French AFU Cancer Committee Guidelines - Update 2022-2024: management of kidney cancer.

AIM: To update the recommendations for the management of kidney cancers. METHODS: A systematic review of the literature was conducted from 2015 to 2022. The most relevant articles on the diagnosis, classification, surgical treatment, medical treatment and follow-up of kidney cancer were selected and incorporated into the recommendations. Therefore, the recommendations were updated while specifying the level of evidence (high or low). RESULTS: The gold standard for the diagnosis and evaluation of kidney cancer is contrast-enhanced chest and abdominal CT. MRI and contrast-enhanced ultrasound are indicated in special cases. Percutaneous biopsy is recommended in situations where the results will influence the therapeutic decision. Renal tumours should be classified according to the pTNM 2017 classification, the WHO 2022 classification and the ISUP nucleolar grade. Metastatic kidney cancer should be classified according to the IMDC criteria. Partial nephrectomy is the gold standard treatment for T1a tumours and can be performed by an open approach, by laparoscopy or by robot-guidance. Active surveillance of tumours less than 2cm in size can be considered regardless of the patient's age. Ablative therapies and active surveillance are options in elderly patients with comorbidity. T1b tumours should be treated by partial or radical nephrectomy depending on the complexity of the tumour. Radical nephrectomy is the first-line treatment for locally advanced cancers. Adjuvant treatment with pembrolizumab should be considered in patients at intermediate and high risk for recurrence after nephrectomy. In metastatic patients: Immediate cytoreductive nephrectomy may be offered to oligometastatic patients in combination with local treatment of metastases if this can be complete and delayed cytoreductive nephrectomy can be proposed for patients with a complete response or a significant partial response. Medical treatment should be proposed as first-line therapy for patients with a poor or intermediate prognosis. Surgical or local treatment of metastases can be proposed in case of single or oligo-metastases. The recommended first-line drugs for metastatic patients with clear cell renal carcinoma are the combinations axitinib/pembrolizumab, nivolumab/ipililumab, nivolumab/cabozantinib and lenvatinib/pembrolizumab. Cabozantinib is the recommended first-line treatment for patients with metastatic papillary carcinoma. Cystic tumours should be classified according to the Bosniak classification. Surgical removal should be proposed as a priority for Bosniak III and IV lesions. It is recommended that patient monitoring be adapted to the aggressiveness of the tumour. CONCLUSION: These updated recommendations are a reference that will allow French and French-speaking practitioners to improve kidney cancer management.

[French ccAFU guidelines - update 2020-2022: management of kidney cancer]. / Recommandations françaises du Comité de cancérologie de l'AFU ­ actualisation 2020­2022 : prise en charge du cancer du rein.

OBJECTIVE: - To update the French guidelines on kidney cancer. METHODS: - A systematic review of the literature between 2015 and 2020 was performed. The most relevant articles regarding the diagnosis, the classification, surgical treatment, medical treatment and follow-up of kidney cancer were retrieved and included in the new guidelines. The guidelines were updated with corresponding levels of evidence. RESULTS: - Thoraco-abdominal CT scan with injection is the best radiological exam for the diagnosis of kidney cancer. MRI and contrast ultra-sound can be useful in some cases. Percutaneous biopsy is recommended when histological results will affect clinical decision. Renal tumours must be classified according to pTNM 2017 classification and ISUP grade. Metastatic kidney cancers must be classified according to IMDC criteria. Partial nephrectomy is the recommended treatment for T1a tumours and can be done through an open, laparoscopic or robotic access. T1b tumours can be treated by partial or total nephrectomy according to tumour complexity. Radical nephrectomy is the recommended treatment of advanced localized tumours. There is no recommended adjuvant treatment. In metastatic patients: cyto-reductive nephrectomy can be offered in case of good prognosis; medical treatment must be counseled first in case of intermediate or bad prognosis. Surgical or local treatment of metastases should be considered in case of solitary lesion or oligo-metastases. First line recommended drugs in metastatic patients include the associations axitinib/pembrolizumab and nivolumab/ipilimumab. Cystic tumours must be classified according to Bosniak Classification. Surgical excision should be offered to patients with Bosniak III and IV lesions. It is recommended to follow patients clinically and with imaging according to tumour aggressiveness. CONCLUSION: - These updated recommendations should assist French speaking urologists for their management of kidney cancers.

Long-term oncological outcomes of cystic renal cell carcinoma according to the Bosniak classification.

OBJECTIVES: To evaluate the prognostic role of the Bosniak classification on the long-term oncological outcomes of cystic renal cell carcinomas. MATERIAL AND METHOD: In a national multicentric retrospective study, we included patients treated surgically for localized cystic RCC from 2000 to 2010. Patients with a follow-up of less than 4 years, benign tumors, and ablative treatments were excluded. The primary outcome was disease-free survival. RESULTS: 152 patients met the inclusion criteria: Bosniak II (6%), III (53%), IV (41%), with a median follow-up of 61 (12-179) months. Characteristics of the population and the tumors were [median, (min-max)] age 57 (25-84) years old, tumor size 43 mm (20-280), RENAL score 7 (4-12), PADUA score 8 (5-14). Treatments were 55% partial nephrectomy, 45% radical nephrectomy, 74% open surgery, and 26% laparoscopy. In pathological report, cystic RCC were mainly of low grade (1-2, 77%) and low stage (pT1, 81%). The two main histological subtypes were conventional (56%) and papillary (23%) RCC. Staging at presentation and histological characteristics were similar between Bosniak III and IV, except for high grade which was more common in Bosniak IV (12 vs 36%, p < 0.01). The Bosniak classification was not predictive of the recurrence, as 5- and 10-year disease-free survival were similar in Bosniak III and IV (92% vs 92% and 84% vs 83%, p = 0.60). CONCLUSION: The Bosniak classification is predictive of the risk of malignancy but not of the oncological prognosis. Regardless of the initial Bosniak categories, almost all cystic RCCs were of low stage/grade and had low long-term recurrence rate.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l'AFU ­ Actualisation 2018­2020 : prise en charge du cancer du reinFrench ccAFU guidelines ­ Update 2018­2020: Management of kidney cancer / Recommandations françaises du Comité de Cancérologie de l'AFU ­ Actualisation 2018­2020 : prise en charge du cancer du rein.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C'est cette nouvelle version qui doit être utilisée pour citer l'article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article.

[French ccAFU guidelines - Update 2018-2020: Management of kidney cancer]. / Recommandations françaises du Comité de Cancérologie de l'AFU ­ Actualisation 2018­2020 : prise en charge du cancer du rein.

OBJECTIVE: To update the French guidelines on kidney cancer. METHODS: A systematic review of the literature between 2015 and 2018 was performed. The most relevant articles regarding the diagnosis, the classification, surgical treatment, medical treatment and follow-up of kidney cancer were retrieved and included in the new guidelines. The guidelines were updated with corresponding levels of evidence. RESULTS: Thoraco-abdominal CT scan with injection is the best radiological exam for the diagnosis of kidney cancer. MRI and contrast ultrasound can be useful in some cases. Percutaneous biopsy is recommended when histological results will affect clinical decision. Renal tumours must be classified according to pTNM 2017 classification and ISUP grade. Metastatic kidney cancers must be classified according to IMDC criteria. Partial nephrectomy is the recommended treatment for T1a tumours and can be done through an open, laparoscopic or robotic access. T1b tumours can be treated by partial or total nephrectomy according to tumour complexity. Radical nephrectomy is the recommended treatment of advanced localized tumours. In metastatic patients: cytoreductive nephrectomy is recommended in case of good prognosis; medical treatment must be offered first in case of intermediate or bad prognosis. Surgical or local treatment of metastases should be considered in case of solitary lesion or oligo-metastases. First-line recommended drugs in metastatic patients include sunitinib, pazopanib, and the association nivolumab/ipilimumab. Cabozantinib can be offered in option in intermediate and bad prognostic patients. Cystic tumours must be classified according to Bosniak Classification. Surgical excision should be offered to patients with Bosniak III and IV lesions. It is recommended to follow patients clinically and with imaging according to tumour aggressiveness. CONCLUSION: These updated recommendations should assist French speaking urologists for their management of kidney cancers.

[CCAFU french national guidelines 2016-2018 on renal cancer]. / Recommandations en onco-urologie 2016-2018 du CCAFU : Cancer du rein.

The previous guidelines from the Cancer Committee of the Association Française d'Urologie were published in 2013. We wanted this new version to be simple, clear and straightforward. All significant recent publications on kidney cancer have been included. The main changes compared to 2013 are the following: © 2016 Elsevier Masson SAS. All rights reserved.

The accuracy of renal tumor biopsy: analysis from a national prospective study.

OBJECTIVE: To assess preoperative renal tumor biopsy (RTB) accuracy. MATERIALS AND METHODS: As part of the prospective NEPHRON study, data from 1,237 renal tumors were collected, including the use and results of RTB and final histology following nephrectomy. During the 6 months period of inclusion, 130 preoperative biopsies were performed. We used the kappa coefficient of the McNemar test to determine the concordance between the biopsy and the nephrectomy specimen (NS) regarding four parameters: malignant/benign status, histological subtype, Fuhrman grade and microscopic necrosis. RESULTS: Preoperative biopsies were performed in 9.7 and 11.4 % of the 667 radical and 570 partial nephrectomies, respectively. Tumor biopsy was inconclusive in 7.7 % of the cases. In 117 cases, a comparison between RTB and NS was available. Benign tumors accounted for three (2.6 %) and five (4.3 %) of the RTB and NS, respectively (κ = 0.769, good). With seven (6 %) discordant results in terms of histological subtype characterization between RTB and final pathology, RTB accuracy was considered excellent (κ = 0.882). In 33 cases (31.7 %), Fuhrman grade was underestimated at biopsy resulting in an intermediate concordance level (κ = 0.498). Tumor microscopic necrosis was identified in 12 RTB (10.4 %) versus 33 NS (28.4 %) (κ = 0.357, poor). CONCLUSIONS: RTB provides good to excellent diagnostic performance for discriminating malignancy and tumor histological subtype. However, its performance is intermediate or even poor when considering prognostic criteria like Fuhrman grade or microscopic necrosis. Thus, this possible inaccuracy should be taken into consideration when using RTB for accurate guidance of treatment strategy.

Is there a volume-outcome relationship for partial nephrectomy?

OBJECTIVE: To investigate the impact of hospital volume on partial nephrectomy indications and outcomes. MATERIALS AND METHODS: Data were extracted from the National Observational Registry on the Practice and Hemostasis in Partial Nephrectomy registry. Four groups were created according to the number of partial nephrectomy (PN) performed: very high (VH, ≥ 19 PN), high (H, 10-18 PN), moderate (M, 4-9 PN) and low (L, <4 PN) PN activity. Indications and surgical outcomes were compared among all groups. The effect of hospital volume on postoperative complications and positive margin rate was examined by a multivariable analysis. RESULTS: Fifty-three centers included a total of 570 PN. There were 9 VH, 13 H, 12 M and 19 L volume centers which performed 270 (47.4 %), 179 (31.4 %), 74 (13 %) and 47 (8.2 %) PN, respectively. Patients in higher volume centers were significantly younger (p = 0.008), had a lower BMI (p = 0.002) and decreased ASA score (p < 0.001). PN was more frequently performed in higher volume centers (p = 0.006) particularly in case of renal masses <4 cm (p = 0.005). Open surgery was the most common approach in all groups, but laparoscopic PN was more frequent in M volume hospitals (p < 0.001). Positive margin (p = 0.06) and complications (p = 0.022) rates were higher in M group. In multivariable analysis, renal chronic disease was an independent predictor of positive margin rate (p < 0.001, OR 3.91). CONCLUSIONS: PN is more frequently performed in high volume institutions particularly for small renal masses. We observed increase positive margin and complication rates in moderate volume centers that might be explained by an increased use of laparoscopy.

[Case report of kidney cancer from JOUM 2010]. / Cas cliniques de cancer du rein des JOUM 2010.

Three clinical cases have shown the superiority of sunitinib in first line therapy intermediate risk metastatic clear cell renal carcinoma and a best safety of bevacizumab plus interferon, the current lack of high level of evidence arguments for the neo-adjuvant treatment of kidney cancer, the importance to prevent mucositis during a mTOR inhibitors treatment and the diagnostic pitfalls of its pulmonary complications.

[Renal cell carcinoma: antiangiogenic therapies and management of the complications. A case report]. / Cancer du rein: traitements anti-angiogéniques et gestion des complications. A propos d'un cas.

Direct side effects of the inhibition of activation of VEGF receptors are well known and could be easily explained (HTA). The indirect toxicity of the inhibitors of tyrosinekinases is much less known and several hypotheses appear. Usually, the common side effects of the inhibitors of tyrosine-kinases can be easily managed and are reversible when the treatment is stopped. Their management is essentially based on prevention measures. It is necessary to stop definitively or temporarily the treatment in case of intensification of pre-existing comorbidities or side effects of rank 3 or 4. There is no predictive factor of treatment toxicity and, at the moment, there is thus no indication in a previous dose adaptation.

[Preoperative evaluation of renal carcinoma using multi-detector CT]. / Bilan préopératoire des cancers du rein en scanner volumique.

When laparoscopic nephrectomy is performed, the limited visibility of many anatomical structures requires additional pre-operative information. However, most of this information can be highlighted by Multislice-CT which depicts all the vascular structures while providing an essential road mapping for the surgeon. Besides underlining arterial abnormalities, this technique allows to depict venous pathways and tumoral invasion. This review illustrates the various potential applications of Multislice-CT in the evaluation of renal tumors.

[Role of multiarray scanner in the choice of therapeutic strategy in kidney cancer. Report of a case of kidney tumor with double thrombus in inferior vena cava]. / Intérêt du scanner multibarrette dans le choix de la stratégie thérapeutique du cancer du rein. A propos d'un cas de tumeur du rein avec double thrombus de la veine cave inférieure.

Renal cancer with caval thrombus is a disease which requires precise preoperative assessment, in order to adapt the surgical technique to the stage and extent of the disease. Recent developments in CT imaging, spiral acquisition and, more recently, the multiarray technique, allow a high quality evaluation. In the light of a case of right renal tumour with bifocal caval extension, the authors discuss the valuable contribution of this imaging modality in the staging assessment and evaluation of arterial (single or multiple artery, anatomical situation in relation to the left renal vein, presence of early bifurcations, etc.), and venous structures (renal vein, genital vein, extension of the thrombus, lumbar vein and hepatic vein). Improvements in CT imaging constitute a major progress in the staging of renal cancers with caval thrombus and make a considerable contribution to the choice of treatment strategy.