ESOU18: The Best Treatment for Renal Masses: T1b in Elderly Patients > 75, Partial Nephrectomy: Yes!
A recent publication reports that rising age (>70 years) is an important risk factor for worse survival outcomes in a patient with low grade T1 tumor. [1] Therefore, the elderly with a T1b tumor obviously carries a higher oncologic risk than a younger patient with the same type of tumor. The guidelines state that many papers report on the equivalence of long-term cancer specific survival after PN and radical nephrectomy for T1b RCC (2-4). This is also true when PN is performed by means of laparoscopy (5). Overall survival is at least as important as cancer specific survival. Overall survival is influenced by comorbidities increasing with age which are not related to tumor therapy. However, with therapy, we induce another long-term comorbidity – chronic renal failure. It has been clearly shown that radical nephrectomy is a significant risk factor for the development of chronic kidney disease, and this risk is greatly reduced by PN (6). Chronic renal failure leads to an increased rate of cardiovascular events and resulting death (7). This influence of chronic kidney disease on overall survival is very clearly demonstrated in a group of patients who were operated for a suspected RCC, which eventually turned out to be a benign tumor. The published data, however, are not completely consistent in this respect. In a large study on more than 10.000 patients the authors conclude that in patients older than 75 years a benefit from surgery was not significant (8).
In any case, There is only one single prospective randomized study comparing PN with radical nephrectomy (9). Both PN and radical nephrectomy provided excellent oncologic results. However, the expected advantage of PN on overall survival could not be demonstrated. On the contrary, there was a trend demonstrating better overall survival after radical nephrectomy, although not statistically significant.
The impact of PN on the risk of noncancer specific mortality is not equal in all patients with normal preoperative renal function, who are diagnosed with a cT1 renal mass. Specifically, in healthier patients without comorbidities, PN does not decrease the risk of other cause mortality relative to radical nephrectomy. Conversely, in patients who are more ill with relevant comorbidities, PN significantly decreases the risk of other cause mortality relative to radical nephrectomy. An identical reduction of GFR may be the caused by two different mechanisms: Either two few of otherwise normally functioning renal parenchyma was left, or the renal parenchyma volume is somewhat reduced or irreversibly damaged. This damage may already exist prior to surgery (diabetes, hypertension), it may be a result of surgery (long ischemia time), or both. The basic investigation to differentiate between this is a MAG 3 scintigraphy and calculation of clearance and split function.
In summary, it seems that the older patient with a T1b tumor profits most from PN despite the increased perioperative morbidity. He has an oncologic risk which is higher compared to that of younger patients, and because the likelihood of comorbidities such as hypertension and diabetes, he has a higher risk to develop ongoing renal insufficiency resulting in cardiac problems and decreased overall mortality.
Speaker: Gunter Janetschek, MD, Department of Urology, Paracelsus Medical University Salzburg, Austria
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands
References
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