Editing Management of Localized and Locally Advanced Disease (section)

=== Partial vs. Radical Nephrectomy ===

* Studies show that CKD increases risk of cardiovascular events and death
* In observational studies, RN has been associated with increased CKD, worse overall survival, and cancer-specific survival compared to PN. The association with worse cancer-specific survival raises concerns about selection bias since PN should not theoretically be a more effective oncologic intervention than RN
* '''<span style="color:#ff00ff">EORTC 30904</span>'''
** '''Population: 541 patients with tumours <5cm suspicious for RCC (and normal contralateral kidney)'''
** '''Randomized to RN vs. PN'''
** '''Primary outcome: OS'''
** '''Secondary outcomes: CSS, cardiovascular events, renal function outcomes'''
** '''Results:'''
*** '''RN significantly improved OS'''
*** '''No difference in CSS (only 2% of patients died of cancer)'''
*** '''Cardiovascular deaths were less common in the RN group'''
*** '''RN favorable in terms of lower perioperative morbidity, while PN provided better renal functional outcomes'''
*** '''In the subgroup analysis of patients with RCC histology, association for OS was extinguished'''
** Trial criticisms: premature study closure, trial designed as non-inferiority design but OS significance is based on superiority, patient comorbidity imbalances, cross-over, low statistical power, variable surgical technique and parenchymal sparing
**[https://pubmed.ncbi.nlm.nih.gov/21186077/ Van Poppel, Hendrik, et al. "A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma." ''European urology'' 59.4 (2011): 543-552.]
* Further studies have suggested that there may be a difference between CKD resulting from medical (CKD-M) and surgical (CKD-S) causes.
** Patients with CKD caused by hypertension or diabetes will continue to suffer from these comorbidities, and will likely experience progressive decline in renal function, eventually affecting survival.
** Patients with CKD primarily resulting from surgical removal of nephrons typically do not need further surgery, and might stabilize
* Despite the above, the following recommendations are made:
** '''<span style="color:#ff0000">PN is preferred over RN for small renal masses (T1a, <4.0 cm) whenever feasible</span>''' when intervention is indicated, because PN minimizes the risk of CKD or CKD progression and is associated with favorable oncologic outcomes, including excellent local control and RN represents gross overtreatment for most such lesions, which tend to have limited biologic potential
** Larger renal tumors (clinical stages T1b and T2) have increased oncologic potential and have often already replaced a substantial portion of the parenchyma, leaving less to be saved by PN. In the setting of a normal contralateral kidney, the relative merits of PN versus RN can be debated in this population.