Faculty Bibliography

PURPOSE/OBJECTIVE:We used a large, population based registry to assess whether a difference in overall and cardiovascular survival may exist between radical nephrectomy and partial nephrectomy for renal cell carcinoma 2 cm or less. MATERIALS AND METHODS/METHODS:From the SEER (Surveillance, Epidemiology and End Results) registry we identified 4,216 patients with histologically confirmed renal cell carcinoma 2 cm or less who were treated with partial or radical nephrectomy. Patient and tumor characteristics were compared between the 2 patient groups. Multivariate logistic regression was done to predict the odds of undergoing radical nephrectomy. Cardiovascular survival and overall survival were compared between the 2 cohorts, adjusting for patient and tumor characteristics. RESULTS:Overall 2,301 patients (55%) underwent partial nephrectomy. Partial nephrectomy use steadily increased during the study period from 27% of all cases in 1998 to 66% in 2007. Patients who underwent partial nephrectomy were an average of 2.5 years younger than those treated with radical nephrectomy (56.4 vs 58.9 years, p <0.001). They were more likely to be white and from the western or northeastern United States. Older age was the only independent predictor of radical nephrectomy (OR 1.02, 95% CI 1.01-1.03). When controlling for patient characteristics and surgery year, radical nephrectomy was associated with worse overall mortality (HR 2.24, 95% CI 1.75-2.84) and cardiovascular mortality (HR 2.53, 95% CI 1.51-4.23). CONCLUSIONS:Radical nephrectomy is associated with worse overall and cardiovascular survival compared to partial nephrectomy in patients with localized renal cell carcinoma 2 cm or less. These findings justify the widespread application of nephron sparing techniques to treat localized kidney cancer.

OBJECTIVE:To analyze the use of radical nephrectomy (RN) and partial nephrectomy during a 10-year period in patients aged≥75 years compared with their younger counterparts. METHODS:Using the Surveillance, Epidemiology, and End Results registry, we identified 18 045 cases of localized renal cell carcinoma of ≤4 cm diagnosed from 1998 to 2007. The baseline differences in demographic and tumor characteristics were compared between the 2 age cohorts (<75 vs ≥75 years), and the rates of RN were determined, stratified by tumor size. A multivariate logistic regression analysis was conducted to predict the odds of undergoing radical nephrectomy for clinical Stage T1a disease. RESULTS:Overall, 2733 patients (15%) were aged≥75 years. The use of radical nephrectomy for clinical Stage T1a renal cell carcinoma decreased during the study period for all patients (79% in 1998 to 49% in 2007). Overall, 66% of patients aged≥75 years underwent RN for their disease compared with 59% of patients aged<75 years (P<.001). For patients with tumors of ≤2 cm, 51% of those aged≥75 years underwent RN compared with 41% of the younger cohort. In a multivariate logistic regression model, age≥75 years independently predicted the use of radical nephrectomy (odds ratio 1.18, 95% confidence interval 1.08-1.29). A 1-year increase in age was associated with a 1% increase in the risk of undergoing RN (odds ratio 1.01, 95% confidence interval 1.01-1.01). CONCLUSION/CONCLUSIONS:Elderly patients with clinically localized small renal masses are treated with RN more frequently than younger patients. Additional studies should address the medical implications of the increased use of radical surgery within the geriatric population.

Bladder cancer is a heterogeneous disease that offers a unique challenge for the patient and the physician as treatment paradigms are continually evolving. There are multiple factors that can influence how each individual is treated, including lymphovascular invasion, micropapillary histology, and p53 nuclear accumulation which have demonstrated a worse prognosis in patients with bladder cancer. They can influence the use of neoadjuvant and adjuvant chemotherapy, which in itself can affect the timing of extirpative surgery. This review will focus on the contemporary management and treatment of bladder cancer focusing on areas of clinical decision making.