Comparative analysis of partial versus radical nephrectomy for renal cell carcinoma: Is oncologic safety compromised during nephron sparing in higher stage disease?

Objectives: Over the past 20 years, the utility of partial nephrectomy (PN), compared to radical nephrectomy (RN), for the management of localized renal cell carcinoma (RCC) has progressively increased, particularly for larger and more complex masses. We sought to compare the recurrence-free survival (RFS) outcomes of PN versus RN in a single-institution cohort. Methods: Between 2002 and 2017, 228 patients underwent RN or PN for lcT1a-T2b, N0M0 RCC at a single tertiary referral center, performed by five surgeons. The clinical end point result was (local or distant) RFS. Univariate and multivariate (cox regression) models were used to evaluate the association between type of surgery (PN vs. RN) and RFS, in the overall cohort and in a subgroup of patients with cT1b. Results: The median age was 59 (interquartile range [IQR] 48-66), and the median tumor size was 4.5 cm (IQR 3-7). There were 128 PN and 100 RN. Over a median follow-up of 4.2 years (IQR 2.2-6.9), the Kaplan-Meier analysis showed no significant RFS difference between PN and RN (logrank P = 0.53). On multivariate analysis, pathologic stage ≥T2a, Fuhrman Grade ≥3, and chromophobe histology were associated with a worse RFS. PN was not significantly associated with diminished RFS (Hazard ratio [HR] 1.78, 95% confidence interval [CI] 0.74-4.3, P = 0.199) in the overall cohort compared to RN. However, in the cT1b subgroup, PN was associated with a significant increase in recurrence compared to RN (HR = 12.4, 95% CI 1.45-133.4, P = 0.038). Conclusions: Our institutional data highlight the possibility of compromise in RFS for clinically localized RCC treated with PN compared to RN, particularly for larger and more complex masses. These data raise concern, especially in light of the nonproven association of survival benefit of PN over RN, warranting future randomized prospective studies for further evaluation.

The R.E.N.A.L score's relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience.

Objective: The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality. Results: A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05-12.7, p = 0.041). Conclusion: Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Immunotherapy-related renal toxicity causes reversible renal enlargement.

PURPOSE: Prior case reports have noted an increase in renal size and perinephric stranding accompanying immunotherapy-related renal toxicity due to checkpoint-inhibitor therapy. The purpose of this investigation was to systematically evaluate if immunotherapy-related renal toxicity affects renal size and possible associated imaging findings. METHODS: This retrospective multi-hospital study included 25 patients (13 men), mean age 67 years (range 46-83) who received immune-checkpoint inhibitors for cancer treatment, developed biopsy-proven immunotherapy-related nephritis, and who also had abdominal imaging before, during, and after nephritis was diagnosed. Long axis renal diameter, renal corticomedullary differentiation/enhancement and perinephric stranding were evaluated by two readers at three timepoints: (1) prior to checkpoint inhibitor therapy (baseline), (2) after biopsy-proven immunotherapy-related nephritis (post-treatment), and (3) following renal function recovery (follow-up). Intraclass correlation coefficient and Cohen's Kappa were calculated to quantify agreement. Logistic regression analysis was implemented to measure the association between each timepoint and imaging features. RESULTS: Reader agreement on kidney measurements was excellent (ICC = 0.87). There was an increase in renal size between baseline and post-treatment (p = 0.001), followed by a decrease between post-treatment to follow-up (p < 0.001). Agreement was perfect for abnormal renal corticomedullary differentiation/enhancement (Kappa = 1, p < 0.001) and almost perfect for perinephric stranding (Kappa = 0.97, p < 0.001). Neither post-treatment nor follow-up imaging findings were significantly associated with these findings compared to the baseline (p = 0.2-0.6). CONCLUSION: Immunotherapy-related renal toxicity was associated with an increase in renal size coincident with acute renal dysfunction.

Coronavirus Disease in the Abdomen.

Numerous abdominal manifestations have been reported in patients with coronavirus disease 2019 (COVID-19), including involvement of the luminal gastrointestinal (GI) tract, hepatobiliary system, pancreas, kidneys, spleen, and blood vessels. Although most of the associated radiological abnormalities are nonspecific without distinguishing imaging features to suggest COVID-19, unique presentations such as findings of bowel ischemia preceding gross findings of bowel necrosis have been reported. Awareness of the spectrum of abdominal manifestations of COVID-19 allows radiologists to optimize their search pattern and to raise the possibility of this etiology when appropriate. Awareness of the possible abdominal manifestations of COVID-19 should enhance detection by radiologists and improve patient care. This review provides a comprehensive overview with illustrative imaging examples of COVID-19 in the abdomen.

Imaging Findings in Immunotherapy-related Renal Toxicity.

Immunotherapy-related adverse events (irAEs) associated with immune-checkpoint inhibitors can affect nearly any organ system including commonly the luminal gastrointestinal tract, hepatobiliary system, lungs, endocrine glands, and skin, many of which have described imaging manifestations. In patients without clinically suspected irAEs, imaging findings may be the first indication of an abnormality that prompts further workup to facilitate early detection and initiation of appropriate treatment, such as therapy discontinuation or corticosteroid therapy. While some irAEs have well described imaging correlates, such as pneumonitis, hypophysitis, and colitis, others are not well described, such as nephritis. We report 2 cases of irAE nephritis associated with PD-1 inhibitor therapy and their imaging features.

Comparative analysis of histopathological subtypes of renal cell carcinoma in the Middle East compared to other world regions.

INTRODUCTION: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. METHODS: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. RESULTS: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7-13.6), Europe (11.1%, 95% CI: 10.0-12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. CONCLUSIONS: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.