Objective: To evaluate the association of the pathology-derived tumor-to-kidney volume ratio (T/K ratio) with adverse pathological features and assess whether it provides prognostic information for cancer-specific survival (CSS) beyond maximum tumor diameter in renal cell carcinoma (RCC) patients undergoing radical nephrectomy. Materials and Methods: We retrospectively reviewed the records of 151 patients who underwent radical nephrectomy for non-metastatic RCC between 2005 and 2018. Tumor and kidney volumes were calculated from three orthogonal dimensions measured pathologically using the ellipsoid formula. An exploratory data-derived T/K ratio cut-off of 0.45 was used for group comparisons. Associations were evaluated using group comparisons, Spearman correlation, Kaplan-Meier analysis, and a parsimonious Cox model (T/K ratio and maximum tumor diameter), with CSS as the primary endpoint. Results: The high T/K ratio group (n=28) had a greater tumor diameter than the low-ratio group (8.5 vs. 5.0 cm; p<0.001) and higher frequencies of renal vein involvement, microvascular invasion, tumor necrosis, collecting system invasion, and positive surgical margins (all p<0.05). The T/K ratio correlated strongly with tumor volume (ρ=0.789) and maximum diameter (ρ=0.747), but not with kidney volume (ρ=0.089). Median follow-up was 73 months [95% confidence interval (CI), 62-86)]. Five-year CSS was 66.9% (95% CI, 42.2-82.9%) in the high-ratio group and 94.7% (95% CI, 87.6-97.8%) in the low-ratio group (p<0.001). In the parsimonious model, the T/K ratio was not independently associated with cancer-specific mortality after adjustment for diameter [hazard ratio (HR) per 0.10 increase, 1.14; 95% CI, 0.90-1.44; p=0.262], whereas diameter remained significant (HR per 1 cm, 1.21; 95% CI, 1.03-1.41; p=0.022). Conclusion: A high T/K ratio was associated with adverse pathological findings and inferior unadjusted survival, but showed no independent association with cancer-specific mortality after adjustment for maximum tumor diameter. The ratio should be considered an exploratory morphometric index.
Objective: Most of the lesions classified as prostate imaging-reporting and data system (PI-RADS) 5 represent clinically significant prostate cancers; the utility of systematic biopsy (SB) in addition to magnetic resonance imaging-targeted biopsy (MRI-TB) is unclear. We evaluated clinically significant prostate cancer detection via SB, TB alone, and combined SB and TB in men with a PI-RADS 5 lesion. The aim of this study was to determine whether SB can be avoided in the case of PI-RADS 5. Materials and Methods: Patients undergoing MRI-TB+SB with a PI-RADS 5 lesion were retrospectively reviewed in a prospectively collected database. Pathology obtained from the MRI-TB was then compared with that of the SB. All patients underwent multiparametric MRI followed by transrectal/transperineal TB of PI-RADS 5 lesion and 12-core SB. The prostate cancer and clinically significant prostate cancer (grade group ≥2) detection on SB, MRI-TB and MRI-TB+SB were determined for all men. A subgroup analysis of the combined group was also performed to identify performances of TB alone, SB alone, and combination of TB+SB for the prediction of final pathology at radical prostatectomy. Statistical significance was set at p<0.05. Results: We identified PI-RADS 5 lesions in 315 patients. 199/315 men, were found to have prostate cancer. Of these, 163 cases were clinically significant. The detection rate of prostate cancer for MRI-TB+SB, MRI-TB and SB was 63%, 59% and 49%, respectively, and the detection rate for clinically significant prostate cancer was 51%, 48% and 37%, respectively. SB detected an additional 6.5% of any grade prostate cancer and 6.7% clinically significant prostate cancer over TB. A total of 89 patients had prostate specific antigen density >0.15 ng/mL. All patients with prostate-specific antigen density (PSAD) >0.28 had cancer of any grade. The clinically significant prostate cancer detection rate improved with increased PSAD for SB. Among 102 patients, 8 had upgraded pathology from MRI-TB+SB. MRI-TB and SB pathology of the PI-RADS 5 lesion separately predicted final pathology with 81% and 69% concordance, respectively. The the downgrade was lowest in both methods, but the upgrade was higher in SB. Conclusion: In the presence of a PI-RADS 5 lesion, SB offers minimal additional but not negligible clinical value. The safety of omitting SB awaits further research.
Renal medullary carcinoma is an uncommon and aggressive variant of renal cell carcinoma (RCC), accounting for less than 0.5% of all RCC cases. It predominantly affects young individuals with sickle cell hemoglobinopathies. However, as seen in this case, unclassified medullary phenotypic RCC without hemoglobinopathy can also occur. This case report discusses a patient diagnosed with unclassified RCC of the medullary phenotype, exhibiting metastases to the left ventricle and liver. Diagnosis was confirmed through percutaneous biopsy, revealing loss of SMARCB1 expression along with positive vimentin and OCT3/4 staining. Treatment included chemotherapy with carboplatin and paclitaxel, followed by second-line therapy with cabozantinib. Left ventricular metastasis and cardiac lesions are rare but poor prognostic features of RCC. This case, one of the few documented in the literature, underscores the importance of a multidisciplinary approach to diagnosis and treatment.
Objective: To investigate preoperative clinical, biopsy-related, and multiparametric magnetic resonance imaging (mpMRI)-derived factors associated with pathological stage ≥ pT3 after radical prostatectomy and to evaluate the discriminatory performance of significant predictors individually and in combination. Materials and Methods: Data prospectively collected from 102 patients who underwent pre-biopsy mpMRI, transrectal ultrasound-guided prostate biopsy, and subsequent radical prostatectomy were analyzed retrospectively. Patients with radiologically detected lymph node involvement or distant metastasis were excluded. Patients were classified as having < pT3 or ≥ pT3 disease according to final pathological findings, and preoperative clinical, biopsy-related, and mpMRI-derived parameters were compared between the two groups. Multivariable binary logistic regression was performed to identify independent predictors of ≥ pT3 disease. Receiver operating characteristic (ROC) curve analyses were used to evaluate the discriminatory performance of the identified predictors and derive cohort-specific thresholds. Results: Pathological stage ≥ pT3 was identified in 49 patients (48.0%). Patients with ≥ pT3 disease had a higher cancer-positive biopsy core rate (52.28±28.21% vs. 32.57±17.76%; p<0.001) and larger MRI index lesions (median, 20.0 vs. 12.0 mm; p<0.001). Both variables remained independently associated with ≥ pT3 disease [odds ratio (OR) per 1% increase: 1.033, 95% confidence interval (CI): 1.009-1.057; p=0.010; OR per 1-mm increase: 1.274, 95% CI: 1.074-1.511; p=0.005]. The area under the curve (AUC) was 0.795 for lesion diameter, 0.703 for cancer-positive core rate, and 0.843 for the combined model. After bootstrap internal validation of the two-variable model, the optimism-corrected AUC was 0.835. ROC-derived thresholds were 17 mm and 38%, respectively. The prevalence of ≥ pT3 disease increased from 21.6% with neither risk factor to 47.6% with one and 91.3% with both factors (p for trend <0.001). Conclusion: MRI index lesion diameter and the cancer-positive biopsy core rate were associated with pathological stage ≥ pT3. Their combined assessment may contribute to preoperative risk stratification, although external validation is required.
Objective: To compare European Association of Urology (EAU), American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology (AUA/ASTRO/SUO), and National Comprehensive Cancer Network (NCCN) recommendations for salvage treatment of recurrent prostate cancer using a harmonized item-level framework. Materials and Methods: This document-based study compared the EAU Prostate Cancer Guideline limited update March 2026, AUA/ASTRO/SUO Salvage Therapy Guideline 2024, and NCCN Prostate Cancer Version 5.2026. Ten domains were decomposed into 35 items. Two authors independently coded recommendation characteristics and operational actionability. Concordance was classified as complete, partial, or discordant; evidence-gap and evidence-limited statuses were recorded separately. Clinical concordance was assessed separately from operational actionability. Pairwise exact-code agreement, linearly weighted Cohen’s kappa, and Gwet’s AC2 were calculated using actionability codes. Results: At the unweighted item level, complete agreement occurred in 12 of 35 items (34.3%), and partial agreement occurred in 23 of 35 (65.7%); no directly opposing clinical direction was identified. One domain contained only complete-agreement items, three contained only partial-agreement items, and six contained both types of items. Nine partial-agreement items (39.1%) carried evidence-status qualifiers: two evidence-gap zones and seven evidence-limited zones. Pairwise exact-code agreement ranged from 68.6% to 74.3; weighted Cohen’s kappa ranged from 0.364 to 0.496; Gwet’s AC2 ranged from 0.733 to 0.780; overall AC2 was 0.755. These coefficients reflect operational actionability, not clinical concordance. The strongest consensus concerned histological confirmation and metastatic exclusion before curative-intent local salvage after radiotherapy; early, risk-adapted salvage radiotherapy at low prostate-specific antigen (PSA) after prostatectomy; and avoiding withholding prostate-bed radiotherapy because of negative prostate-specific membrane antigen positron emission tomography. Conclusion: The guidelines showed broad directional alignment without clinical opposition, although most concordance was partial. Differences remained in PSA thresholds, imaging timing, selection between adjuvant and early-salvage approaches, pelvic nodal irradiation, indication for and duration of androgen deprivation therapy, oligometastatic therapy, and definitions of recurrence after focal or ablative treatment. The recommendations should not be considered interchangeable.
