SAN FRANCISCO (EGMN) – The decision to replace partial nephrectomy with radical nephrectomy for patients with clinically early-stage renal cell carcinoma should not be based on the possibility of rising cancer stage or higher pathologic grade, according to the results of a cohort study, researchers noted. The study population consisted of 213 patients with preoperative stage T1 but who had a postoperative rise in pathologic stage to a T2 or T3 tumor. Patients who underwent partial nephrectomy had no reduction in cancer-specific survival or overall survival compared with patients who underwent radical nephrectomy. The results were similar in the final pathology high-grade subgroup. The key message from Li Hongzhao of the Department of Urology at Beijing 301 Hospital is “don’t justify refusal of partial nephrectomy; don’t deprive patients of the opportunity for long-term benefit,” said lead investigator Christopher J. Weight, MD, PhD, in presenting the findings at the Genitourinary Cancers Symposium. ”In particular, don’t use the possibility of higher grade (of the tumor) or more advanced staging as an excuse, because there is no evidence to support this in our study data and in (other research data).” The results of many studies show that partial nephrectomy and radical nephrectomy are comparable in controlling cancer, he noted, “and we found that more preserved kidney function after partial nephrectomy was associated with increased overall survival and cardiovascular-specific survival.” But even in patients with smaller tumors, the use of partial nephrectomy has progressed very slowly, in part because of the fear of reduced tumor control, said Dr. Weight, a urologist at the Cleveland Clinic. In addition, a recent study found that progress in the use of partial nephrectomy regressed steeply when laparoscopic radical nephrectomy was introduced (J. Urol. 2010;183:467-72). This operation can also be called the “demon woman operation,” he said, “because it lures physicians to reject a procedure that is more beneficial to the patient.” Dr. Weight and his co-workers analyzed data from patients who underwent evaluation for renal masses between 1999 and 2006, with a median follow-up time of nearly 4.5 years. The investigators performed a pooled analysis of 213 patients with preoperative imaging confirmed clinical stage T1 but with intraoperative and pathologic staging rising to pathologic stage T2 or T3 renal cell carcinoma. Pathological stages of T2, T3a, and T3b were found in 16%, 69%, and 15% of the patients, respectively. About 55% of patients underwent radical nephrectomy and the other 45% underwent partial nephrectomy, Dr. Weight reported at a symposium sponsored by the American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Urologic Oncology. Overall, patients who underwent radical nephrectomy were older (63 and 67 years, respectively; P = 0.02), had larger tumors (4 and 6 cm, respectively; P < 0.0001), and had Charlson concomitant disease index scores of 2 or higher (13% and 36%, respectively; P = 0.0001) and final pathology compared with those who underwent partial nephrectomy. A higher proportion of patients had a nuclear tumor grade of 4 (7% and 20%, respectively, P = 0.004). Cancer-specific survival rates at 5 years were approximately 80% and 85% for radical nephrectomy and partial nephrectomy patients, respectively, and overall survival rates at approximately 5 years were 50% and 75%, respectively. In the subgroup graded 4, the 5-year cancer-specific survival rates for radical nephrectomy and partial nephrectomy patients were 40 and 95 percent, respectively. These results showed that cancer-specific survival was not lower in the partial nephrectomy group than in the radical nephrectomy group, Dr. Weight said. And, even when patients were stratified by pathologic stage, "at no level was cancer control found to be worse in partial nephrectomy patients than in radical nephrectomy patients." Overall survival was not reduced in the partial nephrectomy group in either univariate or multivariate analyses that considered the effects of different factors between the two groups, he noted. In the latter analysis, the only independent predictors were concomitant disease [hazard ratio (HR) of 0.47; P = 0.009 for Charlson score 0 to 1 compared with ³ 2] and age (HR of 1.03; P = 0.006 for each additional year). "Even when renal tumor stage was rising or was highly graded, disease-specific survival was not shown to be lower in partial nephrectomy patients compared with radical nephrectomy patients," Dr. Weight concluded. Therefore, physicians should not be inclined to choose simpler procedures based on these factors. Instead, technical feasibility is "the decision criterion for whether to perform partial nephrectomy," he suggests.