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Purpose of Review: To evaluate the current role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) within the context of evolving treatment paradigms, focusing on implications for patient selection., Recent Findings: Two randomized trials failed to show significant benefits from CN for intermediate and poor-risk patients undergoing targeted therapy. Despite this, subgroup analysis and retrospective data suggest potential benefits for a subset of good and intermediate-risk patients. Although currently used risk stratification tools guide CN eligibility, they have limitations, including, subjectivity, perioperative variability, and missing validation. Deferred CN may benefit patients responding to systemic treatment, whereas other patients may benefit from upfront CN. Emerging data supports the value of CN with immune checkpoint inhibitors (ICI) in selected patients, emphasizing the need for ongoing trials in the ICI era., Summary: The role and timing of CN in mRCC have evolved across therapeutic eras. Although awaiting prospective evidence in the current era of ICI, CN still has a role in the therapeutic approach for a subset of patients. The decision to recommend CN must be personalized and involve multidisciplinary discussions considering both patient- and tumor-related factors., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Perioperative blood transfusion (PBT) has been associated with worse prognosis in several malignancies. For renal cell carcinoma (RCC), the effect of PBT is still debated., Objective: To evaluate the impact of PBT on prognosis after nephrectomy in patients with RCC., Methods: This study is A systematic review and meta-analysis of published article data (PRISMA protocol) for literature related to PBT and RCC through extensive search of EMBASE, Medline via PubMed, Web of Science and Cochrane Library, language limited to English, with no time constraint until May 20, 2022. We pooled the results of multivariable cox regression analyses from each study, with subgroup analyses by dose and timing of transfusion. All analyses were done using Stata14., Results: A total of 12 studies involving 27,683 participants were included. Our meta-analysis pooled the results of multivariable cox regression analysis in each study, showing that PBT is associated with higher overall Mortality (OM; hazard ratio [HR] = 1.34, 1.23-1.44), cancer-specific mortality (CSM; HR = 1.35, 1.20-1.51), and disease recurrence (HR = 1.54, 1.18-1.89). when only patients with nonmetastatic RCC were included, PBT was still associated with higher OM (HR = 1.29, 1.11-1.47) and disease recurrence (HR = 1.58, 1.18-1.98), but the association with CSM (HR = 1.26, 0.99-1.52) was not statistically significant. In subgroup analysis by transfusion dose, small (1-2) units of PBT were not associated with CSM (HR = 1.84, 0.95-2.73), but large (≥3) units were associated with higher CSM (HR = 2.98, 1.74-4.22) and disease recurrence (HR = 1.99, 1.31-2.67). Each additional unit of PBT resulted in a higher CSM (HR = 1.07, 1.04-1.10). In subgroup analysis by transfusion timing, intraoperative transfusion was associated with higher CSM and disease recurrence, but postoperative transfusion was not., Conclusions: PBT is associated with higher OM, CSM and disease recurrence. This adverse effect seems to be particularly significant in high-dose intraoperative transfusion. It is necessary to limit the overuse of PBT, especially high-dose intraoperative transfusion, in order to improve the prognosis of patients undergoing nephrectomy for RCC., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Renal cell carcinoma (RCC) is the most common renal neoplasm, accounting for 2.4% of all cancers in Korea. Although the usual clinical manifestations of RCC include flank pain, hematuria, and palpable mass, RCC is generally characterized by a lack of early warning signs and is mostly discovered incidentally in advanced stage. This case report describes a 42-year-old Korean man diagnosed with giant RCC who presented with simple back pain., Patient Concerns: The clinical manifestation of a 42-year-old Korean man was chronic back pain., Diagnoses: Contrast-enhanced computed tomography showed a 19.1-cm sized heterogeneous enhancing mass on the right kidney and tumor thrombosis extending into inferior vena cava., Intervention: Due to the large size of the tumor and extensive tumor thrombosis, the multidisciplinary team decided to administer neoadjuvant chemotherapy and an anticoagulant. Following 12 cycles of treatment with nivolumab and cabozantinib, he underwent a right radical nephrectomy with an adrenalectomy and tumor thrombectomy., Outcomes: Treatment was successful and posttreatment he started a cancer rehabilitation program. He was followed-up as an outpatient and no longer complains of back pain., Lessons: RCC can manifest clinically as back pain, with diagnosis being difficult without appropriate imaging modalities. RCC should be included in the differential diagnosis of patients with low back pain, even at a young age., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: The author declares no funding or conflicts of interest.

Purpose of Review: Renal cell carcinoma (RCC) is the most common kidney neoplasm. Localized RCC can be cured with nephrectomy. However, a proportion of patients will recur with incurable distant metastatic disease. There is a clear need for treatments to reduce the risk of RCC recurrence and thus improve survival. This review describes the landscape of perioperative therapy for RCC, focusing on more recent trials involving immune checkpoint inhibitors (ICIs)., Recent Findings: ICIs have significantly changed outcomes in advanced RCC. Four trials investigating the role of perioperative ICI for RCC are now reported. Only one trial utilizing adjuvant pembrolizumab (Keynote-564) has shown a disease-free survival benefit in resected RCC., Summary: Patients with resected RCC should be counselled on their risk of recurrence and the potential option of adjuvant pembrolizumab, recognizing that overall survival data are not yet available., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Disclosures None.

Rationale: With a high failure rate and multiple postoperative complications, the resection for tumors in the elbow and reconstruction present a formidable challenge to orthopedic surgeons. The maturation of 3-dimension (3D) printing technology has facilitated the preoperative design, intraoperative navigation, and reconstruction of bone defects in patients with complex malignant tumors of the elbow joint. In order to improve prognosis, we explored a method of tumor resection and elbow reconstruction aided by 3D printing technology in this research., Patient Concerns: The patient underwent nephrectomy for clear cell carcinoma of the left kidney 3 years ago. Six months ago, the patient presented with limited movement and lateral tenderness in the right elbow joint. The tumor puncture biopsy demonstrated renal clear cell carcinoma metastasis., Diagnoses: Renal clear cell carcinoma with distal humerus bone metastasis., Interventions: Thin-layer CT scan data of the patient was acquired, and a 3D reconstruction of both upper limb bones and joints was conducted, followed by a simulation of diseased tissue excision. According to the model, individualized osteotomy guidelines and elbow prostheses were designed and manufactured. Then, prior to the completion of the actual operation, a simulation of the preoperative phase was performed., Outcomes: The operation was completed without incident. At the 1-, 3-, and 6-month postoperative examinations, both the position and mobility of the prosthesis were found to be satisfactory, and no complications were observed. The hospital for special surgery score and mayo elbow performance score scores increased in comparison to the preoperative period., Lessons: For patients with complex tumors in the elbow joint, 3D printing technology may assist in the precise excision of the tumor and provide an individualized elbow joint prosthesis that is more precise and effective than traditional surgery. It can accomplish a satisfactory treatment effect for patients when combined with early postoperative scientific rehabilitation training, so it is a method worth promoting., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: To provide a critical overview of the latest evidence on the role of metastasis-direct treatment (MDT) in the management of metastatic renal cell carcinoma (mRCC)., Recent Findings: This is a nonsystematic review of the English language literature published since January 2021. A PubMed/MEDLINE search using various search terms was conducted, including only original studies. After title and abstract screening, selected articles were grouped into two main areas which mirror the main treatment options in this setting: surgical metastasectomy (MS) and stereotactic radiotherapy (SRT). While a limited number of retrospective studies have been reported on surgical MS, the consensus of these reports is that extirpation of metastasis should be part of a multimodal management strategy for carefully selected cases. In contrast, there have been both retrospective studies and a small number of prospective studies on the use of SRT of metastatic sites., Summary: As the management of mRCC rapidly evolves, and evidence on MDT - both in the form of MS and SRT - has continued to build over the past 2 years. Overall, there is growing interest in this therapeutic option, which is increasingly being implemented and seems to be safe and potentially beneficial in well selected disease scenarios., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Inflammatory pseudotumor is rare observed in renal immunoglobulin G4-related disease., Patient Concerns: A 65-year-old female presented with a mass in the right kidney which was found in physical examination., Diagnoses: Based on the imaging findings and clinical manifestations, we preliminarily judged that the mass of the right kidney was renal cell carcinoma., Interventions: The patient finally underwent total nephrectomy., Outcomes: The final result of microscopic pathological examination is renal inflammatory pseudotumor., Lessons: There are some characteristics on magnetic resonance imaging of renal inflammatory pseudotumor, which can improve diagnosis rate by combining with medical history and clinical manifestations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: Cytoreductive nephrectomy has had a variable role in the management of metastatic renal cell carcinoma (RCC) through the different systemic therapy eras. Initially felt to be beneficial with interferon, the utility of cytoreductive nephrectomy was called into question in the tyrosine kinase inhibitor (TKI) era. However, with the advent of immunotherapy for metastatic RCC, the role of cytoreductive nephrectomy continues to be debated. This study sought to evaluate the recent literature and discuss cytoreductive nephrectomy within the context of an improved systemic therapy era., Recent Findings: The literature that exists on the use of cytoreductive nephrectomy with immunotherapy is retrospective in nature and largely derived from large, institutional databases. Although smaller, single-institution articles exist and provide more granular data, issues concerning selection bias and unmeasured confounders persist. Overall, the available studies demonstrate that patient selection is paramount, and cytoreductive nephrectomy should be reserved for patients with no more than one risk factor, those requiring palliation of local symptoms and for those patients with stable, low volume disease or with a complete response following systemic therapy exposure., Summary: The optimal use of cytoreductive nephrectomy in metastatic RCC remains unclear, but certain subgroups of patients, on evaluation of post hoc and retrospective data, seem to benefit from surgical intervention., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Surgery for renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (TT) remains one of the most complex surgeries performed with high rates of associated complications and perioperative mortality. Surgical techniques and neoadjuvant therapies have an important role to play in improving outcomes. This review provides a narrative analysis of recent literature on patients with RCC and TT., Recent Findings: Several imaging techniques are emerging that may improve diagnostic staging of tumor thrombus level. Robotic approaches to surgical resection for all thrombi levels is feasible and safe, while longer term outcomes for higher level thrombi continues to mature. Early data on neoadjuvant immunotherapy and radiotherapy have shown improvements in complication rates and intermediate term oncologic outcomes., Summary: Data suggests that neoadjuvant therapies and minimally invasive techniques may improve outcomes in patients undergoing surgical resection for RCC with tumor thrombus. Larger multiinstitutional series are needed to confirm the benefit of these techniques as well as the durable long term oncologic outcomes., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Primary pulmonary meningioma (PPM) is extremely rare tumor and only a few reports have been reported to date. PPM may be overlooked when it coexists with other types of tumors in the lung. It is essential to have a knowledge of the clinicopathological features of PPM and to recognize this rare coexistence., Patient Concerns: A 57-year-old male underwent surgery for papillary renal cell carcinoma, when 2 pulmonary nodules were detected using chest computed tomography., Diagnosis: The coexistence of benign PPM and metastatic papillary renal cell carcinoma was histologically confirmed., Interventions: A lobectomy was performed., Outcomes: The patient recovered well after surgery and was discharged on postoperative day 4., Lessons: Duo to the rarity of PPM, it is easily overlooked, especially when it coexists with other tumors in the lung. The possibility of PPM needs to be taken into account when diagnosing pulmonary nodules in clinical practice., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: TFEB-associated renal cell carcinoma is very rare and belongs to the microphthalmia - associated transcription family translocation renal cell carcinoma., Patient Concerns: Hospitalized for fever, a 29-year-old male patient had a left kidney lesion without any additional discomfort., Diagnoses: Histopathological and immunohistochemical results were corresponding with TFEB renall cell carcinoma features., Interventions: Surgical resection of the tumor was performed., Outcomes: After 8 months of follow-up, no tumor recurrence was observed., Lessons: TFEB-associated renal cell carcinoma is rare. The diagnosis is explicit. However, the optimal treatment needs to be further explored., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: The benefit of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) was first called into question in the tyrosine kinase inhibitors (TKIs) era. It remains undefined in the context of the recent development and approval of immune checkpoint inhibitors (ICIs) and level one evidence supporting the rapid adoption of dual ICI and combination ICI + TKI therapeutic approaches for mRCC. Our objective is to synthesize the available contemporary data regarding the safety, feasibility, and oncologic outcomes with CN for mRCC in the age of immunotherapy as well as to highlight trials in progress that will address this key knowledge gap., Recent Findings: Data from the SURTIME and CARMENA trials provided insight to guide patient selection for CN in patients with mRCC receiving TKI-based treatment strategies. At present, there is a body of retrospective data supporting the safety and oncologic efficacy of CN in carefully selected patients with mRCC in both the upfront and delayed setting. The results of ongoing trials evaluating the safety and feasibility for CN as well as optimal patient selection and sequencing strategies are eagerly awaited., Summary: Although the optimal selection criteria and timing for CN remains to be established for patients with mRCC in the immunotherapy era, the available body of evidence underscores the importance of careful patient selection. Ongoing prospective studies, such as Cyto-KIK , PROBE , and NORDIC-SUN , will better define the role of CN in the rapidly evolving treatment landscape for mRCC., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The aim of the study was to assess short- and long-term results following radical nephrectomy with renal vein and inferior vena cava thrombectomy in patients with renal cell cancer with venous thrombus and to investigate impact of various demographical, clinical and histological factors on overall survival (OS). The medical records of 102 adult patients with renal cell cancer with venous thrombus admitted for surgery in Department of General, Vascular and Transplant Surgery from 2012 to 2019 were retrospectively analyzed. The tumor was more frequently located on the right side compared to the left one (55 vs. 47). According to Neves Zincke classification, the levels of venous thrombus were as follows: 1 to 48 (47%), 2 to 47 (46%), 3 to 6 (6%), and 4 to 1 (1%). Postoperative complications were noted in 16 (15.7%) patients. One (3%) patient (Neves Zincke 2) died of intraoperative pulmonary embolism during hospitalization. Clear cell carcinoma was the most common pathological type reported in 92 (90.2%) patients. Thirty nine (38.2%) patients were alive at the time of last follow-up. The median OS was 21.50 (0-101.17) months. The 1-year OS was 75.5%. Significantly better OS (median 38.03 months) was noted in patients with RCC Neves Zincke 1 compared to OS (median 14.79 months) in patients with Neves Zincke 2-4 VT (P = .008). Higher tumor staging (T3 vs. T4) (P = .038), nodal staging (N0 vs. N1) (P = .0008), Fuhrman histological grading (G1-2 vs. G3-4) (P = .033) were associated with a shorter OS. Patients with renal cell cancer with venous thrombus, with an acceptable perioperative risk, should be treated surgically, because radical nephrectomy with thrombectomy performed in a high volume surgical center is a safe procedure. Neves Zincke 2-4 venous thrombus, higher tumor and nodal staging, as well higher Fuhrman histological grading are associated with a shorter OS., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Birt-Hogg-Dubé syndrome (BHDS) is a rare genetic disease. Renal cell carcinoma is the most serious complication of BHDS. The histological types of BHDS-related renal cell carcinoma are mostly mixed chromophobe/eosinophil and chromophobe cell types. BHDS with unclassified renal cell carcinoma is extremely rare., Patient Concerns: A 37-year-old man was admitted to the hospital because of lumbago and hematuria., Diagnosis: Combined with abdominal enhanced CT and pulmonary CT, BHDS complicated with renal cell carcinoma was diagnosed, and right partial nephrectomy was performed. The postoperative pathological diagnosis was unclassified renal cell carcinoma. Gene detection revealed the FLCN frameshift mutation., Outcomes: No signs of recurrence were observed after regular follow-up., Conclusion: The pathogenesis of BHDS has not been fully elucidated, and the pathological type of BHDS with unclassified renal cell carcinoma is extremely rare. Through case presentation and review of related literature, this paper summarizes the diagnosis and treatment of BHDS complicated with unclassified renal cell carcinoma., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: Although systemic agents for the treatment of metastatic renal cell carcinoma (mRCC) have improved survival, remission and cure for mRCC remains rare with systemic therapy alone. However, there is a body of observational evidence supporting a survival benefit in mRCC among patients who undergo complete surgical consolidation including resection of the primary tumor and all metastatic deposits. In this review, we aim to synthesize recent evidence regarding metastasectomy (MTS), with or without concurrent systemic therapy, in mRCC., Recent Findings: MTS is a critical component of mRCC patient care, alongside modern systemic therapy. Presently, there is a robust body of observational data supporting the association between surgical MTS and improved oncologic outcomes, especially when complete MTS is feasible., Summary: Among a retrospective, observational body of literature, MTS is associated with improved oncologic outcomes. However, it is impossible to discern to what degree these findings are biased by favorable tumor biology and patient selection, as opposed to being related to surgical MTS itself., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Renal cell carcinoma is one common type of urologic cancers. It has tendencies to invade into the inferior vena cava (IVC) and usually requires an open surgery procedure. High rates of operative complications and mortality are usually associated with an open surgery procedure. The recently emerged robot-assisted laparoscopic radical nephrectomy (RAL-RN) and IVC tumor thrombectomy have shown to reduce operative related complications in patients with renal cell carcinoma.This case series study aimed to summarize technical utilization, perioperative outcomes, and efficacies of RAL-RN and IVC tumor thrombectomy in our hospital. A retrospective analysis was performed on clinical data from 20 patients who underwent RAL-RN and IVC tumor thrombectomy from January 2017 to December 2019 in our department.Patients had a median age of 59 years (interquartile range [IQR], 46-68). Four patients had renal neoplasm on left side and 16 on right side. Nineteen patients underwent RAL-RN (level 0: n = 2) or RAL-RN with IVC thrombectomy (n = 17) (level I: n = 3; level II: n = 12; and level III: n = 3) and 1 patient was converted into an open surgery. The median operative time was 328 minutes (IQR, 221-453). The estimated median blood loss was 500 mL (IQR, 200-1200). The median size of removed renal carcinoma was 67 cm2 (IQR, 40-91); the length of IVC tumor thrombus was 5 cm (IQR, 3-7). The postsurgery hospital length of stay was 6 days (IQR, 5-7). The complications included intestinal obstruction (n = 1), lymphatic fistula (n = 1), heart failure (n = 1), and low hemoglobin level (n = 1). The outcomes for patients after 16 months (IQR, 11-21) follow-up were tumor-free (n = 10), tumor progression (n = 4), loss of contact (n = 1), and death (n = 5).We concluded that RAL-RN and IVC thrombectomy renders good safety profiles including minimal invasiveness, low estimated median blood loss, short hospitalization, low morbidity, and quick renal function recovery. The long-term efficacy needs a further investigation., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Renal cell carcinoma (RCC) almost metastasizes to every organ, the possibility of adrenal metastasis is relatively low in patients that have undergone radical nephrectomy, only a few cases of bilateral adrenal metastasis are reported on literature. Although surgical treatment of metastases from RCC is preferred and contributes to the rate of survival, it is considered challenging to manage such cases due to the rarity of bilateral metastasis to the adrenal glands., Patient Concerns: A 64-year-old Manchus female presented with an incidental ultrasonic finding of a left adrenal mass 4 years after radical nephrectomy for left renal cell carcinoma., Diagnosis: Abdominal contrast enhanced CT scan revealed bilateral adrenal masses, suggesting metastatic lesion. Examinations indicated neither local recurrence nor distant metastasis anywhere have been detected by whole body Positron Emission Tomography/Computed Tomography (PET/CT) scan except high radioactive uptake in bilateral adrenal glands., Interventions: Metachronous bilateral adrenalectomy was taken and laparoscopic right adrenalectomy was first performed. She was discharged home on third postoperative day. Pathological examination revealed metastatic renal cell carcinoma. Two months later she was performed laparoscopic left adrenalectomy., Outcomes: The patient healed without obvious complications and no tumor recurrence., Lessons: Bilateral metastatic adrenal recurrence from RCC is very rare. Early diagnosis of adrenal metastasis is challenging because they are usually silent both anatomically and functionally. Surgical intervention is a wise option for these patients that may improve survival, and metachronous bilateral adrenalectomy is proved to be safe and effective., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Acquired cystic disease-associated renal cell carcinoma (ACKD-RCC) is a unique subtype of renal cell carcinoma (RCC) and is found exclusively in patients with end-stage renal disease. We report a case of intracapsular nephrectomy (ICAN) of renal allograft with ACKD-RCC. To our knowledge, this is the first case in Asia of ICAN of renal allograft to treat ACKD-RCC., Patient Concerns: A 51-year-old male patient with a history of allogeneic kidney transplantation (23 years previously) presented with renal cystic degeneration of the transplanted kidney over the past 2 years., Diagnoses: ICAN was used to remove the cystic kidney., Interventions: The pathology report indicated clear cell renal cell carcinoma., Outcomes: Two years after surgery, computed tomography showed no tumor recurrence, and the patient's creatinine level was 3.5 mg/dl under hemodialysis., Lessons: Removal of transplanted kidney with ACKD-RCC using ICAN is feasible to provide a mid-term tumor-free survival for the patient. Therefore, we consider nephrectomy as an early treatment for the nonfunctional cystic allograft kidney, in order to reduce the dosage of anti-rejection drugs, avoid the occurrence of transplanted kidney tumor, and provide the possibility for the patient an opportunity to receive a second kidney transplantation., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Although renal cell carcinoma (RCC) is one of the common origins of brain metastasis, few cases of extremely delayed brain metastasis from RCC, more than 10 years after nephrectomy, have been reported. We present a rare case of extremely delayed brain metastasis from RCC, also performed a literature review to increase knowledge of the characteristics for extremely delayed brain metastasis from RCC., Patient Concerns: A 72-year-old man presented with right-sided hemiplegia and dysarthria. The patient had a history of radical nephrectomy for RCC with stage T1N0M0 15 years earlier., Diagnosis: Magnetic resonance imaging with contrast revealed a 2-cm sized non-homogenous enhanced mass in the left frontal lobe with peritumoral edema. The pathological examination after surgery reported metastatic clear cell RCC., Interventions: A craniotomy for removal of the mass was performed at the time of diagnosis. Stereotactic radiosurgery was performed for the tumor bed 3 weeks after craniotomy, and then, chemotherapy was started 2 months after the SRS., Outcomes: Metastasis progressed to multiple organs 6 months after the craniotomy. The patient chose a hospice and no longer visited the hospital., Lessons: In cases with a history of nephrectomy for RCC, long period follow-up is necessary for monitoring RCC brain metastasis and pathologic diagnosis should be confirmed., Competing Interests: The authors report no conflict of interest concerning the materials or methods used in this study or the findings described in this paper., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Prognostic nutritional index (PNI) could reflect the nutrition and inflammation status in cancer patients. This study aims to identify the prognostic significance of PNI in patients with renal cell carcinoma (RCC).A total of 694 RCC patients from our institution were included in this study. The prognostic correlation between PNI and overall survival (OS) and recurrence-free survival (RFS) was analyzed respectively using Kaplan-Meier method and univariate and multivariate Cox model. Studies about the association between pretreatment or preoperative PNI and prognosis of RCC were systemically reviewed and a meta-analysis method was performed to further evaluate the pooled prognostic value of PNI in RCC.267 (38.47%) RCC patients had low PNI according to the cut off value (49.08). Low PNI was associated with poor OS (P < .001) and RFS (P < .001), respectively. In the multivariate Cox analysis, PNI was identified to be an independent prognostic factor for OS (hazard ratio [HR] = 2.13, 95%CI: 1.25-3.62, P = .005). Compared to other nutritional indexes, this risk correlation of PNI is better than that of geriatric nutritional risk index (GNRI; HR = 1.19; P = .531), while is no better than that of neutrophil-lymphocyte ratio (NLR; 1/HR = 2.56; P < .001) and platelet-lymphocyte ratio (PLR; 1/HR = 2.85; P < .001) respectively. Meanwhile, additional 4785 patients from 6 studies were included into pooled analysis. For RCC patients who underwent surgery, low preoperative PNI was significantly associated with worse OS (pooled HR = 1.57, 95%CI: 1.37-1.80, P < .001) and worse RFS (pooled HR = 1.69, 95%CI: 1.45-1.96, P < .001). Furthermore, low PNI (<41-51) was also significantly associated with poor OS (HR = 1.78, 95%CI: 1.26-2.53 P < .05) and poor RFS (HR = 2.03, 95%CI: 1.40-2.95, P < .05) in advanced cases treated with targeted therapies.The present evidences show that PNI is an independent prognostic factor in RCC. Low PNI is significant associated with poor prognosis of RCC patients., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Magnetic resonance imaging guidance has been sporadically reported for renal tumor cryoablation (CA); therefore, clinical experience with this modality is still limited.The aim of this study is to retrospectively analyze our 10-year experience with renal tumor CA performed on a 1.5 T magnetic resonance imaging unit with the intent of reporting procedural safety and oncologic outcomes., Materials and Methods: We included 143 patients (102 men; 41 women; median age, 73 years; range, 34-91 years) with 149 tumors (median size, 2.6 cm; range, 0.6-6.0 cm), treated between 2009 and 2019. Patient, tumor, procedure, and follow-up data were collected and analyzed. The Kaplan-Meier method was used to estimate local recurrence-free (LRFS), metastasis-free (MFS), disease-free (DFS), cancer-specific, and overall (OS) survival. Univariate and multivariate models were used to identify factors associated with complications, LRFS, MFS, DFS, and OS., Results: The overall complication rate was 10.7% (16/149 tumors), with 1 major (1/149 [0.7%]; 95% confidence interval, 0.0%-3.7%) hemorrhagic complication. Other minor complications (15/149 [10.1%]; 95% confidence interval, 0.6%-16.1%) did not include any cases of injury to nearby organs. There were no factors associated with complications.Five-year estimates of LRFS (primary/secondary), MFS, DFS, cancer-specific survival, and OS were 82.8%/91.5%, 91.1%, 75.1%, 98.2%, and 89.6%, respectively. Increasing tumor size (hazard radio [HR], 1.8; P = 0.02) and intraparenchymal tumor location (HR, 5.6; P < 0.01) were associated with lower LRFS; increasing patient's age (HR, 0.5; P = 0.01), high tumor grade (HR, 23.3; P < 0.01) and non-clear-cell/nonpapillary histology (HR, 20.1; P < 0.01) with metastatic disease; and high tumor grade (HR, 3.2; P = 0.04) with lower DFS., Conclusion: Magnetic resonance imaging-guided CA of renal tumors is associated with acceptable morbidity and high survival estimates at 5-year follow-up. Given the absence of complications resulting from injuries to nearby organs, further studies are required to evaluate whether the potential reduced incidence of these adverse events justifies large-scale implementation of this interventional modality., Competing Interests: Conflicts of interest and source of funding: Drs Gangi and Garnon are advisors to BTG., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Gallbladder polyps are common in the general population, but gallbladder metastasis of renal cell carcinoma (RCC) is very rare. In a patient with RCC diagnosed with a small gallbladder polyp that does not meet the traditional size criteria, the surgeon faces a dilemma of whether cholecystectomy should be performed given the possibility of metastasis., Patient Concerns: A 55-year-old man who had received a left nephrectomy for RCC presented with a gallbladder polyp that was noted at the time of the nephrectomy. Imaging showed the maximum diameter of the polyp had increased from 5 mm to 24 mm in the 40 months after the initial diagnosis., Diagnosis: Pathological and immunohistology findings confirmed the gallbladder polyp as a metastasis of clear-cell RCC., Interventions: : We performed a laparoscopic cholecystectomy., Outcomes: Even though the synchronous solitary gallbladder metastasis was left untreated and a cholecystectomy was not performed over the 40 months, no metastasis occurred in other sites. The patient is free from disease 10 months after the cholecystectomy., Lessons: Solitary gallbladder metastasis of RCC may have more favorable outcomes than typical metastases. Although gallbladder metastasis of RCC occur rarely, it can occur, and any changes in gallbladder polyps in RCC patients should be managed under a strong suspicion of metastasis., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The aim of this systematic review and meta-analysis is to evaluate the efficacy and safety of adjuvant targeted therapy by sunitinib combined with surgery in the treatment of advanced or metastatic renal cell carcinoma., Methods: PubMed/Medline, Web of Science, Cochrane Library, ClinicalTrials.gov (http://www.ClinicalTrials.gov), China National Knowledge Infrastructure (CNKI) will be searched for clinical research articles related to the efficacy and safety of adjuvant therapy combined with surgery in the treatment of advanced and metastatic RCC. The identification, inclusion and exclusion flow charts will be conducted according to the PRISMA guidelines. The quality assessment will be done by Quadas-2 evaluation tool. Key parameters including OS in 10, 20, 30, and 40 months, PFS in 10, 20, and 30 months, objective response rate (ORR), stable disease (SD) rate, progressive disease (PD) rate, median OS and PFS, types of AEs and their occurrence rates, etc will be extracted. The evaluation of the efficacy and safety will be pooled by CMA., Results: This systematic review will provide evidence on the efficacy and safety of adjuvant therapy by sunitinib combined with surgery in treating advanced and metastatic RCC., Conclusion: The study aims to generalize data concerning the response rate, OS, PFS and rates of adverse effects of the perioperative use of sunitinib in advanced and metastatic RCC patients. The evidence provided by this systematic review and meta-analysis will help guide the clinical decision making and enlighten the future management of advanced or metastatic RCC., Registration: This protocol has been registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY registration number: INPLASY2020110093; INPLASY DOI number: 10.37766/inplasy2020.11.0093 Available at: https://inplasy.com)., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Renal cell carcinoma (RCC) is infrequent in the pediatric population. In addition, till date, only a few reports have summarized the characteristics of pediatric RCC and differences between pediatric and adult RCC. Therefore, the current study aimed to investigate the clinical characteristics of RCC in children and adolescents, and identify the differences between children and adolescent patients and adult patients through literature retrieval.The data of 13 pediatric patients diagnosed with RCC at the Children's Hospital of Zhejiang University School of Medicine between 2005 and 2019 were retrospectively analyzed.Three patients were aged <5 years, 2 were aged 6 to 10 years, and 8 were aged 11 to 18 years. Among the 13 patients, common clinical manifestations included abdominal pain in 5 patients, gross hematuria in 4, and an abdominal mass in 1, while the other 3 patients were incidentally detected after an abdominal contusion. The pathological types were microphthalmia family translocation RCC in 9 patients, clear-cell RCC in 2, papillary RCC in 1, and unclassified in 1. All the children underwent radical nephrectomy, including 2 patients with advanced disease who underwent preoperative transcatheter arterial chemoembolization. The mean follow-up time was 58.6 months. Two patients died after 4 and 17 months of follow-up, respectively.In conclusion, microphthalmia family translocation renal cell carcinoma is the predominant type of pediatric RCC associated with advanced tumor stage. The early diagnosis and treatment of pediatric patients is important for improving prognosis. Nevertheless, future studies are urgently needed to determine the treatment for pediatric advanced RCC to increase the survival rate., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Double primary clear cell carcinomas of the liver (PCCCL) and kidney are extremely rare; moreover, there have been no reported cases of adrenal metastasis from primary clear cell tumors of the liver., Patient Concerns: A 47-year-old male patient was admitted to our clinic with space-occupying lesions in the left kidney and liver during a regular medical examination., Diagnoses: The tumors in the kidney and liver were diagnosed as primary clear cell carcinoma by histopathological examination., Interventions: The patient subsequently underwent nephron-sparing surgery of the left kidney and radical partial excision of the right liver lobe by laparoscopic surgery. Transcatheter arterial chemoembolization (TACE) was performed for the patient 2 weeks after tumor resection. One month after the operation, the patient started adjuvant therapy with sorafenib (400 mg twice per day orally). However, follow-up CT imaging revealed a solid mass measuring 1.9 × 2.0 × 2.0 cm in the right adrenal gland at 2 months postoperatively, and then the patient underwent radiofrequency ablation (RFA) for the right adrenal tumor., Outcomes: The patient remained cancer free for 2 years following the diagnosis despite early right adrenal metastasis., Lessons: Hepatocyte immunostaining is sufficient for the diagnosis of PCCCL.

Multilocular cystic renal neoplasm of low malignant potential (MCRNLMP) might be benefited from nephron-sparing surgery. Contrast-enhanced computed tomography is used for the diagnosis of MCRNLMP but contrast-enhanced ultrasound has lack of nephrotoxicity and several advantages over contrast-enhanced computed tomography and contrast-enhanced magnetic resonance. The purpose of the study was to compare diagnostic parameters of preoperative contrast-enhanced ultrasound against contrast-enhanced computed tomography for the detection of MCRNLMP in patients who faced curative surgery for complex cystic renal mass.Data regarding contrast-enhanced ultrasound, contrast-enhanced computed tomography, and clinicopathological results of 219 patients who underwent curative surgery for complex cystic renal mass (Bosniak classification III or IV) were retrospectively collected and analyzed. Bosniak classification for imaging modality and the 2016 WHO criteria for clinic pathology were used for detection of MCRNLMP.Contrast-enhanced ultrasound, contrast-enhanced computed tomography, and clinicopathology were detected 68, 66, and 67 as a MCRNLMP respectively. Contrast-enhanced ultrasound and contrast-enhanced computed tomography had 30.37% and 29.27% sensitivities for the detection of MCRNLMP. While 60% and 50% specificities respectively. Bosniak classification III (P = .045) and lower mean Hounsfield unit (P = .049) were associated with the prevalence of MCRNLMP. Contrast-enhanced computed tomography was detected 6 and 7, while contrast-enhanced ultrasound detected 3 and 2 complex cystic renal mass as false positive and false negative MCRNLMP respectively. A contrast-enhanced ultrasound had 0.011 to 1.0 diagnostic confidence and contrast-enhanced computed tomography had 0.045 to 0.983 diagnostic confidence for decision making of nephron-sparing surgeries.Contrast-enhanced ultrasound may have better visualization of MCRNLMP than contrast-enhanced computed tomography.Level of Evidence: III.

Purpose of Review: To evaluate emerging evidence and practical applications of thulium-fiber laser (TFL) for genitourinary soft tissue disease and urinary stone disease treatment., Recent Findings: A systematic review was developed using the PubMed, ScienceDirect, Wiley, SpringerLink and Mary Ann Liebert Scopus databases between 2012 and 2020 years, using the PRISMA statement. We analyzed recent publications including in vitro and in humans outcomes of surgery using TFL. This new laser technology can be used in soft tissue diseases and stones present in the genitourinary system. Most of the comparisons are made with the Ho:YAG laser, using completely different settings. Nevertheless, TFL is safe, feasible and effective in the management of urologic diseases, showing superiority to Ho:YAG even in some studies., Summary: The introduction of pulsed TFL technology has enabled the ablation of stones at rates comparable to or better than currently existing lasers in vitro, while also potentially reducing stone retropulsion. TFL is effective in treating genitourinary soft tissue diseases, including benign prostatic hyperplasia, and early data indicate that it may be effective in the treatment of urinary stone disease. More clinical studies are needed to better understand the indications for this novel technology and clarify its position in the urologic endoscopy armamentarium.

Determining the appropriate patients for cytoreductive nephrectomy (CN) has evolved with the integration of more effective systemic therapies for patients with metastatic renal cell carcinoma (mRCC). While previously considered to be first-line therapy for mRCC, CN has not demonstrated a significant survival advantage over systemic therapy in more recent randomized trials when compared with targeted therapy. Conversely, multiple observational studies demonstrate a therapeutic benefit for CN. This review synthesizes the current literature regarding patient selection for CN and further evaluates the role of CN in the current era of immune checkpoint inhibitor therapy. With careful patient selection, CN maintains an important role in the management of mRCC patients.

Introduction: Patent foramen ovale is a common congenital cardiac abnormality. An association with acute ischemic stroke is well described. Extension of renal cell carcinoma (RCC) into the adjacent veins is common. Surgical resection is felt to be an effective approach to treatment, even in the setting of extensive venous involvement., Case Report: A 55-year-old woman with recently diagnosed right renal mass and cavoatrial tumor thrombus was transferred to our facility for surgical resection. She subsequently underwent open radical right nephrectomy, regional lymph node dissection, inferior vena cava and right atrial tumor thrombectomy, and resection of the infrahepatic vena cava. An intraoperative transesophageal echocardiogram confirmed the absence of tumor thrombus from the inferior vena cava and right atrium and also identified a patent foramen ovale (PFO). Upon weaning sedation, she was noted to be agitated and have left hemiplegia. Her National Institutes of Health Stroke Scale (NIHSS) was 30 and Glasgow Coma Scale (GCS) 6. The computerized tomography scan of head revealed extensive hypoattenuation right in the middle and left posterior cerebral artery territories. There was associated cerebral edema and 5-mm midline shift. In the setting of devastating neurological injury, her family elected to transition to comfort care and the patient died on the postoperative day 7., Conclusions: This is the first reported case of intraoperative paradoxical embolism in the setting of RCC with cavoatrial extension and PFO. The presence of PFO may be a risk factor for severe cerebrovascular complications in the surgical management of RCC with venous involvement.

The primary treatment for localized renal cell carcinoma (RCC) is surgical resection with curative intent. Despite this, many patients, especially those with high-risk features, will develop recurrent or metastatic disease. Antiangiogenic therapies targeting vascular endothelial growth factor have been a mainstay of treatment of advanced RCC for more than 10 years. Evidence supporting the use of these therapies in the adjuvant setting is mixed, although one clinical trial, S-TRAC, has shown improvements in disease-free survival with 1 year of adjuvant sunitinib among patients with clear cell histology and high-risk features, leading to the first US Food and Drug Administration approval of an adjuvant therapy for high-risk RCC patients. Further investigation into combination therapies with immunotherapy, neoadjuvant approaches, and patient selection will be key to determining optimal adjuvant therapy regimens to improve outcomes and increase cure rates for patients with localized RCC.

The incidence of renal cell carcinoma (RCC) has been increasing, with a moderate subgroup of individuals who later develop metastatic disease. Historically, metastatic RCC has been managed with systemic therapy because RCC was believed to be radioresistant. Local therapies, such as stereotactic body radiation therapy, also known as stereotactic ablative radiotherapy, which utilize focused high-dose-rate radiation delivered over a limited number of treatments, have been successful in controlling local disease and, in some cases, extending survival in patients with intracranial and extracranial metastatic RCC. Stereotactic ablative radiotherapy is highly effective in treating intact disease when patients are not surgical candidates. Stereotactic ablative radiotherapy is well tolerated when used in conjunction with systemic therapy such as tyrosine kinase inhibitors and immune checkpoint inhibitors. These successes have prompted investigators to evaluate the efficacy of stereotactic body radiation therapy in novel settings such as neoadjuvant treatment of advanced RCC with tumor thrombus and oligometastatic/oligoprogressive disease states.

Rationale: Cerebral carbon dioxide embolism (CCDE) is a rare cause of stroke and is a recognized life-threatening complication.CCDE may result from direct intravascular CO2 insufflation during surgery. Due to the lack of typical clinical manifestations, the disease is often missed or mistaken for another condition. The clinical signs and symptoms depend on the speed and volume of embolized gas entering the blood and the patient's condition. In particular, patent foramen ovale has been found to be associated, in rare cases, with the intraoperative entry of gas into the arterial system., Patient Concerns: In this report, we present the case of a 35-year-old woman with kidney cancer who underwent laparoscopic right partial nephrectomy., Diagnosis: After the laparoscopic surgery, the patient was initially diagnosed with acute cerebral infarction., Interventions: The patient was treated according to the standard method for treatment of acute cerebrovascular disease., Outcomes: Three days after the laparoscopic procedure, the patient gained consciousness, and she was discharged without any neurologic sequelae on postoperative day 12., Lessons Subsections as per Style: Due to the low incidence and sudden occurrence of CCDE, there is a strong likelihood of missed diagnosis or misdiagnosis, and it is; therefore, important to be aware of the risk. The findings from this report would be highly useful as a reference to clinicians in the future.

Purpose of Review: The role of metastasectomy in the management of metastatic renal cell carcinoma (mRCC) remains controversial. The aim of this review is to summarize and evaluate the recent findings about the surgical treatment of patients with mRCC focusing on the literature published in the last 2 years., Recent Findings: Despite the lack of randomized controlled trials, the benefit of metastasectomy in term of cancer-specific and overall survival have been demonstrated in large observational studies. Results of ongoing clinical trials evaluating the impact of combination of surgical and systemic therapies are eagerly awaited and may shed the light on a new treatment armamentarium in this subset of patients., Summary: Several novel systemic agents have emerged and is continuously changing the treatment paradigm in patients with advanced RCC. However, surgical resection of the primary tumor and metastatic deposits represents a definitive cure option in well selected patients.

The present study aimed to detect the A-kinase interacting protein 1 (AKIP1) expression in clear cell renal cell carcinoma (ccRCC) tumor tissues and adjacent tissues, and further investigate the correlation of tumor AKIP1 expression with clinicopathological features and survival profile in ccRCC patients.Totally 210 ccRCC patients who underwent resection were retrospectively reviewed, and their tumor and adjacent tissue specimens were acquired for immunohistochemical detection of AKIP1 expression. The survival data of patients were collected for overall survival (OS) assessment.AKIP1 was upregulated in ccRCC tumor tissues compared with adjacent tissues (P < .001). Tumor AKIP1 expression was positively associated with T stage (P = .019), N stage (P = .032), and TNM stage (P = .005) in ccRCC patients. According to AKIP1 expression in tumor tissues, all patients were grouped as AKIP1 low and high expression (AKIP1 high expression were further divided into AKIP1 high+, high++, and high+++ expression). OS was the lowest in the patients with AKIP1 high+++ expression, followed by those with AKIP1 high++ expression and AKIP1 high+ expression, and then patients with AKIP1 low expression (P < .001). Furthermore, multivariate Cox regression exhibited tumor AKIP1 high expression (P = .017), age (>60 years) (P = .030), pathological grade (G2/G3 vs G1) (P = .037), and TNM stage (II/III vs I) (P < .001) were independent predictive factors for decreased OS in ccRCC patients.AKIP1 presents potency to be a novel biomarker for tumor progression and prognosis surveillance in ccRCC.

Objective: The objective of this study was to assess the value of a preoperative Prognostic Nutritional Index (PNI) for predicting the survival of patients with nonmetastatic renal cell carcinoma (RCC) treated with partial or radical nephrectomy., Materials and Methods: The medical records of 480 patients with RCC who underwent partial or radical nephrectomy at 2 institutions between June 1994 and July 2017 were retrospectively reviewed. After the exclusion of 21 patients with lymph node or distant metastasis, the data of 459 patients with nonmetastatic RCC were included. The PNI was calculated using a combination of serum albumin level and lymphocyte count in the peripheral blood, as described previously. The prognostic significance of various clinicopathologic variables, including the PNI, was assessed in univariate and multivariate analyses., Results: The univariate analysis identified anemia, PNI, tumor size, T stage, Fuhrman nuclear grade, sarcomatoid differentiation, and lymphovascular invasion as significant prognostic factors of recurrence-free survival (RFS) and cancer-specific survival (CSS). In the multivariate analysis, anemia (P=0.010), PNI (P<0.001), tumor size (P<0.001), T stage (P<0.001), Fuhrman nuclear grade (P=0.023), sarcomatoid differentiation (P=0.003), and lymphovascular invasion (P=0.005) were independent prognostic factors for RFS, versus anemia (P=0.020), PNI (P=0.002), tumor size (P<0.001), T stage (P<0.001), sarcomatoid differentiation (P<0.001), and lymphovascular invasion (P=0.018) for CSS., Conclusions: The PNI is an independent prognostic factor for RFS and CSS in patients with nonmetastatic RCC treated with partial or radical nephrectomy. It may, therefore, be a useful tool for predicting recurrence and survival in these patients.

Purpose of Review: As the biology of metastatic renal cell carcinoma (mRCC) continues to be elucidated, novel treatments focused around immunotherapies and targeted therapies will continue to emerge. In this review, we will highlight recent treatment advances and their implications for surgical and systemic therapy., Recent Findings: Several new treatments, including the tyrosine kinase inhibitor cabozantinib, the combination of a programmed cell death protein 1 antibody (nivolumab) with a cytotoxic T-lymphocyte-associated antigen 4 antibody (ipilimumab), and the combination of axitinib with pembrolizumab or avelumab have been approved by the US Food and Drug Administration as first-line therapy for the treatment of mRCC. Although promising survival benefits have been seen with these new therapies, careful patient selection is still critical., Summary: The introduction of novel therapies and the investigation of combinatorial therapies have shifted the treatment paradigm for advanced RCC. Present trials have provided promising data that could lead to further therapeutic advances.

Rationale: Renal carcinoma is a common malignant tumor of the urinary system, 4%-10% of which are complicated with tumor thrombi in the renal vein and the inferior vena cava; in about 1% of patients, the inferior vena cava tumor thrombus invades the right atrium. Surgery is the treatment of choice. Real-time monitoring with transesophageal echocardiography (TEE) has been widely used in various operations, including cardiac and non-cardiac operations for congenital heart diseases, coronary diseases, vascular heart diseases, and aorta diseases, etc. In this article, a case of a patient with right renal carcinoma complicated with an inferior vena cava tumor thrombus is reported., Patient Concerns: A 52-year-old man who was admitted to our hospital for lumbar pain lasting for one month., Diagnosis: Right renal carcinoma complicated with an inferior vena cava tumor thrombus., Interventions: Radical nephrectomy of the renal carcinoma and removal of an inferior vena cava tumor thrombus under real-time monitoring with TEE were performed., Outcomes: Radical nephrectomy was successfully performed within 5 minutes after the inferior vena cava was clamped, and then the inferior vena cava tumor thrombus was removed. On the second day after the operation, the patient's conditions improved; his consciousness was clear; he was transferred to a general ward. On the third day after the operation, the patient was able to get out of bed and was discharged on the sixth day after the operation., Lessons: Real-time monitoring with TEE played an important role in many aspects in the radical nephrectomy of the renal carcinoma and removal of the inferior vena cava tumor thrombus.

Rationale: Prostate cancer along with colorectal and lung cancers accounts for 42% of cancer cases in men globally. It is the first cancer indication for which the use of active immunotherapy, Sipuleucel-T (Provenge) was granted by the FDA in 2010. This study presents a case of prostate carcinoma and the tumour remission observed after administration of a personalised Dendritic cell vaccine (APCEDEN)., Patient Concerns: A 58 years old Caucasian male diagnosed with prostate carcinoma with GLEASON score 8. The patient had previously been diagnosed with Renal Cell Carcinoma (RCC) in 1996 and had undergone nephrectomy of the right kidney. PET CT scan revealed multiple intensely PSMA avid lesions noted in both lobes of the prostate gland with SUVmax -28.3 and the prostate gland measuring 3.2 × 3.2 cm displaying maximum dimensions., Diagnosis: FNAC followed by PETCT confirmed CA Prostate and further supported by increased serum PSA level., Interventions: The patient underwent personalised Dendritic Cell Immunotherapy APCEDEN regimen of six doses biweekly, in a time frame of 3 months were given both via intravenous and intradermal route. Six months post completion of APCEDEN, the patient was administered 6 booster shots for 6 months., Outcomes: Progressive remission of carcinoma was observed along with reduction in PSA and Testosterone levels. PET CT showed decline in PSMA avidity by 50% with SUVmax -14.0 and normal size and shape of prostate gland., Lessons: Prostate carcinoma is the second most common cancer in men with majority of them exhibiting locally advanced disease. Apparently 20% to 30% of them are categorized as relapsed cases after various therapeutic interventions. Modulating immune system is an emerging therapy termed as Immunotherapy and potentiates the killing cancer cells via immune activation. Interestingly, prostate cancer is slow growing and it provides the scope and time to mount an anti-tumor response which makes it an attractive target for immunotherapy. This case study demonstrates the efficacy of APCEDEN Immunotherapy regimen resulting in a significant disease remission benefiting the patient.

Objective: Long-lasting control is rarely achieved with tyrosine kinase inhibitors (TKI) alone in metastatic renal cell carcinoma (mRCC). Our study aimed to investigate the survival outcomes of adding stereotactic body radiotherapy (SBRT) to TKI in mRCC., Materials and Methods: From September 2015 to September 2018, 56 patients treated with TKI received SBRT for 103 unresectable lesions. A total of 24 and 32 patients were irradiated before and after TKI failure, respectively. Overall survival (OS) was calculated from metastases. Progression-free survival (PFS) was calculated from SBRT., Results: Overall, 10, 32, and 12 patients had International Metastatic Renal Cell Carcinoma Database Consortium favorable, intermediate, and poor risk. Median follow-up was 21.7 months (range, 5.1 to 110.6 mo). Median OS was 61.2 months. The median PFS was 11.5 months, while the 2-year LC rate was 94%. Sixteen (34%) lesions achieved complete response (CR) in patients irradiated before TKI failure, whereas only 4 (7%) lesions yielded CR in those irradiated after TKI failure (P=0.001). The median PFS in CR group was significantly longer than that of non-CR group (18.9 vs. 7.1 mo; P=0.003). The 5-year OS in CR group was 86%, compared with 48% in non-CR group (P=0.010). Four (7%) patients experienced Grade 3 toxicity., Conclusions: Adding SBRT to TKI is safe and seems to improve survival in mRCC. Patients irradiated before TKI failure have higher CR rate, and the favorable local response might turn into survival benefit.

Purpose of Review: Over the past few years the treatment options for renal cell cancer (RCC) have rapidly evolved. Even in the setting of metastatic disease, a consistent component of treatment in RCC patients has been cytoreductive nephrectomy based on the results of research carried out over a decade ago. Despite huge shifts in systemic treatment modalities, cytoreductive nephrectomy continued to be recommended despite a lack of evidence for its use in metastatic RCC in those patients receiving state-of-the-art therapies., Recent Findings: To address the lack of evidence, two recent trials [Cancer du Rein Metastatique Nephrectomie et Antiangioge[Combining Acute Accent]niques (CARMENA) and SURTIME] sought to assess the role and sequence of cytoreductive nephrectomy in metastatic RCC patients receiving vascular endothelial growth factor-targeted tyrosine kinase inhibitor treatment. The results of one of these trials, namely CARMENA, demonstrated no benefit of cytoreductive nephrectomy when used in combination with the vascular endothelial growth factor-targeted tyrosine kinase inhibitor Sunitinib. However, with further developments in medical treatment and questions regarding the specific methods of the trial - do these results change everything for the role of cytoreductive nephrectomy?, Summary: While the results from CARMENA and SURTIME are not conclusive, they suggest that those patients with advanced disease requiring systemic therapy should indeed receive this first prior to any cytoreductive nephrectomy.

Rationale: Conventional computerized tomography (CT) examination can differentiate renal cortical tumor from urothelial carcinoma on the basis of the highly contrast-enhanced vessels in renal cortical tumors. However, the capillary distribution of renal cell carcinoma (RCC) has been under-investigated. Here, we present a micro-CT image of tumor tissue in a patient with RCC., Patient Concerns: The patient was a 72-year-old woman with a past history of diabetes mellitus and hypertension. She did not have tumor-related symptoms., Diagnosis and Interventions: The tumor was diagnosed using abdominal CT during her yearly routine health check. After radical nephrectomy, the tumor was subjected to pathological examination and micro-CT imaging. Pathological analysis confirmed a clear cell renal carcinoma. The capillary distribution of the tumor was significantly lesser than that of the normal cortex on micro-CT image., Lessons: Microvessels of RCC can be detected by micro-CT. We also found that the distribution of microvessels was uneven and lower than that in the normal cortex in this case. For a more general diagnosis, more micro-CT images of RCC tumors are needed.

Purpose of Review: To review the evidence related to cytoreductive nephrectomy in metastatic renal cell carcinoma (mRCC) treated in the targeted therapy era, with a focus on observational studies and randomized trials., Recent Findings: A number of retrospective observational studies exploring the role of cytoreductive nephrectomy have been reported. These have suggested an association between cytoreductive nephrectomy and survival, with hazard ratio estimates ranging from 0.39 to 0.68 in favour of cytoreductive nephrectomy. In contrast, the CARMENA randomized trial demonstrated that sunitinib alone was noninferior to cytoreductive nephrectomy followed by sunitinib in intermediate-risk and poor-risk patients. The results of the SURTIME trial suggest that initial sunitinib followed by a deferred cytoreductive nephrectomy may also be a reasonable approach in select patients., Summary: On the basis of the evidence to date, there is still a role for cytoreductive nephrectomy in the multimodality treatment of mRCC. Careful patient selection is of paramount importance and discussion in multidisciplinary tumour boards is encouraged. As the treatment landscape of mRCC continues to change, the role of cytoreductive nephrectomy in the modern immuno-oncology era will need to be explored.

Purpose of Review: Metastatic renal cell carcinoma (mRCC) has traditionally been treated with a combination of targeted systemic therapy and cytoreductive nephrectomy. This approach has recently become a topic of debate, because of new randomized data suggesting a lack of survival benefit for cytoreductive nephrectomy. We review the literature relevant to cytoreductive nephrectomy in the modern era of targeted and immune systemic therapy, and discuss the ongoing role of surgery for treatment of patients with mRCC., Recent Findings: Randomized trials in the cytokine era of systemic therapy for mRCC demonstrated a survival benefit to cytoreductive nephrectomy, which led to its widespread adoption. There is overwhelming support in favor of cytoreductive nephrectomy from large studies using retrospective data in the targeted therapy era. A recent randomized control trial (CARMENA) failed to show superiority of cytoreductive nephrectomy in combination with sunitinib, versus sunitinib alone with respect to overall survival. The trial had major limitations including selection of many poor-risk patients, which we know do not benefit from surgery. The results of CARMENA should lead to the abandonment of cytoreductive nephrectomy in poor-risk and many intermediate-risk patients with mRCC. However, there is a knowledge gap with respect to the role of cytoreductive nephrectomy in patients with good risk disease, and we argue that these patients should be strongly considered for cytoreductive nephrectomy., Summary: Cytoreductive nephrectomy continues to play an important role in the multidisciplinary management of mRCC; however, diligent patient selection is crucial, as only patients with good risk features are likely to derive benefit from surgery.