The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4cm

Abstract

Objectives Delaying nephrectomy <3 months does not adversely affect treatment outcome of renal tumors. Whether surgical waiting time (SWT; time from diagnosis to surgery) >3 months affects treatment outcome for large renal masses has not been well studied. We aimed to evaluate if SWT is associated with treatment outcome of renal masses >4cm, and identify patients more likely to experience prolonged SWT. Materials and Methods Data from 1,484 patients undergoing radical or partial nephrectomy at a single institution for a non-metastatic renal mass >4cm between 1995–2013 were reviewed. Patients with benign tumors and incomplete preoperative data were excluded. The association between SWT and disease upstaging at the time of surgery and recurrence at 2 and 5 years was assessed using logistic regression. Cancer-specific survival (CSS) and overall survival (OS) were assessed with landmark survival analyses and multivariable Cox proportional hazards models. All analyses were adjusted for patient and tumor characteristics. Results Of the final cohort of 1,278 patients, 267 (21%) had SWT >3 months. Patients with larger, symptomatic tumors had shorter SWT. Median follow-up for survivors was 3.8 years (IQR 1.5–7.4). On multivariable analysis, SWT was not associated with disease upstaging, recurrence or CSS. Longer SWT was associated with decreased OS (HR=1.17, 95% CI, 1.08–1.27, p=0.0002). Gender and tumor size, histology, and presentation were associated with disease upstaging, recurrence and CSS. The most common cause for surgical delay >3 months was evaluation and treatment of comorbidities. Conclusion Patient and tumor characteristics, rather than SWT, were associated with disease upstaging, recurrence and CSS, and should guide the decision to delay surgery when treating non-metastatic renal tumors >4cm.

Association of Surgical Delay and Overall Survival in Patients With T2 Renal Masses: Implications for Critical Clinical Decision-making During the COVID-19 Pandemic

“…[10][11][12][13][14] Similar to our results, Mano et al retrospectively reviewed 1,278 patients at a single center and found that increasing surgical delay for renal masses >4 cm (median tumor size, 6.2 cm) was significantly associated with decreased OS after adjusting for patient and tumor characteristics. 8 Interestingly, these investigators did not find surgical delay to be associated with tumor upstaging, recurrence, or cancer-specific survival. In contrast, a study conducted by Kim et al retrospectively reviewed 319 patients with cT2 or greater renal cancer who underwent radical nephrectomy at a single institution and found no difference in survival or oncologic outcomes when comparing patients who underwent surgery within 1 month to those who had Adjusted for tumor size, age, sex, year of surgery, race, urban/ rurality index, distance from the hospital, insurance type, education status, income, comorbidity index, hospital type, and transfer status.…”

“…Published reports largely consist of retrospective single institution studies 7 , 8 , 9 , 25 or focus on poor surgical candidates undergoing observation of large renal masses 10 , 11 , 12 , 13 , 14 . Similar to our results, Mano et al retrospectively reviewed 1,278 patients at a single center and found that increasing surgical delay for renal mass >4 cm (median tumor size, 6.2cm) was significantly associated with decreased OS after adjusting for patient and tumor characteristics 8 . Interestingly, these investigators did not find surgical delay to be associated with tumor upstaging, recurrence, or cancer specific survival.…”

“…[2][3][4][5][6] Although larger renal tumors are known to harbor higher oncologic risks, it remains unclear to what extenta short to intermediate term delay in time to definitive management may impact survival. Prior studies on larger renal masses are limited by relatively small numbers from single institutions [7][8][9] or describe preselected patients who were poor surgical candidates. [10][11][12][13][14][15] There is a paucity of literature evaluating the impact of surgical delay on survival in the setting of large renal masses in contemporary patient cohorts.…”

Urologic oncology practice during COVID-19 pandemic: A systematic review on what can be deferrable vs. nondeferrable

“…There was no significant difference in disease upstaging at time of surgery, recurrence of malignancy, or cancer specific survival for patients having increased surgical wait time (>3 months) at a median follow up of 4 years, but there was a decrease in overall survival seen associated in the cohort with longer delays until surgery. A subgroup analysis including patients with Stage III and Stage IV cancer found that surgical wait time was not significant for recurrence at 2 or 5 years [9]. As such, patient co-morbidities, rather than the cancer itself, caused the patient's mortality.…”

Collateral damage: the impact on cancer outcomes of the COVID-19 pandemic

“…We used published data on the impact on overall survival from delay in cancer surgery to estimate per day hazard ratios (HRs) of mortality associated with delay for the different cancers [11][12][13][14][15][16][17][18][19][20][21] . Where data was not available for a given cancer we assumed equivalence of HRs with a cancer for which an estimated could be generated, based on comparable 5-year survivorship 4 .…”