Patients with renal cell carcinoma tumours larger than 4 cm benefit from undergoing elective partial nephrectomy (PN) rather than radical nephrectomy (RN) surgery, a study has found.
There is a considerable body of evidence to support the use of PN in tumours smaller than 4 cm to preserve renal function, but surgeons have traditionally favoured the use of RN for tumours over the 4 cm cutoff.
“After showing oncologic safety and limited morbidity following elective PN, we demonstrate that functional benefit is effective for tumors larger than 4 cm as well as for tumors smaller than 4 cm”, the study authors write in Urologic Oncology.
They looked back at the clinical records of 973 patients who underwent either RN or PN at one of nine institutions across three countries (France, USA and Italy). Data on age, gender, tumour size, TNM stage, and preoperative and postoperative glomerular filtration rate (GFR) were retrieved.
To ensure a fair comparison between the two surgical techniques, all patients with imperative indications for PN were excluded, as were those with extremely low preoperative GFR rates.
Patients were stratified into four groups depending on their GFR, based on the abbreviated Modification of the Diet in Renal Disease equation. A shift to a less favourable GFR group at the end of postoperative follow-up (average 46.7 months) was considered clinically significant.
Of the 973 patients included in the study, 655 were male and 318 were female. The median age at diagnosis was 60 years and median tumour size was 3.3 cm, with 665 being 4 cm or smaller and 308 being over 4 cm. PN was performed in 540 tumours that were 4 cm or smaller and 123 tumours larger than 4 cm.
Those patients who underwent PN despite having larger tumours were significantly younger than those who underwent RN.
In a univariate analysis, patients who underwent PN had a significantly smaller risk of developing a significant change in GFR after surgery compared with those who underwent RN, and this was true for all sizes of tumours.
Multivariate analysis showed that the use of RN, a preoperative GFR of less than 60 mL/min per 1.73 m2, tumour size greater than 4 cm and older age at diagnosis were all independent predictive factors for developing significant postoperative GFR loss.
Lead author Géraldine Pignot (Bicêtre Hospital, Paris, France) and colleagues conclude: “The renal function benefit carried out by elective PN over RN persists even when expanding nephron-sparing surgery indications beyond the traditional 4-cm cutoff.”
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