27 / 32
invasion. In contrast, MIBC urine and plasma
tDNA levels correlated with one another (r =
0.6). In patients with NMIBCs, urine tDNA lev-
els correlated with progression, even when
tumors were stratified by stage (although,
in patients with T1 tumors, the results just
missed statistical significance). In patients
with MIBC, plasma tDNA levels were asso-
ciated with recurrence (P < 0.001).
Overall, the Christensen study reinforces
the group’s previous conclusion
9
that
measuring tumor DNA alterations in urine
(NMIBC and MIBC) and plasma (MIBC) is
feasible and probably clinically impactful.
However, important questions remain. First
and foremost, it is still not clear that meas-
uring tDNA in urine will outperform routine
cystoscopy, and more longitudinal studies
need to be performed to determine how
tumor resection and intravesical therapy
affect tDNA levels. The longitudinal data
presented in Figure 3 are very interesting
but do not directly address how clinical
management impacts the amount of tDNA
that is present. Related to this point, the
sensitivity of the ddPCR assay in detecting
subclinical disease is still not clear. Ideally,
increases in tDNA should anticipate the
emergence of clinically evident disease as
measured by cystoscopy and/or cytology
(hopefully by several weeks or months).
Finally, it would be preferable to have a
“tumor-agnostic” test that is capable of
detecting all bladder cancers without the
need to perform whole or panel exome
sequencing on a patient’s primary tumor
to identify relevant biomarkers. Commer-
cial vendors like UrologyDx, Guardant, and
PGDx are developing such panels, but it
will take some time to fully appreciate
their performance characteristics. Nev-
ertheless, this study represents another
important step forward in the integration
of genomics into the routine clinical man-
agement of patients with bladder cancer.
Building on this foundation, we will hope-
fully see robust urine- and plasma-based
tests emerge in the next 1 to 2 years.
Dr McConkey is Professor in
the Departments of Urology
and Cancer Biology and
Director of Urological
Research at Johns Hopkins
in Baltimore, Maryland.
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Similar oncological outcomes with partial
and radical nephrectomy in RCC ≥4 cm
Urologic Oncology: Seminars & Original Investigations
Take-home message
•
In a retrospective analysis, researchers compared the outcomes of radical nephrectomy
with outcomes of partial nephrectomy (PN) in renal cell carcinoma (RCC) ≥4 cm. Using
propensity scorematching, they found no differences in progression-free, cancer-specific,
or overall survival between radical and partial nephrectomy. However, the PN group did
experience more complications within 30 days after surgery (P < 0.001). Survival was
associated with tumor size, cellular grade, pathologic state, and patient age.
•
Oncological outcomes were found to be similar with partial and radical nephrectomy
in RCC ≥4 cm, and the authors suggest that PN remains a valuable treatment option
even though the early complication rate was higher with PN compared with the
radical approach.
Abstract
OBJECTIVE
Although partial nephrectomy (PN) is
the standard treatment for localized clinical T1a
renal cell carcinoma (RCC), treatment of larger
renal tumors is controversial. We evaluated the
oncological outcomes and perioperative com-
plications after radical and PN for RCC ≥4cm.
PATIENTS AND METHODS
We retrospectively
analyzed the data of 2,373 patients surgically
treated for nonmetastatic RCC with clinical T1b
or T2 (≥4cm). The propensity scores for surgery
type were calculated, and the partial group was
matched to the radical group in a 1:3 ratio. The
oncological outcomes were compared using
Kaplan-Meier analysis and multivariate Cox
regression models were used to identify the
independent predictors of progression-free,
cancer-specific, and overall survival.
RESULTS
All differences in preoperative clini-
cal characteristics disappeared after matching.
There were no significant differences in pro-
gression-free, cancer-specific, or overall survival
between the partial and radical groups in the
matched cohort. The patients’ age, tumor size,
cellular grade, and pathologic stage were inde-
pendent predictors for all 3 survival outcomes.
However, early complications (<30d postoper-
ative) were significantly more common in the
partial group (P<0.001). In a subgroup analysis of
the patients with clinical T2 stage, there were no
significant differences in all 3 survival outcomes.
CONCLUSIONS
The partial and radical nephrec-
tomy groups had equivalent oncological
outcomes. Although the early complication rate
was significantly higher after PN, it should be
considered as a valuable treatment option even
in patients with clinical T1b or higher RCC.
Can partial nephrectomy provide equal onco-
logical efficiency and safety compared with
radical nephrectomy in patients with renal cell
carcinoma (≥4cm)? A propensity score-matched
study.
Urol Oncol
2017 Mar 08;[EPub Ahead of
Print], H Lee, JJ Oh, SS Byun, et al.
Although the early complication rate was significantly higher
after PN, it should be considered as a valuable treatment option
even in patients with clinical T1b or higher RCC.
GENITOURINARY
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VOL. 1 • NO. 2 • 2017