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Tomita Y. Treatment strategies for advanced renal cell carcinoma: A new paradigm for surgical treatment. Int J Urol 2015; 23:13-21. [PMID: 26347163 DOI: 10.1111/iju.12899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/12/2015] [Indexed: 11/30/2022]
Abstract
The induction of targeted drugs for the treatment of metastatic renal cell carcinoma has changed the treatment strategy for systemic therapy. Surgical treatment for metastatic renal cell carcinoma should also be reconsidered in the light of the effect of targeted drugs. The clinical benefit of cytoreductive nephrectomy for cases of metastatic renal cell carcinoma was proved in randomized trials in the cytokine era. However, at present, there has not been level 1 evidence for this in the targeted therapy era. Patients with better performance status and without poor risk factors tend to benefit from cytoreductive nephrectomy. Two ongoing large-scale randomized studies might shed light on this issue. One of the remarkable differences in the efficacy between cytokines and targeted drugs, particularly tyrosine kinase inhibitors, is the reduction in the size of the primary tumors by tyrosine kinase inhibitors, including sunitinib and axitinib. Initial experiences with targeted therapy suggest that the neoadjuvant setting of tyrosine kinase inhibitors could be a viable option when the primary tumor shows local invasion and/or is unresectable. The present study does not support the routine neoadjuvant use of sunitinib because of the possibility of disease progression during the neoadjuvant therapy, and modest response and benefit. Axitinib, in contrast, shows larger reduction in the size of the primary tumor and might be used in the near future. Another issue is the combination of targeted therapy with metastasectomy. There is a lack of evidence for improved prognosis resulting from the neoadjuvant setting of tyrosine kinase inhibitors followed by metastasectomy. Further studies are warranted to investigate this.
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Affiliation(s)
- Yoshihiko Tomita
- Departments of Urology and Molecular Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Gershman B, Moreira DM, Boorjian SA, Lohse CM, Cheville JC, Costello BA, Leibovich BC, Thompson RH. Comprehensive Characterization of the Perioperative Morbidity of Cytoreductive Nephrectomy. Eur Urol 2015; 69:84-91. [PMID: 26044802 DOI: 10.1016/j.eururo.2015.05.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/12/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although cytoreductive nephrectomy (CN) has been associated with perioperative morbidity, data are lacking regarding the risk of prolonged length of stay (pLOS) and delay to receipt of systemic therapy (ST). OBJECTIVE To evaluate the association of clinicopathologic features with postoperative complications, pLOS, and time to receipt of ST. DESIGN, SETTING, AND PARTICIPANTS We evaluated 294 patients with M1 renal cell carcinoma treated between 1990 and 2009. INTERVENTIONS CN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Logistic and Cox regressions were used to evaluate associations of clinicopathologic features with 30-d postoperative complications, pLOS (LOS ≥75th percentile), and time to receipt of ST. RESULTS AND LIMITATIONS Fifteen (5%) patients experienced at least one Clavien grade ≥3 early complication. Among patients for whom postsurgical ST was recommended, 61% did not receive ST within 60 d, but the delay was surgery-related in only 11%. In multivariable models limited to preoperative features, liver metastases were associated with complications (odds ratio [OR] 3.73, p=0.004) and pLOS (OR 2.46, p=0.03), while a laparoscopic approach was associated with earlier administration of ST (hazard ratio [HR] 5.05, p<0.001). In multivariable models incorporating operative features, intraoperative transfusion was associated with complications (OR 1.14, p<0.001) and pLOS (OR 1.22, p<0.001), while pN1 disease was associated with pLOS (OR 2.12, p=0.049) and delay to ST (HR 0.38, p=0.004). Limitations include the retrospective design and surgical selection bias. CONCLUSIONS Overall, 61% of CN patients did not receive timely ST, but only 5% of patients experienced Clavien grade ≥3 complications and the delay to ST was surgery-related in 11%. Liver metastases, intraoperative transfusion, and pN1 disease were independently associated with perioperative morbidity. PATIENT SUMMARY We evaluated the morbidity of cytoreductive nephrectomy and identified predictors of unfavorable perioperative outcomes. Although 61% of patients did not receive timely systemic therapy, the rates of complications and surgery-related delay to systemic therapy were low.
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Affiliation(s)
| | | | | | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Rini BI, Plimack ER, Takagi T, Elson P, Wood LS, Dreicer R, Gilligan T, Garcia J, Zhang Z, Kaouk J, Krishnamurthi V, Stephenson AJ, Fergany A, Klein EA, Uzzo RG, Chen DYT, Campbell SC. A Phase II Study of Pazopanib in Patients with Localized Renal Cell Carcinoma to Optimize Preservation of Renal Parenchyma. J Urol 2015; 194:297-303. [PMID: 25813447 DOI: 10.1016/j.juro.2015.03.096] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Preservation of renal function is prioritized during surgical management of localized renal cell carcinoma. VEGF targeted agents can downsize tumors in metastatic renal cell carcinoma and may do the same in localized renal cell carcinoma, allowing for optimal preservation of renal parenchyma associated with partial nephrectomy. MATERIALS AND METHODS Localized clear cell renal cell carcinoma patients meeting 1 or both of the following criteria were enrolled in a prospective phase II trial, including radical or partial nephrectomy likely to yield a glomerular filtration rate of less than 30 ml/minute/1.73 m(2), or partial nephrectomy high risk due to high complexity (R.E.N.A.L. 10 to 12) or tumor adjacent to hilar vessels. Pazopanib (800 mg once daily) was administered for 8 to 16 weeks with repeat imaging at completion of therapy, followed by surgery. RESULTS A total of 25 patients enrolled with a median tumor size of 7.3 cm and a median R.E.N.A.L. score of 11. Of index lesions 80% were high complexity and 56% of patients had a solitary kidney. Patients received a median of 8 weeks of pazopanib. The median interval from treatment start to surgery was 10.6 weeks. R.E.N.A.L. score decreased in 71% of tumors and 92% of patients experienced a reduction in tumor volume. Six of 13 patients for whom partial nephrectomy was not possible at baseline were able to undergo partial nephrectomy after treatment. The mean parenchymal volume that could be saved with surgery increased from an estimated 107 to 173 cc (p = 0.0015). In 5 patients a urine leak developed, which was managed conservatively, and 7 received a transfusion, of whom 1 required embolization. CONCLUSIONS Neoadjuvant pazopanib resulted in downsizing localized renal cell carcinoma, allowing for improved preservation of renal parenchyma and enabling partial nephrectomy in a select subset of patients who would otherwise require radical nephrectomy.
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Affiliation(s)
- Brian I Rini
- Department of Urology, Cleveland Clinic, Cleveland, Ohio; Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth R Plimack
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Toshio Takagi
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Paul Elson
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Laura S Wood
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Robert Dreicer
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Timothy Gilligan
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jorge Garcia
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Zhiling Zhang
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Jihad Kaouk
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Amr Fergany
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Eric A Klein
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Robert G Uzzo
- Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - David Y T Chen
- Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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New Challenges in Kidney Cancer Management: Integration of Surgery and Novel Therapies. Curr Treat Options Oncol 2015; 16:337. [DOI: 10.1007/s11864-015-0337-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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The Impact of Targeted Therapy on Management of Metastatic Renal Cell Carcinoma: Trends in Systemic Therapy and Cytoreductive Nephrectomy Utilization. Urology 2015; 85:442-50. [DOI: 10.1016/j.urology.2014.10.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 09/30/2014] [Accepted: 10/11/2014] [Indexed: 11/20/2022]
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Loh J, Davis ID, Martin JM, Siva S. Extracranial oligometastatic renal cell carcinoma: current management and future directions. Future Oncol 2014; 10:761-74. [PMID: 24799057 DOI: 10.2217/fon.14.40] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The term 'oligometastases' was formulated to describe an intermediate state between widespread metastases and locally confined disease. The standard of care in metastatic renal cell carcinoma is systemic therapy; however, in patients with solitary or limited metastases, aggressive local therapies may potentially prolong survival. The literature suggests a survival benefit with surgical metastasectomy, with a reported 5-year survival as high as 45% in those who achieve complete resection. More recently, an expanding body of evidence supports the role of stereotactic ablative body radiation therapy for the treatment of oligometastatic renal cell carcinoma and early results demonstrate comparable local control rates with surgery. There is also increasing interest in the abscopal and immunologic effects of localized radiation. With the proliferation of newer targeted agents and immunomodulatory agents, current work is addressing the optimization of patient selection and avenues towards sequencing and combining the various treatment options.
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Affiliation(s)
- Jasmin Loh
- Department of Radiation Oncology, Calvary Mater Hospital, Edith Street, Waratah NSW 2298, Australia
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Lane BR, Derweesh IH, Kim HL, O'Malley R, Klink J, Ercole CE, Palazzi KL, Thomas AA, Rini BI, Campbell SC. Presurgical sunitinib reduces tumor size and may facilitate partial nephrectomy in patients with renal cell carcinoma. Urol Oncol 2014; 33:112.e15-21. [PMID: 25532471 DOI: 10.1016/j.urolonc.2014.11.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/27/2014] [Accepted: 11/13/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether presurgical sunitinib reduces primary renal cell carcinoma (RCC) size and facilitates partial nephrectomy (PN). METHODS Data from potential candidates for PN treated with sunitinib with primary RCC in situ were reviewed retrospectively. Primary outcome was reduction in tumor bidirectional area. RESULTS Included were 72 potential candidates for PN who received sunitinib before definitive renal surgery on 78 kidneys. Median primary tumor size was 7.2 cm (interquartile range [IQR]: 5.3-8.7 cm) before and 5.3 cm (IQR: 4.1-7.5 cm) after sunitinib treatment (P<0.0001), resulting in 32% reduction in tumor bidirectional area (IQR: 14%-46%). Downsizing occurred in 65 tumors (83%), with 15 partial responses (19%). Tumor complexity per R.E.N.A.L. score was reduced in 59%, with median posttreatment score of 9 (IQR: 8-10). Predictors of lesser tumor downsizing included clinical evidence of lymph node metastases (P<0.0001), non-clear cell histology (P = 0.0017), and higher nuclear grade (P = 0.023). Surgery was performed for 68 tumors (87%) and was not delayed in any patient owing to sunitinib toxicity. Grade ≥ 3 surgical complications occurred in 5 patients (7%). PN was performed for 49 kidneys (63%) after sunitinib, including 76% of patients without and 41% with metastatic disease (P = 0.0026). PN was completed in 100%, 86%, 65%, and 60% of localized cT1a, cT1b, cT2, and cT3 tumors, respectively. CONCLUSION Presurgical sunitinib leads to modest tumor reduction in most primary RCC, and many patients can be subsequently treated with PN with acceptable morbidity and preserved renal function. A randomized trial is required to definitively determine whether presurgical therapy enhances feasibility of PN.
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Affiliation(s)
- Brian R Lane
- Division of Urology, Spectrum Health Hospital System, Michigan State University, Grand Rapids, MI.
| | - Ithaar H Derweesh
- Department of Urology, University of California-San Diego, La Jolla, CA
| | - Hyung L Kim
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Rebecca O'Malley
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY; Department of Urology, University of Albany, Albany, NY
| | - Joseph Klink
- Department of Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Cesar E Ercole
- Department of Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Kerrin L Palazzi
- Department of Urology, University of California-San Diego, La Jolla, CA
| | - Anil A Thomas
- Department of Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Brian I Rini
- Department of Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Steven C Campbell
- Department of Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
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Rendon RA, Kapoor A, Breau R, Leveridge M, Feifer A, Black PC, So A. Surgical management of renal cell carcinoma: Canadian Kidney Cancer Forum Consensus. Can Urol Assoc J 2014; 8:E398-412. [PMID: 25024794 DOI: 10.5489/cuaj.1894] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Anil Kapoor
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON
| | - Rodney Breau
- Division of Urology, University of Ottawa, Ottawa, ON
| | - Michael Leveridge
- Departments of Urology and Oncology, Queen's University, Kingston, ON
| | | | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC
| | - Alan So
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC
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Takagi T, Sugihara T, Yasunaga H, Horiguchi H, Fushimi K, Kondo T, Homma Y, Tanabe K. Cytoreductive nephrectomy for metastatic renal cell carcinoma: A population-based analysis of perioperative outcomes according to clinical stage. Int J Urol 2014; 21:770-5. [DOI: 10.1111/iju.12446] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 02/18/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Toshio Takagi
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Toru Sugihara
- Department of Quantitative Health Sciences; Cleveland Clinic Foundation; Cleveland Ohio USA
- Department of Urology; The University of Tokyo; Tokyo Japan
| | - Hideo Yasunaga
- Department of Health Economics and Epidemiology Research; School of Public Health; The University of Tokyo; Tokyo Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research; Clinical Research Center; National Hospital Organization Headquarters; Tokyo Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics; Tokyo Medical and Dental University; Tokyo Japan
| | - Tsunenori Kondo
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Yukio Homma
- Department of Urology; The University of Tokyo; Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
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Krabbe LM, Haddad AQ, Westerman ME, Margulis V. Surgical management of metastatic renal cell carcinoma in the era of targeted therapies. World J Urol 2014; 32:615-22. [PMID: 24700309 DOI: 10.1007/s00345-014-1286-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/19/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cytoreductive nephrectomy (CN) has been considered standard management for patients with metastatic renal cell carcinoma (mRCC) for over a decade. This practice, based on evidence from the immunotherapy era, has now come into question with the dramatic shift in management of mRCC patients due to the development and approval of several targeted molecular therapies (TMT). METHODS A comprehensive English language literature review was performed using MEDLINE/PubMed to identify articles and guidelines pertinent to CN in mRCC. RESULTS Retrospective studies have demonstrated improved survival for patients who underwent CN compared to those that did not; however, these studies suffer from heavy selection bias. Furthermore, the optimal timing of TMT, before or after surgery is not known. Pre-surgical TMT has the advantage of early treatment of metastases, downsizing of the primary, and may be an effective 'litmus test' for the selection of patients for CN based on response to TMT. The results of two ongoing phase III trials (CARMENA and SURTIME) will address much of the controversy on the role of CN and the timing of systemic therapy in the TMT era. In this review, we aim to present the evidence that lead to adoption of CN in the era of immunotherapies as well as the available data about the oncologic benefit of CN in patients with mRCC who receive TMT as their primary systemic therapy. CONCLUSION There seems to be an important role for CN in the era of TMT, mostly in patients with favorable risk and where a high percentage of tumor burden can be removed by cytoreductive surgery.
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Affiliation(s)
- Laura-Maria Krabbe
- Department of Urology, UT Southwestern Medical Center, J8.148, 5235 Harry Hines Boulevard, Dallas, TX, 75390-9110, USA
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Sassa N, Kato M, Funahashi Y, Maeda M, Inoue S, Gotoh M. Efficacy of pre-surgical axitinib for shrinkage of inferior vena cava thrombus in a patient with advanced renal cell carcinoma. Jpn J Clin Oncol 2014; 44:370-3. [PMID: 24571808 DOI: 10.1093/jjco/hyu014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The authors present the first case report of pre-surgical axitinib treatment on primary renal tumor and vena cava thrombus. We report the case of a 78-year-old woman with renal cell carcinoma and inferior vena cava tumor thrombus, successfully downstaged with pre-surgical therapy with axitinib. A significant objective response was observed for tumor size and thrombus. After initiation of axitinib therapy, computed tomography showed a decrease, from 57 to 51 mm, in the maximal renal tumor diameter. The tumor thrombus had shortened to 42 mm and had moved to the inferior hepatic vein (Levels 4-3), thereby obviating the need for thoracotomy. The patient finally accepted surgical treatment. Our case was enabled to perform less surgery for advanced renal cell carcinoma with tumor thrombus using axitinib as a pre-surgical therapy.
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Affiliation(s)
- Naoto Sassa
- *Graduate School of Medicine, Nagoya University, Showa-ku Tsurumai-chyo 65, Nagoya, Aichi, Japan.
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Timsit MO, Albiges L, Méjean A, Escudier B. Neoadjuvant treatment in advanced renal cell carcinoma: current situation and future perspectives. Expert Rev Anticancer Ther 2014; 12:1559-69. [DOI: 10.1586/era.12.142] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Koie T, Ohyama C, Okamoto A, Yamamoto H, Imai A, Hatakeyama S, Yoneyama T, Hashimoto Y. Presurgical therapy with axitinib for advanced renal cell carcinoma: a case report. BMC Res Notes 2013; 6:484. [PMID: 24267160 PMCID: PMC4222084 DOI: 10.1186/1756-0500-6-484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 11/21/2013] [Indexed: 01/14/2023] Open
Abstract
Background Targeted therapy with tyrosine kinase inhibitors has been shown to reduce tumor volumes and prolong the survival of patients with metastatic renal cell carcinoma. Tyrosine kinase inhibitors, particularly sunitinib, have recently been used in neoadjuvant and presurgical settings. Axitinib is a promising second-line therapy option for advanced or metastatic renal cell carcinoma. Herein, we report a patient with advanced renal cell carcinoma who received presurgical treatment with axitinib. Case presentation A 73-year-old man was transported by ambulance to a community hospital with chief complaints of high fever and a gait disorder. Computed tomography screening revealed a hypervascular tumor (size, 9 × 8.5 cm) in the lower pole of the left kidney. Upon admission to our hospital, his general condition was poor and his performance status was judged as 3, based on the Eastern Cooperative Oncology Group performance status criteria. After biopsy for the renal tumor, he received 5 mg of axitinib twice daily for 3 months. No serious adverse events were reported during this treatment. The tumor diameter shrank by 56%. Left radical nephrectomy was performed, and there were no intraoperative or postoperative complications. Pathological examination indicated a pT3aN0M0, Furman grade 3, clear cell renal cell carcinoma with necrosis, hyaline degeneration, and hemosiderosis. The patient was asymptomatic and disease-free at 1 year post-diagnosis. Conclusion This case study demonstrate that presurgical therapy with axitinib is feasible and might have several potential advantages for patients with advanced renal cell carcinoma.
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Affiliation(s)
- Takuya Koie
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki 036-8562, Japan.
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[New anti-angiogenic strategies in the management of kidney cancer]. Prog Urol 2013; 23:841-8. [PMID: 24034795 DOI: 10.1016/j.purol.2013.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 01/30/2013] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The aim of this study was to clarify the current role of adjuvant and neo-adjuvant in the treatment of kidney cancer. MATERIALS AND METHODS The data were explored in Medline (http://www.ncbi.nlm.nih.gov) using the following MeSH terms or combinations of these keywords: "cancer", "rein", "kidney", "adjuvant", "neoadjuvant", "antiangiogenique", "antiangiogenic" and selecting the items produced in their methodology, their relevance to the theme explored and their date of publication. RESULTS Thirty-two English and French items published between 2001 and 2011 were selected: five studies of evidence level 1, nine level 2 studies, nine level 4 studies, five studies at level 5 and four literature reviews. The cytoreductive nephrectomy as first-line treatment of locally advanced or metastatic kidney cancer is now controversial with the advent of new targeted anti-angiogenic therapies. In neoadjuvant setting, these treatments showed a moderate decrease in tumor volume and rarely improved resectability. In adjuvant setting, their place has yet to be specified and several trials are currently underway. CONCLUSION Recent years have seen the anti-angiogenic therapeutic strategies upset in locally advanced and metastatic renal cancer. The development of clinical trials and research protocols will allow us to determine in the near future the optimal therapeutic sequences.
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Abe H, Kamai T. Recent advances in the treatment of metastatic renal cell carcinoma. Int J Urol 2013; 20:944-55. [PMID: 23692504 DOI: 10.1111/iju.12187] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 04/07/2013] [Indexed: 12/21/2022]
Abstract
In the past 5 years, the treatment of patients with metastatic renal cell carcinoma has changed dramatically from being largely cytokine-based with the emergence of targeted therapy. Following the elucidation of various molecular pathways in renal cell carcinoma, targeted agents (particularly vascular endothelial growth factor-targeting antiangiogenic agents) now form the backbone of most therapeutic strategies for patients with metastatic renal cell carcinoma and the outcome of treatment has improved. However, many tumors eventually develop resistance to targeted therapy due to secondary mutation of the target protein or compensatory changes within the target pathway that bypass the site of inhibition. On the other hand, there are new forms of immunotherapy that hold the promise of improving the outcome for patients with metastatic renal cell carcinoma. In this article, we describe some of these new therapies, including the anti-vascular endothelial growth factor monoclonal antibody bevacizumab, several receptor tyrosine kinase inhibitors (sorafenib, sunitinib, pazopanib, axitinib, and tivozanib), the mammalian target of rapamycin inhibitors temsirolimus and everolimus, and new immunotherapy modalities, such as anti-cytotoxic T-lymphocyte-associated antigen 4 antibody and anti-programmed cell death 1/programmed cell death-ligand 1 antibody. We also discuss their role in the current management of patients with metastatic renal cell carcinoma.
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Affiliation(s)
- Hideyuki Abe
- Department of Urology, Dokkyo Medical University, Mibu, Tochigi, Japan
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Advancements in Urology 2013: An American Urological Association/Japanese Urological Association Symposium. Int J Urol 2013. [DOI: 10.1111/iju.12155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Neoadjuvant targeted molecular therapies in patients undergoing nephrectomy and inferior vena cava thrombectomy: is it useful? World J Urol 2013; 32:109-14. [PMID: 23624719 DOI: 10.1007/s00345-013-1088-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/20/2013] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess the effect of neoadjuvant targeted molecular therapies (TMTs) on size and level of inferior vena cava tumor thrombi and to evaluate their impact on surgical management. METHODS We retrospectively analyzed the data of 14 patients treated for a clear cell renal cell carcinoma with inferior vena cava thrombi by neoadjuvant TMT before nephrectomy. Clinical, pathological and perioperative data were gathered retrospectively at each institution. The primitive tumor size and the thrombus size were defined by computed tomography before TMT. The tumor thrombus level was defined according to the Novick's classification. RESULTS Before TMT, thrombus level was staged I for 1 (7%), II for 10 (72%) and III (21%) for 3 patients. First-line therapy was sunitinib in 11 cases and sorafenib in 3 cases. Median therapy duration was two cycles (1-5). Three patients experienced major adverse effects (grade III) during TMT. Following TMT, 6 (43%) patients had a measurable decrease, 6 (43%) had no change, and 2 (14%) had an increase in the thrombus. One patient (7%) had a downstage of thrombus level, 12 (85%) had stable thrombi, and 1 (7%) had an upstage. Regarding primary tumor, 7 (50%), 5 (36%) and 2 (14%) patients had a decrease, stabilization and an increase in tumor size, respectively. CONCLUSION Neoadjuvant TMT appears to have limited effects on renal tumor thrombi. This retrospective study failed to demonstrate a significant impact of neoadjuvant TMT on surgical management of clear cell renal cell carcinoma with inferior vena cava tumor thrombi.
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Bigot P, Lebdai S, Ravaud A, Azzouzi AR, Ferrière JM, Patard JJ, Bernhard JC. The role of surgery for metastatic renal cell carcinoma in the era of targeted therapies. World J Urol 2013; 31:1383-8. [PMID: 23542915 DOI: 10.1007/s00345-013-1060-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/15/2013] [Indexed: 12/23/2022] Open
Abstract
PURPOSE With the emergence of targeted therapies, the indications of cytoreductive nephrectomy have to be redefined. This review article presents the evidence data guiding our current indications of surgery in the management of metastatic renal cell carcinoma (mRCC) in the era of targeted therapies. METHODS A nonsystematic review of the electronic databases PubMed and MEDLINE from 1980 to 2012 was performed and limited to English language. RESULTS Two studies based on immunotherapy (EORTC 30947 and SWOG 8949) were at the origins of the recommendations on initial nephrectomy for patients with mRCC. Since the introduction of angiogenesis inhibitors, there is still no high-level evidence from prospective studies assessing the indication of surgery for mRCC. However, surgery still has its importance in the management of primary tumors and metastasis with the objective of an optimal balance between morbidity, quality of life, and survival. The treatment sequence between surgery and targeted therapies is still to be established and two randomized prospective studies were then specifically designed and are currently recruiting. CONCLUSIONS Preliminary evidence data from retrospective series seem to be in favor of a benefit of surgery for patients with good and intermediate prognosis. However, patients' inclusions in current prospective studies are highly recommended to clearly precise nephrectomy's indications.
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Affiliation(s)
- Pierre Bigot
- Department of Urology, Angers University Hospital, Angers, France,
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Rational Therapy for Renal Cell Carcinoma Based on its Genetic Targets. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 779:291-308. [DOI: 10.1007/978-1-4614-6176-0_13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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71
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Tsao CK, Small AC, Kates M, Moshier EL, Wisnivesky JP, Gartrell BA, Sonpavde G, Godbold JH, Palese MA, Hall SJ, Oh WK, Galsky MD. Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis. World J Urol 2012; 31:1535-9. [PMID: 23223962 DOI: 10.1007/s00345-012-1001-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 11/27/2012] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Two randomized trials published in 2001 provided level 1 evidence for the use of cytoreductive nephrectomy (CyNx) for the treatment of metastatic renal cell carcinoma (mRCC). However, the regulatory approval of vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) in 2005 has left an "evidence void" regarding the use of CyNx. We evaluated the patterns in the use of CyNx in the cytokine and VEGFR-TKI eras, and the patient characteristics associated with the use of CyNx. METHODS The Surveillance, Epidemiology, and End Results registry was used to identify patients with histologically or cytologically confirmed stage IV RCC between 2001 and 2008. Patients were classified as treated during the cytokine (2001-2005) or VEGFR-TKI (2006-2008) eras. A multivariate logistic regression analysis was performed to calculate the odds of undergoing CyNx according to treatment era and socioeconomic characteristics. RESULTS Overall, 1,112 of 2,448 patients (45%) underwent CyNx. CyNx use remained stable between 2001 and 2005 (50%), but decreased to 38% in 2008. Logistic regression analysis revealed that older age (OR 0.82, 95% CI: 0.68, 0.99), black race (OR 0.64, 95% CI: 0.46, 0.91), Hispanic ethnicity (OR 0.71, 95% CI: 0.54, 0.93), and treatment in the VEGFR-TKI era (OR 0.82, 95% CI: 0.68, 0.99) were independently associated with decreased use of CyNx. CONCLUSIONS Use of CyNx in the United States has declined in the VEGFR-TKI era. Older patients and minorities are less likely to receive CyNx. Results of ongoing phase III trials are needed to refine the role of this treatment modality.
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Affiliation(s)
- Che-kai Tsao
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Mount Sinai School of Medicine, 1 Gustave L Levy Place, New York, NY, 10029, USA
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Bex A, Powles T. Selecting patients for cytoreductive nephrectomy in advanced renal cell carcinoma: who and when. Expert Rev Anticancer Ther 2012; 12:787-97. [PMID: 22716495 DOI: 10.1586/era.12.54] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Renal cell carcinoma presents with metastatic disease in approximately 30% of patients at the time of diagnosis. Cytoreductive nephrectomy (CN) of the primary tumor in the face of metastatic disease is part of a multimodality approach including systemic therapy that is based on evidence from randomized trials in the cytokine era. Data from the pretargeted therapy era showed that CN had a clear role in metastatic renal cell carcinoma, increasing life expectancy by approximately 6 months. The substantial improvement in outcomes reported for targeted therapy has challenged the previous role of CN. However, despite the absence of data from Phase III trials, available evidence suggests that some patients may benefit substantially from CN in the era of targeted therapy. This review summarizes current arguments for CN and how to best select patients for surgery. Ongoing trials are key in generating evidence towards a personalized approach to debulking nephrectomy.
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Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Jilg CA, Rischke HC, Reske SN, Henne K, Grosu AL, Weber W, Drendel V, Schwardt M, Jandausch A, Schultze-Seemann W. Salvage lymph node dissection with adjuvant radiotherapy for nodal recurrence of prostate cancer. J Urol 2012; 188:2190-7. [PMID: 23083862 DOI: 10.1016/j.juro.2012.08.041] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE We evaluated the impact of salvage lymph node dissection with adjuvant radiotherapy in patients with nodal recurrence of prostate cancer. By default, nodal recurrence of prostate cancer is treated with palliative antihormonal therapy, which causes serious side effects and invariably leads to the development of hormone refractory disease. MATERIALS AND METHODS A total of 47 patients with nodal recurrence of prostate cancer based on evidence of (11)C-choline/(18)F-choline ((18)F-fluorethylcholine) positron emission tomography-computerized tomography underwent primary (2 of 52), secondary (45 of 52), tertiary (4 of 52) and quaternary (1 of 52) salvage lymph node dissection with histological confirmation. Of 52 salvage lymph node dissections 27 were followed by radiotherapy. Biochemical response was defined as a prostate specific antigen less than 0.2 ng/ml after salvage therapy. The Kaplan-Meier method, binary logistic regression and Cox regression were used to analyze survival as well as predictors of biochemical response and clinical progression. RESULTS Mean prostate specific antigen at salvage lymph node dissection was 11.1 ng/ml. A mean of 23.3 lymph nodes were removed per salvage lymph node dissection. Median followup was 35.5 months. Of 52 salvage lymph node dissections 24 resulted in complete biochemical response followed by 1-year biochemical recurrence-free survival of 71.8%. Gleason 6 or less (OR 7.58, p = 0.026), Gleason 7a/b (OR 5.91, p = 0.042) and N0 status at primary therapy (OR 8.01, p = 0.011) were identified as independent predictors of biochemical response. Gleason 8-10 (HR 3.5, p = 0.039) as a preoperative variable, retroperitoneal positive lymph nodes (HR 3.76, p = 0.021) and incomplete biochemical response (HR 4.0, p = 0.031) were identified as postoperative predictors of clinical progression. Clinical progression-free survival was 25.6% and cancer specific survival was 77.7% at 5 years. CONCLUSIONS Based on (11)C/(18)F-choline positron emission tomography-computerized tomography as a diagnostic tool, salvage lymph node dissection is feasible for the treatment of nodal recurrence of prostate cancer. Most patients experience biochemical recurrence after salvage lymph node dissection. However, a specific population has a lasting complete prostate specific antigen response.
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Affiliation(s)
- C A Jilg
- Department of Urology, Albert-Ludwigs University of Freiburg, Freiburg, Germany.
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Fisher R, Gore M, Larkin J. Current and future systemic treatments for renal cell carcinoma. Semin Cancer Biol 2012; 23:38-45. [PMID: 22705280 DOI: 10.1016/j.semcancer.2012.06.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 06/05/2012] [Indexed: 12/19/2022]
Abstract
Systemic treatment of renal cell carcinoma has changed dramatically since 2007, with the development and approval of six new agents, which target complex molecular pathways regulating tumour angiogenesis and cell proliferation and survival. These treatments have significantly improved survival times in metastatic renal cell carcinoma, but remain palliative. A number of newer agents are in clinical development, which offer theoretical advantages over existing treatments, and research methodologies are adapting with the aim of defining an individualised approach to therapy which exploits the underlying tumour biology. This review will provide an overview of current and emerging systemic treatments and how they might be integrated with surgical therapy, with a particular focus on advanced, clear cell metastatic renal cell carcinoma.
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Trends in the use of cytoreductive nephrectomy in the United States. Clin Genitourin Cancer 2012; 10:159-63. [PMID: 22651971 DOI: 10.1016/j.clgc.2012.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 03/14/2012] [Accepted: 03/21/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Two randomized trials published in 2001 established CyNx for patients with metastatic renal carcinoma (mRCC) as a treatment standard in the cytokine era. However, first-line systemic therapy for mRCC changed in 2005 with FDA approval of VEGFR TKIs. We evaluated the patterns of use of CyNx from 2000 to 2008. MATERIALS AND METHODS The National Cancer Database was queried for patients diagnosed with mRCC. Patients who underwent CyNx were identified and were further categorized by pre-VEGFR versus VEGFR TKI era, race, insurance status, and hospital. For these subcategories, prevalence ratios (PRs) were generated using the proportion of patients with mRCC undergoing CyNx versus those not undergoing CyNx. RESULTS Of the 47,417 patients (pts) identified with mRCC, the prevalence of cytoreductive nephrectomy increased 3% each year from 2000 to 2005 (P < .0001), then decreased 3% each year from 2005 to 2008 (P = .0048), with a significant difference between the eras (0.97 vs. 1.025; P < .0001). Black and Hispanic pts were less likely than Caucasian pts to undergo CyNx. Pts with Medicaid, Medicare, and no insurance were less likely than pts with private insurance to undergo CyNx. Pts diagnosed at community hospitals were significantly less likely than pts at teaching hospitals to undergo CyNx. CONCLUSION The use of CyNx has declined in the VEGFR-TKI era. In addition, racial and socioeconomic disparities exist in the use of CyNx. The results of pending randomized trials evaluating the role of CyNx in the VEGFR-TKI era are awaited to optimize use of this modality and address potential disparities.
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Crispen PL, Blute ML. Role of cytoreductive nephrectomy in the era of targeted therapy for renal cell carcinoma. Curr Urol Rep 2012; 13:38-46. [PMID: 22105577 DOI: 10.1007/s11934-011-0225-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
With the advent of targeted therapy for the treatment of metastatic renal cancer, the routine use of cytoreductive nephrectomy has been questioned. However, available data suggest that cytoreductive nephrectomy remains an integral part of treatment in properly selected patients. This review details the rationale for the continued use of cytoreductive nephrectomy in acceptable surgical candidates in the era of targeted therapy.
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Affiliation(s)
- Paul L Crispen
- Department of Surgery, University of Kentucky, Lexington, KY 40513, USA
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Schrader AJ, Steffens S, Schnoeller TJ, Schrader M, Kuczyk MA. Neoadjuvant therapy of renal cell carcinoma: a novel treatment option in the era of targeted therapy? Int J Urol 2012; 19:903-7. [PMID: 22640774 DOI: 10.1111/j.1442-2042.2012.03065.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The study was carried out to evaluate the effectiveness, toxicity and optimal duration of neoadjuvant therapy for patients with organ-confined or locally advanced renal cell carcinoma in the era of targeted agents. A literature review was carried out using Medline/Pubmed articles, as well as congress reports from the last five American Society of Clinical Oncology, American Urological Association and European Association of Urology Annual Meetings. Neoadjuvant targeted therapy is feasible and shows toxicity similar to that seen in a palliative setting. Most studies recommend an application for 2-4 months. The current data situation is best for sunitinib. Surgery can apparently be carried out the day right after discontinuing the drug. However, even sunitinib leads to only a mean 10% decrease in primary tumor size, and one-quarter to one-fifth of all patients show local tumor progression during treatment. Few patients (approximately 12%) with a vena cava tumor thrombus achieve a significant decrease in its level under neoadjuvant therapy; here too, progression is observed in a significant number of cases. Even the new targeted agents show limited effectiveness in achieving relevant remissions of the primary tumor. Furthermore, tumor progression is seen in a significant percentage of patients during neoadjuvant therapy. Thus, even today in the era of targeted agents, a neoadjuvant approach should only be made in patients with localized or locally advanced renal cell carcinoma, which primarily seem to be absolutely inaccessible by (partial) nephrectomy.
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Kim KH, You D, Jeong IG, Song C, Hong JH, Ahn H, Kim CS. The impact of delaying radical nephrectomy for stage II or higher renal cell carcinoma. J Cancer Res Clin Oncol 2012; 138:1561-7. [PMID: 22547152 DOI: 10.1007/s00432-012-1230-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 04/10/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the impact of surgical waiting time (SWT) on outcomes of patients who underwent radical nephrectomy for stage II or higher renal cell carcinoma (RCC). METHODS Of the 1,732 patients who underwent surgery for RCC between 1989 and 2007, medical records of 319 with clinical stage II or higher RCC without distant metastases were retrospectively reviewed. Ten patients with SWT greater than 3 months were excluded from analysis, and we compared pathological upstaging and survival rates between patients with SWT <1 month (234/319, 73.3 %) and 1-3 months (75/319, 23.5 %). RESULTS Clinicopathological characteristics between two groups were not different except the presence of symptom. The pathological upstaging was higher in patients with SWT of 1-3 months but statistically not significant. SWT of 1-3 months was not an independent predictor of pathological upstaging, recurrence-free survival (RFS; p = 0.896), or cancer-specific survival (CSS; p = 0.737). On subgroup analysis by TNM stage (cT2NxcM0 and cT3-4NxcM0), SWT of 1-3 months was not an independent predictor of pathological upstaging and was not associated with RFS or CSS. SWT, treated as a continuous variable, was also not an independent predictor of outcome in any subgroup. Similar results were found in symptomatic patients. CONCLUSIONS The outcomes of patients with prolonged SWT did not differ from those of most patients who underwent nephrectomy within 1 month. In patients with stage II or higher RCC who underwent nephrectomy within 3 months after diagnosis, prolonged SWT was not an independent predictor of pathological upstaging, RFS, or CSS.
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Affiliation(s)
- Kwang Hyun Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap 2-dong, Songpa-gu, Seoul, 138-736, Korea
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Consolidative surgery after targeted therapy for renal cell carcinoma. Urol Oncol 2011; 31:914-9. [PMID: 22153755 DOI: 10.1016/j.urolonc.2011.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 10/04/2011] [Accepted: 10/05/2011] [Indexed: 01/16/2023]
Abstract
Renal cell carcinoma is the most lethal of the common genitourinary neoplasms, with 30% to 40% of patients eventually dying from disease progression. Although the recent development of targeted therapies against kidney cancer has yielded substantially improved tumor response rates and progression-free survival, these agents are still not curative. The integration of systemic therapies with surgery still represents the best management for select patients with advanced disease. Specifically, consolidative surgery may play a vital role in the management of this challenging patient population. However, concerns remain regarding the potential for increased surgical morbidity complicating the integration of surgery after targeted therapy. Careful patient selection and specific precautions to increase surgical safety should be implemented.
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Bessede T, Pignot G, Patard JJ. Safety Issues and Rationale for Neoadjuvant Approaches in Renal Cell Carcinoma. Eur Urol 2011; 60:972-4. [DOI: 10.1016/j.eururo.2011.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 06/03/2011] [Indexed: 10/18/2022]
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Fisher R, Larkin J. Renal cell cancer: what can we learn from pre-operative studies? Front Oncol 2011; 1:51. [PMID: 22655250 PMCID: PMC3356090 DOI: 10.3389/fonc.2011.00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 11/23/2011] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rosalie Fisher
- Department of Medical Oncology, Royal Marsden Hospital London, UK
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