Which one of the following statements regarding ablative therapies for renal cell cancer is CORRECT?
Answer B
EAU and AUA guidelines advise a partial nephrectomy in healthy patients for T1a renal cell cancers. Cryotherapy and radiofrequency ablation should be reserved for carefully selected high-risk surgical patients with small renal masses <4 cm. Pain or paraesthesia at the probe insertion site is the commonest complication after cryotherapy, occurring in 7.2%. High-intensity frequency ultrasound should presently be considered an experimental treatment for small renal masses. Local recurrence rates for radiofrequency ablation are similar or higher than cryotherapy and both are significantly higher than for open partial nephrectomy. The radiographic measurements of post ablative success for cryotherapy and radiofrequency ablation are not well-established presently.
Which one of the following statements regarding renal biopsy is CORRECT?
Traditionally, percutaneous renal biopsy has been criticised for the problems with non-diagnostic samples, complications and a small but real risk of tumour seeding into the biopsy tract (0.01%). Contemporary series however show a 94.5% diagnostic accuracy for percutaneous renal mass biopsies. Complications rates are low at 3.5%. The Canadian small renal mass surveillance study demonstrated an 80% diagnostic accuracy when re-biopsying for a non-diagnostic initial biopsy. Percutaneous renal biopsies have a learning curve and are operator dependent. No tumour seeding has been reported in the biopsy tract in contemporary series.
Which one of the following statements regarding laparoscopic nephrectomy is CORRECT?
Answer D
The EAU and AUA guidelines recommend a partial nephrectomy should be attempted in T1b renal cell cancers where feasible though open and laparoscopic radical nephrectomies are options when partial nephrectomy is not possible. No clear benefits have been shown of performing a laparoscopic nephrectomy retroperitoneally or transperitoneally. Port site metastases have been reported in a very small number of cases after laparoscopic radical nephrectomy for renal cell cancer. Both intermediate- and long-term outcomes for laparoscopic radical nephrectomy for RCC in T1 and T2 disease have been shown to be equivalent. Vascular injuries and bleeding are the commonest complication seen from laparoscopic nephrectomy.
Which one of the following statements regarding the surgical management of metastatic renal cancer is CORRECT?
Answer E
The role of cytoreductive nephrectomy in combination with TKIs for metastatic renal cancer has been the subject of several ongoing clinical trials. There is no evidence to date of increases in progression free survival due to cytoreductive nephrectomy in combination with TKIs.
Sunitinib alone was not inferior to nephrectomy followed by sunitinib in patients with metastatic renal-cell carcinoma who were classified as having intermediate-risk or poor-risk disease (CARMENA). Progression-free Rate has been found to be unaffected by the sequence of cytoreductive nephrectomy and Sunitinib in patients with synchronous mRCC (EORTC – NCT01099423). There have been no reported cases of cure to date when TKIs have been combined with cytoreductive nephrectomy in metastatic renal cell cancer. Up to 50% 5-year survival rates have been reported following excision of a solitary renal cell carcinoma metastasis. Positive surgical margins after resection of a local recurrence, size >5 cm of a local recurrence, presence of sarcomatoid dedifferentiation in a local recurrence and abnormal serum alkaline phosphatase/lactate dehydrogenase at the time of the local recurrence are all associated with worse prognosis.
Which of the following molecular biomarkers improves the accuracy of the SSIGN scoring system in predicting cancer specific survival in renal cell carcinoma?
A number of prognostic models for patients with RCC have been developed to predict cancer specific survival. One model is the stage, size, grade and necrosis (SSIGN) score developed by the Mayo Clinic, which predicts cancer specific survival (CSS) in patients with clear cell RCC. This validated scoring system scores renal tumours on the basis of the following parameters:
continued:
Patients can then be stratified into low-risk = 0–2 (5-year CSS = 96%–99%), intermediaterisk = 3–5 (5-year CSS = 65%–88%) and high-risk >6 (5-year CSS = 7%–55%). The use of scoring systems such as SSIGN or the UCLA devised integrated staging system (UISS), which relies on the TNM stage, Fuhrman grade and Eastern Cooperative Oncology Group Performance Status (ECOG-PS), can be used to tailor follow-up regimens and potentially identify patients that may benefit from adjuvant therapy.
A greater understanding of the molecular basis of renal carcinoma has led to the identification of a number of biomarkers that may help improve individual prognostication and risk-stratified clinical decision making.
Loss of functional VHL leads to increased expression levels of HIF in clear cell RCC. Elevated HIF-1a levels in tumour tissue are associated with worse survival in clear cell RCC. High levels of HIF-1a or HIF-2a confer a favourable response to Sunitinib therapy in metastatic RCC. Vascular endothelial growth factor (VEGF) plays a key role in tumour angiogenesis in RCC. In clear cell RCC VEGF expression correlates with tumour size, Fuhrman grade, tumour necrosis, tumour stage, microvessel invasion, RCC progression rate and RCC-specific survival. Carbonic anhydrase IX (CAIX) is a HIF-1a-regulated transmembrane protein thought to assist in regulating intracellular and extracellular pH. In clear cell RCC, CAIX can establish the diagnosis as it is expressed in >80% of RCC samples and 90% of clear cell RCC specimens. High CAIX expression is associated with a better prognosis in localised RCC and mRCC. The p53 protein plays an important role in regulating cell growth and proliferation by stopping cell cycle and inducting apoptosis in the presence of DNA damage. The prognostic role of p53 in RCC remains controversial though one study has shown that p53 over-expression was an independent predictor of metastasis-free survival in patients with localised clear cell RCC (p = 0.01). Insulin-like growth factor II mRNA-binding protein 3 (IMP3) regulates transcription of insulinlike growth factor II. IMP3 expression was significantly associated with advanced T stage and grade, increased regional lymph node involvement, and distant metastases, tumour necrosis and sarcomatoid differentiation. In addition, multivariable, Positive IMP3 expression was independently associated with an increased risk of death from RCC even after adjusting for prognostic features comprising the SSIGN score.
Click to expand