Advertisement

When to Perform Preoperative Bone Scintigraphy for Kidney Cancer Staging

Indications for Preoperative Bone Scintigraphy
  • Alessandro Larcher
    Correspondence
    Address correspondence to: Alessandro Larcher, M.D., URI—Urological Research Institute, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy.
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
    Search for articles by this author
  • Fabio Muttin
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Nicola Fossati
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
    Search for articles by this author
  • Paolo Dell'Oglio
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Ettore Di Trapani
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Armando Stabile
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Francesco Ripa
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Francesco Trevisani
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Cristina Carenzi
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Maria Picchio
    Affiliations
    Unit of Radiology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Alberto Briganti
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Andrea Salonia
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Alexandre Mottrie
    Affiliations
    Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
    Search for articles by this author
  • Roberto Bertini
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Francesco Montorsi
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
  • Umberto Capitanio
    Affiliations
    Unit of Urology, Division of Experimental Oncology, URI—Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
    Search for articles by this author
Published:September 07, 2017DOI:https://doi.org/10.1016/j.urology.2017.08.043

      Objective

      To identify an objective and reproducible strategy for preoperative staging bone scintigraphy (BS) in patients diagnosed with renal cell carcinoma (RCC), because in the absence of objective criteria, the decision to perform preoperative BS remains a subjective practice.

      Patients and Methods

      The study included a total of 2008 patients with RCC treated with surgery and prospectively included into an institutional database. The study outcome was the presence of 1 or more bone lesions suspicious for metastases at staging BS. A multivariable logistic regression model predicting a positive BS was fitted. The predictors consisted of the preoperative clinical tumor (cT) and clinical nodal (cN) stages, the presence of systemic symptoms, and the platelet-to-hemoglobin (PLT/Hb) ratio.

      Results

      The rate of positive BS was 4% (n = 81). At the multivariable logistic regression analysis, cT2, cN1, the presence of systemic symptoms, and the PLT/Hb ratio were all associated with am increased risk of positive BS (P <.05). Following the 2000-sample bootstrap validation, the concordance index was 0.77 (proposed model) vs 0.63 (decision making based on symptoms only). At the decision curve analysis, the proposed strategy was associated with a higher net benefit. If BS is performed when the risk of positive result is >5%, a negative BS is spared in 80% and a positive BS is missed in 2% of the population only.

      Conclusion

      Using preoperative variables, it is possible to accurately estimate the risk of positive BS at RCC staging using preoperative characteristics. Compared with the strategy supported by available guidelines, the proposed model was more objective, statistically more accurate, and clinically associated with higher net benefit.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2015.
        CA Cancer J Clin. 2015; 65: 5-29https://doi.org/10.3322/caac.21254
        • Capitanio U.
        • Montorsi F.
        Renal cancer.
        Lancet. 2016; 387: 894-906https://doi.org/10.1016/S0140-6736(15)00046-X
        • Dabestani S.
        • Marconi L.
        • Hofmann F.
        • et al.
        Local treatments for metastases of renal cell carcinoma: a systematic review.
        Lancet Oncol. 2014; 15: e549-e561https://doi.org/10.1016/S1470-2045(14)70235-9
        • Bianchi M.
        • Sun M.
        • Jeldres C.
        • et al.
        Distribution of metastatic sites in renal cell carcinoma: a population-based analysis.
        Ann Oncol. 2012; 23: 973-980https://doi.org/10.1093/annonc/mdr362
        • McKay R.R.
        • Lin X.
        • Perkins J.J.
        • Heng D.Y.C.
        • Simantov R.
        • Choueiri T.K.
        Prognostic significance of bone metastases and bisphosphonate therapy in patients with renal cell carcinoma.
        Euro Urol. 2014; 66: 502-509https://doi.org/10.1016/j.eururo.2014.02.040
        • Ljungberg B.
        • Bensalah K.
        • Canfield S.
        • et al.
        EAU guidelines on renal cell carcinoma: 2014 update.
        Euro Urol. 2015; 67: 913-924https://doi.org/10.1016/j.eururo.2015.01.005
        • Motzer R.J.
        • Jonasch E.
        • Agarwal N.
        • et al.
        Kidney cancer, version 3.2015.
        J Natl Compr Canc Netw. 2015; 13: 151-159
        • Campbell S.C.
        • Novick A.C.
        • Belldegrun A.
        • et al.
        Guideline for management of the clinical T1 renal mass.
        J Urol. 2009; 182: 1271-1279https://doi.org/10.1016/j.juro.2009.07.004
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383https://doi.org/10.1016/0021-9681(87)90171-8
        • Edge S.B.
        • Compton C.C.
        The American Joint Committee on Cancer: the 7th Edition of the AJCC Cancer Staging Manual and the Future of TNM.
        Ann Surg Oncol. 2010; 17: 1471-1474https://doi.org/10.1245/s10434-010-0985-4
        • Vickers A.J.
        • Sjoberg D.D.
        Guidelines for reporting of statistics in European urology.
        Euro Urol. 2015; 67: 181-187https://doi.org/10.1016/j.eururo.2014.06.024
        • Larcher A.
        • Dell'Oglio P.
        • Fossati N.
        • et al.
        When to perform preoperative chest computed tomography for renal cancer staging.
        BJU Int. 2016; 65: 5https://doi.org/10.1111/bju.13670
        • Heng D.Y.C.
        • Xie W.
        • Regan M.M.
        • et al.
        Prognostic factors for overall survival in patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor-targeted agents: results from a large, multicenter study.
        J Clin Oncol. 2009; 27: 5794-5799https://doi.org/10.1200/JCO.2008.21.4809
        • Carpenter J.
        • Bithell J.
        Bootstrap confidence intervals: when, which, what? A practical guide for medical statisticians.
        Statist Med. 2000; 19 (doi:10.1002/(sici)1097-0258(20000515)19:9<1141::aid-sim479>3.0.co;2-f): 1141-1164
        • Vickers A.J.
        • Elkin E.B.
        Decision curve analysis: a novel method for evaluating prediction models.
        Med Decis Making. 2006; 26: 565-574https://doi.org/10.1177/0272989X06295361
        • R Development Core Team
        R: a language and environment for statistical computing.
        • Stewart-Merrill S.B.
        • Thompson R.H.
        • Boorjian S.A.
        • et al.
        Oncologic surveillance after surgical resection for renal cell carcinoma: a novel risk-based approach.
        J Clin Oncol. 2015; 33: 4151-4157https://doi.org/10.1200/JCO.2015.61.8009
        • Kim H.L.
        • Belldegrun A.S.
        • Freitas D.G.
        • et al.
        Paraneoplastic signs and symptoms of renal cell carcinoma: implications for prognosis.
        J Urol. 2003; 170: 1742-1746https://doi.org/10.1097/01.ju.0000092764.81308.6a
        • Bensalah K.
        • Leray E.
        • Fergelot P.
        • et al.
        Prognostic value of thrombocytosis in renal cell carcinoma.
        J Urol. 2006; 175: 859-863https://doi.org/10.1016/S0022-5347(05)00526-4
        • Kriteman L.
        • Sanders W.H.
        Normal alkaline phosphatase levels in patients with bone metastases due to renal cell carcinoma.
        Urology. 1998; 51: 397-399https://doi.org/10.1016/S0090-4295(97)00618-3
        • Henriksson C.
        • Haraldsson G.
        • Aldenborg F.
        • Lindberg S.
        • Pettersson S.
        Skeletal metastases in 102 patients evaluated before surgery for renal cell carcinoma.
        Scand J Urol Nephrol. 2010; 26: 363-366https://doi.org/10.3109/00365599209181227
        • Seaman E.
        • Goluboff E.T.
        • Ross S.
        • Sawczuk I.S.
        Association of radionuclide bone scan and serum alkaline phosphatase in patients with metastatic renal cell carcinoma.
        Urology. 1996; 48: 692-695https://doi.org/10.1016/S0090-4295(96)00236-1
        • Koga S.
        • Tsuda S.
        • Nishikido M.
        • et al.
        The diagnostic value of bone scan in patients with renal cell carcinoma.
        J Urol. 2001; 166: 2126-2128https://doi.org/10.1097/00005392-200112000-00025
        • Falchook A.D.
        • Salloum R.G.
        • Hendrix L.H.
        • Chen R.C.
        Use of bone scan during initial prostate cancer workup, downstream procedures, and associated Medicare costs.
        Int J Radiat Oncol Biol Phys. 2014; 89: 243-248https://doi.org/10.1016/j.ijrobp.2013.10.023
        • Zelefsky M.J.
        • Greco C.
        • Motzer R.
        • et al.
        Tumor control outcomes after hypofractionated and single-dose stereotactic image-guided intensity-modulated radiotherapy for extracranial metastases from renal cell carcinoma.
        Int J Radiat Oncol Biol Phys. 2012; 82: 1744-1748https://doi.org/10.1016/j.ijrobp.2011.02.040
        • Hunter G.K.
        • Balagamwala E.H.
        • Koyfman S.A.
        • et al.
        The efficacy of external beam radiotherapy and stereotactic body radiotherapy for painful spinal metastases from renal cell carcinoma.
        Prac Radiat Oncol. 2012; 2: e95-e100https://doi.org/10.1016/j.prro.2012.01.005
        • Fuchs B.
        • Trousdale R.T.
        • Rock M.G.
        Solitary bony metastasis from renal cell carcinoma.
        Clin Orthop Relat Res. 2005; : 187-192https://doi.org/10.1097/01.blo.0000149820.65137.b4
        • Abdollah F.
        • Sun M.
        • Thuret R.
        • et al.
        Mortality and morbidity after cytoreductive nephrectomy for metastatic renal cell carcinoma: a population-based study.
        Ann Surg Oncol. 2011; 18: 2988-2996https://doi.org/10.1245/s10434-011-1715-2
        • Trinh Q.-D.
        • Bianchi M.
        • Hansen J.
        • et al.
        In-hospital mortality and failure to rescue after cytoreductive nephrectomy.
        Euro Urol. 2013; 63: 1107-1114https://doi.org/10.1016/j.eururo.2012.08.069
        • Tosco L.
        • Van Poppel H.
        • Frea B.
        • Gregoraci G.
        • Joniau S.
        Survival and impact of clinical prognostic factors in surgically treated metastatic renal cell carcinoma.
        Euro Urol. 2013; 63: 646-652https://doi.org/10.1016/j.eururo.2012.09.037
        • Lughezzani G.
        • Briganti A.
        • Karakiewicz P.I.
        • et al.
        Predictive and prognostic models in radical prostatectomy candidates: a critical analysis of the literature.
        Euro Urol. 2010; 58: 687-700https://doi.org/10.1016/j.eururo.2010.07.034