Content of this journal is licensed under a Abstract
Objective:
Renal cell carcinoma (RCC) patients in clinical T1 RCC generally exhibit a favorable prognosis. Guidelines recommend partial nephrectomy (PN), also for cT1b RCCs. Despite a favorable prognosis, there remains risks for upstaging and recurrence for cT1b RCC patients, and the preference for PN has been questionable. Clinical and morphological variables and overall survival (OS) were characterized in a national real-world population.
Methods:
Data from the the National Swedish Kidney Cancer Register 2005-2014, with non-metastatic cT1bRCC patients treated surgically and having ≥5 years potential follow-up were included (n = 2006). Patients gender, age, stage, tumor size, RCC type, local and distant tumor recurrence were evaluated.
Results:
Among 2006 patients (1219 males, 787 females; mean age 66 years), 1705 underwent radical nephrectomy (RN), and 301 PN. Upstage from cT1b to pathological T3a occurred in 304 (15%) patients. Recurrent disease was diagnosed in 318 (16%) patients, with higher rates in pT3a (25%) compared to pT1b (14%). There was no significant difference in disease recurrences observed between the surgical techniques. Factors associated with increased recurrence risk included age, T-stage, N-stage, and tumor size, while papillary and chromophobe RCCs were associated with decreased risk. Patients with pT3a RCC had a worse 5-year OS rate (67%) compared with pT1b (83%; P < .001, log-rank test). In adjusted analyses, age, tumor size, pT-stage, and pN-stage were associated with OS, while treatment with PN was non-inferior compared with RN (hazard ratio 0.91, 95% CI: 0.71-1.45, P = .431).
Conclusion:
Patients with clinical T1b RCCs face a non-negligible risk for tumor upstaging, disease recurrence, and decreased OS. The adjusted analyses showed that PN was non-inferior to RN, supporting the recommendation to offer PN.
Keywords: cT1b, partial nephrectomy, pT1b, radical nephrectomy, RCC type, renal cell carcinoma, survival, tumor size, tumor stage
Main Points
Patients with clinical T1b RCCs have a non-negligible risk for tumor upstaging, disease recurrence, and decreased OS.
Tumor size increase and upstaging from clinical T1b to pathological T3a were factors afflicted with worse prognosis.
The adjusted analyses showed that PN was non-inferior to RN supporting the recommendation to offer PN.
Introduction
Renal cell carcinoma (RCC) incidence has slowly been rising over the last decades, mostly attributable to an increase in abdominal imaging and increased detection of asymptomatic renal masses.1 Presently, more than 60% of the RCCs are diagnosed incidentally, which has brought on generally lower tumor stages.2 By this shift to lower stages, currently more than 60% are T1 RCC, being in the stage with the lowest tumor progression. The treatment of patients with T1 RCCs therefore has changed from radical nephrectomy (RN) to nephron-sparing treatments. Currently, guidelines recommend nephron-sparing treatment to preserve maximum kidney function when feasible.3,4 Patients with clinical T1b RCC, however, exhibit a higher incidence of pathological upstaging than pT1a and have a higher risk for metastases.5 Since recommendations for ablative treatments are limited to cT1a, surgery is the treatment option for most patients with cT1b3 Partial nephrectomy (PN) is more complex and challenging and is afflicted with higher risks of leaving tumor cells behind compared with RN, which includes removal of the entire kidney within the Gerota’s fascia. This risk is especially high in patients with local tissue and vein invasion.3,4,6,7 Positive surgical margins are discovered in 7%-10% after PN, which is associated with recurrent disease that may impair survival.8-10 However, oncological outcomes were shown to be similar between PN and RN for T1b RCC patients.3,11 Thus, the optimal treatment for patients with cT1b RCC, considering oncological outcomes and renal function, remains unclear.
Aim
The aim of this study was to assimilate the outcomes of patients with cT1b RCC in terms of recurrence and overall survival (OS) treated with RN or PN in a real-world setting.
Material and Methods
Participants and Eligibility Criteria
The present study included all surgicallytreated patients with primary non-metastatic cT1b RCC having a potential follow-up time of more than 5 years, registered prospectively in the the National Swedish Kidney Cancer Register (NSKCR) between January 2005 and January 2014. The 2006 patients had a mean age of 66 years at, 1219 (61%) males and 787 (39%) females (Table 1).
Table 1.
Characteristics of the 2006 Patients with Clinical T1b Renal Cell Carcinoma Included in the Study, in Relation to Performed Surgical Treatment
| Variable | All Patients | Radical Nephrectomy | Partial Nephrectomy | P |
|---|---|---|---|---|
| n = 2006 | n = 1705 | n = 301 | ||
| 100% | 85.0% | 15.0% | ||
| Male, n (%) | 1219 (60.8) | 1002 (58.8) | 217 (72.1) | <.001 |
| Female, n (%) | 787 (39.2) | 703 (41.2) | 84 (27.9) | |
| Age at surgery (years), mean (SD) | 66.1 (11.7) | 66.4 (11.6) | 64.3 (11.8) | .010 |
| pT-stage, n (%) | <.001 | |||
| pT1b | 1702 (84.8) | 1426 (83.2) | 276 (91.7) | |
| Upstaged p3a | 304 (15.2) | 279 (16.4) | 25 (8.3) | |
| N-stage, n (%) | N/A | |||
| N0 | 1972 (98.3) | 1672 (98.1) | 300 (9.7) | |
| N1 | 34 (1.7) | 33 (1.9) | 1 (0.3) | |
| Tumor size (mm), mean (SD) | 55.8 (8.6) | 52.5 (7.5) | 56.3 (8.7) | <.001 |
| RCC type, n (%) | <.001 | |||
| Clear cell RCC | 1625 (81.0) | 1419 (71.8) | 206 (68.4) | |
| Papillary RCC | 232 (11.6) | 164 (9.6) | 68 (22.6) | |
| Chromophobe RCC | 115 (5.7) | 93 (5.5) | 22 (7.3) | |
| Other RCC types | 34 (1.7) | 29 (1.7) | 5 (1.7) | |
| Tumor recurrencea, n (%) | 318 (15.8) | 281 (16.5) | 37 (12.3) | N/A |
| Local recurrence | 17 (5.3) | 2 (0.7) | 15 (40.5) | |
| Metastases | 301 (94.7) | 279 (99.3) | 22 (59.5) |
N/A, not applicable; RCC, renal cell carcinoma; SD, standard deviation.
aTumor recurrence refers to observed recurrence during follow-up.
Study Design and Outcome Measures
After 5 years follow-up, the patients were retrospectively evaluated by their urological department to determine whether any recurrence had occurred during the follow-up time. Recurrence-free survival timewas measured from thedate of treatment to the dateof recurrence. The ´Swedish National Population Register was used for information on OS. Survival time was calculated from the date of treatment to the date of any cause of death or censored if alive at the end of December 2020. Information on clinical data and primary surgery was extracted from NSKCR. The seventh TNM stage and the 2016 WHO classification were used for TNM stage and RCC type classification, respectively.12,13 The largest diameter of the tumors on the preoperative computerized tomography defined the tumor size.Part of this patient cohort was included in a previous study.5
Ethical Approval
The study was approved by the regional Ethical Review Board of Northern Sweden (Dnr 2012-418-31M) and the Swedish Ethical Review Agency (Dnr 2019-02579).
Statistical Analyses
Categorical data are shown with numbers and percentages. Ordinal and continuous data are shown as means ± SDs. Pearson’s χ2-test was used between groups and the Mann–Whitney U test for continuous variables. The Kaplan–Meier method was used to construct survival curves and tested with the log-rank test. Cox proportional hazards regression tests were done for unadjusted and adjusted analyses with time-to-death as the outcome. Results are reported as hazard ratios (HRs) and accompanying 95% CI. For statistical analyses, IBM SPSS Statistics 26.0 (IBM SPSS Corp.; Armonk, NY, USA) was used with 2-sided P-values <.05 regarded as significant.
Results
Of the 2006 included patients, RN was performed in 1705 (85%) and PN in 301 (15%) of the patients (Table 1). Most patients (n = 1625, 81%) had clear cell RCC (ccRCC), while 232 (12%) patients had papillary RCC-type (pRCC), 115 (6%) chromophobe RCC-type (chRCC), and the remaining 34 (2%) had other RCC types.
Among the 2006 patients with cT1b, 303 (15.1%) were upstaged to pT3a, including 250 (15.4%) ccRCCs, 27 (11.6%) pRCCs, 20 (17.4%) chRCCs, and 6 (17.6%) patients with other RCC types. The occurrence of recurrences was observed among 281 (16.5%) of the RN-treated patients and 37 (12.3%) of the PN-treated patients. Notably, 279 (99.3%) of the RN-treated patients with tumor recurrence experienced metastases, compared with 22 (59.5%) of the PN-treated patients (Table 1).
In total, recurrent disease during ≥5 years follow-up, including local recurrences and distant metastases, was diagnosed in 318 patients (15.9%), including 281 (17.3%) ccRCCs, 25 (10.8%) pRCCs, 5 (4.3%) chRCCs, and 7 (20.6%) patients with other RCC types (not in table). Among patients with recurrent disease, 238 (14%) had pT1b and 80 (25%) patients were upstaged to pT3a (not in table). The lung was the most common recurrence site (50.6%), as shown in Table 2. Among the 318 patients with recurrent disease, 95 (30.0%) had 2 or more metastatic sites (Table 2). Most patients (15 of 17) with local recurrence were primarily treated with PN while 2 RN patients had local kidney groin recurrence. Patients’ age at diagnosis, stage upgrade to pT3a, N-stage, and tumor size all had a significant independent association with increased risks of recurrent disease, while patients having pRCCs or chRCC had decreased risks (Table 3).
Table 2.
Distribution of Sites of Recurrent Disease in Relation to Surgical Treatment in 2006 Patients with cT1bM0 Renal Cell Carcinoma at Primary Diagnosis
| Site of Recurrence | Total | RN | PN |
|---|---|---|---|
| n = 318 | n = 281 | n = 37 | |
| All sites | 440 | 386 | 54 |
| Lung | 161 | 143 | 18 |
| Skeletal | 73 | 68 | 5 |
| Lymph nodes | 48 | 46 | 2 |
| Treated kidney | 20 | 0 | 20 |
| Local groin | 28 | 28 | 0 |
| Adrenal | 24 | 22 | 2 |
| Contralateral kidney | 9 | 9 | 0 |
| Liver | 36 | 32 | 4 |
| Brain | 10 | 10 | 0 |
| Other | 28 | 25 | 3 |
Among the 318 patients with recurrent disease, 95 (29.9%) had more than 1 site registered.
Table 3.
Results for Cox Regression Analysis of Factors Important for Time to Diagnosis of Recurrence in 2006 Patients with Clinical T1b Renal Cell Carcinoma Adjusted for Age, Gender, Upgraded pT3a, N-Stage, RCC Type, Tumor Size, and Performed Surgery (PN vs. RN)
| Predictor | Unadjusted | Adjusteda | ||||
|---|---|---|---|---|---|---|
| HR | 95% CI | P | HR | 95% CI | P | |
| Age (year) | 1.024 | 1.014-1.035 | <.001 | 1.023 | 1.012-1.034 | <.001 |
| Female vs. male | 0.839 | 0.667-1.056 | .135 | 0.793 | 0.628-1.002 | .052 |
| pT3a vs. pT1b | 2.239 | 1.737-2.884 | <.001 | 1.967 | 1.520-2.546 | <.001 |
| N1 vs. N0 | 6.971 | 4.314-10.943 | <.001 | 1.343 | 1.120-1.611 | .001 |
| RCC type | ||||||
| ccRCC | Ref. | Ref. | ||||
| pRCC | 0.608 | 0.404-0.915 | .017 | 0.551 | 0.359-0.846 | .006 |
| chRCC | 0.234 | 0.097-0.566 | .001 | 0.250 | 0.103-0.607 | .002 |
| Other | 1.363 | 0.644-2.885 | .419 | 1.500 | 0.708-3.180 | .290 |
| Tumor size (mm) | 1.029 | 1.016-1.042 | <.001 | 1.024 | 1.011-1.037 | <.001 |
| PN vs. RN | 0.716 | 0.508-1.009 | .056 | 0.896 | 0.626-1.284 | 0.551 |
Significant P-values are given in bold.
HR, hazard ratio; PN, partial nephrectomy; Ref., reference category; RN, radical nephrectomy. aAdjusted for: age at surgery (years), female vs. male sex, pT1b vs. upgraded pT3a, RCC type, tumor size (mm), and surgery PN vs. RN.
Patients with pT3a RCC had significantly lower (67%, P < 0.001) 5-year OS rate compared to those with pT1b (83%, data not shown). Partial nephrectomy patients had a significantly better OS (P = .023) than RN-treated patients (Figure 1). In adjusted analyses, age, pT-stage, cN-stage, and tumor size remained significantly associated with OS, while PN compared with RN had a non-different association (HR 0.91; 95% CI: 0.71-1.16, P = .431) (Table 4).
Figure 1.
Kaplan–Meier curves of univariate overall survival probability in relation to PN vs. RN in 2006 patients with clinical T1b renal cell carcinoma. Number of patients at risk are shown below the corresponding time points.
Table 4.
Results for Cox Regression Analysis on Overall Survival in 2006 Patients with Clinical T1b Renal Cell Carcinoma Adjusted for Age, Gender, Upgraded cT1b to pT3a, RCC Type, Tumor Size, and Performed Surgery (PN vs. RN)
| Predictor | Unadjusted | Adjusteda | ||||
|---|---|---|---|---|---|---|
| HR | 95% CI | P | HR | 95% CI | P | |
| Age (years) | 1.065 | 1.057-1.074 | <.001 | 1.018 | 1.009-1.026 | <.001 |
| Female vs. male | 0.972 | 0.836-1.130 | .711 | 0.864 | 0.740-1.007 | .062 |
| pT3a vs. pT1b | 1.753 | 1.461-2.105 | <.001 | 1.491 | 1.239-1.794 | <.001 |
| N1 vs. N0 | 1.240 | 1.066-1.443 | .005 | 1.206 | 1.019-1.428 | .029 |
| RCC type | ||||||
| ccRCC | Ref. | Ref. | ||||
| pRCC | 1.108 | 0.887-1.383 | .386 | 1.010 | 0.805-1.267 | .930 |
| chRCC | 0.565 | 0.378-0.843 | .005 | 0.622 | 0.416-0.928 | .020 |
| Other | 1.638 | 0.996-2.691 | .052 | 1.737 | 1.055-2.861 | .030 |
| Tumor size (mm) | 1.019 | 1.011-1.028 | <.001 | 1.018 | 1.009-1.026 | <.001 |
| PN vs. RN | 0.761 | 0.601-0.963 | .023 | 0.906 | 0.708-1.159 | .431 |
Significant P-values are given in bold.
HR, hazard ratio; PN, partial nephrectomy; Ref., reference category; RN, radical nephrectomy. aAdjusted for: age at surgery (years), female vs. male sex, pT1b vs. upgraded pT3a, RCC type, tumor size (mm), and surgery PN vs. RN.
Discussion
It was shown, after adjusted analyses, that surgical treatment with PN entailed a non-inferior OS compared with RN, in a nationwide cohort of real-world patients with clinical T1b RCC. This non-differential survival was obtained despite the significantly higher risk of positive surgical margins when performing PN due to leaving unrecognized local tumor tissue and vein invasion.
Generally, RCC patients without metastases in clinical stage T1 at diagnosis have the best prognosis among the RCC stages.3 However, despite this advantageous prognosis, there remains a risk for progressive disease.5 This is partly due to the risk of pathological tumor upstage to pT3a in patients with cT1b RCC, who are at a higher risk for local and metastatic recurrent disease.5,14-16 Radical nephrectomy has an advantage for these patients with pathological upstage, lowering the risk of leaving tumor tissue behind compared with PN. Improved preoperative imaging is desirable to enhance the detection of upstaging and to guide surgery planning.17,18 It is well-known that local recurrence implies reduced survival, while nephron-sparing aligns with fewer cardiovascular events.3,19 Partial nephrectomy with more remaining nephrons is advocated in patients with already reduced kidney function, especially to prevent any need for hemodialysis. Also, in newly diagnosed RCC patients with normal baseline serum creatinine levels, 26% had a glomerular filtration rate ≤60 mL/min.20 Therefore, PN is an advised option for oncological outcomes and preserving kidney function in patients with cT1 RCC.3,21
Performing PN is more intricate than RN and has a higher incidence of complications.3,22 It has been debated whether PN enhances OS compared with RN due to more preserved renal function. Several retrospective analyses have suggested increased cardiovascular mortality and decreased OS for RN-treated patients compared to those treated with PN. In some series, this survival difference was found only for patients with comorbidity.23 In a systematic review by Chung et al,24 the authors reported significantly improved OS in PN-treated compared to RN-treated patients (HR 0.74; 95% CI 0.75-0.95). In contrast, the significant advantage in OS for PN found in univariate analysis in our study disappeared in the adjusted analysis, showing a similar risk for reduced OS in PN-treated patients compared with RN-treated. Our data confirm results from 2 studies using meta-analyses showing similar RFS and OS rates.21,25 Furthermore, we found that patients treated with PN had similar risks for disease recurrence as patients treated with RN. This unexpected equality might be due to the tumor biology irrespective of type of performed surgery but also due to the patient’s treatment being based on several considerations judged by individual surgeons such as tumor location, complexity, and tumor size, as well as the patient’s preferences.3,4 Moreover, morphologic RCC type remained, after adjusted analyses, a significant factor for both disease recurrence and OS. Patients with chRCC had significantly fewer occurrences of recurrences and showed a 58% lower risk for reduced OS than ccRCC, while patients with pRCC had a 46% lower risk for disease recurrence. These results are in line with those found in earlier studies.5,26
Furthermore, we showed that increased tumor size raised the risk for reduced OS by 1.8% per mm increase in tumor size. Thus, we show that tumor size is important for survival even in T1b RCCs, corroborating the outcome of prior research.5,27 Using the SEER cancer database, Tang et al also showed importance of tumor size for both overall mortality and cancer-specific mortality.28 The independent risks for tumor recurrence and lower OS by increasing tumor size clearly indicate that early tumor treatment is desirable even in patients with cT1b RCC.
Strengths and Limitations
Limitations of the present study were that data on comorbidities, performance status, and cancer specificwere unavailable. Another limitation was that the NSKCR data was registered from several hospitals, which is why uniformity in data collection might have been unattainable and may have resulted in register discrepancies. However, when the register was validated, it had high equivalence and quality.29 The treatments of the patients were ultimately based on surgeons' and patients’ preferences. An important strength is that the patients represented a nationwide cohort, including practically all RCC patients nationwide.
It was shown that there was no statistically significant difference in OS between patients with cT1b-RCC treated with PN or with RN. Age at diagnosis, upstaging from cT1b to pT3a RCC, RCC type, and tumor size all were associated with OS. Furthermore, age, T-stage, RCC-type, and tumor size were associated with the occurrence of recurrent disease. The recommendation to offer PN to patients with cT1b RCC is supported by the results.
Members of the Study Group:
The members of the National Swedish Kidney Cancer Register Steering Committee are given in the Appendix.
Funding Statement
The authors declared that this study has received no financial support.
Footnotes
Ethics Committee Approval: This study was approved by the Ethical Review Board of Northern Sweden (Dnr 2012-418-31M) and the Swedish Ethical Review Agency (Dnr 2019-02579).
Informed Consent: Written informed consent was obtained from the patients who agreed to take part in the study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – S.L., B.L.; Design – S.L., B.L.; Supervision – B.L.; Resources – N/A; Materials – S.L., T.A., A.R.K., B.L.; Data Collection and/or Processing – S.L., T.A., A.R.K., B.L.; Analysis and/or Interpretation – A.R.K., B.L.; Literature Search – S.L., T.A., A.R.K., B.L.; Writing – S.L., B.L.; Critical Review – S.L., T.A., A.R.K., B.L.
Declaration of Interests: The authors have no conflict of interest to declare.
Appendix: The National Swedish Kidney Cancer Register Steering Committee has the following members: Anca Dragomir, Anders Kjellman, Bianca Scholtz, Börje Ljungberg, Britt-Inger Dahlin, Emma Mangelus, Emma Ulvskog, Linn Pettersson, Magnus Lindskog, Marcus Thomasson, Martin Johansson, Mikael Hellström, Per Lindblad, Per Skoglund, Pernilla Sundqvist, Sigrid Isaksson, Stephanie Bonn, Susanna Holst, Sven Lundstam, Ulrika Harmenberg.
Data Availability Statement:
The National Swedish Kidney Cancer Register (NSKCR) is an ongoing register and it is notavailable for open access.
References
- 1. Bukavina L, Bensalah K, Bray F. Epidemiology of renal cell carcinoma: 2022 update. Eur Urol. 2022;82(5):529 542. (doi: 10.1016/j.eururo.2022.08.019 ) [DOI] [PubMed] [Google Scholar]
- 2. Thorstenson A Harmenberg U Lindblad P Ljungberg B Lundstam S Swedish Kidney Cancer Quality Register Group. . Impact of quality indicators on adherence to National and European guidelines for renal cell carcinoma. Scand J Urol. 2016;50(1):2 8. (doi: 10.3109/21681805.2015.1059882 ) [DOI] [PubMed] [Google Scholar]
- 3. Ljungberg B, Albiges L, Abu-Ghanem Y. European Association of Urology guidelines on renal cell carcinoma: the 2022 update. Eur Urol. 2022;82(4):399 410. (doi: 10.1016/j.eururo.2022.03.006 ) [DOI] [PubMed] [Google Scholar]
- 4. Campbell S, Uzzo RG, Allaf ME. Renal mass and localized renal Cancer: AUA Guideline. J Urol. 2017;198(3):520 529. (doi: 10.1016/j.juro.2017.04.100 ) [DOI] [PubMed] [Google Scholar]
- 5. Almdalal T, Karlsson Rosenblad A, Hellström M. Predictive characteristics for disease recurrence and overall survival in non-metastatic clinical T1 renal cell carcinoma - results from the National Swedish Kidney Cancer Register. Scand J Urol. 2023;57(1-6):67 74. (doi: 10.1080/21681805.2022.2154383 ) [DOI] [PubMed] [Google Scholar]
- 6. Guðmundsson E Hellborg H Lundstam S Erikson S Ljungberg B Swedish Kidney Cancer Quality Register Group. . Metastatic potential in renal cell carcinomas ≤7 cm: Swedish Kidney Cancer Quality Register data. Eur Urol. 2011;60(5):975 982. (doi: 10.1016/j.eururo.2011.06.029 ) [DOI] [PubMed] [Google Scholar]
- 7. Ishiyama R, Omae K, Kondo T. Predictive factors and oncological outcomes of pathological T3a upstaging in patients with clinical T1 renal cell carcinoma undergoing partial nephrectomy. Jpn J Clin Oncol. 2024;54(2):160 166. (doi: 10.1093/jjco/hyad142 ) [DOI] [PubMed] [Google Scholar]
- 8. Wood EL, Adibi M, Qiao W. Local tumor bed recurrence following partial nephrectomy in patients with small renal masses. J Urol. 2018;199(2):393 400. (doi: 10.1016/j.juro.2017.09.072 ) [DOI] [PubMed] [Google Scholar]
- 9. Carvalho JAM, Nunes P, Tavares-da-Silva E. Impact of positive surgical margins after partial nephrectomy. Eur Urol Open Sci. 2020;21:41 46. (doi: 10.1016/j.euros.2020.08.006 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Shah PH, Moreira DM, Okhunov Z. Positive surgical margins increase risk of recurrence after partial nephrectomy for high risk renal tumors. J Urol. 2016;196(2):327 334. (doi: 10.1016/j.juro.2016.02.075 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Weight CJ Lythgoe C Unnikrishnan R Lane BR Campbell SC Fergany AF. . Partial nephrectomy does not compromise survival in patients with pathologic upstaging to pT2/pT3 or high-grade renal tumors compared with radical nephrectomy. Urology. 2011;77(5):1142 1146. (doi: 10.1016/j.urology.2010.11.058 ) [DOI] [PubMed] [Google Scholar]
- 12. Sobin LH, Gospodarowicz MK, Wittekind C. TNM Classification of Malignant Tumours. 7th ed. New York: Wiley-Liss; 2009. [Google Scholar]
- 13. Moch H Cubilla AL Humphrey PA Reuter VE Ulbright TM. . The 2016 WHO classification of tumours of the urinary system and male Genital organs-part A: renal, penile, and testicular tumours. Eur Urol. 2016;70(1):93 105. (doi: 10.1016/j.eururo.2016.02.029 ) [DOI] [PubMed] [Google Scholar]
- 14. Chevinsky M, Imnadze M, Sankin A. Pathological Stage T3a significantly increases disease recurrence across all tumor sizes in renal cell carcinoma. J Urol. 2015;194(2):310 315. (doi: 10.1016/j.juro.2015.02.013 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Guo P, Wang Y, Han Y. Oncological outcomes of patients with different pathological features of pT3a renal tumor: a systematic review and quantitative synthesis. Front Oncol. 2021;11:678459. (doi: 10.3389/fonc.2021.678459 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Patel SH, Uzzo RG, Larcher A. Oncologic and functional outcomes of radical and partial nephrectomy in pT3a pathologically upstaged renal cell carcinoma: a multi-institutional analysis. Clin Genitourin Cancer. 2020;18(6):e723 e729. (doi: 10.1016/j.clgc.2020.05.002 ) [DOI] [PubMed] [Google Scholar]
- 17. Teishima J, Hayashi T, Kitano H. Impact of radiological morphology of clinical T1 renal cell carcinoma on the prediction of upstaging to pathological T3. Jpn J Clin Oncol. 2020;50(4):473 478. (doi: 10.1093/jjco/hyz154 ) [DOI] [PubMed] [Google Scholar]
- 18. Renard AS, Nedelcu C, Paisant A. Is multidetector CT-scan able to detect T3a renal tumor before surgery? Scand J Urol. 2019;53(5):350 355. (doi: 10.1080/21681805.2019.1675756 ) [DOI] [PubMed] [Google Scholar]
- 19. Capitanio U, Terrone C, Antonelli A. Nephron-sparing techniques independently decrease the risk of cardiovascular events relative to radical nephrectomy in patients with a T1a-T1b renal mass and normal preoperative renal function. Eur Urol. 2015;67(4):683 689. (doi: 10.1016/j.eururo.2014.09.027 ) [DOI] [PubMed] [Google Scholar]
- 20. Huang WC, Levey AS, Serio AM. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 2006;7(9):735 740. (doi: 10.1016/S1470-2045(06)70803-8 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Zhang Y, Long G, Shang H. Comparison of the oncological, perioperative and functional outcomes of partial nephrectomy versus radical nephrectomy for clinical T1b renal cell carcinoma: a systematic review and meta-analysis of retrospective studies. Asian J Urol. 2021;8(1):117 125. (doi: 10.1016/j.ajur.2019.11.004 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Pyrgidis N, Schulz GB, Stief C. Surgical trends and complications in partial and radical nephrectomy: results from the GRAND study. Cancers (Basel). 2023;16(1):97. (doi: 10.3390/cancers16010097 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Larcher A, Capitanio U, Terrone C. Elective nephron sparing surgery decreases other cause mortality relative to radical nephrectomy only in specific subgroups of patients with renal cell carcinoma. J Urol. 2016;196(4):1008 1013. (doi: 10.1016/j.juro.2016.04.093 ) [DOI] [PubMed] [Google Scholar]
- 24. Chung DY Kang DH Kim JW Kim DK Lee JY Cho KS. . Comparison of oncologic outcomes between partial nephrectomy and radical nephrectomy in patients who were upstaged from cT1 renal tumor to pT3a renal cell carcinoma: an updated systematic review and meta-analysis. Ther Adv Urol. 2020;12:1756287220981508. (doi: 10.1177/1756287220981508 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Jiang YL Peng CX Wang HZ Qian LJ. . Comparison of the long-term follow-up and perioperative outcomes of partial nephrectomy and radical nephrectomy for 4 cm to 7 cm renal cell carcinoma: a systematic review and meta-analysis. BMC Urol. 2019;19(1):48. (doi: 10.1186/s12894-019-0480-6 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Abu-Ghanem Y, Powles T, Capitanio U. The impact of histological subtype on the incidence, timing, and patterns of recurrence in patients with renal cell carcinoma after surgery-results from RECUR consortium. Eur Urol Oncol. 2021;4(3):473 482. (doi: 10.1016/j.euo.2020.09.005 ) [DOI] [PubMed] [Google Scholar]
- 27. Sorce G, Hoeh B, Hohenhorst L. Cancer-specific mortality in T1a renal cell carcinoma treated with local tumor destruction versus partial nephrectomy. Eur Urol Focus. 2023;9(1):125 132. (doi: 10.1016/j.euf.2022.07.005 ) [DOI] [PubMed] [Google Scholar]
- 28. Tang Y, Liu F, Mao X. The impact of tumor size on the survival of patients with small renal masses: a population-based study. Cancer Med. 2022;11(12):2377 2385. (doi: 10.1002/cam4.4595 ) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Landberg A, Bruce D, Lindblad P. Validation of data quality in the National Swedish Kidney Cancer Register. Scand J Urol. 2021;55(2):142 148. (doi: 10.1080/21681805.2021.1885485 ) [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The National Swedish Kidney Cancer Register (NSKCR) is an ongoing register and it is notavailable for open access.