECTIVE To determine the progression and growth rates for newly diagnosed SRMs stratified by needle core biopsy pathology . DESIGN , SETTING , AND PARTICIPANTS A multicenter prospect i ve phase 2 clinical trial of active surveillance of 209 SRMs in 178 elderly and /or infirm patients was conducted from 2004 until 2009 with treatment delayed until progression . INTERVENTION Patients underwent serial imaging and needle core biopsies . MEASUREMENTS We measured rates of change in tumor diameter ( growth measured by imaging ) and progression to ≥ 4 cm , doubling of tumor volume , or metastasis with histology on biopsy . RESULTS AND LIMITATIONS Local progression occurred in 25 patients ( 12 % ) , plus 2 progressed with metastases ( 1.1 % ) . Of the 178 subjects with 209 SRMs , 127 with 151 SRMs had>12 mo of follow-up with two or more images , with a mean follow-up of 28 mo . Their tumor diameters increased by an average of 0.13 cm/yr . Needle core biopsy in 101 SRMs demonstrated that the presence of RCC did not significantly change growth rate . Limitations included no central review of imaging and pathology and a short follow-up . CONCLUSIONS This is the first SRM active surveillance study to correlate growth with histology prospect ively . In the first 2 yr , the rate of local progression to higher stage is low , and metastases are rare . SRMs appear to grow very slowly , even if biopsy proven to be RCC . Many patients with SRMs can therefore be initially managed conservatively with serial imaging , avoiding the morbidity of surgical or ablative treatment BACKGROUND Currently two pretreatment prognostic models with limited accuracy ( 65 - 67 % ) can be used to predict survival in patients with localized renal cell carcinoma ( RCC ) . OBJECTIVE We set out to develop a more accurate pretreatment model for predicting RCC-specific mortality after nephrectomy for all stages of RCC . DESIGN , SETTING , AND PARTICIPANTS The data originated from a series of prospect ively recorded contemporary cases of patients treated with radical or partial nephrectomy between 1984 and 2006 . Model development was performed using data from 2474 patients from five centers and external validation was performed using data from 1972 patients from seven centers . MEASUREMENTS The probability of RCC-specific mortality was modeled using Cox regression . The significance of the predictors was confirmed using competing risks analyses , which account for mortality from other causes . RESULTS AND LIMITATIONS Median follow-up in patients who did not die of RCC-specific causes was 4.2 yr and 3.5 yr in the development and validation cohorts , respectively . The freedom from cancer-specific mortality rates in the nomogram development cohort were 75.4 % at 5 yr after nephrectomy and 68.3 % at 10 yr after nephrectomy . All variables except gender achieved independent predictor status . In the external validation cohort the nomogram predictions were 88.1 % accurate at 1 yr , 86.8 % accurate at 2 yr , 86.8 % accurate at 5 yr , and 84.2 % accurate at 10 yr . CONCLUSIONS Our model substantially exceeds the accuracy of the existing pretreatment models . Consequently , the proposed nomogram-based predictions may be used as benchmark data for pretreatment decision making in patients with various stages of RCC PURPOSE We report on a prospect i ve r and omized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor . MATERIAL S AND METHODS Between June 1999 and June 2001 , 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospect ively r and omized to undergo either a transperitoneal ( group 1 , 50 patients ) or retroperitoneal ( group 2 , 52 patients ) laparoscopic radical nephrectomy with intact specimen extraction . Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest . Both groups were matched regarding age ( 63 versus 65 years , p = 0.69 ) , BMI ( 29 versus 28 , p = 0.89 ) , American Society of Anesthesiologists class ( 2.7 versus 2.8 , p = 0.37 ) , laterality ( right side 46 % versus 48 % , p = 0.85 ) and mean tumor size ( 5.3 versus 5.0 cm , p = 0.73 ) . RESULTS All 102 procedures were technically successful without the need for open conversion . Compared to the transperitoneal approach , the retroperitoneal approach was associated with a shorter time to renal artery control ( 91 versus 34 minutes , p < 0.0001 ) , shorter time to renal vein control ( 98 versus 45 minutes , p < 0.0001 ) and shorter total operative time ( 207 versus 150 minutes , p = 0.001 ) . However , the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss ( 180 versus 242 cc , p = 0.13 ) , hospital stay ( 43 versus 45 hours , p = 0.55 ) , intraoperative complications ( 10 % versus 7.7 % , p = 0.30 ) , postoperative complications ( 20 % versus 13.5 % , p = 0.14 ) and postoperative analgesia requirements ( 27 versus 26 mg MSO4 equivalent p = 0.13 ) . Pathology revealed renal cell carcinoma in 84 % and 75 % of cases , respectively , with no positive surgical margin in any case . CONCLUSIONS Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach . While renal hilar control and total operative time may be quicker with retroperitoneoscopy , the approaches are similar in terms of other patient outcomes evaluated BACKGROUND Interferon alfa is widely used for metastatic renal-cell carcinoma but has limited efficacy and tolerability .  Temsirolimus , a specific inhibitor of the mammalian target of rapamycin kinase , may benefit patients with this disease . METHODS In this multicenter , phase 3 trial , we r and omly assigned 626 patients with previously untreated , poor-prognosis metastatic renal-cell carcinoma to receive 25 mg of intravenous temsirolimus weekly , 3 million U of interferon alfa ( with an increase to 18 million U ) subcutaneously three times weekly , or combination therapy with 15 mg of temsirolimus weekly plus 6 million U of interferon alfa three times weekly . The primary end point was overall survival in comparisons of the temsirolimus group and the combination-therapy group with the interferon group . RESULTS Patients who received temsirolimus alone had longer overall survival ( hazard ratio for death , 0.73 ; 95 % confidence interval [ CI ] , 0.58 to 0.92 ; P=0.008 ) and progression-free survival ( P<0.001 ) than did patients who received interferon alone . Overall survival in the combination-therapy group did not differ significantly from that in the interferon group ( hazard ratio , 0.96 ; 95 % CI , 0.76 to 1.20 ; P=0.70 ) . Median overall survival times in the interferon group , the temsirolimus group , and the combination-therapy group were 7.3 , 10.9 , and 8.4 months , respectively . Rash , peripheral edema , hyperglycemia , and hyperlipidemia were more common in the temsirolimus group , whereas asthenia was more common in the interferon group . There were fewer patients with serious adverse events in the temsirolimus group than in the interferon group ( P=0.02 ) . CONCLUSIONS As compared with interferon alfa , temsirolimus improved overall survival among patients with metastatic renal-cell carcinoma and a poor prognosis . The addition of temsirolimus to interferon did not improve survival . ( Clinical Trials.gov number , NCT00065468 [ Clinical Trials.gov ] . ) PURPOSE Laparoscopic partial nephrectomy is an increasingly performed , minimally invasive alternative to open partial nephrectomy . We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less . MATERIAL S AND METHODS Data on 1,800 consecutive open or laparoscopic partial nephrectomies  were collected prospect ively or retrospectively in tumor registries at 3 large referral centers . Demographic , intraoperative , postoperative and followup data were compared between the 2 groups . RESULTS Compared to the  laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy  were a higher risk group with a greater percent presenting symptomatically with decreased performance status , impaired renal function and tumor in a solitary functioning kidney ( p<0.0001 ) . More tumors in the open partial nephrectomy group were more than 4 cm and central ly located and more proved to be malignant ( p<0.0001 and 0.0003 , respectively ) . Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time ( p<0.0001 ) , decreased operative blood loss ( p<0.0001 ) and shorter hospital stay ( p<0.0001 ) . The chance of intraoperative complications was comparable in the 2 groups . However , laparoscopic partial nephrectomy was associated with longer ischemia time ( p<0.0001 ) , more postoperative complications , particularly urological ( p<0.0001 ) , and an increased number of subsequent procedures ( p<0.0001 ) . Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9 % and 99.6 % of renal units retaining function , respectively . Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3 % and 99.2 % after laparoscopic and open partial nephrectomy , respectively . CONCLUSIONS Early experience with laparoscopic partial nephrectomy is promising . Laparoscopic partial nephrectomy offered the advantages of less operative time , decreased operative blood loss and a shorter hospital stay . When applied to patients with a single renal tumor 7 cm or less , laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy . However , equivalent functional and early oncological outcomes were achieved OBJECTIVE Modern imaging modalities increase the detection of small ( < or=4 cm ) renal tumors , of which about 20 % are benign . As a result , minimal invasive treatments , such as radiofrequency ablation and cryotherapy , and surveillance strategies are gaining popularity . Information that would be helpful when choosing the most appropriate management strategy for this patient group could be obtained from pretherapeutic image-guided biopsy . METHODS Under computed tomography (CT)-fluoroscopic guidance  78 patients with solid renal tumors prospect ively underwent 18-gauge core biopsy . In addition , using the same sheath , fine-needle aspiration was taken in 44 patients and analyzed cytologically . The renal masses were subsequently removed surgically and evaluated histologically . RESULTS Mean patient age was 63+/-13.5 yr ; mean tumor size was 4+/-1.8 cm . The sensitivity of  core biopsy and fine-needle aspiration for the detection of renal cell carcinoma ( RCC ) was 93.5 % and 90.6 % , respectively ; Fuhrman grade was correctly predicted in 76 % and 28 % and the correct histologic subtype was identified 91 % and 86 % , respectively . Cytology from fine-needle aspiration revealed a sensitivity in detecting malignant and benign lesions of 100 % and 75 % , respectively . Two of the renal tumors diagnosed as oncocytomas on core biopsy were hybrid tumors with scattered areas of oncocytomas and chromophobe RCC . Complications of CT-guided biopsy included one marginal pneumothorax , which resolved under conservative management , and four small perirenal hematomas detected at follow-up ultrasonography not requiring further therapy . CONCLUSION CT-guided percutaneous preoperative renal tumor biopsy had a high diagnostic accuracy , particularly in predicting malignancy PURPOSE To integrate stage , grade , and Eastern Cooperative Oncology Group ( ECOG ) performance status ( PS ) into a clinical ly useful tool capable of stratifying the survival of renal cell carcinoma ( RCC ) patients . PATIENTS AND METHODS The medical records of 661 patients undergoing nephrectomy at University of California Los Angeles between 1989 and 1999 were evaluated . Median age was 61 years , male-to-female ratio was 2.2:1 , and median follow-up was 37 months .  Survival time was the primary end point assessed . Sixty-four possible combinations of stage , grade , and ECOG PS were analyzed and collapsed into distinct groups . The internal validity of the categorized was challenged by a univariate analysis and a multivariate analysis testing for the accountability of each UCLA Integrated Staging System ( UISS ) category against independent variables shown to have impact on survival . RESULTS Combining and stratifying 1997 tumor-node-metastasis stage , Fuhrman 's grade and ECOG PS result ed in five survival stratification groups design ated UISS , and numbered I to V. The projected 2- and 5-year survival for the UISS groups are as follows for the groups : I , 96 % and 94 % ; II , 89 % and 67 % ; III , 66 % and 39 % ; IV , 42 % and 23 % ; and V , 9 % and 0 % , respectively . UISS accounted for the significant variables in the variate analysis . CONCLUSION A novel system for staging and predicting survival for RCC integrating clinical variables is offered . UISS is simple to use and is superior to stage alone in differentiating patients ' survival . Our data suggests that UISS is an important prognostic tool for counseling patients with various stages of kidney cancer . Further prospect i ve large-scale validation with external data is awaited Previous studies suggest that obesity is related to increased risk of renal cell carcinoma ( RCC ) ; however , only a few studies report on measures of central vs. peripheral adiposity . We examined the association between anthropometric measures , including waist and hip circumference  and  RCC risk among 348,550 men and women free of cancer at baseline from 8 countries of the European Prospect i ve Investigation into Cancer and Nutrition ( EPIC ) . During 6.0 years of follow-up we identified 287 incident cases of RCC . Relative risks were calculated using Cox regression , stratified by age and study center and adjusted for smoking status , education , alcohol consumption , physical activity , menopausal status , and hormone replacement therapy use . Among women , an increased risk of RCC was conferred by body weight ( relative risk [ RR ] in highest vs. lowest quintile = 2.13 ; 95 % confidence interval [ CI ] = 1.16 - 3.90 ; p-trend = 0.003 ) , body mass index ( BMI ) ( RR = 2.25 ; 95 % CI = 1.14 - 4.44 ; p-trend = 0.009 ) , and waist ( RR = 1.67 ; 95 % CI = 0.94 - 2.98 ; p-trend = 0.003 ) and hip circumference ( RR = 2.30 ; 95 % CI = 1.22 - 4.34 ; p-trend = 0.01 ) ; however , waist and hip circumference were no longer significant after controlling for body weight . Among men , hip circumference ( RR = 0.44 ; 95 % CI = 0.20 - 0.98 ; p-trend = 0.03 ) was related significantly to decreased RCC risk only after accounting for body weight . Height was not related significantly to RCC risk . Our findings suggest that obesity is related to increased risk of RCC irrespective of fat distribution among women , whereas low hip circumference is related to increased RCC risk among men . Our data give further credence to public health efforts aim ing to reduce the prevalence of obesity to prevent RCC , in addition to other chronic diseases BACKGROUND Percutaneous needle core biopsy has become established in the management of small renal masses ≤ 4 cm ( SRMs ) . Recent series have reported success rates of ≥ 80 % . Nondiagnostic results continue to be problematic . OBJECTIVE To determine the results of SRM biopsy and the outcomes of nondiagnostic biopsy and repeat biopsy . DESIGN , SETTING , AND PARTICIPANTS Patients undergoing renal tumor biopsy ( RTB ) for suspected renal cell carcinoma ( RCC ) were included in a prospect ively maintained data base . MEASUREMENTS The data base was analyzed retrospectively to determine the pathology and outcomes of SRM biopsy . Outcomes of patients with nondiagnostic biopsy  were determined . Patients undergoing repeat biopsy were identified and their outcomes analyzed . RESULTS AND LIMITATIONS Three hundred forty-five biopsies were performed ( mean diameter : 2.5 cm ) . Biopsy was diagnostic in 278 cases ( 80.6 % ) and nondiagnostic in 67 cases ( 19.4 % ) . Among diagnostic biopsies , 221 ( 79.4 % ) were malignant , 94.1 % of which were RCC . Histologic subtyping and grading of RCC was possible in 88.0 % and 63.5 % of cases , respectively . Repeat biopsy was performed in 12 of the 67 nondiagnostic cases , and a diagnosis was possible in 10 ( 83.3 % ) . Eight lesions were malignant and two were oncocytic neoplasms . Pathology was available for 15 masses after initial nondiagnostic biopsy ; 11 ( 73 % ) were malignant . Larger tumor size and a solid nature on imaging predicted a successful biopsy on multivariate analysis . Grade 1 complications were experienced in 10.1 % of cases , with no major bleeding and no seeding of the biopsy tract . There was one grade 3a complication ( 0.3 % ) . This is a retrospective study and some data are unavailable on factors that may affect biopsy success rates . Repeat biopsy was not st and ard practice prior to this analysis . CONCLUSIONS RTB can be performed safely and accurately in the investigation of renal masses ≤ 4 cm . A nondiagnostic biopsy should not be considered a surrogate for the absence of malignancy . Repeat biopsy can be performed with similar accuracy , providing a diagnosis for most patients CONTEXT AND OBJECTIVES The European Association of Urology Guideline Group for renal cell carcinoma ( RCC ) has prepared these guidelines to help clinicians assess the current evidence -based management of RCC and to incorporate the present recommendations into daily clinical practice . EVIDENCE ACQUISITION The recommendations provided in the current up date d guidelines are based on a thorough review of available RCC guidelines and review articles combined with a systematic literature search using Medline and the Cochrane Central Register of Controlled Trials . EVIDENCE SYNTHESIS A number of recent prospect i ve r and omised studies concerning RCC are now available with a high level of evidence , whereas earlier publications were based on retrospective analyses , including some larger multicentre validation studies , meta-analyses , and well- design ed controlled studies . CONCLUSIONS These guidelines contain information for the treatment of an individual patient according to a current st and ardised general approach . Up date d recommendations concerning diagnosis , treatment , and follow-up can improve the clinical h and ling of patients with RCC
target: The 2014 guideline has been up date d by a multidisciplinary panel using the highest method ological st and ards , and provides the best and most reliable contemporary evidence base for RCC management .
background: CONTEXT The European Association of Urology Guideline Panel for Renal Cell Carcinoma ( RCC ) has prepared evidence -based guidelines and recommendations for RCC management .
  OBJECTIVES To provide an up date of the 2010 RCC guideline based on a st and ardised methodology that is robust , transparent , reproducible , and reliable .