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1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018;68(1):7-30. Review/Other-Dx N/A Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data. Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2014, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2015, were collected by the National Center for Health Statistics. In 2018, 1,735,350 new cancer cases and 609,640 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2005-2014) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2006-2015) declined by about 1.5% annually in both men and women. The combined cancer death rate dropped continuously from 1991 to 2015 by a total of 26%, translating to approximately 2,378,600 fewer cancer deaths than would have been expected if death rates had remained at their peak. Of the 10 leading causes of death, only cancer declined from 2014 to 2015. In 2015, the cancer death rate was 14% higher in non-Hispanic blacks (NHBs) than non-Hispanic whites (NHWs) overall (death rate ratio [DRR], 1.14; 95% confidence interval [95% CI], 1.13-1.15), but the racial disparity was much larger for individuals aged <65 years (DRR, 1.31; 95% CI, 1.29-1.32) compared with those aged >/=65 years (DRR, 1.07; 95% CI, 1.06-1.09) and varied substantially by state. For example, the cancer death rate was lower in NHBs than NHWs in Massachusetts for all ages and in New York for individuals aged >/=65 years, whereas for those aged <65 years, it was 3 times higher in NHBs in the District of Columbia (DRR, 2.89; 95% CI, 2.16-3.91) and about 50% higher in Wisconsin (DRR, 1.78; 95% CI, 1.56-2.02), Kansas (DRR, 1.51; 95% CI, 1.25-1.81), Louisiana (DRR, 1.49; 95% CI, 1.38-1.60), Illinois (DRR, 1.48; 95% CI, 1.39-1.57), and California (DRR, 1.45; 95% CI, 1.38-1.54). Larger racial inequalities in young and middle-aged adults probably partly reflect less access to high-quality health care. 4
2. Motzer RJ, Jonasch E, Agarwal N, et al. Kidney Cancer, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2017;15(6):804-834. Review/Other-Dx N/A To provide recommendations for the clinical management of patients with clear cell and non-clear cell renal carcinoma. No results stated in abstract. 4
3. Iannuccilli JD, Dupuy DE, Beland MD, Machan JT, Golijanin DJ, Mayo-Smith WW. Effectiveness and safety of computed tomography-guided radiofrequency ablation of renal cancer: a 14-year single institution experience in 203 patients. Eur Radiol. 26(6):1656-64, 2016 Jun. Observational-Dx 203 patients To define effectiveness and safety of computed tomography (CT)-guided radiofrequency ablation (RFA) of renal tumours and prognostic indicators for treatment success. Mean tumour size was 2.5 cm (range 1.0-6.0). Mean follow-up was 34.1 months (range 1-131). There was an increase in likelihood of residual disease for tumours >/=3.5 cm (P < 0.05), clear cell subtype of renal cell carcinoma (P </= 0.005) and maximum treatment temperature </=70 degrees C (P < 0.05). There was a decrease in likelihood of residual disease for exophytic tumours (P = 0.01) and no difference based on age, gender, tumour location or type of radio freqency (RF) electrode used. Major complications occurred in 3.9 %. Median post-treatment survival was 7 years for patients with tumours <4 cm, and 5-year overall survival was 80 %. Probability of minor complication increased with tumour size (P = 0.03), as did all-cause mortality (P = 0.005). 2
4. Katsanos K, Mailli L, Krokidis M, McGrath A, Sabharwal T, Adam A. Systematic review and meta-analysis of thermal ablation versus surgical nephrectomy for small renal tumours. Cardiovasc Intervent Radiol. 2014;37(2):427-437. Meta-analysis 6 studies To provide a meta-analysis of clinical trials comparing thermal ablation with surgical nephrectomy for small renal tumours. Six clinical trials (1 randomized and 5 cohort; 6-8 stars on the Newcastle-Ottawa Scale (NOS) ) involving 587 patients with small renal tumors (mean size 2.5 cm) treated with either thermal ablation (percutaneous or laparoscopic application of radiofrequency or microwave) or surgical nephrectomy (open or laparoscopic) were analyzed. Overall complication rate was significantly lower in the ablation group (7.4 vs. 11%; risk ratios (RR): 0.55, 95% confidence interval [CI]: 0.31-0.97, p = 0.04). Postoperative decline of estimated glomerular filteration rate (eGFR) was higher in case of nephrectomy (mean difference: -14.6 ml/min/1.73 m(2), 95% CI: -27.96 to -1.23, p = 0.03). Local recurrence rate was the same in both groups (3.6 vs. 3.6%; RR: 0.92, 95% CI: 0.4-2.14, p = 0.79) and disease-free survival also was similar up to 5 years (Hazard ratios (HR): 1.04, 95% CI: 0.48-2.24, p = 0.92). Good
5. Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. [Review]. Cancer. 118(4):997-1006, 2012 Feb 15. Meta-analysis 18 studies To systematically review the literature and conduct a pooled analysis of studies on small renal masses who underwent active surveillance to identify the risk progression and the characteristics associated with metastases. Eighteen series (880 patients, 936 masses) met screening criteria; and, among these, 18 patients were identified who had tumors that progressed to metastasis (mean, 40.2 months). Six studies (259 patients, 284 masses) provided individual-level data for pooled analysis. At a mean (+/- standard deviation) follow-up of 33.5 +/- 22.6 months, the mean initial greatest tumor dimension was 2.3 +/- 1.3 cm, and mean linear growth rate was 0.31 +/- 0.38 cm per year. Sixty-five masses (23%) exhibited zero net growth under surveillance, and none of those masses progressed to metastasis. A pooled analysis revealed increased age (age 75.1 +/- 9.1 years vs 66.6 +/- 12.3 years; P = .03), an initial greatest tumor dimension (4.1 +/- 2.1 cm vs 2.3 +/- 1.3 cm; P < .0001), initial estimated tumor volume (66.3 +/- 100.0 cm(3) vs 15.1 +/- 60.3 cm(3) ; p = .0001), linear growth rate of (0.8 +/- 0.65 cm per year vs 0.3 +/- 0.4 cm per year; P = .0001), and a volumetric growth rate of 27.1 +/- 24.9 cm(3) per year (vs 6.2 +/- 27.5 cm(3) per year; P < .0001) in the progression cohort. Good
6. Donat SM, Diaz M, Bishoff JT, et al. Follow-up for Clinically Localized Renal Neoplasms: AUA Guideline. J Urol. 190(2):407-16, 2013 Aug. Review/Other-Dx N/A To provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy. Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of postoperative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathological tumor stage. 4
7. Ljungberg B, Bensalah K, Canfield S, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol. 2015;67(5):913-924. Review/Other-Tx 151 studies To provide an update of the 2010 Renal Cell Carcinoma (RCC) guideline based on a standardised methodology that is robust, transparent, reproducible, and reliable. A total of 151 studies reporting on 78,792 patients were eligible for inclusion; where applicable, data from randomised controlled trials (RCTs) were included and meta-analyses were performed. For RCTs, there was low Risk of bias (RoB) across studies; however, clinical and methodological heterogeneity prevented data pooling for most studies. The majority of studies included were retrospective with matched or unmatched cohorts based on single or multi-institutional data or national registries. The exception was for systemic treatment of metastatic RCC, in which several RCTs have been performed, resulting in recommendations based on higher levels of evidence. 4
8. Williamson TJ, Pearson JR, Ischia J, Bolton DM, Lawrentschuk N. Guideline of guidelines: follow-up after nephrectomy for renal cell carcinoma. [Review]. BJU Int. 117(4):555-62, 2016 Apr. Review/Other-Dx 17 articles To review and compare the international guidelines and surveillance protocols for post-nephrectomy renal cell carcinoma (RCC). A total of 17 articles were reviewed. These included three articles on urological guidelines, three on oncological guidelines and 11 on proposed strategies. Guidelines and strategies varied significantly in relation to follow-up, specifically with regard to the frequency and timing of radiological imaging. Although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. 4
9. Antonelli A, Furlan M, Sodano M, et al. Features, risk factors and clinical outcome of "very late" recurrences after surgery for localized renal carcinoma: A retrospective evaluation of a cohort with a minimum of 10 years of follow up. Int J Urol. 23(1):36-40, 2016 Jan. Observational-Dx 554 patients To evaluate the features and the predictors of "very late" recurrences after surgery for localized renal cell carcinoma. A total of 554 patients (231 women, 323 men; age 59.3 +/- 11.6 years) followed for a mean/median time of 15.1/13.6 years (range 10.0-34.1 years) were analyzed. A recurrence was observed in 26 patients (4.6%) after a mean/median interval of 13.3/12.3 years (range 10.5-30.2 years). The pathological stage 2/3 was the only independent predictor of recurrence (P = 0.003), and it was related also to the latency of recurrence (mean/median latency 15.4/14.0, 11.4/10.8 and 12.5/12.0 years, respectively, for stage 1, 2 and 3; P < 0.005 for stage 1 vs stage 2 or 3). The contralateral kidney was the most frequent site of relapse in patients with stage pT1, whereas multiple sites were more frequent for stage pT2 and pT3. 2
10. Levy DA, Slaton JW, Swanson DA, Dinney CP. Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol. 1998; 159(4):1163-1167. Review/Other-Dx 286 patient cases To design radiologic follow-up protocol for patients after treatment for RCC. 59/92 recurrences asymptomatic with 32 on CXR and 12 with abnormal labs. Six patients (2 T2, 4 T3 tumors) with isolated intra-abdominal metastases — all after 24 months. The risk of metastatic RCC is stage dependent. Therefore, surveillance protocols should be based on the pathological stage of the primary tumor. An annual CXR, and serum liver function and alkaline phosphatase level tests for patients with pT1 disease is recommended. 4
11. 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(1):58-62. Observational-Tx 495 patients To analyze the pattern of disease relapse after nephrectomy to develop effective surveillance guidelines. Median follow-up was 42 months. Risk of abdominal recurrence 14% for T3A-B tumors vs 1.8% for T1-2 tumors. 27/30 T1-2 recurrences symptomatic. 11/15 T3A-B recurrences symptomatic. For the surveillance of recurrent disease after nephrectomy it is recommended to have an annual clinical assessment and CXR in pT1-2 cases. Patients with pT3A-B should be followed every 6 months for the first 3 years with clinical assessment and CXR, and annual follow-up thereafter. The higher risk of abdominal relapse in patients with pT3A-B indicates that they should receive surveillance abdominal imaging. It is recommended to have abdominal computerized tomography 6, 12, 24 and 36 months postoperatively. 2
12. Stewart-Merrill SB, Thompson RH, Boorjian SA, et al. Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-Based Approach. J Clin Oncol. 33(35):4151-7, 2015 Dec 10. Observational-Dx 676 patients To provide an approach to surveillance that balances the risk of recurrence versus the risk of non-renal cell carcinoma (RCC) death. At a median follow-up of 9.0 years (interquartile range, 6.4 to 12.7 years), a total of 676 patients developed recurrence. By using a competing-risk model, vastly different surveillance durations were appreciated. Specifically, among patients with pT1Nx-0 disease and a Charlson comorbidity index (CCI) </= 1, risk of non-RCC death exceeded that of abdominal recurrence risk at 6 months in patients age 80 years and older but failed to do so for greater than 20 years in patients younger than age 50 years. For patients with pT1Nx-0 disease but a CCI >/= 2, the risk of non-RCC death exceeded that of abdominal recurrence risk already at 30 days after surgery, regardless of patient age. 3
13. Zisman A, Pantuck AJ, Wieder J, et al. Risk group assessment and clinical outcome algorithm to predict the natural history of patients with surgically resected renal cell carcinoma. J Clin Oncol. 2002; 20(23):4559-4566. Observational-Tx 814 patients; (346 M1 or N1/N2M0, 468 N0M0) To create an algorithm that can predict postoperative RCC patient outcomes and response to therapy. NM-LR patients had 91% disease-specific survival at 5 years, lower recurrence rate, and better disease-free survival compared with NM-IR and HR patients. Disease progressed in 50% of NM-HR patients. Disease-specific survival of NM-HR patients who received immunotherapy (IMT) for recurrent disease was similar to that of M-LR patients treated with cytoreductive nephrectomy and adjuvant IMT. Time from recurrence to death for NM-HR patients was inferior to that for M-LR patients. After IMT, approximately 25% of M-LR and 12% of M-IR patients had long-term progression-free survival. M-HR patients did poorly despite IMT. 1
14. Itano NB, Blute ML, Spotts B, Zincke H. Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. J Urol. 2000; 164(2):322-325. Observational-Tx 1,737 cases; 30 patients with ipsilateral renal fossa recurrence of RCC To determine incidence of isolated renal fossa recurrence after nephrectomy and outcome in those observed, treated surgically, or treated medically. 30 patients were identified with an ipsilateral renal fossa recurrence of renal cell carcinoma after complete nephrectomy in the absence of disseminated disease. Mean followup was 3.3 years (range 0.006 to 14.8) and no patient was lost to followup. The T stage of the primary tumor was T1/T2 in 13 cases, T3a in 4, T3b in 12, and T3c in 1, and all were node negative. Mean time to metastasis was 1. 6 years (range 0.006 to 7.3) in the 19 patients who had documented interval metastatic disease after local recurrence. There were 26 deaths, of which 25 were disease specific. Estimated overall crude and cause specific survival at 1 and 5 years was 66% and 28%, respectively. Calculating survival among symptomatic and asymptomatic patients revealed no discernible difference in outcome (p = 0.94). The 5-year survival rate with surgical resection was 51% (SE 18) compared to 18% (12) treated with adjuvant medical therapy and only 13% (12) with observation alone. The differences in cause specific survival were significant (p 2
15. Sandock DS, Seftel AD, Resnick MI. A new protocol for the followup of renal cell carcinoma based on pathological stage. J Urol. 1995; 154(1):28-31. Observational-Tx 158 patients To design radiologic follow-up protocol for patients after treatment for RCC. Disease recurred in 0%, 14.6% and 52.8% (50%, 44.4% and 75%) of the patients, respectively. The average interval to recurrence was 29.5 months (range 3.5 to 88.8) for patients with stage T2 carcinoma and 22 months (range 3 to 138) for those with stage T3 disease. Routine use of bone scans and computerized tomography does not appear to be necessary. 2
16. Saidi JA, Newhouse JH, Sawczuk IS. Radiologic follow-up of patients with T1-3a,b,c or T4N+M0 renal cell carcinoma after radical nephrectomy. Urology. 1998; 52(6):1000-1003. Review/Other-Dx 45 patients To determine the pattern of disease recurrence after radical nephrectomy in patients with node-positive RCC in order to design a schedule for subsequent radiologic evaluation. Mean follow-up of patients without progression was 39 months. Abdominal CT with CXR detects recurrence in all patients with T1-3a, b, or c or T4N+M0 RCC whose disease progresses and more than 90% of recurrences occur within the first 3 years after surgery. Abdominal CT and CXR are recommended every 6 months for at least 3 years and yearly thereafter in this high-risk group of patients. 4
17. Lau WK, Blute ML, Weaver AL, Torres VE, Zincke H. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000; 75(12):1236-1242. Observational-Tx 1,492 and 189 patients (164 in each cohort) To report the long-term follow-up of a matched comparison of radical nephrectomy (RN) and nephron-sparing surgery (NSS) in patients with single unilateral renal cell carcinoma (RCC) and a normal contralateral kidney. At last follow-up, 126 RN patients (77%) and 130 NSS patients (79%) were alive with no evidence of disease. There was no significant difference observed between patients who had RN and those who had NSS with respect to overall survival (risk ratio, 0.96; 95% confidence interval [CI], 0.52-1.74; P = .88) or cancer-specific survival (risk ratio, 1.33; 95% CI, 0.30-5.95; P = .71). At 10 years, similar rates of contralateral recurrence (0.9% for RN vs 1% for NSS) and metastasis (4.9% for RN vs 4.3% for NSS) were seen in each group, whereas the rate of ipsilateral local recurrence for patients who underwent RN and NSS was 0.8% and 5.4%, respectively (P = .18). There was no significant difference in the early complications between the RN and NSS groups. However, patients who underwent RN had a significantly higher risk for proteinuria as defined by a protein/osmolality ratio of 0.12 or higher (55.2% vs 34.5%; P = .01). At 10 years, the cumulative incidence of chronic renal insufficiency (creatinine > 2.0 mg/dL at least 30 days after surgery) was 22.4% and 11.6%, respectively, for the RN and NSS groups (risk ratio, 3.7; 95% CI, 1.2-11.2; P = .01). 2
18. Canvasser NE, Stouder K, Lay AH, et al. The Usefulness of Chest X-Rays for T1a Renal Cell Carcinoma Surveillance. J Urol. 2016;196(2):321-326. Observational-Dx 258 patients To evaluate the usefulness of chest x-rays based on the current AUA (American Urological Association) guidelines and National Comprehensive Cancer center (NCCC) Guidelines(R) for T1a renal cell carcinoma surveillance. Pulmonary metastases developed in 3 of 258 patients (1.2%) but only 1 (0.4%) was diagnosed by standard chest x-ray surveillance. Median followup in the entire cohort was 36 months (range 6 to 152) and 193 of 258 patients (75%) had greater than 24 months of followup. A mean of 3.3 surveillance chest x-rays were completed per patient. When assessed by treatment type, there was no significant difference in the recurrence rate for partial nephrectomy (0 of 191 cases), radical nephrectomy (0 of 22) or radio frequency ablation (1 of 45 or 2.2%) (p = 0.09). 2
19. Doornweerd BH, de Jong IJ, Bergman LM, Ananias HJ. Chest X-ray in the follow-up of renal cell carcinoma. World J Urol. 32(4):1015-9, 2014 Aug. Observational-Dx 249 patients To evaluate the value of chest X-ray in the follow-up of surgically treated T1-3N0M0 renal cell carcinoma. In 17.5 years, 249 patients with a T1-3N0M0 renal cell carcinoma underwent a radical or partial nephrectomy. In 221 patients, 823 chest X-rays were performed during a median follow-up of 3.3 years (range 0.5-17 years). In 19 patients, a pulmonary recurrence occurred, of which 10 were not detected by the regular follow-up. Of the 9 patients that were diagnosed with a pulmonary recurrence with a chest X-ray during follow-up, 7 were asymptomatic at the time of diagnosis, and the chest X-ray has led to the detection; 0.85 % of the performed chest X-rays (7/823) have led to the detection of asymptomatic lung metastases. 2
20. Kowalczyk KJ, Harbin AC, Choueiri TK, et al. Use of surveillance imaging following treatment of small renal masses. J Urol. 190(5):1680-5, 2013 Nov. Review/Other-Dx 1,682 patients To determine the rate of post-treatment imaging after various treatments for small renal mass. On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy ([odds ratio] OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent. 4
21. Hafez KS, Novick AC, Campbell SC. Patterns of tumor recurrence and guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. J Urol. 1997; 157(6):2067-2070. Observational-Tx 327 patients To delineate patterns of tumor recurrence and develop guidelines for follow-up after nephron sparing surgery for sporadic RCC. Renal cell carcinoma recurred after nephron sparing surgery in 38 patients (11.6%), including 13 (4.0%) who had local tumor recurrence with (7) or without (6) metastatic disease and 25 (7.6%) who had metastatic disease without local tumor recurrence. Recurrent renal cell carcinoma was detected by associated symptoms in 25 patients and by a followup chest x-ray or abdominal computerized tomography (CT) in 13. The respective incidences of postoperative local tumor recurrence and metastatic disease according to initial pathological tumor stage were 0 and 4.4% for stage T1, 2.0 and 5.3% for stage T2, 8.2 and 11.5% for stage T3a, and 10.6 and 14.9% for stage T3b disease. The peak postoperative intervals until local tumor recurrence were 6 to 24 months (7 of 10 patients with stage T3 renal cell carcinoma) and longer than 48 months (all 3 with stage T2 disease). Patients with isolated local tumor recurrence had better survival compared to those with local tumor recurrence and metastatic disease or metastases only. 2
22. Jain Y, Liew S, Taylor MB, Bonington SC. Is dual-phase abdominal CT necessary for the optimal detection of metastases from renal cell carcinoma? Clin Radiol. 2011; 66(11):1055-1059. Observational-Dx 100 patients To determine whether dual-phase abdominal computed tomography (CT) detected more metastases than portal-phase CT alone in patients with renal cell carcinoma (RCC). Metastases were identified in the liver in 27 patients, pancreas in 12, and contralateral kidney in 23 patients. Nine of the 27 (33%) liver metastases, three of the 12 (25%) pancreatic metastases, and two of the 23 (9%) renal metastases were only detected in the arterial phase, whilst four of the 27 (15%) liver metastases, three of the 12 (25%) pancreatic metastases, and two of the 23 (9%) renal metastases were only detected in the portal phase. Nine patients (9%) had metastases only visualized in the arterial phase, and six (6%) only in the portal phase. Detection of metastases only visible in the arterial phase led to a change of management in two patients (2%). 2
23. Fielding JR, Aliabadi N, Renshaw AA, Silverman SG. Staging of 119 patients with renal cell carcinoma: the yield and cost-effectiveness of pelvic CT. AJR. 1999; 172(1):23-25. Review/Other-Dx 119 patients Computerized review of medical records to determine the yield and cost-effectiveness of pelvic CT in staging RCC. Total estimated cost of the 119 CT examinations of the pelvis was $40,698 ($342 each). No findings of probable malignancy were identified. In 27 patients, CT showed benign findings; these results did not cause planned surgery to be delayed. Three of these 27 patients underwent further radiologic tests at an estimated total cost of $243. 4
24. Khaitan A, Gupta NP, Hemal AK, Dogra PN, Seth A, Aron M. Is there a need for pelvic CT scan in cases of renal cell carcinoma? Int Urol Nephrol. 2002; 33(1):13-15. Review/Other-Dx 400 patients Retrospective study to determine the necessity of pelvic CT in patients of RCC. Of the 400 cases, 114 were stage I, 68 were stage II, 99 were stage III and 119 were stage IV. In all patients, tumor was identified in the kidney on preoperative CT scan. 14 patients (3.5%) had an abnormality on pelvic CT. Five (1.25%) had category 1, three (0.75%) had category 2 and six (1.5%) had category 3 abnormality on pelvic CT. However, all these abnormalities in pelvis were detected prior to CT by other investigations (ultrasonograms or plain radiograph). Of the six cases with malignant findings, two had superficial bladder cancer, one had RCC in a pelvic kidney and three had bone metastases in the pelvis. Pelvic CT does not offer additional information in the vast majority of cases with RCC and should be performed selectively. Thus the cost of diagnostic imaging in RCC can be reduced. 4
25. Winter H, Meimarakis G, Angele MK, et al. Tumor infiltrated hilar and mediastinal lymph nodes are an independent prognostic factor for decreased survival after pulmonary metastasectomy in patients with renal cell carcinoma. J Urol. 2010; 184(5):1888-1894. Observational-Dx 110 patients To analyze the value of computerized tomography to predict mediastinal/hilar lymph node involvement as well as the impact of systematic lymphadenectomy on survival in patients with pulmonary renal cell carcinoma metastasis. Lymph node metastasis was histologically proved in 35% of patients. Metastasis was not associated with initial tumor grade, lymph node status, the number of pulmonary metastases or recurrent pulmonary metastasis. Computerized tomography had 84% sensitivity and 97% specificity to predict lymph node metastasis. Sensitivity was markedly better for detecting mediastinal than hilar lymph node metastasis (90% vs 69%). Patients with lymph node metastasis had significantly shorter median survival than patients without lymph node metastasis (19 vs 102 months, p <0.001). Multivariate analysis revealed that tumor infiltrated mediastinal lymph nodes were an independent prognostic factor for patient survival. Match paired analysis showed that after lymph node dissection patients showed a trend toward improved survival. 3
26. Platzek I, Zastrow S, Deppe PE, et al. Whole-body MRI in follow-up of patients with renal cell carcinoma. Acta Radiol. 2010; 51(5):581-589. Observational-Dx 28 patients To compare the diagnostic accuracy of whole-body MRI and computed tomography (CT) in follow-up of patients with renal cell carcinoma. MRI demonstrated a significantly better diagnostic accuracy regarding musculoskeletal metastases compared with CT (97.7% vs 82%, P<0.001). In contrast, CT was superior in the detection of pulmonary metastases (88.5% vs 71.9%, P<0.001). Both methods had similar diagnostic performance regarding lymph node metastases (CT, accuracy 82.4%; MRI, accuracy 83.4%, P=0.25). The concordance of both modalities regarding N and M stage was excellent (Cohen's kappa 1.00). In two patients cerebral metastases were revealed by MRI, which led to a change in therapy. 2
27. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Review/Other-Dx N/A To assist radiologists in recognizing and managing risks associated with the use of contrast media. No abstract available. 4
28. Barwari K, Wijkstra H, van Delden OM, de la Rosette JJ, Laguna MP. Contrast-enhanced ultrasound for the evaluation of the cryolesion after laparoscopic renal cryoablation: an initial report. J Endourol. 27(4):402-7, 2013 Apr. Observational-Dx 45 cases To demonstrate microvasculature without using either ionizing radiation or toxic contrast agent. In total, 45 tumors were included (29 biopsy proven renal cell carcinoma (RCC), mean size 2.66 cm). One cryoablation failed, resulting in a nonenhancing cryolesion apart from the persisting renal tumor. There were no postablation recurrences during the study period. Pre-laparoscopic renal cryoablation (LCA): Both modalities were available in 26 cases. In 20 out of 26, there was concordance of enhancement score (77%, all cases score 3 or 4). Three months: Both modalities were available in 32 cases. Enhancement score corresponded in 23 out of 32 cases (72%). Seven cases showed enhancement on contrast-enhanced computed tomography (CECT)/ Magnetic resonance imaging (MRI) ("1" in six cases, "4" in one case) with enhancement score "0"on Contrast-enhanced ultrasound (CEUS). Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 92%, negative predictive value [NPV] 77%). Except one case, all enhancement resolved on subsequent imaging. Twelve months: Both modalities were available in 21 tumors. Enhancement score corresponded in 19 out of 21 cases (91%). Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 90%, NPV 100%). 2
29. Garbajs M, Popovic P. Contrast-enhanced ultrasound for assessment of therapeutic response after percutaneous radiofrequency ablation of small renal tumors. J. Balk. Union Oncol.. 21(3):685-90, 2016 May-Jun. Observational-Dx 20 patients To evaluate the efficacy of contrast-enhanced ultrasound (CEUS) in the assessment of therapeutic response, after percutaneous radiofrequency ablation (RFA) of small renal tumors. Median time from RFA to diagnostic imaging was 16.8 months. All 20 patients underwent computed tomography (CT). CEUS was finally performed in only 14 out of 20 patients (70%), since 2 out of 6 had contraindications for the application of a ultrasound (US) contrast agent. Also, one patient refused the application and a further 3 had tumors that were impossible to differentiate adequately on the conventional B-mode US, in order to satisfactorily monitor the contrast enhancement. CEUS showed a complete response in 9 out of 14 (64.3%) patients, residual tumor in 4 (28.6%) and tumor progression in 1 patient (7.1%). Median thickness of the enhancing area on contrast-enhanced computed tomography (CECT) and CEUS was 20 mm vs 17 mm, respectively, with no statistically significant difference in the thickness (t =-0.816, p=0.461) between both modalities. The concordance between CECT and CEUS in the assessment of tumor response and detection of residual vascular enhancement was 100%. 2
30. Hoeffel C, Pousset M, Timsit MO, et al. Radiofrequency ablation of renal tumours: diagnostic accuracy of contrast-enhanced ultrasound for early detection of residual tumour. Eur Radiol. 20(8):1812-21, 2010 Aug. Experimental-Dx 43 patients; 76 ablation sessions To evaluate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in the early detection of residual tumour after radiofrequency ablation (RFA) of renal tumours. A total of 66 renal tumours in 43 patients (median age 62 years; range 44-71.5) were studied. Inter-reader agreement (kappa value) was 0.84 for CEUS. Prevalence of residual disease was 19%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), respectively, were as follows: 64% [confidence interval (CI) 39-84], 98% [CI 91-100], 82% [CI 52-95] and 92% [CI 83-97] on 24-h CEUS; 79% [CI 52-92], 100% [CI 94-100], 100% [CI 74-100] and 95% [CI 87-100] on 6-week CEUS; 79% [CI 52-92], 95% [CI 86-98], 79% [CI 52-92] and 95% [CI 86-98] on 24-h computed tomography (CT) or magnetic resonance imaging (MRI); and 100% [CI 72-100], 98% [CI 90-100], 91% [CI 62-98] and 100% [CI 93-100] on 6-week CT/MRI. 2
31. Kong WT, Zhang WW, Guo HQ, et al. Application of contrast-enhanced ultrasonography after radiofrequency ablation for renal cell carcinoma: is it sufficient for assessment of therapeutic response?. Abdom Imaging. 36(3):342-7, 2011 Jun. Experimental-Dx 63 patients To assess the efficacy of contrast-enhanced ultrasonography (CEUS) with Sonovue in the evaluation of therapeutic response to radiofrequency ablation (RFA) of renal cell carcinoma (RCC). On the 1-month CEUS and computed tomography (CT) imaging after RFA, 62 of 64 tumors (96.9%) were successfully ablated with one session, and residual tumors were found in two RCCs. One of the two tumors was subjected to additional RFA treatment. We could not obtain a complete ablation in the other tumor of a patient with solitary kidney. The diagnostic concordance between the CEUS and 1-month follow-up CT was 100%. Sixty-one patients survived in the follow-up phase which ranged from 2 to 34 months. One patient with solitary kidney died of systemic disease progression and one patient was lost to follow-up. Of the 61 tumors without residual on both CT and CEUS after RFA, four had suspicious findings of recurrence on follow-up CEUS, and two of them were confirmed by subsequent CT examination. With CT as the reference imaging procedure in the assessment of renal tumor ablation, the sensitivity, specificity, positive predictive value, and negative predictive value of CEUS for detecting recurrence during follow-up were 100%, 96.6%, 50%, and 100%. 2
32. Sanz E, Hevia V, Arias F, et al. Contrast-enhanced ultrasound (CEUS): an excellent tool in the follow-up of small renal masses treated with cryoablation. Curr Urol Rep. 16(1):469, 2015 Jan. Observational-Dx 16 patients; 16 tumors To compare outcomes between Contrast-enhanced ultrasound (CEUS) and computed tomography (CT) in the follow-up of small renal masses (SRMs) treated with cryoablation, as well as to assess degree of agreement between them. CEUS detected contrast enhancement in three patients (3/16, 18.8%) and CT in two patients (2/16, 12.5%). Degree of agreement between CEUS and CT, according to Landis-Koch classification, was 0.76 (CI 0.33-1.19; p = 0.0165), which is excellent and higher than expected by random. Sensitivity of the test is 93.75% (15/16). Median time of follow-up after cryoablation is 22 months (15.5-36.5). 3
33. Zeccolini G, Del Biondo D, Cicero C, Casarin A, Guarise A, Celia A. Comparison of Contrast-Enhanced Ultrasound Scan (CEUS) and MRI in the follow-up of cryoablation for small renal tumors. Experience on 25 cases. Urologia. 81 Suppl 23:S1-8, 2014 Jan-Mar. Observational-Dx 25 patients To focus on the efficiency of contrast enhanced ultrasound scan (CEUS) as compared to contrast enhanced magnetic resonance imaging (MRI) during the follow-up after cryoablation of small renal tumors. The mean age of the 25 pts was 67.7 years (range 56-79); 5 pts were females and 20 were males. The mean tumor size was 2.8 cm (range 1.5-3.5). No patient required conversion to open procedure. 19 tumors were located at the lower pole, 4 were interpolar and 2 tumors were located at the upper pole. There were no intraoperative complications. The mean hospital stay was 4 days (range 1-7). Two pts required a blood transfusion; there was no statistically significant difference between preoperative and postoperative serum creatinine levels. The biopsy showed Renal Cell Carcinoma (RCC) in all cases. In 24/25 patients both CEUS and MRI showed no enhancement. In 1/25 pts, during the follow-up, CEUS and MRI showed a well visible recurrence at the perfusion study. It was histologically confirmed. The final results of CEUS and MRI were concordant in all pts. 2
34. Blacher E, Johnson DE, Haynie TP. Value of routine radionuclide bone scans in renal cell carcinoma. Urology, 1985; 26(5):432-434. Observational-Dx 85 patients To evaluate routine bone scanning for staging for RCC. Sensitivity 93%, specificity 86%. Although bone scanning was useful for confirming clinically or radiographically suspected metastatic disease, it did not influence the staging of the RCC in any patient. It is concluded that bone scans should be used to confirm the presence and to determine the extent of osseous metastases in patients with RCC but are unnecessary as a routine staging procedure. 3
35. Koga S, Tsuda S, Nishikido M, et al. The diagnostic value of bone scan in patients with renal cell carcinoma. J Urol. 2001;166(6):2126-2128. Observational-Dx 162 men; 43 women To assess the diagnostic value of bone scan in patients with renal cell carcinoma. Of the 56 patients (27%) with an abnormal bone scan 32 (57%) had osseous metastatic lesions. Overall bone metastasis was present in 34 of the 205 patients (17%). Bone scan had 94% sensitivity and 86% specificity. Of the 124 patients with clinically localized, stages T1-2N0M0 disease exclusive of bone metastasis 6 (5%) had bone metastasis only, whereas 28 of 81 (35%) with locally advanced or metastatic disease had bone metastasis, including 12 (35%) who complained of bone pain and 19 (56%) who presented with other symptoms due to local tumor growth or metastasis at other sites. Three patients (9%) were asymptomatic. There was osseous metastasis without other metastasis, enlarged regional lymph nodes or bone pain in 7 patients, including 1 with stage T1b (2% of all with that stage), 2 with stage T2 (5%), 1 with stage T3a (4%), 1 with stage T3b (6%), 1 with stage T3c (14%) and 1 with stage T4 (6%) disease. 3
36. Ma H, Shen G, Liu B, Yang Y, Ren P, Kuang A. Diagnostic performance of 18F-FDG PET or PET/CT in restaging renal cell carcinoma: a systematic review and meta-analysis. [Review]. Nucl Med Commun. 38(2):156-163, 2017 Feb. Meta-analysis 15 studies To evaluate its diagnostic performance for detecting metastatic or recurrent lesions in patients with renal cell carcinoma (RCC). A total of 15 studies involving 1168 patients fulfilled the inclusion criteria. After excluding one study on the basis of the sensitivity analysis, the pooled estimates of 14 studies were 0.86 [95% confidence interval (CI), 0.88-0.93] for sensitivity, 0.88 (95% CI, 0.84-0.91) for specificity, 5.85 (95% CI, 4.27-8.03) for positive likelihood ratio, 0.18 (95% CI, 0.12-0.26) for negative likelihood ratio, and 42.12 (95% CI, 21.56-82.28) for diagnostic odds ratio. The area under the curve and Q* estimates were 0.9310 and 0.8663, respectively. Good
37. Gerety EL, Lawrence EM, Wason J, et al. Prospective study evaluating the relative sensitivity of 18F-NaF PET/CT for detecting skeletal metastases from renal cell carcinoma in comparison to multidetector CT and 99mTc-MDP bone scintigraphy, using an adaptive trial design. Ann Oncol. 26(10):2113-8, 2015 Oct. Observational-Dx 10 participants To assess the sensitivity of (18)F-labelled sodium fluoride in conjunction with positron emission tomography/computed tomography ((18)F-NaF PET/CT) for detecting renal cell carcinoma (RCC) bone metastases, compared with conventional imaging by bone scintigraphy or computed tomography (CT). Seventy-seven lesions were diagnosed as malignant: 100% were identified by (18)F-NaF PET/CT, 46% by CT and 29% by bone scintigraphy/single photon emission computed tomography (SPECT). Standard-of-care imaging with CT and bone scintigraphy identified 65% of the metastases reported by (18)F-NaF PET/CT. On an individual patient basis, (18)F-NaF PET/CT detected more RCC metastases than (99m)Tc-labelled methylene diphosphonate ((99m)Tc-MDP) bone scintigraphy/SPECT or CT alone (P = 0.007). The metabolic volumes, mean and maximum standardized uptake values (SUV mean and SUV max) of the malignant lesions were significantly greater than those of the benign lesions (P < 0.001). 3
38. Sawicki LM, Buchbender C, Boos J, et al. Diagnostic potential of PET/CT using a 68Ga-labelled prostate-specific membrane antigen ligand in whole-body staging of renal cell carcinoma: initial experience. Eur J Nucl Med Mol Imaging. 44(1):102-107, 2017 Jan. Observational-Dx 6 male patients To evaluate the diagnostic potential of whole-body PET/CT using a 68Ga-labelled PSMA ligand in renal cell carcinoma (RCC). Five primary RCCs and 16 metastases were evaluated. The mean standardized uptake value (SUVmax) of the primary RCCs was 9.9 +/- 9.2 (range 1.7 - 27.2). Due to high uptake in the surrounding renal parenchyma, the mean Tumour-to-background SUVmax ratios (TBRSUVmax) of the primary RCCs was only 0.2 +/- 0.3 (range 0.02 - 0.7). Eight metastases showed focal galium 68 prostate-specific membrane antigen (68Ga-PSMA) uptake (SUVmax 9.9 +/- 8.3, range 3.4 - 25.6). The mean Metastasis-to background SUVmax ratios (MBRSUVmax) of these Positron emission tomography (PET)-positive metastases was 11.7 +/- 0.2 (range 4.4 - 28.1). All PET-negative metastases were subcentimetre lung metastases. 3
39. Mues AC, Okhunov Z, Haramis G, D'Agostino H, Shingleton BW, Landman J. Comparison of percutaneous and laparoscopic renal cryoablation for small (<3.0 cm) renal masses. J Endourol. 2010; 24(7):1097-1100. Observational-Tx 90 PCA patients for 99 lesions; 81 LCA patients for 97 lesions To review laparoscopic cryoablation (LCA) and percutaneous cryoablation (PCA) in the management of small renal tumors and to compare clinical outcomes, short-term oncologic results, and patient complications. The PCA group had two major complications (2%), and the LCA group had three major complications (3.7%) (P = 0.374). In the LCA group, estimated blood loss was associated with tumor location with hilar tumor demonstrating a significantly higher mean blood loss (191 mL) compared with endophytic, mesophytic, and exophytic tumors (70 mL, 71 mL, 73.5 mL), respectively (P = 0.05). Malignancies rated in the PCA and LCA groups were 50.5% and 60.0%, respectively (P < 0.05). In the PCA group, nine (9.1%) patients demonstrated treatment failure with a persistent enhancement in the ablation bed. All nine were treated with a subsequent PCA. One patient had subsequent tumor bed enhancement and underwent an open radical nephrectomy. Treatment failed in three (3.1%) patients in the LCA cohort (incomplete ablation or recurrence). 2
40. Pirasteh A, Snyder L, Boncher N, Passalacqua M, Rosenblum D, Prologo JD. Cryoablation vs. radiofrequency ablation for small renal masses. Acad Radiol. 2011; 18(1):97-100. Observational-Tx 111 patients A retrospective review of the imaging and histologic outcomes during the transition from CT-guided percutaneous RFA to cryoablation. There were four cases of suspicious enhancement on follow-up computed tomography or magnetic resonance imaging in each group, with cumulative imaging recurrence rates of 11% and 7% for radiofrequency ablation and cryoablation, respectively. Log rank test analysis revealed no significant difference between rates of imaging recurrence between the two groups (P = .6044). 2
41. Young EE, Castle SM, Gorbatiy V, Leveillee RJ. Comparison of safety, renal function outcomes and efficacy of laparoscopic and percutaneous radio frequency ablation of renal masses. J Urol. 2012; 187(4):1177-1182. Observational-Tx 298 patients with 316 renal tumors To compare the laparoscopic and percutaneous approach for the radio frequency ablation of renal tumors under the guidance of urological surgeons. There were no statistically significant differences between the laparoscopic and computerized tomography guided radio frequency ablation groups with respect to patient demographics, complication rates and renal functional outcomes (p>0.05). The 3-year Kaplan-Meier estimation of radiographic recurrence-free probability was 95% for computerized tomography guided radio frequency ablation and 94% for laparoscopic radio frequency ablation (p=0.84). Subanalysis of the 212 (67%) renal cell carcinoma tumors showed a 3-year Kaplan-Meier estimation of oncologic recurrence-free probability (post-ablation biopsy proven viable tumor) of 94% for computerized tomography guided radio frequency ablation and 100% for laparoscopic radio frequency ablation (p=0.16). Median followup was 21 months for laparoscopic radio frequency ablation) and 19 months for computerized tomography guided radio frequency ablation. 2
42. Aron M, Kamoi K, Remer E, Berger A, Desai M, Gill I. Laparoscopic renal cryoablation: 8-year, single surgeon outcomes. J Urol. 2010; 183(3):889-895. Observational-Tx 80 patients To report oncological outcomes in patients at a minimum 5-year follow-up after laparoscopic renal cryoablation done by a single surgeon. In the 80 patients with minimum 5-year follow-up mean age was 66 years, mean tumor size was 2.3 cm (range 0.9 to 5.0), median American Society of Anesthesiologists score was 3 and mean body mass index was 28 kg/m2. Five patients had local recurrence, 2 had locoregional recurrence with metastasis and 4 had distant metastasis without locoregional recurrence. Six patients died of cancer. In the 55 patients with biopsy proven renal cell cancer at a median follow-up of 93 months (range 60 to 132) 5-year overall, disease specific and disease-free survival rates were 84%, 92% and 81%, and 10-year rates were 51%, 83% and 78%, respectively. On multivariate analysis previous radical nephrectomy for RCC was the only significant predictor of disease-free and disease specific survival (p 0.023 and 0.030, respectively). 2
43. Balageas P, Cornelis F, Le Bras Y, et al. Ten-year experience of percutaneous image-guided radiofrequency ablation of malignant renal tumours in high-risk patients. Eur Radiol. 23(7):1925-32, 2013 Jul. Observational-Dx 93 patients To evaluate survival and outcomes after percutaneous radiofrequency ablation (RFA) of malignant renal tumours in high-risk patients with long-term follow-up. Radiofrequency ablation was technically possible for all patients. Mean follow-up was 38.8 months (range: 18-78 months). Primary and secondary technique effectiveness was 95.2 % and 98.4 % per patient respectively. The rates of local tumour progression and metastatic evolution were 3.2 % and 9.7 % per patient and were associated with tumour size >4 cm (P = 0.005). The disease-free survival rates were 88.3 % and 61.9 % at 3 and 5 years. No significant difference in glomerular filtration rates before and after the procedure was observed (P = 0.107). The major complications rate was 5.9 % per session with an increased risk in the case of central locations (P = 0.006). 2
44. Breen DJ, Bryant TJ, Abbas A, et al. Percutaneous cryoablation of renal tumours: outcomes from 171 tumours in 147 patients. BJU Int. 112(6):758-65, 2013 Oct. Experimental-Dx 147 patients; 171 tumours To evaluate the technical and oncological efficacy of an image-guided cryoablation programme for renal tumours. No variables were found to predict subtotal treatment, although gender (P = 0.08), tumour size of >4 cm (P = 0.09) and central location of tumour (P = 0.07) approached significance. Upper pole location was the single variable that was found to predict complications (P = 0.006). Among the 104 patients (125 tumours), radiologically assessed at >/=6 months and with a mean radiological follow-up of 20.1 months, we found a single case of unexpected late local recurrence. 2
45. Georgiades CS, Rodriguez R. Efficacy and safety of percutaneous cryoablation for stage 1A/B renal cell carcinoma: results of a prospective, single-arm, 5-year study. Cardiovasc Intervent Radiol. 37(6):1494-9, 2014 Dec. Observational-Tx 134 patients To perform a prospective study on the safety and efficacy of percutaneous computed tomography (CT)-guided cryoablation for stage 1 renal cell carcinoma (RCC) and determine the 5-year efficacy and oncologic outcomes. The 1-, 2-, 3-, 4-, and 5-year efficacy of percutaneous cryoablation for RCC was 99.2, 99.2, 98.9, 98.5, and 97.0%, respectively. Median tumor size was 2.8 +/- 1.4 cm. All-cause mortality during the study period was 3 (none from RCC), yielding an overall 5-year survival of 97.8%. The cancer-specific 5-year survival was 100%. No patient developed metastatic disease during the follow-up period. The overall significant common terminology criteria for adverse events (CTCAE) version 4.0 complication rate was 6%, with the most frequent being transfusion-requiring hemorrhage, at 1.6%. There was one 30-day mortality unrelated to the procedure. 2
46. McDougal WS, Gervais DA, McGovern FJ, Mueller PR. Long-term followup of patients with renal cell carcinoma treated with radio frequency ablation with curative intent. J Urol. 2005; 174(1):61-63. Review/Other-Tx 16 patients (20 tumors) To evaluate the success rate of RFA of RCC followed for a minimum of 4 years. All tumors were biopsy proven RCC. 5/16 patients died of unrelated causes before 4 years of follow-up. All except one tumor was successfully treated. Surveillance protocol: postablation contrast-enhanced CT (or MRI if abnormal renal function) was performed within 1 month, at 3 months and 6 months if no residual disease requiring treatment. At 6 months patients were imaged at 6 months to yearly intervals thereafter. RFA of exophytic RCC >5 cm in diameter is effective in eradicating the tumor and comparable to surgical extirpation at 4 years. 4
47. Wah TM, Irving HC, Gregory W, Cartledge J, Joyce AD, Selby PJ. Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): experience in 200 tumours. BJU Int. 113(3):416-28, 2014 Mar. Observational-Tx 165 patients To evaluate our clinical experience with percutaneous image-guided radiofrequency ablation (RFA) of 200 renal tumours in a large tertiary referral university institution. In all, 200 tumours were RF ablated with a mean (range) tumour size of 2.9 (1-5.6) cm and the mean (range) patient age was 67.7 (21-88.6) years with a mean follow-up period of 46.1 months. The primary technical and overall technical success rate was 95.5% and 98.5%, respectively. Two independent predictors of successful RFA in a single sitting were tumour size (<3 cm) and exophytic location in multivariate logistic regression analysis. Major complications included ureteric injury (six patients), calyceal-cutaneous fistula (one), acute tubular necrosis (one) and abscess (two). Two independent predictors of ureteric injury were central location and lower pole position. Within this cohort of patients, only four patients developed significant renal function deterioration i.e. >25% decreased in GFR. In all, 161 (98%) patients of the 165 patients have preservation of renal function. Any change in renal function after RFA was not influenced by tumour factors or solitary kidney status. In our clinical series, this yielded a 5-year OS, CSS, LRFS and MFS rates of 75.8%, 97.9%, 93.5% and 87.7% respectively. 2
48. Zagoria RJ, Pettus JA, Rogers M, Werle DM, Childs D, Leyendecker JR. Long-term outcomes after percutaneous radiofrequency ablation for renal cell carcinoma. Urology. 2011; 77(6):1393-1397. Observational-Tx 48 RCCs in 41 patients To assess the long-term oncological efficacy of radiofrequency ablation (RFA) for treatment of renal cell carcinoma (RCC). Median size of RCC treated was 2.6 cm (range: 0.7-8.2 cm). Of the 48 treated RCCs, 5 (12%) had recurrent tumor after a single ablation session. The median size of the index lesion in the cases with recurrence was 5.2 cm (interquartile range [IQR]: 4-5.3) compared with 2.2 cm (IQR: 1.7-3.1, P = .0014) without local recurrence. There were no recurrences when RCCs less than 4 cm were treated. Seventeen (41%) patients with 18 treated RCCs died during the follow-up period at a median time of 34 (IQR: 10-47) months. One patient (2%) died of metastatic RCC, whereas 16 died of unrelated causes. Twenty-four patients with 30 RCCs treated with RFA survived. For the remaining 30 RCCs, median follow up was 61 months (IQR: 54-68). No patients in this group of survivors had metastatic RCC, 1 had recurrence diagnosed at 68 months. The long-term recurrence-free survival rate was 88% after RFA. 2
49. Best SL, Park SK, Yaacoub RF, et al. Long-term outcomes of renal tumor radio frequency ablation stratified by tumor diameter: size matters. J Urol. 2012; 187(4):1183-1189. Observational-Tx 159 tumors To analyze tumor size related outcomes for RFA, focusing on patients with long-term followup. Median tumor size was 2.4 cm (range 0.9 to 5.4) with a median followup of 54 months (range 1.5 to 120). Renal cell carcinoma was confirmed in 72% of the 150 tumors that had pre-ablation biopsy (94%). The 3 and 5-year disease-free survival was comparable at 92% and 91% overall, and was dependent on tumor size, being 96% and 95% for tumors smaller than 3.0 cm and 79% and 79%, respectively, for tumors 3 cm or larger (p=0.001). Most failures (14 of 18) were local, either incomplete ablations or local recurrences. This is an intent to treat analysis and, therefore, includes patients ultimately found to have benign tumors, although outcomes were comparable in patients with cancer. 2
50. Javadi S, Ahrar JU, Ninan E, Gupta S, Matin SF, Ahrar K. Characterization of contrast enhancement in the ablation zone immediately after radiofrequency ablation of renal tumors. J Vasc Interv Radiol. 21(5):690-5, 2010 May. Review/Other-Dx 34 patients To characterize the degree of contrast enhancement within the ablation zone immediately after radiofrequency (RF) ablation of renal tumors. A total of 36 renal tumors in 34 patients were treated with computed tomography (CT)-guided RF ablation in 35 sessions. Before RF ablation, all tumors exhibited enhancement after intravenous administration of contrast material. The peak density was reached during the parenchymal phase, with a partial washout of contrast agent in the excretory phase. On CT images acquired immediately after RF ablation (day 0), 28 of the 36 ablated tumors (78%) exhibited clinically significant homogeneous enhancement (ie, density change >10 hounsfield unit (HU) within the ablation zone. However, contrast-enhanced CT studies performed at 1 and 6 months revealed no clinically significant enhancements in any of the 36 treated tumors (mean density changes of 4 HU at 1 month and 3 HU at 6 months). 4
51. Nielsen TK, Ostraat O, Andersen G, Hoyer S, Graumann O, Borre M. Computed Tomography Contrast Enhancement Following Renal Cryoablation--Does it Represent Treatment Failure?. J Endourol. 29(12):1353-60, 2015 Dec. Observational-Dx 107 patients To investigate the proportion of spontaneous resolutions after initial contrast enhancement in relation to cryoablation. A total of 107 patients with a biopsy-verified malignant tumor were included in the study. On postoperative imaging, 33 (31%) patients presented with contrast enhancement. Spontaneous resolution was observed in 15 (45%) patients after a mean follow-up time of 14 months. Patients with cryolesions that resolved spontaneously were found to have a less anatomical complex tumor compared to patients with treatment failure (PADUA 7.8 vs 9.5, p?<?0.01). A total of seven patients with a preoperative aspects and dimensions used for anatomical (PADUA) score =10 and contrast-enhancing cryolesions were found to have treatment failure. No association was found among body mass index, histology, treatment modality, enhancement pattern, number of applied cryoprobes, and resolution. 2
52. Park SY, Kim CK, Park BK. Dual-energy CT in assessing therapeutic response to radiofrequency ablation of renal cell carcinomas. Eur J Radiol. 83(2):e73-9, 2014 Feb. Observational-Dx 47 patients To investigate the utility of dual-energy (DE) computed tomography (CT) using virtual noncontrast (VNC) and iodine overlay (IO) images to assess therapeutic response to radiofrequency ablation (RFA) for renal cell carcinomas (RCCs). The iodine overlay (IO) images from corticomedullary and late nephrographic phases showed excellent diagnostic performance (each sensitivity 100% and each specificity 91.5%) for predicting local tumor progression. The degree of enhancement of local tumor progression was not significantly different between linearly blended and IO images (P>0.05). The mean CT numbers were not significantly different between true noncontrast (TNC) and VNC images (P>0.05). In renal cortex-to-RFA site, Contrast-to-noise ratios (CNR) between linearly blended and IO images was not significantly different (P>0.05). The VNC imaging quality from the two phases was given a good rating. 3
53. Lee HJ, Chung HJ, Wang HK, et al. Evolutionary magnetic resonance appearance of renal cell carcinoma after percutaneous cryoablation. Br J Radiol. 89(1065):20160151, 2016 Sep. Review/Other-Dx 26 patients To determine the evolutionary magnetic resonance imaging (MRI) appearance of renal cell carcinoma (RCC) following cryoablation. A total of 26 patients were enrolled. The ablated tumours exhibited predominantly high signals on T1WI at 1–9-month follow-up (47.1% strong hyperintense at 3 months) and subsequently returned to being isointense. In T2WI, the signals of the ablated tumours were highly variable during the first 3 months and became strikingly hypointense after 6 months (58.3% strong hypointense at 6 months). Diffusion restriction was prominent during the first 3 months (lowest apparent diffusion coefficient (ADC): 0.6260.2931023mm2 s21 at 1month). Contrast enhancement persisted up to 6 months after the procedure. The residual enhancement gradually increased in the dynamic scan and was most prominent in the delay phase. 4
54. Takaki H, Nakatsuka A, Cornelis F, et al. False-Positive Tumor Enhancement After Cryoablation of Renal Cell Carcinoma: A Prospective Study. AJR Am J Roentgenol. 206(2):332-9, 2016 Feb. Observational-Dx 30 patients To prospectively evaluate the frequency of false-positive tumor enhancement after cryoablation of renal cell carcinoma (RCC). The planned protocol was completed by 30 of the 33 enrolled patients (90.9%) with 30 RCCs (mean [± SD] size, 23.0 ± 8.7 cm; range, 1.0–4.7 cm). Complete tumor ablation was achieved for 25 RCCs (83.3%). Residual tumors were found in association with the other five RCCs (16.7%). Of the 25 completely ablated RCCs, false-positive tumor enhancement was observed for 15 tumors (60.0%) at 2–3 days after cryoablation; it continued to be observed for 13 tumors (52.0%) at 5–7 days and for one tumor (4.0%) at 1 month after cryoablation. The rate of false-positive tumor enhancement noted at 5–7 days after cryoablation was statistically significantly higher for clear cell RCCs (63.2%; 12/19) than for other RCC subtypes (16.7%; 1/6; p < 0.05). 2
55. Porter CA 4th, Woodrum DA, Callstrom MR, et al. MRI after technically successful renal cryoablation: early contrast enhancement as a common finding. AJR Am J Roentgenol. 194(3):790-3, 2010 Mar. Observational-Dx 23 patients To assess the magnetic resonance imaging(MRI) appearance and enhancement of renal masses within 36 hours after cryoablation. Eight of the 23 renal masses imaged within 6–36 hours after ablation were enhanced on MR images. Five of the eight lesions exhibited homogeneous enhancement, and the other three had heterogeneous or rim enhancement. Seven of the eight lesions exhibited no enhancement at the 6-month follow-up examination. One patient underwent follow-up imaging 10 months rather than 3–6 months after the procedure, but no enhancement was seen. T2- weighted signal intensity was mixed among the 23 renal masses. T1-weighted signal intensity was mixed among the 23 renal masses and the eight lesions that became enhanced, but there was a trend for higher T1 signal intensity at the 3- to 6-month follow-up examination. 2
56. Borghesi M, Brunocilla E, Volpe A, et al. Active surveillance for clinically localized renal tumors: An updated review of current indications and clinical outcomes. [Review]. Int J Urol. 22(5):432-8, 2015 May. Review/Other-Dx N/A To offer a comprehensive and updated review of the current criteria, indications and results of active surveillance in patients with clinically localized renal tumor. No results stated in abstract. 4
57. Mason RJ, Abdolell M, Trottier G, et al. Growth kinetics of renal masses: analysis of a prospective cohort of patients undergoing active surveillance. Eur Urol. 59(5):863-7, 2011 May. Observational-Dx 82 patients To report the analysis of a multi-institutional cohort of patients undergoing Active surveillance (AS) for small renal masses. With a median follow-up of 36 mo (range: 6-96), the mean annual renal mass growth rate for the entire cohort was 0.25 cm/yr (standard deviation [SD]: 0.49 cm/yr). Only one patient (1.2%) developed metastatic Renal cell carcinoma (RCC). Amongst all variables, maximum diameter at diagnosis was the only predictor of tumour growth rate, and two distinct growth rates were identified. Masses that are >/=2.45 cm in largest diameter at diagnosis grow faster than smaller masses. This series was limited by its moderate sample size, although it is the largest published prospective series to date. 2
58. Patel N, Cranston D, Akhtar MZ, et al. Active surveillance of small renal masses offers short-term oncological efficacy equivalent to radical and partial nephrectomy. BJU Int. 110(9):1270-5, 2012 Nov. Observational-Dx 202 patients; 234 small renal masses To compare the oncological outcomes of active surveillance (AS), radical nephrectomy (RN) and partial nephrectomy (PN) in the management of T1a small renal masses (SRMs). A total of 202 patients with 234 T1a small renal masses (SRMs) (solid or Bosniak IV) were identified; 71 patients were managed with AS, 41 with an RN and 90 by PN. * Over a median follow-up of 34 months the mean growth rate on AS was 0.21 cm/year with 53% of SRMs managed with AS showing negative or zero growth. * No statistically significant difference was observed in overall (OS) and cancer-specific (CSS) survival for AS, RN and PN (AS-CSS 98.6%, AS-OS 83%; RN-CSS 92.6%, RN-OS 80.4%; PN-CSS 96.6%, PN-OS 90.0%). 3
59. Pierorazio PM, Johnson MH, Ball MW, et al. Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry. Eur Urol. 68(3):408-15, 2015 Sep. Experimental-Tx 497 patients To determine the characteristics and clinical outcomes of patients who chose active surveillance (AS) for management of their small renal masses (SRMs). Of the 497 patients enrolled, 274 (55%) chose primary intervention (PI) and 223 (45%) chose AS, of whom 21 (9%) crossed over to delayed intervention. AS patients were older, had worse Eastern Cooperative Oncology Group scores, total comorbidities, and cardiovascular comorbidities, had smaller tumors, and more often had multiple and bilateral lesions. Overall survival (OS) for PI and AS was 98% and 96% at 2 yr, and 92% and 75% at 5 yr, respectively (log rank, p=0.06). At 5 yr, cancer-specific survival (CSS) was 99% and 100% for PI and AS, respectively (p=0.3). AS was not predictive of OS or CSS in regression modeling with relatively short follow-up. 1
60. Van Poppel H, Becker F, Cadeddu JA, et al. Treatment of localised renal cell carcinoma. [Review]. Eur Urol. 60(4):662-72, 2011 Oct. Review/Other-Dx N/A To critically review the recent data on the management of localised renal cell carcinoma (RCC) to arrive at a general consensus. No results stated in abstract. 4
61. Yang G, Villalta JD, Meng MV, Whitson JM. Evolving practice patterns for the management of small renal masses in the USA. BJU Int. 110(8):1156-61, 2012 Oct. Review/Other-Dx 48,148 patients To describe the changing practice patterns in the management of small renal masses, including the use of surveillance and ablative techniques. In all, 48 148 patients from 17 registry sites with a mean age of 63.4 years were included for analysis. Between 1998 and 2008, for masses of <2 cm and 2.1-4 cm, there was a dramatic increase in the proportion of patients undergoing partial nephrectomy (PN) (31% vs 50%, 16% vs 33%, respectively) and ablation (1% vs 11%, 2% vs 9%, respectively). In multivariable analysis, later year of diagnosis, male gender, being married, clinically localised disease, and smaller tumours were associated with increased use of PN vs radical nephrectomy (RN). Later year of diagnosis, male gender, being unmarried, smaller tumour, and the presence of bilateral masses were associated with increased use of ablation and surveillance vs RN. 4
62. Haramis G, Mues AC, Rosales JC, et al. Natural history of renal cortical neoplasms during active surveillance with follow-up longer than 5 years. Urology. 77(4):787-91, 2011 Apr. Observational-Dx 44 patients To present our experience with patients who elected active surveillance for renal cortical neoplasms (RCNs) with >/=5 years of follow-up. Few data are available regarding the long-term natural history of RCNs during surveillance. The median patient age was 71.7 years (range 55-92), with 32 patients (72.7%) having a Charlson comorbidity index of >/=2. The median tumor size was 2.67 cm (range 0.9-8.6) at diagnosis. Biopsy was performed in 17 patients (38.6%). Of these 17 patients, clear cell renal cell carcinoma was diagnosed in 15 and papillary renal cell carcinoma in 2 patients. The median follow-up was 77.1 months (range 60-137), and the median growth rate was 0.15 cm/y. Of these patients, 2 (4.5%) required delayed intervention. One underwent laparoscopic radical nephrectomy because of a high tumor growth rate, and one elected to withdraw from active surveillance because of personal anxiety, despite having a stable tumor size for 72 months. The latter patient underwent laparoscopic renal cryoablation. Histopathologic examination revealed clear cell renal cell carcinoma in both cases. No metastases or cancer-related deaths occurred in our cohort; 1 patient died of cardiovascular disease. 3
63. Nayyar M, Cheng P, Desai B, et al. Active Surveillance of Small Renal Masses: A Review on the Role of Imaging With a Focus on Growth Rate. [Review]. J Comput Assist Tomogr. 40(4):517-23, 2016 Jul-Aug. Meta-analysis 21 articles To systematically summarize the current literature in the field of active surveillance for small renal masses, with the primary focus being the role of imaging in the primary decision-making and subsequent follow-up. Twenty-one articles studying imaging in active surveillance of small renal masses were selected. Seventy-two percent (15/21) of studies were retrospective; 19% (4/21) were prospective; and 9% (2/21) studies were bidirectional. Mean age of patients was 69 years (range, 57-81 years). A total of 1386 patients were in the study; 59% of patients were men. Mean follow-up was 39 months (range, 18.8-91.5 months). Sixty-seven percent of masses discussed in this review were followed up using more than one imaging modality; 19% consistently used computed tomography for follow-up whereas the remaining 14% did not specify what imaging modality was used. Imaging studies were reviewed by the investigators centrally in 86% (18/21). In 14% of the studies, only imaging report was reviewed. Biopsy was performed in 24% of masses. Mean growth rate for all tumors was 0.27 cm/y (range, 0.06-0.7 cm/y). For studies where growth rate of benign and malignant masses were differentiated, mean growth rate for benign masses was 0.3 cm/y and mean growth rate for malignant masses was 0.35 cm/y. Good
64. Ficarra V, Brunelli M, Cheng L, et al. Prognostic and therapeutic impact of the histopathologic definition of parenchymal epithelial renal tumors. [Review]. Eur Urol. 58(5):655-68, 2010 Nov. Review/Other-Dx N/A To review the most recent literature on the role of traditional histopathologic features obtained from renal core biopsy or nephrectomy specimens in the management of confined, locally advanced, and metastatic renal cell carcinoma (RCC). No results stated in abstract. 4
65. Doshi AM, Huang WC, Donin NM, Chandarana H. MRI features of renal cell carcinoma that predict favorable clinicopathologic outcomes. AJR Am J Roentgenol. 204(4):798-803, 2015 Apr. Observational-Dx 230 patients To determine whether magnetic resonance imaging (MRI)) features of renal cell carcinoma (RCC), such as enhancing solid component and T1 signal intensity, are associated with clinicopathologic outcomes. The following tumor features were observed: predominantly cystic morphologic features (defined as solid component</=25%, n=33), solid component greater than 25% (n=208), T1 hypointensity (n=97), and T1 intermediate intensity or hyperintensity (n=144). Local recurrence or metastases were observed in 14 patients. Compared with T1-intermediate or -hyperintense lesions, T1-hypointense RCCs were more likely to be low stage (90.7% vs 74.3%; p=0.001) and low grade (78.9% vs 41.8%; p<0.001) and had a lower rate of recurrence or metastases (3.3% vs 8%; p=0.167). Compared with lesions with greater than 25% solid enhancement, predominantly cystic RCCs were more likely to be lower stage (93.9% vs 78.8%; p=0.053) and lower grade (94.7 vs 56.5%; p<0.001) and to have no incidence of recurrence or metastasis (0% vs 6.9%; p=0.227). RCCs that were both cystic and T1 hypointense (n=14) were lower stage (100% vs 79.6%; p=0.047) and lower grade (92.9% vs 58.1%; p=0.01) and had no recurrence or metastases on follow-up. 3
66. Rosenkrantz AB, Mussi TC, Somberg MB, Taneja SS, Babb JS. Comparison of CT-based methodologies for detection of growth of solid renal masses on active surveillance. AJR Am J Roentgenol. 199(2):373-8, 2012 Aug. Observational-Dx 40 patients To retrospectively compare 1Dimentional (D), 2D, and 3D measurements on computed tomography (CT) for detection of growth of solid renal masses on active surveillance. The accuracy of gestalt visual, 1D, 2D, and 3D assessments for detection of interval growth was 72.5%, 70.0%, 82.5%, and 85% for reader 1 and 77.5%, 70.0%, 90.0%, and 95.0% for reader 2. These differences were significant or nearly significant (p = 0.003-0.054) for the greater accuracy of 2D or 3D measurements than for 1D measurements for reader 1 as well as the greater accuracy of 2D measurements than 1D measurements and 3D measurements than gestalt visual assessment or 1D measurements for reader 2. The accuracy of prospective reports for detection of growth was 65.0%. Reader agreement was fair for gestalt visual assessment (kappa = 0.31) and nearly perfect for 1D, 2D, and 3D measurements (intraclass correlation coefficient = 0.97-0.99). 3
67. Quaia E, Bertolotto M, Cioffi V, et al. Comparison of contrast-enhanced sonography with unenhanced sonography and contrast-enhanced CT in the diagnosis of malignancy in complex cystic renal masses. AJR Am J Roentgenol. 2008; 191(4):1239-1249. Observational-Dx 40 patients To evaluate contrast-enhanced sonography in the diagnosis of malignancy in complex cystic renal masses. Final diagnoses comprised two multilocular cystic nephromas, two inflammatory and seven hemorrhagic cysts, and eight uncomplicated benign cysts and 21 cystic RCCs. The overall diagnostic accuracy of contrast-enhanced sonography was better than unenhanced sonography and CT (contrast-enhanced sonography vs unenhanced sonography vs CT: reader 1, 83% vs 30% vs 75%; reader 2, 83% vs 30% vs 63%; reader 3, 80% vs 30% vs 70%; P<0.05, McNemar test). 2
68. Barr RG, Peterson C, Hindi A. Evaluation of indeterminate renal masses with contrast-enhanced US: a diagnostic performance study. Radiology. 271(1):133-42, 2014 Apr. Observational-Dx 721 patients To determine the utility of contrast material–enhanced ultrasonography (US) in the characterization of indeterminate renal masses. Contrast-enhanced US had a sensitivity of 100% (126 of 126; 95% confidence interval [CI]: 97.1%, 100%), specificity of 95.0% (132 of 139; 95% CI: 89.9%, 98.0%), positive predictive value (PPV) of 94.7% (126 of 133), and negative predictive value (NPV) of 100% (132 of 132). The five false-positive masses included three oncocytomas and two Bosniak category 3 cystic lesions. Of the 290 lesions that had follow-up of at least 36 months, none of the lesions demonstrated changes that necessitated lesion reclassification. If these lesions were included, assuming lesions classified as malignant were malignant, then of the 596 lesions, sensitivity was 100% (161 of 161), specificity was 96.6% (420 of 435), PPV was 91.5% (161 of 176), and NPV was 100% (420 of 420). 3
69. Zarzour JG, Lockhart ME, West J, et al. Contrast-Enhanced Ultrasound Classification of Previously Indeterminate Renal Lesions. J Ultrasound Med. 36(9):1819-1827, 2017 Sep. Observational-Dx 134 lesions, 116 patients To determine the utility of contrast-enhanced ultrasound (US) for characterizing renal lesions that were indeterminate on prior imaging. A total of 134 lesions were evaluated with contrast-enhanced US, and 106 were indeterminate by preceding computed tomography, magnetic resonance imag-ing, or US. Only the largest lesion per patient was included in analysis. A total of 95.7% (90 of 94) of the previously indeterminate lesions were successfully classified with contrast-enhanced US. The sensitivity was 100% (20 of 20; 95% confidence interval [CI], 83%–100%; P<.0001); specificity was 85.7% (18 of 21; 95% CI, 62%–97%; P5.0026); positive predictive value was 87.0% (20 of 23; 95% CI, 66%–97%; P5.0005); negative predictive value was 100% (18 of 18; 95% CI, 81%–100%; P<.001); and accuracy was 90.2% (37 of 41; 95% CI, 80%–98%; P<.0001). 3
70. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4