title: Computed tomography characteristics of unresectable primary renal cell carcinoma treated with neoadjuvant sunitinib.
abstract: Neoadjuvant sunitinib might downsize unresectable renal cell carcinoma (RCC) and enable nephrectomy in a subset of patients. After neoadjuvant sunitinib in 27 RCC patients, tumors were resected in 13 patients. Higher attenuation using computed tomography (CT) scans and favorable response according to Morphology, Attenuation, Size, and Structure (MASS) criteria after 2 cycles of sunitinib were independent predictors of subsequent tumor resection.
  
  
  BACKGROUND
  In patients with locally advanced and metastatic RCC, selection criteria for nephrectomy are imprecise. Neoadjuvant sunitinib might downsize unresectable tumors and enable nephrectomy. CT scans of unresectable primary RCCs before and after neoadjuvant sunitinib were retrospectively reviewed to identify radiographic features associated with patient selection for surgery.
  
  
  METHODS
  CT scans of 27 patients with RCC (31 tumors) treated with neoadjuvant sunitinib were performed as part of a prospective clinical trial. After neoadjuvant sunitinib, tumors were surgically resected in 13 patients (17 tumors) and not resected in 14 patients (14 tumors). Response to treatment with sunitinib was assessed with Response Evaluation Criteria in Solid Tumors and MASS criteria.
  
  
  RESULTS
  On the contrast-enhanced CT scan before nephrectomy compared with the baseline CT scan, 88% of resected tumors demonstrated decreased size (median decrease 26%; -2.0 cm; P < .001), 88% had decreased attenuation (median decrease 30%; -27 Hounsfield units; P = .004), and 76% had increased necrosis (P < .001). Response to sunitinib was significantly more favorable (according to MASS criteria) in resected than in nonresected tumors (P = .005). In addition, the degree of baseline necrosis was less in tumors subsequently resected than in nonresected tumors (P = .05). Multivariate analysis showed that higher tumor attenuation after 2 cycles of sunitinib therapy and a favorable response (MASS criteria) after 2 cycles of sunitinib therapy were independent predictors of subsequent tumor resection.
  
  
  CONCLUSIONS
  In unresectable primary RCC tumors, changes in select CT parameters after 2 cycles of neoadjuvant sunitinib might be associated with the potential for surgical resection.
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Mohamed E
authors.initials: ME
authors.lastname: Salem
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Imaging Institute, Cleveland Clinic, Cleveland, OH. Electronic address: shahs2@ccf.org.
authors.forename: Shetal N
authors.initials: SN
authors.lastname: Shah
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Paul
authors.initials: P
authors.lastname: Elson
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Jorge A
authors.initials: JA
authors.lastname: Garcia
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Laura S
authors.initials: LS
authors.lastname: Wood
authors.affiliation: Imaging Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Avinash
authors.initials: A
authors.lastname: Medsinge
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Steven
authors.initials: S
authors.lastname: Campbell
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Robert
authors.initials: R
authors.lastname: Dreicer
authors.affiliation: Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Brian I
authors.initials: BI
authors.lastname: Rini
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D002292:Carcinoma, Renal Cell / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D007211:Indoles / Q000494:pharmacology / Q000627:therapeutic use*; D007680:Kidney Neoplasms / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000601:surgery; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009392:Nephrectomy; D011758:Pyrroles / Q000494:pharmacology / Q000627:therapeutic use*; D012189:Retrospective Studies; D000077210:Sunitinib; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D047368:Tumor Burden / Q000187:drug effects
chemical_list: D000970:Antineoplastic Agents; D007211:Indoles; D011758:Pyrroles; D000077210:Sunitinib
keywords: CT; MASS criteria; Neoadjuvant; Renal cell carcinoma; Sunitinib