Urological Survey Urological Oncology: Adrenal, Renal, Ureteral and Retroperitoneal Tumors Re: Cumulative Incidence of Cancer after Solid Organ Transplantation E. C. Hall, R. M. Pfeiffer, D. L. Segev and E. A. Engels Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland Cancer 2013; 119: 2300e2308.
Abstract available at http://jurology.com/ Editorial Comment: The authors present an analysis of the risk of primary cancer after solid organ transplantation in terms of cumulative incidence, which not only depends on the relative risk of cancer but also takes into account the risk of competing events such as death and graft failure. Assessment of absolute risk may permit identification of possible screening targets in comparison to the nontransplanted population. Of further interest for urological readers is that kidney transplantation is by far the largest contributor to the solid organ transplants cohort, that among the 6 study targeted cancers kidney and prostate cancer (PCa) were considered, and that outcomes of solid organ transplantation have improved in the last few decades. Using the Transplant Cancer Match Study, which links data from transplant recipients with 14 population based cancer registries in the United States and covers approximately 43% of the United States transplant population, the authors assessed the absolute risk of cancer during 2 periods, 1987 to 1999 and 2000 to 2008. The 5-year cumulative cancer incidence increased slightly from 4.2% to 4.4%, respectively, in the face of a decreasing incidence of competing events, with 5-year cumulative incidences of death, graft failure or re-transplantation of 31.9% and 26.6%, respectively. The incidence of kidney cancer in the native kidneys was higher than in the general population. The 5-year cumulative incidence was greatest in kidney recipients and increased steadily in those older than 35 years. A greater 5-year cumulative incidence of PCa was found for patients 50 to 60 years old among heart, kidney, liver and lung recipients compared to the general population. The results of this study are valuable when considering the opportunity for cancer screening in risk groups. However, this benefit has to be weighed against the current outcomes of transplantation. In kidney transplantation the implementation of living donor programs and preemptive transplantation has resulted in excellent graft survival and high quality of life. The current guidelines advise cancer treatment policies in these patients that are similar to those for the general population. This study further supports the same screening policy (or not) for patients with PCa as for the general population, and for patients with kidney cancer the identification of subgroups with specific increased risk of native kidney cancer, eg kidney transplant recipients older than 35 years. M. Pilar Laguna, MD, PhD
Suggested Reading Leveridge M, Musquera M, Evans A et al: Renal cell carcinoma in the native and allograft kidneys of renal transplant recipients. J Urol 2011; 186: 219. Melchior S, Franzaring L, Shardan A et al: Urological de novo malignancy after kidney transplantation: a case for the urologist. J Urol 2011; 185: 428. Ehdaie B, Stukenborg GJ and Theodorescu D: Renal transplant recipients and patients with end stage renal disease present with more advanced bladder cancer. J Urol 2009; 182: 1482.
0022-5347/14/1914-0948/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
948
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.01.061 Vol. 191, 948-951, April 2014 Printed in U.S.A.
ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS
Re: Features Associated with Recurrence beyond 5 Years after Nephrectomy and Nephron-Sparing Surgery for Renal Cell Carcinoma: Development and Internal Validation of a Risk Model (PRELANE Score) to Predict Late Recurrence Based on a Large Multicenter Database (CORONA/SATURN Project) S. Brookman-May, M. May, S. F. Shariat, E. Xylinas, C. Stief, R. Zigeuner, T. Chromecki, M. Burger, W. F. Wieland, L. Cindolo, L. Schips, O. De Cobelli, B. Rocco, C. De Nunzio, B. Feciche, M. Truss, C. Gilfrich, S. Pahernik, M. Hohenfellner, S. Zastrow, M. P. Wirth, G. Novara, M. Carini, A. Minervini, C. Simeone, A. Antonelli, V. Mirone, N. Longo, A. Simonato, G. Carmignani and V. Ficarra Klinikum Grosshadern, Department of Urology, Ludwig-Maximilians-University Munich, Munich, Germany Eur Urol 2013; 64: 472e477.
Abstract available at http://jurology.com/ Editorial Comment: Followup schedules after renal cell carcinoma (RCC) surgery with curative intention have been characterized as having a wide variability of tests and inconsistency in time frames. Overall guidelines define minimum requirements but are inconsistent regarding followup beyond 5 years. This article investigates late recurrence in patients with RCC treated with partial or radical nephrectomy with curative intention. Subjects free of disease 5 years postoperatively were selected for analysis from an international retrospective database. The late recurrence rate was low (6.5%), and independent risk factors for recurrence were aggressive pathological features, lymphovascular invasion, Fuhrman grade 3 to 4 disease and pT stage greater than 1. Based on regression analysis, a risk predictive score was constructed including these risk factors and classified cases at low, intermediate and high risk for late recurrence. The AUC of the predictive model was 70%. Factors such as the consistent trend in decreasing age at diagnosis, increasing incidence of renal tumors in the young population and decreasing competing death risks underscore the importance of tailoring followup based on individual risk of recurrence. However, the applicability of the model described by the authors is uncertain. Selection bias is almost unavoidable in retrospective series, although large samples tend to overcome it. Lymphovascular invasion is not yet systematically reported worldwide and foremost is not included as a prognostic factor in the 2010 TNM classification. Conversely RCC grade is not homogeneously reported according to Fuhrman grade, and it is to be expected that not every center is using the original 4 grades. Finally, predictive models for the different oncologic outcomes are abundant in the literature, although the penetration of most of them is unknown. On the other hand the beauty of the model is that it is purely based on clinical findings and easy to obtain pathological risk factors. Despite the lack of explanation regarding how to score the 3 predictive factors and the lack of external validation, the present work draws attention to the fact that the late risk of recurrence is evenly distributed at 5 to 10 years, and to the opportunity for prolonging and customizing followup, especially for younger individuals. M. Pilar Laguna, MD, PhD
Suggested Reading Donat SM, Diaz M, Bishoff JT et al: Follow-up for clinically localized renal neoplasms: AUA Guideline. J Urol 2013; 190: 407. Lam JS, Shvarts O, Leppert JT et al: Postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma based on a validated prognostic nomogram and risk group stratification system. J Urol 2005; 174: 466. Stephenson AJ, Chetner MP, Rourke K et al: Guidelines for the surveillance of localized renal cell carcinoma based on the patterns of relapse after nephrectomy. J Urol 2004; 172: 58.
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Abstract available at http://jurology.com/ Editorial Comment: The authors present an analysis of the risk of primary cancer after solid organ transplantation in terms of cumulative incidence, which not only depends on the relative risk of cancer but also takes into account the risk of competing events such as death and graft failure. Assessment of absolute risk may permit identification of possible screening targets in comparison to the nontransplanted population. Of further interest for urological readers is that kidney transplantation is by far the largest contributor to the solid organ transplants cohort, that among the 6 study targeted cancers kidney and prostate cancer (PCa) were considered, and that outcomes of solid organ transplantation have improved in the last few decades. Using the Transplant Cancer Match Study, which links data from transplant recipients with 14 population based cancer registries in the United States and covers approximately 43% of the United States transplant population, the authors assessed the absolute risk of cancer during 2 periods, 1987 to 1999 and 2000 to 2008. The 5-year cumulative cancer incidence increased slightly from 4.2% to 4.4%, respectively, in the face of a decreasing incidence of competing events, with 5-year cumulative incidences of death, graft failure or re-transplantation of 31.9% and 26.6%, respectively. The incidence of kidney cancer in the native kidneys was higher than in the general population. The 5-year cumulative incidence was greatest in kidney recipients and increased steadily in those older than 35 years. A greater 5-year cumulative incidence of PCa was found for patients 50 to 60 years old among heart, kidney, liver and lung recipients compared to the general population. The results of this study are valuable when considering the opportunity for cancer screening in risk groups. However, this benefit has to be weighed against the current outcomes of transplantation. In kidney transplantation the implementation of living donor programs and preemptive transplantation has resulted in excellent graft survival and high quality of life. The current guidelines advise cancer treatment policies in these patients that are similar to those for the general population. This study further supports the same screening policy (or not) for patients with PCa as for the general population, and for patients with kidney cancer the identification of subgroups with specific increased risk of native kidney cancer, eg kidney transplant recipients older than 35 years. M. Pilar Laguna, MD, PhD
Suggested Reading Leveridge M, Musquera M, Evans A et al: Renal cell carcinoma in the native and allograft kidneys of renal transplant recipients. J Urol 2011; 186: 219. Melchior S, Franzaring L, Shardan A et al: Urological de novo malignancy after kidney transplantation: a case for the urologist. J Urol 2011; 185: 428. Ehdaie B, Stukenborg GJ and Theodorescu D: Renal transplant recipients and patients with end stage renal disease present with more advanced bladder cancer. J Urol 2009; 182: 1482.
0022-5347/14/1914-0948/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
948
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.01.061 Vol. 191, 948-951, April 2014 Printed in U.S.A.
ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS
Re: Features Associated with Recurrence beyond 5 Years after Nephrectomy and Nephron-Sparing Surgery for Renal Cell Carcinoma: Development and Internal Validation of a Risk Model (PRELANE Score) to Predict Late Recurrence Based on a Large Multicenter Database (CORONA/SATURN Project) S. Brookman-May, M. May, S. F. Shariat, E. Xylinas, C. Stief, R. Zigeuner, T. Chromecki, M. Burger, W. F. Wieland, L. Cindolo, L. Schips, O. De Cobelli, B. Rocco, C. De Nunzio, B. Feciche, M. Truss, C. Gilfrich, S. Pahernik, M. Hohenfellner, S. Zastrow, M. P. Wirth, G. Novara, M. Carini, A. Minervini, C. Simeone, A. Antonelli, V. Mirone, N. Longo, A. Simonato, G. Carmignani and V. Ficarra Klinikum Grosshadern, Department of Urology, Ludwig-Maximilians-University Munich, Munich, Germany Eur Urol 2013; 64: 472e477.
Abstract available at http://jurology.com/ Editorial Comment: Followup schedules after renal cell carcinoma (RCC) surgery with curative intention have been characterized as having a wide variability of tests and inconsistency in time frames. Overall guidelines define minimum requirements but are inconsistent regarding followup beyond 5 years. This article investigates late recurrence in patients with RCC treated with partial or radical nephrectomy with curative intention. Subjects free of disease 5 years postoperatively were selected for analysis from an international retrospective database. The late recurrence rate was low (6.5%), and independent risk factors for recurrence were aggressive pathological features, lymphovascular invasion, Fuhrman grade 3 to 4 disease and pT stage greater than 1. Based on regression analysis, a risk predictive score was constructed including these risk factors and classified cases at low, intermediate and high risk for late recurrence. The AUC of the predictive model was 70%. Factors such as the consistent trend in decreasing age at diagnosis, increasing incidence of renal tumors in the young population and decreasing competing death risks underscore the importance of tailoring followup based on individual risk of recurrence. However, the applicability of the model described by the authors is uncertain. Selection bias is almost unavoidable in retrospective series, although large samples tend to overcome it. Lymphovascular invasion is not yet systematically reported worldwide and foremost is not included as a prognostic factor in the 2010 TNM classification. Conversely RCC grade is not homogeneously reported according to Fuhrman grade, and it is to be expected that not every center is using the original 4 grades. Finally, predictive models for the different oncologic outcomes are abundant in the literature, although the penetration of most of them is unknown. On the other hand the beauty of the model is that it is purely based on clinical findings and easy to obtain pathological risk factors. Despite the lack of explanation regarding how to score the 3 predictive factors and the lack of external validation, the present work draws attention to the fact that the late risk of recurrence is evenly distributed at 5 to 10 years, and to the opportunity for prolonging and customizing followup, especially for younger individuals. M. Pilar Laguna, MD, PhD
Suggested Reading Donat SM, Diaz M, Bishoff JT et al: Follow-up for clinically localized renal neoplasms: AUA Guideline. J Urol 2013; 190: 407. Lam JS, Shvarts O, Leppert JT et al: Postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma based on a validated prognostic nomogram and risk group stratification system. J Urol 2005; 174: 466. Stephenson AJ, Chetner MP, Rourke K et al: Guidelines for the surveillance of localized renal cell carcinoma based on the patterns of relapse after nephrectomy. J Urol 2004; 172: 58.
949
