Added Value of Systemic Inflammation Markers in Predicting Clinical Stage T1 Renal Cell Carcinoma Pathologically Upstaged to T3a

Abstract

ObjectivesWe aimed to determine preoperative risk factors associated with pathologic T3a (pT3a) upstaging of clinical T1 (cT1) renal cell carcinomas (RCCs) and develop a novel model capable of accurately identifying those patients at high risk of harboring occult pT3a characteristics.MethodsA retrospective analysis of 1324 cT1 RCC patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) was performed. The study cohort was divided into training and testing datasets in a 70:30 ratio for further analysis. Univariable and multivariable logistic regression analyses were performed to identify predictors associated with cT1 to pT3a upstaging and subsequently, those significant risk factors were used to construct models. We used the area under the curve (AUC) to determine the model with the highest discrimination power. Decision curve analyses (DCAs) were applied to evaluate clinical net benefit associated with using the predictive models.ResultsThe rates of upstaging were 6.1% (n = 81), 5.8% (n = 54) and 6.8% (n = 27) in the total population, training cohort and validation cohort, respectively. Tumor size, clinical T stage, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior) nephrometry score, lymphocyte to monocyte ratio (LMR), prognostic nutrition index (PNI) and albumin to globulin ratio (AGR) were significantly associated with pT3a upstaging. The model that consisted of R.E.N.A.L. score, LMR, AGR and PNI achieved the highest AUC of 0.70 in the validation cohort and yielded the highest net benefit. In the subpopulation with complete serum lipid profile, the inclusion of low-density lipoprotein cholesterol (LDL-C) and Castelli risk index-I (CRI-I) significantly improved the discrimination of model (AUC = 0.86).ConclusionsOur finding highlights the importance of systemic inflammation response markers and serum lipid parameters in predicting pT3a upstaging. Our model had relatively good discrimination in predicting occult pT3a disease among patients with cT1 renal lesions, and the use of the model may be greatly beneficial to urologists in risk stratification and management decisions.

A novel nomogram can predict pathological T3a upstaged from clinical T1a in localized renal cell carcinoma

“…The C-index for the nomogram was 0.712 (95% CI, 0.638-0.785). Compared with other studies (20,21), the advantage of our study was that the ARFS nomogram was more objective and could be easily calculated with 4 preoperative quantitative risk factors.…”

Comparison of prognosis between patients undergoing radical nephrectomy versus partial nephrectomy for renal cell carcinoma ≤7 cm T3aN0/xM0: Survival benefit is biased toward partial nephrectomy

“…1 Clinically, T1 RCC tumors can be identified as more aggressive T3a masses after final pathology analysis post-PN, with prior publications reporting a 1.9%-14% incidence rate. [7][8][9] In large RCC tumors, extrarenal fat extension is usually grossly visible on computed tomography or magnetic resonance imaging, whereas microscopic examination is generally required for small tumors. 23 Thus, the vast majority of pathological T3a RCC tumors, upstaged from the clinical T1 stage, need a pathological diagnosis and cannot be detected by preoperative imaging.…”

“…4 Another study indicated that RCC diameter, R.E.N.A.L. score, and systemic inflammatory response markers (such as lymphocyte to monocyte ratio) can be used to predict postoperative T3a upstaging 7 ; however, more accurate and better characterization of RCC is needed to predict preoperative T3a RCC upstaging.…”

“…1 Although three-dimensional reconstruction and virtual imaging techniques were reported to allow to facilitate the surgical planning preoperatively in complex renal masses evaluation, 2,3 there is still limited ability to accurately predict T3a stage disease preoperatively based on the current imaging modalities, it is not uncommon for T1 RCC to be upgraded to pathological stage T3a following PN, with reported incidence rates of 1.9%-14%. [4][5][6][7][8][9] This fact has led to a treatment strategy dilemma in clinical practice regarding whether it is preferable to keep PN unchanged, or change to radical nephrectomy (RN), since there is limited and controversial evidence of the surgical benefit of PN compared with RN for T3a RCC. 5,8,[10][11][12][13][14] Currently, there have been raised concerns about the oncological safety of PN for patients with T3a RCC.…”

A morphology-based nephrometry score to predict pathological upstaging to T3 renal cell carcinoma

“…The purpose of PN is to completely remove the tumor while preserving the surrounding structures, making less excision of the peritumoral tissue. However, it has led to increasing numbers of missing cases with adverse pathological features, such as sinus fat, calyx or venous infiltration ( 2 ).…”