Publications by authors named "Teele Kuusk"

31 Publications

The 2021 Updated European Association of Urology Guidelines on Renal Cell Carcinoma: Immune Checkpoint Inhibitor-based Combination Therapies for Treatment-naive Metastatic Clear-cell Renal Cell Carcinoma Are Standard of Care.

Eur Urol 2021 May 29. Epub 2021 May 29.

The Royal Free London NHS Foundation Trust, London, UK; UCL Division of Surgery and Interventional Science, London, UK; Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. Electronic address:

The recent randomized controlled phase III CLEAR trial results are the last to complement immune checkpoint inhibitor (ICI)-based doublet combination therapies for treatment-naïve metastatic clear-cell renal cell carcinoma. The CLEAR trial demonstrated an improved progression-free survival (PFS), overall survival (OS), and an objective response rate (ORR) benefit for the combination of lenvatinib plus pembrolizumab over sunitinib. The CheckMate-9ER trial update demonstrated an ongoing PFS, OS, and quality-of-life benefit for cabozantinib plus nivolumab over sunitinib as did the update of Keynote-426 for axitinib plus pembrolizumab in the intention-to-treat population, with a PFS benefit seen across all International Metastatic Database Consortium (IMDC) subgroups. In the IMDC intermediate- and poor-risk groups, the CheckMate-214 trial of ipilimumab plus nivolumab confirmed the OS benefit with a PFS plateauing after 30 months. The RCC Guidelines Panel recommends three tyrosine kinase inhibitors + ICI combinations of axitinib plus pembrolizumab, cabozantinib plus nivolumab, and lenvatinib plus pembrolizumab across all IMDC risk groups in advanced first-line RCC, and dual immunotherapy of ipilimumab and nivolumab in IMDC intermediate- and poor-risk groups. PATIENT SUMMARY: New data from combination trials with immune checkpoint inhibitors for advanced kidney cancer confirm a survival benefit for lenvatinib plus pembrolizumab, cabozantinib plus nivolumab (with improved quality-of-life), axitinib plus pembrolizumab, and ipilimumab plus nivolumab. These combination therapies are recommended as first-line treatment for advanced kidney cancer.
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http://dx.doi.org/10.1016/j.eururo.2021.04.042DOI Listing
May 2021

The European Association of Urology COVID Intermediate-priority Group is Poorly Predictive of Pathological High Risk Among Patients with Renal Tumours.

Eur Urol 2021 Aug 20;80(2):265-267. Epub 2021 May 20.

UCL Medical School, University College London, London, UK; Specialist Centre For Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2021.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136273PMC
August 2021

Impact of the first surge of the COVID-19 pandemic on a tertiary referral centre for kidney cancer.

BJU Int 2021 May 8. Epub 2021 May 8.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

Objective: To analyse the impact of the COVID-19 pandemic on a centralized specialist kidney cancer care pathway.

Materials And Methods: We conducted a retrospective analysis of patient and pathway characteristics including prioritization strategies at the Specialist Centre for Kidney Cancer located at the Royal Free London NHS Foundation Trust (RFH) before and during the surge of COVID-19.

Results: On 18 March 2020 all elective surgery was halted at RFH to redeploy resources and staff for the COVID-19 surge. Prioritizing of patients according to European Association of Urology guidance was introduced. Clinics and the specialist multidisciplinary team (SMDT) meetings were maintained with physical distancing, kidney surgery was moved to a COVID-protected site, and infection prevention measurements were enforced. During the 7 weeks of lockdown (23 March to 10 May 2020), 234 cases were discussed at the SMDT meetings, 53% compared to the 446 cases discussed in the 7 weeks pre-lockdown. The reduction in referrals was more pronounced for small and asymptomatic renal masses. Of 62 low-priority cancer patients, 27 (43.5%) were deferred. Only one (4%) COVID-19 infection occurred postoperatively, and the patient made a full recovery. No increase in clinical or pathological upstaging could be detected in patients who underwent deferred surgery compared to pre-COVID practice.

Conclusion: The first surge of the COVID-19 pandemic severely impacted diagnosis, referral and treatment of kidney cancer at a tertiary referral centre. With a policy of prioritization and COVID-protected pathways, capacity for time-sensitive oncological interventions was maintained and no immediate clinical harm was observed.
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http://dx.doi.org/10.1111/bju.15441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239749PMC
May 2021

Perioperative therapy in renal cancer in the era of immune checkpoint inhibitor therapy.

Curr Opin Urol 2021 05;31(3):262-269

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust.

Purpose Of Review: Immune checkpoint inhibitor (ICI) combination therapy has revolutionized therapy of metastatic renal cancer. The success of immunotherapy has renewed an interest to study these agents in adjuvant and neoadjuvant settings and prior to cytoreductive nephrectomy. This narrative review will give an overview of ongoing trials and early translational research outcomes.

Recent Findings: In nonmetastatic renal cell carcinoma (RCC), five phase 3 adjuvant and neoadjuvant trials with ICI monotherapy or combinations are ongoing with atezolizumab (IMmotion 010; NCT03024996), pembrolizumab (KEYNOTE-564; NCT03142334), nivolumab (PROSPER; NCT03055013), nivolumab with or without ipilimumab (CheckMate 914; NCT03138512) and durvalumab with or without tremelimumab (RAMPART; NCT03288532). Phase 1b/2 neoadjuvant trials demonstrate safety, efficacy and dynamic changes of immune infiltrates and provide rationales for neoadjuvant trial concepts as well as prediction of response to therapy. In primary metastatic RCC, two phase 3 trials investigate the role of deferred cytoreductive nephrectomy following pretreatment with ICI combination (NORDICSUN; NCT03977571 and PROBE; NCT04510597).

Summary: The outcomes of the major phase 3 trials are awaited as early as 2023. Meanwhile, translational data from phase 1b/2 studies enhance our understanding of the tumour immune microenvironment and its dynamic changes.
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http://dx.doi.org/10.1097/MOU.0000000000000868DOI Listing
May 2021

Outcome after resection of occult and non-occult lymph node metastases at the time of nephrectomy.

World J Urol 2021 Feb 25. Epub 2021 Feb 25.

Department of Urology, Renal Cancer Unit, Royal Free Hospital, London, UK.

Purpose: There is sparse evidence on outcomes of resected occult LN metastases at the time of nephrectomy (synchronous disease). We sought to analyse a large international cohort of patients and to identify clinico-pathological predictors of long-term survival.

Materials And Methods: We collected data of consecutive patients who underwent nephrectomy and LND for T cN0-1pN1 and cM0-1 RCC at 7 referral centres between 1988 and 2019. Patients were stratified into four clinico-pathological groups: (1) cN0cM0-pN1, (2) cN1cM0-pN1(limited, 1-3 positive nodes), (3) cN1cM0-pN1(extensive, > 3 positive nodes), and (4) cM1-pN1. Overall survival (OS) was estimated using the Kaplan-Meier method, and associations with all-cause mortality (ACM) were evaluated using Cox models with multiple imputations.

Results: Of the 4370 patients with LND, 292 patients with pN1 disease were analysed. Median follow-up was 62 months, during which 171 patients died. Median OS was 21 months (95% CI 17-30 months) and the 5-year OS rate was 24% (95% CI 18-31%). Patients with cN0cM0-pN1 disease had a median OS of 57 months and a 5-year OS rate of 43%. 5-year OS (median OS) decreased to 29% (33 months) in cN1cM0-pN1(limited) and to 23% (23 months) in cN1cM0-pN1(extensive) patients. Those with cM1-pN1 disease had the worst prognosis, with a 5-year OS rate of 13% (9 months). On multivariable analysis, age (p = 0.034), tumour size (p = 0.02), grade (p = 0.02) and clinico-pathological group (p < 0.05) were significant predictors of ACM.

Conclusion: Depending on clinico-pathological group, grade and tumour size, 5-year survival of patients with LN metastases varies from 13 to 43%. Patients with resected occult lymph node involvement (cN0/pN1 cM0) have the best prognosis with a considerable chance of long-term survival.
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http://dx.doi.org/10.1007/s00345-021-03633-5DOI Listing
February 2021

Radiomics to better characterize small renal masses.

World J Urol 2021 Jan 26. Epub 2021 Jan 26.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

Purpose: Radiomics is a specific field of medical research that uses programmable recognition tools to extract objective information from standard images to combine with clinical data, with the aim of improving diagnostic, prognostic, and predictive accuracy beyond standard visual interpretation. We performed a narrative review of radiomic applications that may support improved characterization of small renal masses (SRM). The main focus of the review was to identify and discuss methods which may accurately differentiate benign from malignant renal masses, specifically between renal cell carcinoma (RCC) subtypes and from angiomyolipoma without visible fat (fat-poor AML) and oncocytoma. Furthermore, prediction of grade, sarcomatoid features, and gene mutations would be of importance in terms of potential clinical utility in prognostic stratification and selecting personalised patient management strategies.

Methods: A detailed search of original articles was performed using the PubMed-MEDLINE database until 20 September 2020 to identify the English literature relevant to radiomics applications in renal tumour assessment. In total, 42 articles were included in the analysis in 3 main categories related to SRM: prediction of benign versus malignant SRM, subtypes, and nuclear grade, and other features of aggressiveness.

Conclusion: Overall, studies reported the superiority of radiomics over expert radiological assessment, but were mainly of retrospective design and therefore of low-quality evidence. However, it is clear that radiomics is an attractive modality that has the potential to improve the non-invasive diagnostic accuracy of SRM imaging and prediction of its natural behaviour. Further prospective validation studies of radiomics are needed to augment management algorithms of SRM.
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http://dx.doi.org/10.1007/s00345-021-03602-yDOI Listing
January 2021

Updated European Association of Urology Guidelines on Renal Cell Carcinoma: Nivolumab plus Cabozantinib Joins Immune Checkpoint Inhibition Combination Therapies for Treatment-naïve Metastatic Clear-Cell Renal Cell Carcinoma.

Eur Urol 2021 Mar 24;79(3):339-342. Epub 2020 Dec 24.

The Royal Free London NHS Foundation Trust, London, UK; UCL Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. Electronic address:

Longer follow-up and new trial data from phase 3 randomised controlled trials investigating immune checkpoint blockade (PD-1 or its ligand PD-L1) in advanced clear-cell renal cell carcinoma (RCC) have recently become available. The CheckMate 9ER trial demonstrated an improved progression-free survival (PFS) and overall survival (OS) benefit for the combination of cabozantinib plus nivolumab. A Keynote-426 update demonstrated an ongoing OS benefit for pembrolizumab plus axitinib in the intention-to-treat population, with a PFS benefit seen across all International Metastatic Database Consortium (IMDC) subgroups, while an update of CheckMate 214 confirmed the long-term benefit of ipilimumab plus nivolumab in IMDC intermediate and poor risk patients. The RCC Guidelines Panel continues to recommend these tyrosine kinase inhibitors + immunotherapy (IO) combination across IMDC risk groups in advanced first-line RCC and dual immunotherapy of ipilimumab and nivolumab in IMDC intermediate and poor risk. PATIENT SUMMARY: New data from trials of immune checkpoint inhibitors for advanced kidney cancer confirm a survival benefit with the combination of cabozantinib plus nivolumab and pembrolizumab plus axitinib and ipilimumab plus nivolumab. These combination therapies are recommended as first-line treatment for advanced kidney cancer.
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http://dx.doi.org/10.1016/j.eururo.2020.12.005DOI Listing
March 2021

Re: Adjuvant Chemotherapy in Upper Tract Urothelial Carcinoma (the POUT Trial): A Phase 3, Open-label, Randomised Controlled Trial.

Eur Urol 2020 10 22;78(4):630-631. Epub 2020 May 22.

Specialist Centre for Kidney Cancer, UCL Division of Surgery and Interventional Science, Royal Free London NHS Foundation Trust, London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2020.04.021DOI Listing
October 2020

Limitations of Available Studies Prevent Reliable Comparison Between Tumour Ablation and Partial Nephrectomy for Patients with Localised Renal Masses: A Systematic Review from the European Association of Urology Renal Cell Cancer Guideline Panel.

Eur Urol Oncol 2020 08 31;3(4):433-452. Epub 2020 Mar 31.

Department of Urology, University of Rennes, Rennes, France. Electronic address:

The European Association of Urology (EAU) Renal Cell Carcinoma (RCC) Guideline Panel performed a protocol-driven systematic review (SR) on thermal ablation (TA) compared with partial nephrectomy (PN) for T1N0M0 renal masses, in order to provide evidence to support its recommendations. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed, and only comparative studies published between 2000 and 2019 were included. Twenty-six nonrandomised comparative studies were included, recruiting a total of 167 80 patients. Risk of bias (RoB) assessment revealed high or uncertain RoB across all studies, with the vast majority being retrospective, observational studies with poorly matched controls and short follow-up. Limited data showed TA to be safe, but its long-term oncological effectiveness compared with PN remains uncertain. A quality assessment of pre-existing SRs (n=11) on the topic, using AMSTAR, revealed that all SRs had low confidence rating, with all but two SRs being rated critically low. In conclusion, the current data are inadequate to make any strong and clear conclusions regarding the clinical effectiveness of TA for treating T1N0M0 renal masses compared with PN. Therefore, TA may be cautiously considered an alternative to PN for T1N0M0 renal masses, but patients must be counselled carefully regarding the prevailing uncertainties. We recommend specific steps to improve the evidence base based on robust primary and secondary studies. PATIENT SUMMARY: In this report, we looked at the literature to determine the effectiveness of thermoablation (TA) in the treatment of small kidney tumours compared with surgical removal. We found that TA could cautiously be offered as an option due to many remaining uncertainties regarding its effectiveness.
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http://dx.doi.org/10.1016/j.euo.2020.02.001DOI Listing
August 2020

Topographic distribution of first landing sites of lymphatic metastases from patients with renal cancer.

Urol Oncol 2020 05 3;38(5):521-525. Epub 2020 Mar 3.

Netherlands Cancer Institute, Department of Urology, Amsterdam, the Netherlands; Royal Free Hospital, Department of Urology, Renal Cancer Unit, London, United Kingdom. Electronic address:

Introduction And Objective: Adjuvant studies with checkpoint inhibitors have attracted new interest in accurate pathological lymph node (LN) staging in renal cell carcinoma. Sentinel lymph node (SN) studies in cN0 patients revealed the pattern of lymphatic radiotracer drainage from renal tumors. The aim of this study was to describe the location of single- or oligometastatic LN and analyze if the topography of these first landing sites matches the drainage pattern observed in SN studies of renal tumors.

Materials And Methods: We collected data from 8 referral centers from 1990 to 2018 of all patients with pT1-4 cN0 or cN1 M0 renal cell carcinoma with pathologically confirmed single- or oligometastases in locoregional LN. The location of LN metastases, number, size of metastatic LN, and survival were analyzed using descriptive statistics with SPSS version 22 (IBM, Chicago, IL).

Results: From 3,794 patients with histologically confirmed pN1, a total of 76 patients (2%) with single- or oligometastatic pN1 were identified, of whom 24 (31.6%) and 52 (68.4%) were cN0 and cN1, respectively. On the left side, LN metastases were predominantly located in the para-aortal (48.0%; 95% confidence interval [CI] 29.22-63.12%) and hilar (31.42%; 95% CI 17.4-49.4%) area. On the right side, metastases located in retrocaval (26.82%; 95% CI 14.7-43.2%), hilar (26.82%; 95% CI 14.7-43.2%), interaortocaval (26.82%; 95% CI 14.7-43.2%), and paracaval (17.07%; 95% CI 7.6-32.6%) LNs. These landing sites exactly matched the lymphatic drainage pattern of intratumorally injected radiotracer reported in SN studies for both sides.

Conclusions: Single- or oligometastatic LNs in renal cancer are mainly located in the hilar, retro-, para, and interaortocaval region on the right side and para-aortal region on the left side. These first landing sites match the drainage pattern reported in SN trials.
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http://dx.doi.org/10.1016/j.urolonc.2019.12.023DOI Listing
May 2020

Deferred Cytoreductive Nephrectomy Following Presurgical Vascular Endothelial Growth Factor Receptor-targeted Therapy in Patients with Primary Metastatic Clear Cell Renal Cell Carcinoma: A Pooled Analysis of Prospective Trial Data.

Eur Urol Oncol 2020 04 16;3(2):168-173. Epub 2020 Jan 16.

Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, UCL Division of Surgical and Interventional Science, London, UK. Electronic address:

Background: Cancer du Rein Métastatique Nephrectomie et Antiangiogéniques (CARMENA) concluded that sunitinib alone is not inferior to cytoreductive nephrectomy (CN) followed by vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR-TKIs) in patients with metastatic renal cell carcinoma. It remains uncertain whether deferred CN is beneficial in this setting.

Objective: The aim of this study was to compare outcome in patients treated with presurgical VEGFR-TKI followed by CN (deferred CN) with that in patients receiving CN followed by VEGFR-TKI (upfront CN).

Design, Setting, And Participants: Pooled data from prospective trials in which a strategy of deferred CN in the absence of disease progression was investigated were compared with a retrospective dataset of upfront CN.

Outcome Measurements And Statistical Analysis: Overall survival (OS) in the Memorial Sloan-Kettering Cancer Center (MSKCC) intermediate-risk group.

Results And Limitations: Patients were treated between 2006 and 2016. In the MSKCC intermediate-risk group, 144 patients with a strategy of deferred CN after systemic therapy were compared with 131 patients treated with upfront CN. OS in the deferred cohort was 33.0 mo (95% confidence interval [CI] 25.0-51.0) compared with 22.8 mo (95% CI 17.9-30.6) after upfront CN (hazard ratio 0.72 [95% CI 0.52-0.996], p = 0.047). This study is limited by retrospective comparison of data, subgroup analysis, and a lack of intention-to-treat data for the upfront CN cohort.

Conclusions: In MSKCC intermediate-risk patients, a strategy of deferred CN in the absence of progression yields OS, which compares favourably with upfront CN and published trial data from CARMENA. This warrants a formal individual patient data analysis of CARMENA, SURTIME, and single-arm prospective studies to define the role and timing of deferred CN in intermediate-risk patients.

Patient Summary: In this study, we report outcomes in patients with metastatic renal cell cancer treated with targeted therapy followed by nephrectomy, which compared favourably with nephrectomy followed by targeted therapy and results from published studies.
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http://dx.doi.org/10.1016/j.euo.2019.12.004DOI Listing
April 2020

Cytoreductive nephrectomy: does CARMENA (Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques) change everything?

Curr Opin Urol 2020 01;30(1):36-40

Department of Oncology, Barts Cancer Centre Specialist Centre For Kidney Cancer, Royal Free Hospital Bart's and the London School of Medicine, Queen Mary University UCL Division of Surgical and Interventional Science, London, UK.

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.
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http://dx.doi.org/10.1097/MOU.0000000000000696DOI Listing
January 2020

Cytoreductive nephrectomy in the current treatment algorithm.

Ther Adv Med Oncol 2019 27;11:1758835919879026. Epub 2019 Sep 27.

Royal Free Hospital, Department of Urology, Renal Cancer Unit, University College London, Division of Surgical and Interventional Sciences, London, UK.

The two recent prospective randomized trials CARMENA and SURTIME have changed the therapy paradigm of metastatic renal cell carcinoma. The CARMENA trial was conducted to investigate whether cytoreductive nephrectomy (CN) is required in the targeted therapy area, whereas SURTIME studied whether deferred CN in combination with sunitinib can be used to identify patients with inherent targeted therapy resistance. In the current review, we provide a comprehensive discussion of two randomized studies and the current evidence with up-do-date algorithms for treating primary metastatic clear-cell renal cell carcinoma in the era of targeted therapy and immune-checkpoint inhibition.
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http://dx.doi.org/10.1177/1758835919879026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767741PMC
September 2019

Management of Sporadic Renal Angiomyolipomas: A Systematic Review of Available Evidence to Guide Recommendations from the European Association of Urology Renal Cell Carcinoma Guidelines Panel.

Eur Urol Oncol 2020 02 4;3(1):57-72. Epub 2019 Jun 4.

Department of Urology, University of Rennes, Rennes, France.

Context: Little is known about the natural history of sporadic angiomyolipomas (AMLs); there is uncertainty regarding the indications of treatment and treatment options.

Objective: To evaluate the indications, effectiveness, harms, and follow-up of different management modalities for sporadic AML to provide guidance for clinical practice.

Evidence Acquisition: A systematic review of the literature was undertaken, incorporating Medline, Embase, and the Cochrane Library (from 1 January 1990 to 30 June 2017), in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No restriction on study design was imposed. Patients with sporadic AML were included. The main interventions included active surveillance, surgery (nephron-sparing surgery and radical nephrectomy), selective arterial embolisation, and percutaneous or laparoscopic thermal ablations (radiofrequency, microwaves, or cryoablation). The outcomes included indications for active treatment, AML growth rate, AML recurrence rate, risk of bleeding, post-treatment renal function, adverse events of treatments, and modalities of follow-up. Risk of bias assessment was performed using standard Cochrane methods.

Evidence Synthesis: Among 2704 articles identified, 43 were eligible for inclusion (zero randomised controlled trials, nine nonrandomised comparative retrospective studies, and 34 single-arm case series). Most studies were retrospective and uncontrolled, and had a moderate to high risk of bias.

Conclusions: In active surveillance series, spontaneous bleeding was reported in 2% of patients and active treatment was undertaken in 5%. Active surveillance is the most chosen option in 48% of the cases, followed by surgery in 31% and selective arterial embolisation in 17% of the cases. Selective arterial embolisation appeared to reduce AML volume but required secondary treatment in 30% of the cases. Surgery (particularly nephron-sparing surgery) was the most effective treatment in terms of recurrence and need for secondary procedures. Thermal ablation was an infrequent option. The association between AML size and the risk of bleeding remained unclear; as such the traditional 4-cm cut-off should not per se trigger active treatment. In spite of the limitations and uncertainties relating to the evidence base, the findings may be used to guide and inform clinical practice, until more robust data emerge.

Patient Summary: Sporadic angiomyolipoma (AML) is a benign tumour of the kidney consisting of a mixture of blood vessels, fat, and muscle. Large tumours may have a risk of spontaneous bleeding. However, the size beyond which these tumours need to be treated remains unclear. Most small AMLs can be monitored without any active treatment. For those who need treatment, options include surgical removal of the tumour or stopping its blood supply (selective embolisation). Surgery has a lower recurrence rate and lower need for a repeat surgical procedure.
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http://dx.doi.org/10.1016/j.euo.2019.04.005DOI Listing
February 2020

Updated European Association of Urology Guidelines on Renal Cell Carcinoma: Immune Checkpoint Inhibition Is the New Backbone in First-line Treatment of Metastatic Clear-cell Renal Cell Carcinoma.

Eur Urol 2019 Aug;76(2):151-156

Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK; UCL Division of Surgery and Interventional Science, London, UK. Electronic address:

Recent randomised trials have demonstrated a survival benefit for a front-line ipilimumab and nivolumab combination therapy, and pembrolizumab and axitinib combination therapy in metastatic clear-cell renal cell carcinoma. The European Association of Urology Guidelines Panel has updated its recommendations based on these studies. PATIENT SUMMARY: Pembrolizumab plus axitinib is a new standard of care for patients diagnosed with kidney cancer spread outside the kidney and who did not receive any prior treatment for their cancer (treatment naïve). This applies to all risk groups as determined by the International Metastatic Renal Cell Carcinoma Database Consortium criteria.
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http://dx.doi.org/10.1016/j.eururo.2019.05.022DOI Listing
August 2019

Sentinel Lymph Node Biopsy in Renal Tumors: Surgical Technique and Safety.

Urology 2019 Aug 30;130:186-190. Epub 2019 Apr 30.

Department of Urology, The Netherlands Cancer Institute, Amsterdam, the Netherlands. Electronic address:

Objective: To understand uncertainties and knowledge gaps regarding lymphatic drainage in renal tumors, we performed 2 prospective studies to demonstrate regional lymph node (LN) drainage with sentinel lymph node (SN) imaging and biopsy. Here, we report the technique and perioperative safety of retroperitoneal SN dissection with different surgical approaches.

Methods: Seventy three patients from the 2 trials were included in the analysis. Patients had cT1-2N0M0 renal tumors (
Results: There were no grade ≥3 intraoperative CTCAE 5.0 AEs. Postoperative AE rate was 16.4% of which 7 (9.6%) were CD grade 1-2 and 5 (6.8%) were 3a grade complications. There were no statistically significant differences between presence of AE, CD grade, and surgical modality (P = .27 and P = .13, respectively). Blood loss was a median of 550 ml (IQR 200-900 ml) and 225 (IQR 42-751 ml) for partial nephrectomy (PN) and radical nephrectomy, respectively. Length of the procedure was 170 minutes (IQR 149-184 minutes), 155 minutes (IQR 130-177 minutes) 180 minutes (IQR 162-202 minutes) in open, laparoscopic, and robot-assisted procedures, respectively.

Conclusion: The addition of retroperitoneal SN dissection combined with locoregional LND during (partial) nephrectomy is surgically safe. Complication rate is low and does not differ between surgical approaches.
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http://dx.doi.org/10.1016/j.urology.2019.04.026DOI Listing
August 2019

A Phase II, single-arm trial of neoadjuvant axitinib plus avelumab in patients with localized renal cell carcinoma who are at high risk of relapse after nephrectomy (NEOAVAX).

Future Oncol 2019 07 26;15(19):2203-2209. Epub 2019 Apr 26.

Department of Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.

Surgery is the standard treatment for nonmetastatic renal cell carcinoma. Despite curative intent, patients with a high risk of relapse have a 5-year metastasis-free survival rate of only 30% and prevention of recurrence is an unmet need. In a Phase III trial (JAVELIN Renal 101), progression-free survival of axitinib + avelumab was superior to sunitinib with a favorable objective response rate and no added toxicity profiles as known for axitinib or avelumab single agent. NEOAVAX is designed as open label, single arm, Phase II trial with a Simon's two-stage design evaluating neoadjuvant axitinib + avelumab followed by complete surgical resection in 40 patients with high-risk nonmetastatic clear-cell renal cell carcinoma. Primary end point is remission of the primary tumor (RECIST 1.1; Response Evaluation Criteria In Solid Tumors) following neoadjuvant therapy. Secondary end points include disease-free survival, overall survival, rate of metastasis and local recurrence, safety, and tolerability. Exploratory end points include investigation of effects on neoangiogenesis, immune infiltrates and myeloid-derived suppressor cell components to support a rationale for the combined use of axitinib and avelumab (NCT03341845).
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http://dx.doi.org/10.2217/fon-2019-0111DOI Listing
July 2019

European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update.

Eur Urol 2019 05 23;75(5):799-810. Epub 2019 Feb 23.

The Royal Free London NHS Foundation Trust, London, UK; UCL Division of Surgery and Interventional Science, London, UK; Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.

Context: The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.

Objective: To provide an updated RCC guideline based on standardised methodology including systematic reviews, which is robust, transparent, reproducible, and reliable.

Evidence Acquisition: For the 2019 update, evidence synthesis was undertaken based on a comprehensive and structured literature assessment for new and relevant data. Where necessary, formal systematic reviews adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were undertaken. Relevant databases (Medline, Cochrane Libraries, trial registries, conference proceedings) were searched until June 2018, including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm, systematic reviews, and meta-analyses. Where relevant, risk of bias (RoB) assessment, and qualitative and quantitative syntheses of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Clinical practice recommendations were developed and issued based on the modified GRADE framework.

Evidence Synthesis: All chapters of the RCC guidelines were updated based on a structured literature assessment, for prioritised topics based on the availability of robust data. For RCTs, RoB was low across studies. For most non-RCTs, clinical and methodological heterogeneity prevented pooling of data. The majority of included studies were retrospective with matched or unmatched cohorts, based on single- or multi-institutional data or national registries. The exception was for the treatment of metastatic RCC, for which there were several large RCTs, resulting in recommendations based on higher levels of evidence.

Conclusions: The 2019 RCC guidelines have been updated by the multidisciplinary panel using the highest methodological standards. These guidelines provide the most reliable contemporary evidence base for the management of RCC in 2019.

Patient Summary: The European Association of Urology Renal Cell Carcinoma Guideline Panel has thoroughly evaluated the available research data on kidney cancer to establish international standards for the care of kidney cancer patients.
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http://dx.doi.org/10.1016/j.eururo.2019.02.011DOI Listing
May 2019

Outcome of sentinel lymph node biopsy in patients with clinically non-metastatic renal cell carcinoma.

Scand J Urol 2018 Oct - Dec;52(5-6):411-418. Epub 2018 Dec 11.

a Department of Urology, The Netherlands Cancer Institute , Amsterdam , The Netherlands.

Objective: To investigate the rate of occult SN metastases, oncological outcome, and association of recurrence with the pattern of lymphatic tumour drainage in RCC.

Materials And Methods: A pooled RCC sub-group analysis was conducted of secondary endpoints from a published feasibility and a phase II prospective single-arm SN study to investigate oncological outcome. Patients with cT1-3 (<10 cm) cN0M0 RCC of any sub-type were enrolled. After intratumoural injection of Tc nanocolloid, pre-operative imaging of SNs with SPECT/CT was followed by (partial) nephrectomy with SN and regional lymph node dissection using a γ-probe. The patients were followed with a risk-adapted surveillance programme. Endpoints of the studies were analysed using Cox proportional hazard models.

Results: Sixty-six RCC patients were included. Two patients (3%, 95% CI =0.5-11%) had occult SN metastases and remained free of disease at 57 and 72 months. Ten patients (15%, 95% CI =7-26%) developed recurrences, and four (6%, 95% CI =2.3-14.5%) had died of disease at a median follow-up of 57 months (IQR =18-72 months). Occurrence of distant metachronous metastases were associated with tumour size (HR =1.39, p = 0.02), pT stage (HR =6.83, p < 0.01 for comparison T1 vs T3/4), Grade 3/4 (HR =8.38, p = 0.05 for comparison 1/2 vs 3/4) and interaortocaval sentinel lymph node location (HR =10.52, p = 0.03 for comparison yes vs no).

Conclusions: The rate of occult metastatic SN is low, but long disease-free survival (DFS) was observed in two patients with occult SN metastases. We hypothesize an interaortocaval lymphatic route in thoracic recurrences. Evaluation of the prognostic and therapeutic role of sentinel lymph node biopsy (SLNB) requires a clinical trial in high-risk RCC.
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http://dx.doi.org/10.1080/21681805.2018.1531057DOI Listing
August 2019

An analysis of SPECT/CT non-visualization of sentinel lymph nodes in renal tumors.

EJNMMI Res 2018 Dec 3;8(1):105. Epub 2018 Dec 3.

Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands.

Background: Sentinel lymph node biopsy (SLNB) after intratumoral injection of Tc labeled nanocolloid and imaging with scintigraphy and SPECT/CT in renal tumors is feasible. However, sentinel lymph node (SN) non-detection rate with scintigraphy and SPECT/CT is high. The aim of the study was to determine factors affecting non-visualization (NV) of SN imaging in renal tumors. Seventy-eight patients with cT1-3 renal tumors received intratumoral injection of 225 MBq Tc-labeled nanocolloid 1 day before (partial) nephrectomy. Radiotracer injection was followed by anterioposterior and lateral scintigraphy in combination with SPECT/CT 20 min and 2-4 h after. Surgical treatment of the tumor with sentinel lymph node biopsy by aid of γ-probe and-camera was performed the next day. Scintigraphy and SPECT/CT images were evaluated and patient, tumor, and procedure characteristics were collected for 73 eligible patients used in uni- and multivariable analysis of a potential association with NV.

Results: A total of 80 (mean 1.1, IQR 0-2, max 6) sentinel lymph nodes in 46 patients were detected with scintigraphy and SPECT/CT. Preoperative visualization rate and intraoperative detection rate was 63% [95% CI 50-73%] and 61% [95% CI 49-72%], respectively. In uni- and multivariable analysis, the only factor associated with non-visualization was age, showing higher odds of non-visualization with higher age.

Conclusion: Our study demonstrated that non-visualization of SNs in renal tumors is relatively high and is associated with patient age. Furthermore, kidneys and also its tumors are highly vascularized which may cause a wash-out effect that could be identified with decreased kidney-liver ratios. However, in our data, the effect was statistically inconclusive. Further studies are needed to improve visualization and standardize the procedure of SLNB in renal tumors. The percentage of NV limits the use of SLNB for research and clinical purposes in renal cancer.
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http://dx.doi.org/10.1186/s13550-018-0460-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277398PMC
December 2018

Follow-up after curative treatment of localised renal cell carcinoma.

World J Urol 2018 Dec 16;36(12):1953-1959. Epub 2018 May 16.

Division of Surgical Oncology, Department of Urology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.

Purpose: Patients with localised renal cell carcinoma (RCC) receiving curative surgery, either radical or partial nephrectomy, have been shown in contemporary studies to develop recurrence within 5 years in 20-30% of case. Therefore, post-operative follow-up (FU) imaging plays a crucial role in detecting recurrent or metastatic disease. A number of prognostic scores have been developed to predict risk of recurrence. This review summarises the current knowledge on established FU protocols and their limitations.

Methods: A non-systematic literature search was conducted using Medline. Furthermore, major guidelines [European Association of Urology (EAU), American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN)] were reviewed and assessed.

Results: The EAU, AUA and NCCN post-operative follow-up guidelines differ in the frequency and type of imaging modalities recommended. The optimal duration of follow-up remains to be elucidated as does the impact of follow-up protocols on patient outcomes and quality of life. Established follow-up protocols do not take non-RCC-related factors, such as patient age and performance status into account. However, in the future individualised duration of FU based on competing risks of cancer recurrence and non-RCC death may be optimised, maximising resources and patient quality of life.

Conclusion: There is a clear need to establish evidence-based follow-up protocols and to assess the impact of follow-up protocols on individual patients and society.
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http://dx.doi.org/10.1007/s00345-018-2338-zDOI Listing
December 2018

Robotic-assisted Laparoscopic Partial Nephrectomy in a Horseshoe Kidney. A Case Report and Review of the Literature.

Urology 2018 Apr 27;114:e3-e5. Epub 2017 Dec 27.

Department of Urology, Royal Free Hospital, London, United Kingdom. Electronic address:

Horseshoe kidney is a rare renal fusion anomaly, and because of limited mobilization of the kidney and its multiple arterial blood supplies, minimally invasive surgery for renal tumors can be challenging. We describe a case of a right-side oncocytoma in a horseshoe kidney managed robotically and review the literature of robotic-assisted laparoscopic surgical resection of kidney tumors in renal fusion anomalies. Robotic-assisted laparoscopic partial nephrectomy in a horseshoe kidney is feasible. Fusion-related limited mobility during the procedure, as well as an extremely variable blood supply, require meticulous planning. Multi-phase computed tomography and interactive 3D anatomical models are helpful tools to prepare for surgery.
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http://dx.doi.org/10.1016/j.urology.2017.12.003DOI Listing
April 2018

Lymphatic Drainage from Renal Tumors In Vivo: A Prospective Sentinel Node Study Using SPECT/CT Imaging.

J Urol 2018 06 6;199(6):1426-1432. Epub 2017 Dec 6.

Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands. Electronic address:

Purpose: Lymphatic drainage from renal tumors is unpredictable. In vivo drainage studies of primary lymphatic landing sites may reveal the variability and dynamics of lymphatic connections. The purpose of this study was to investigate the lymphatic drainage pattern of renal tumors in vivo with single photon emission/computerized tomography after intratumor radiotracer injection.

Materials And Methods: We performed a phase II, prospective, single arm study to investigate the distribution of sentinel nodes from renal tumors on single photon emission/computerized tomography. Patients with cT1-3 (less than 10 cm) cN0M0 renal tumors of any subtype were enrolled in analysis. After intratumor ultrasound guided injection of 0.4 ml Tc-nanocolloid we performed preoperative imaging of sentinel nodes with lymphoscintigraphy and single photon emission/computerized tomography. Sentinel and locoregional nonsentinel nodes were resected with a γ probe combined with a mobile γ camera. The primary study end point was the location of sentinel nodes outside the locoregional retroperitoneal templates on single photon emission/computerized tomography. Using a Simon minimax 2-stage design to detect a 25% extralocoregional retroperitoneal template location of sentinel nodes on imaging at α = 0.05 and 80% power at least 40 patients with sentinel node imaging on single photon emission/computerized tomography were needed.

Results: Of the 68 patients 40 underwent preoperative single photon emission/computerized tomography of sentinel nodes and were included in primary end point analysis. Lymphatic drainage outside the locoregional retroperitoneal templates was observed in 14 patients (35%). Eight patients (20%) had supradiaphragmatic sentinel nodes.

Conclusions: Sentinel nodes from renal tumors were mainly located in the respective locoregional retroperitoneal templates. Simultaneous sentinel nodes were located outside the suggested lymph node dissection templates, including supradiaphragmatic sentinel nodes in more than a third of the patients.
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http://dx.doi.org/10.1016/j.juro.2017.11.112DOI Listing
June 2018

Observation After Cytoreductive Nephrectomy in Patients With Synchronous Not Completely Resected Metastases of Renal Cell Carcinoma.

Urology 2017 11 2;109:127-133. Epub 2017 Aug 2.

Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.

Objective: To determine the time-to-targeted therapy (TTT) in patients with not completely resected low-volume oligometastatic disease who were observed following debulking cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC).

Methods: Patients with synchronous mRCC with not completely resected low-volume metastases and in whom observation after CN was a multidisciplinary tumor board recommendation were identified from an approved institutional database. Patient data, International Metastatic Renal Cell Cancer Database Consortium (IMDC) risk, Fuhrman grade, site, and number of sites, time-to-progression (TTP), TTT, and overall survival (OS) were retrospectively analyzed.

Results: From 251 synchronous mRCC patients treated since 2006, 40 (15.9 %) were identified who underwent CN with observation as a result of low-volume multiple metastasis considered not completely resectable (19 single site and 21 with ≥2 sites). IMDC risk was favorable in 7, intermediate in 24, and poor in 9 patients. Median TTP was 6 (range 2-30) months and TTT was 16 (range 2-43) months. In 11 patients targeted therapy was further deferred by observation beyond Response Evaluation Criteria in Solid Tumors progression and in 10 patients by additional local therapy of the most rapidly progressing lesion. Median OS was 30 (range 2-71) months.

Conclusion: In patients with synchronous mRCC and not completely resected low-volume metastasis, the TTT following CN was substantial. Local therapy to control the most rapidly progressing lesion or observation beyond progression was an additional means to defer systemic therapy.
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http://dx.doi.org/10.1016/j.urology.2017.06.048DOI Listing
November 2017

The Impact of Adding Sentinel Node Biopsy to Extended Pelvic Lymph Node Dissection on Biochemical Recurrence in Prostate Cancer Patients Treated with Robot-Assisted Radical Prostatectomy.

J Nucl Med 2018 02 26;59(2):204-209. Epub 2017 Jul 26.

Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.

The benefit of adding sentinel node biopsy (SNB) to extended pelvic lymph node dissection (ePLND) remains controversial. The aim of our study was to evaluate biochemical recurrence (BCR) after robot-assisted radical prostatectomy and ePLND in prostate cancer patients, stratified by the application of SNB. The results were compared with the predictions of the updated Memorial Sloan Kettering Cancer Center nomogram. Between January 2006 and November 2016, 920 patients underwent robot-assisted radical prostatectomy and ePLND with or without SNB (184 and 736 patients, respectively). BCR was defined as 2 consecutive prostate-specific antigen rises of at least 0.2 ng/mL. The Kaplan-Meier method and Cox regression analyses were used to identify predictors of BCR. Median follow-up was 28 mo (interquartile range, 13-56.7 mo). The 5-y BCR-free survival rate was 80.5% and 69.9% in the ePLND+SNB and ePLND groups, respectively. At multivariate analysis, prostate-specific antigen level, primary Gleason grade greater than 3, seminal vesicle invasion, and higher number of removed and positive nodes were independent predictors of BCR in the ePLND group. In the ePLND+SNB group, only the number of positive nodes was an independent predictor of BCR. The overall accuracy of the Memorial Sloan Kettering Cancer Center nomogram was higher in the ePLND+SNB than in the ePLND group. However, the nomogram was underestimating the probability of BCR-free status in the ePLND+SNB group, whereas the ePLND group was performing as predicted. Adding SNB to ePLND improves BCR-free survival, although the precise explanation of this observation remains speculative. Our results should be interpreted cautiously, given the nonrandomized nature and the selection bias of the study.
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http://dx.doi.org/10.2967/jnumed.117.195644DOI Listing
February 2018

External beam radiation for the treatment of castration-resistant prostate cancer following primary hormonal therapy with androgen ablation: Analysis and outcome of 21 patients.

Mol Clin Oncol 2017 Mar 6;6(3):428-432. Epub 2017 Feb 6.

Division of Operative Care and Medical Research Center Oulu, Oulu University Hospital, 90220 Oulu, Finland.

Patients who undergo early androgen-deprivation therapy for prostate cancer may eventually develop castration-resistant prostate cancer. However, no optimal treatment for non-metastasized castration-resistant prostate cancer has yet been established. In the present retrospective, single-institutional study, the radiotherapy (RT) outcomes were evaluated in patients who underwent androgen-deprivation therapy for non-metastatic prostate cancer and subsequently developed castration-resistant disease. Following a thorough chart review, the data of 21 patients with castration-resistant prostate cancer who were treated between 2000 and 2010 with external beam radiation therapy (EBRT) at a prostate radiation dose of >45 Gy were evaluated. Of the 21 patients, 16 (76%) developed biochemical recurrence after RT, with a mean time to biochemical recurrence of 17 months. A total of 18 patients succumbed to the disease during follow-up, with a mean survival of 3 years after RT. A radiation dose of >66 Gy was associated with a longer time to biochemical recurrence after RT (P=0.011) and a longer survival, compared with a dose of ≤66 Gy (P=0.028). The mean overall survival time after RT was 42 months and did not depend on the primary hormonal treatment. Prostate-specific survival time was negatively associated with the Gleason score at diagnosis. The prostate-specific antigen (PSA) concentration prior to RT was a prognostic factor for biochemical recurrence of prostate cancer after RT, as well as for prostate cancer-specific survival. Finally, the multivariate analysis revealed that age, PSA concentration prior to RT and a high Gleason score were independent prognostic factors for prostate cancer-specific survival. Overall, our study findings demonstrated that disease progression was common after EBRT for castration-resistant prostate cancer and that survival was limited. However, young patients and those with low-risk disease at the time of diagnosis may benefit from RT.
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http://dx.doi.org/10.3892/mco.2017.1156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403359PMC
March 2017

Antiangiogenic therapy combined with immune checkpoint blockade in renal cancer.

Angiogenesis 2017 May 11;20(2):205-215. Epub 2017 Apr 11.

Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands.

Antiangiogenic therapy with vascular endothelial growth factor (VEGF) inhibitors is the current first-line treatment in metastatic renal cell carcinoma (mRCC). Immunotherapy with checkpoint inhibitor has been recently added to the armamentarium of mRCC treatment. These therapies are based on treatment with antibodies that block programmed cell death-1 (PD-1), programmed cell death ligand 1 (PD-L1) pathways, demonstrating impressive response rates and improved survival in several tumour types. So far, nivolumab is the only approved anti-PD-1 monoclonal antibody after VEGF therapy in mRCC. According to preclinical and clinical studies, combination therapies with VEGF- and checkpoint inhibitors have synergistic effect achieving improved response rates. However, toxicity in some combinations is high. In this article, we present a review of the ongoing trials with these drug combinations for RCC.
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http://dx.doi.org/10.1007/s10456-017-9550-0DOI Listing
May 2017

Long-term Survival After Resection of Sentinel Node Metastatic Renal Cell Carcinoma.

Urology 2017 May 14;103:e5-e6. Epub 2017 Feb 14.

Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.

We present a case of a patient who took part in a prospective sentinel lymph node (SN) study to investigate the drainage pattern from renal tumors. The patient was treated with laparoscopic radical nephrectomy, for a clinically node negative left renal tumor of 6 cm combined with SN and non-SN lymph node dissection. Histopathologic examination revealed a papillary type 2 pT1b renal cell carcinoma with 2 para-aortic metastatic SNs. No adjuvant treatment was applied. The patient is free of disease at 63 months after surgery.
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http://dx.doi.org/10.1016/j.urology.2017.02.012DOI Listing
May 2017

The current management of renal cell carcinoma.

Minerva Med 2017 Aug 7;108(4):357-369. Epub 2017 Feb 7.

Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands -

Introduction: Although the broad use of ultrasound and computed tomography (CT) has led to an early diagnosis of the disease, renal cell carcinoma (RCC) remains one of the most lethal urological cancers. The present review is based on the latest data published on RCC management.

Evidence Acquisition: A literature search was carried out searching recent publications from PubMed, MEDLINE, Embase up to December 2016 as well as European Association of Urology (EAU) and European Society of Medical Oncology (ESMO) guidelines.

Evidence Synthesis: A narrative synthesis based on recent publications was undertaken. Current evidence regarding treatment strategies and guidelines is based on prospective randomized controlled trials and retrospective studies although the level of evidence for surgical management is generally lower than for systemic therapy.

Conclusions: This narrative review depicts a summary of the evidence base for treatment of RCC. Management of RCC is a rapidly evolving and changing field. As a consequence guidelines need regular updating and patients may benefit from centralization of care and multidisciplinary approach.
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http://dx.doi.org/10.23736/S0026-4806.17.05058-3DOI Listing
August 2017

Re: Detection of Micrometastases by Flow Cytometry in Sentinel Lymph Nodes from Patients with Renal Tumours.

Eur Urol 2017 04 17;71(4):691-692. Epub 2017 Jan 17.

Department of Urology, Division of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2017.01.002DOI Listing
April 2017
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