Renal angiomyolipoma-patient characteristics and treatment with focus on active surveillance.

Objectives: To present a patient material of renal angiomyolipoma (AML) with focus on the risk of bleeding during active surveillance (AS).Methods: Medical records, 1999-2014, were studied and 98 patients (80 female, 18 men) with renal AML were identified. Eleven patients had tuberous sclerosis complex (TSC). Mean age was 54 (13-89) years.Results: Sixty patients (61%) were asymptomatic at presentation, 33 (34%) presented with flank pain and five (5%) with hematuria. Retroperitoneal bleeding or hematuria was diagnosed in 20 patients with a mean AML size of 74 mm (25-200 mm). Twenty-one patients were treated with angioembolization at time of diagnosis and 25 had surgery. Forty-five patients with sporadic AML (mean size 34 mm) and six with TSC (mean size 120 mm) were selected for AS. Only one patient with sporadic AML (46 mm) had a bleeding, whereas two of the six TSC patients had bleedings from three kidneys (AML 70-300 mm). In 25 patients (49%), the AML-size increased with 2.7 mm/year in sporadic and 5.4 mm/year in TSC-associated AML. Thirteen patients were treated with AE (including all six TSC-patients) and five with surgery in 22 kidneys due to AML-size in 16, bleeding in four and suspicion of cancer in two.Conclusion: Bleeding occurred in 20% of AML at presentation. In patients selected for AS, we found a very low risk of bleeding in sporadic AML justifying our cut off size of 50 mm to trigger intervention. In TSC-associated AML individually tailored follow-up is needed due to a higher intervention rate.

Improved outcome with combined US/CT guidance as compared to US guidance in percutaneous radiofrequency ablation of small renal masses.

BACKGROUND: When performing percutaneous radiofrequency ablation (RFA) of small renal masses (SRM), use of optimized periprocedural image guidance is essential to secure curative outcome of the treatment. PURPOSE: To retrospectively compare the short-term radiological and clinical outcomes of RFA under combined ultrasound (US) and computed tomography (CT) guidance with that of a previously performed US-guided series at the same institution. MATERIAL AND METHODS: From November 2009 to November 2013, 60 patients (mean age, 70.1 years; range, 34-86 years) with renal masses measuring in the range of 13-50 mm in maximal diameter (mean diameter, 25.4 ± 6.8 mm) underwent percutaneous RFA with combined US/CT guidance. The technical success rate, recurrence-free survival, rate of complications, and the percentage change in the estimated glomerular filtration rate (eGFR) were compared with that of a previously published series of 41 patients with SRM treated with US-guided RFA between November 2002 and December 2008. RESULTS: The tumor and patient characteristics were similar between the two treatment groups. The primary and secondary technical success rate was significantly higher in the group treated with combined US/CT guidance compared with the group treated with US guidance alone (100% and 100% vs. 82% and 91%, respectively). The local recurrence-free survival was significantly better in the combined US/CT-guided group than in the US-guided group (P = 0.016). There was no significant difference in the rate of overall complications (13% vs. 17%) or the mean percentage decrease in the eGFR after the respective treatment (1.1 ± 18.3% vs. 5.0 ± 11.7%). CONCLUSION: The use of combined US/CT guidance when performing renal RFA resulted in superior primary and short-term outcome compared to the use of US guidance alone in patients treated at the same institution.

Kidney cancer in Sweden: a decrease in incidence and tumour stage, 1979 - 2001.

OBJECTIVE: In the Western world the incidence of renal cell carcinoma (RCC) has been increasing for several decades. In Sweden the incidence has decreased since 1980. This may reflect better health of the population. Another possible explanation could be a decrease in incidentally diagnosed RCC. Since these tumours are smaller, relatively more advanced tumours would then enter the cancer registry. The aim of this study was to compare methods of detection of RCC, tumour characteristics and survival from three periods over a timespan of more than 20 years. MATERIAL AND METHODS: Adult patients (n = 515) with RCC were identified in a well-defined population-based area with the same incidence of RCC as the rest of Sweden. Patient data from three periods, 1979 - 1981 (A), 1989 - 1991 (B) and 1999 - 2001 (C), were collected for gender, age, tumour side, method of detection, tumour size, tumour type, metastasis, T stage and Fuhrman grade at the time of diagnosis. Using the Swedish Cause-of-Death Register, cause-specific survival was calculated. When available, tissue was reanalysed according to modern standards by an experienced pathologist. RESULTS: The frequency of ultrasound and computed tomography increased and autopsy and intravenous pyelography decreased with time as the first detection method. There was a significant change towards smaller tumours and less severe stages and grades in more recent periods. Metastatic disease was most common in the first period. The distribution between the different histological tumour types did not change over time. Five-year cause-specific survival increased significantly from 41% to 63%. Subgroup analysis found significantly increased survival for patients with no metastases or with low-grade tumours. CONCLUSION: The data support a true decrease in the incidence of RCC over time in Sweden with a migration towards lower tumour stages but no change in distribution between the different histological subtypes over time.

Ultrasound-guided percutaneous radiofrequency ablation of small renal tumors: Clinical results and radiological evolution during follow-up.

BACKGROUND: Treatment of small renal masses with percutaneous radiofrequency ablation (RFA) is under development. Data are limited regarding the oncologic efficacy and complication rates of ultrasound (US)-guided RFA. PURPOSE: To retrospectively analyze results and factors predictive of incomplete ablation and local recurrence in patients treated for small renal tumors with US-guided percutaneous RFA. MATERIAL AND METHODS: Forty-one consecutive patients (27 males), mean 70 (40-86) years, with 44 tumors were included. Core biopsies were obtained before treatment. Follow-up was performed with CT or MRI. Tumor diameter, tumor volume, volume of the ablation zone, necrosis index, tumor location, distance from tumor to skin, and BMI were analyzed. RESULTS: Biopsies showed malignancy in 72%, 10% were benign, and 18% were inconclusive. Thirty-six tumors (82%) were completely ablated after first RFA and 40 tumors (91%) after a second treatment. Mean follow-up was 27 months. Nine completely ablated tumors (23%) showed local recurrence during follow-up, six of them were retreated. Tumor size was significantly larger and mean necrosis index lower in tumors with incomplete ablation compared with those completely ablated initially. In tumors <30 mm, the initial complete ablation rate was 93% and the local recurrence rate during follow-up was 16% (4/25). CONCLUSION: US guidance is feasible for RFA of small renal tumors. However, thorough long-term follow-up appears mandatory, as a substantial proportion of the patients will develop late local recurrence and will need more than one RFA treatment session. Large tumor diameter and volume and a low necrosis index were predictive indicators of incomplete ablation after the first treatment.

Evaluation of sorafenib treatment in metastatic renal cell carcinoma with 2-fluoro-2-deoxyglucose positron emission tomography and computed tomography.

OBJECTIVE: New potent tyrosine kinase inhibitors such as sorafenib are the most effective treatment for metastatic renal cell carcinoma (MRCC) today. In this study, we used [18F]-2-fluoro-2-deoxyglucose (FDG) with positron emission tomography (PET) combined with computed tomography (CT) to evaluate early effects of sorafenib in patients with MRCC. METHODS: Ten patients, eight males and two females, with a mean age of 61 years (49-72 years), with MRCC were enrolled. A total of 52 lesions, two to nine lesions/patient, out of which 39 were soft lesions, were evaluated. The [18F]FDG-PET/CT was performed before treatment and after 1-2 months. A region of interest (ROI) was identified including the lesions where the glucose uptake was measured, calculating the average value within the ROI and using the cerebellum as the reference. The same ROI was measured in the subsequent FDG-PET. The sum of the diameters was measured in CT according to the Response Evaluation Criteria in Solid Tumors (RECIST). Sorafenib was given 400 mg twice daily orally. RESULTS: After 1-2 months, the mean glucose uptake in all lesions decreased to 75% (32-105%) of initial values of ROI as measured by FDG-PET. The mean glucose uptake in soft lesions decreased to 71% (32-108%) and in skeletal lesions to 82% (53-101%). The sum of the diameters measured by CT decreased to 80% (57-94%) of the initial value in soft lesions according to the RECIST. CONCLUSION: An early decrease in the mean glucose uptake was found in both soft and skeletal lesions after treatment with sorafenib. FDG-PET thus seems to be advantageous, compared with RECIST evaluation, which is limited to soft lesions.

Metastatic renal cell carcinoma treated with Peg-interferon alfa-2b.

INTRODUCTION: Peginterferon has an increased plasma half-life and enables a constant exposure to interferon. This modification might increase the antiangiogenic effect of the treatment and influence the efficacy. We report the results of a phase II open-label study with Peginterferon alfa-2b (Pegintron Schering-Plough) on efficacy and tolerability in patients with advanced renal cell carcinoma (MRCC). MATERIALS AND METHODS: Twenty eight patients with MRCC were treated with Peginterferon in escalating doses of 0.5 microg/kg once weekly until 2 microg/kg was reached or prohibited toxicity occurred. Lesions were evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS: Thirteen patients tolerated a dose of 2 microg/kg/week. At 6 months 16 patients (57%) had disease control of which four had partial response (PR) and 12 stable disease whereas 12 (43%) had progressed. PR was only seen in the lung parenchyma or mediastinum. Median time to progression (TTP) was 8 months in all patients and 13 months for PR and SD patients. Correspondingly, median survival was 19.5 months and 28 months, respectively (seven patients received second-line treatment with tyrosine kinase inhibitor). The mean dose during long-term treatment was 1.5 and at the end of treatment 1.2 microg/kg/week. Most side effects were grade 1-2 and only two patients stopped treatment for that reason. VEGF levels in serum before and during treatment did not correlate to the therapeutic response. DISCUSSION: Peginterferon was well tolerated in MRCC albeit with dose modification during long-term treatment. Response pattern seems to be the same as with nonpegylated interferon. Peginterferon may be used as monotherapy in selected patients and in trials of combinations with targeted drugs.

Nephron-sparing surgery for renal cell carcinoma--long-term results.

OBJECTIVES: Renal cell carcinoma (RCC) is most often treated using radical nephrectomy. However, in patients with only one kidney or with bilateral RCC, nephron-sparing surgery (NSS) is mandatory. NSS may also be undertaken in patients with a normal contralateral kidney, providing that the tumour is fairly small and not unfavourably located. The aim of the present study was to determine the long-term results in patients treated with NSS for RCC. MATERIAL AND METHODS: We reviewed the records of 87 patients with RCC subjected to NSS between 1980 and 1999. The survival rate was determined, as well as the tumour grade (Skinner classification) and stage (1992 World Health Organisation classification). RESULTS: Cancer-specific survival, in patients with no demonstrable distant metastases and regardless of stage and grade, was 80% and 75% at 5 and 10 years, respectively. Long-term survival was significantly dependent on tumour stage and grade. CONCLUSION: In this patient series, long-term survival did not differ from the results obtained using radical nephrectomy, judging from the available literature. An exception was found in patients with high-stage RCC, where NSS appeared to be a less favourable procedure. We therefore recommend that NSS should be performed in cases with bilateral tumour disease or an absent/malfunctioning contralateral kidney. NSS may also be considered in cases of low-stage RCC with a normal contralateral kidney, especially in patients with local or systemic conditions that may adversely affect renal function in the future.