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      Nephron-Sparing Robotic Radiosurgical Therapy for Primary Renal Cell Carcinoma: Single-Institution Experience and Review of the Literature

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          Abstract

          Purpose

          We report our single-institution stereotactic body radiation therapy (SBRT) experience on stage I renal cancer with prospectively collected toxicity and efficacy data.

          Methods and Materials

          A total of 21 patients with solitary renal tumors, including 14 surgical candidates who refused surgery (66%), were treated with SBRT. Histologic confirmation was obtained on all patients before treatment; 2 had transitional cell carcinoma and 19 had renal cell carcinoma. The median age was 71 years (range, 58-88). Nearly all patients received 48 Gy in 3 fractions.

          Results

          The median follow-up was 78 months (range, 5-107). At 5 years post treatment, the local tumor control rate was 100%. Tumor size decreased by a median value of 5.3% at 1 year post treatment, 15.6% at 2 years post treatment, and 15.4% at 5 years post treatment. Glomerular filtration rate had decreased by a median value of 1.5% at 1 year post treatment, 7.0% at 2 years post treatment, and 14.2% at 5 years post treatment. Three patients experienced grade 1 toxicity; no other treatment-related adverse effects were reported.

          Conclusions

          SBRT is a promising noninvasive treatment in the management of primary renal cell carcinoma, with evolving clinical evidence demonstrating encouraging results with respect to local control and toxicity.

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          Most cited references28

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          Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study.

          Chronic kidney disease is a graded and independent risk factor for substantial comorbidity and death. We aimed to examine new onset of chronic kidney disease in patients with small, renal cortical tumours undergoing radical or partial nephrectomy. We did a retrospective cohort study of 662 patients with a normal concentration of serum creatinine and two healthy kidneys undergoing elective partial or radical nephrectomy for a solitary, renal cortical tumour (
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            Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy.

            We reviewed our surgical experience with small renal tumors, comparing overall survival in patients treated with radical and partial nephrectomy. Using our nephrectomy registry we identified patients with sporadic, unilateral, solitary and localized renal masses 4 cm or less who underwent radical or partial nephrectomy between 1989 and 2003. Patients with a solitary kidney or impaired renal function at presentation were excluded, leaving 648 available for analysis. Overall survival was estimated using the Kaplan-Meier method and associations with death were evaluated using Cox proportional hazards regression. At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical nephrectomy was not significantly associated with death from any cause compared with partial nephrectomy (RR 1.12, p = 0.52). However, there was a significant interaction with age, leading us to stratify our analysis at the median age of 65 years. In 327 patients younger than 65 years radical nephrectomy was significantly associated with death from any cause compared with partial nephrectomy (RR 2.16, p = 0.02). The increased risk of death persisted after adjusting for year of surgery (p = 0.02), preoperative creatinine (p = 0.03), Charlson-Romano index (p = 0.04), symptoms at presentation (p = 0.02), diabetes at presentation (p = 0.03) and histology (p = 0.02). Our results suggest that, compared with partial nephrectomy, radical nephrectomy is associated with decreased overall survival in younger patients with small renal masses.
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              Factors predicting renal functional outcome after partial nephrectomy.

              Compared to radical nephrectomy, partial nephrectomy better preserves renal parenchyma and function. Although several clinical factors may impact renal function after partial nephrectomy including preoperative function, age, gender and comorbidities, the contributions of tumor and surgical factors have not been well studied. We evaluate independent factors predicting functional outcomes after partial nephrectomy. Preoperative and all postoperative serum creatinine values for 1,169 patients undergoing partial nephrectomy were used to estimate glomerular filtration rate. Postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate were analyzed using multiple pertinent covariates. Median preoperative, postoperative nadir and ultimate glomerular filtration rates were 77, 57 and 71 ml per minute per 1.73 m(2), respectively. Increasing age, gender, lower preoperative glomerular filtration rate, solitary kidney, tumor size, ischemia time and longer time to nadir glomerular filtration rate significantly predicted postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate. Acute loss of renal function predicted lower ultimate glomerular filtration rate. In the entire cohort, in patients with normal preoperative renal function, and in those with baseline stage 3 and those with stage 4 chronic kidney disease the incidence of postoperative acute kidney injury after partial nephrectomy was 3.6%, 0.8%, 6.2% and 34%, and the incidence of chronic end stage renal disease after partial nephrectomy was 2.5%, 0.1%, 3.7% and 36%, respectively. Lower preoperative glomerular filtration rate, solitary kidney, older age, gender, tumor size and longer ischemic interval all predicted lower glomerular filtration rate after partial nephrectomy. Therefore, duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, and efforts to limit ischemic time and injury should be pursued in open and laparoscopic partial nephrectomy.
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                Author and article information

                Contributors
                Journal
                Adv Radiat Oncol
                Adv Radiat Oncol
                Advances in Radiation Oncology
                Elsevier
                2452-1094
                15 October 2019
                Mar-Apr 2020
                15 October 2019
                : 5
                : 2
                : 204-211
                Affiliations
                [a ]Radiation Oncology, Colorado Springs, Colorado
                [b ]Colorado Associates in Medical Physics, Penrose Cancer Center, Colorado Springs, Colorado
                [c ]Department of Urology, DaVita Medical Group, Colorado Springs, Colorado
                Author notes
                []Corresponding author: Anuj V. Peddada, MD anujpeddada@ 123456centura.org
                Article
                S2452-1094(19)30156-3
                10.1016/j.adro.2019.10.001
                7136638
                32280820
                5d7d97b1-42c4-4f54-b58b-886d2f0704e0
                © 2019 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 20 March 2019
                : 28 September 2019
                : 6 October 2019
                Categories
                Genitourinary Cancer

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