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Healy KA, Marshall FF, Ogan K. Cytoreductive nephrectomy in metastatic renal cell carcinoma. Expert Rev Anticancer Ther 2014; 6:1295-304. [PMID: 16925495 DOI: 10.1586/14737140.6.8.1295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Metastatic renal cell carcinoma is associated with a poor prognosis and a median survival time of only 6-12 months. However, the emergence of immunotherapies has rekindled interest in cytoreductive nephrectomy as a therapeutic option. Phase III randomized trials have demonstrated that cytoreductive nephrectomy significantly improves overall survival in selected patients with metastatic renal cell carcinoma treated with interferon immunotherapy. While cytokine-based immunotherapy may be considered the standard systemic therapy, clinical studies are ongoing to develop molecular biomarkers and new therapies with improved efficacy and tolerability. With further advances in our understanding of the pathogenesis, behavior and molecular biology of renal cell carcinoma, cytoreductive nephrectomy, in combination with molecular targeted therapies, may become the new standard of care for patients with metastatic renal cell carcinoma.
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Affiliation(s)
- Kelly A Healy
- Emory Department of Urology, 1365 Clifton Road, Suite B, Atlanta, GA 30322, USA.
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2
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Smaldone MC, Fung C, Uzzo RG, Haas NB. Adjuvant and neoadjuvant therapies in high-risk renal cell carcinoma. Hematol Oncol Clin North Am 2011; 25:765-91. [PMID: 21763967 DOI: 10.1016/j.hoc.2011.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The standard of care for renal cell carcinoma (RCC) is surgical resection as a monotherapy or as part of a multimodal approach. A significant number of patients undergoing surgery for localized RCC experience recurrence, suggesting that there are some individuals in whom surgical excision is necessary but insufficient because of the presence of micrometastatic disease at diagnosis. This review summarizes current algorithms used to identify patients at high risk for disease recurrence following the surgical resection of RCC, the outcomes of contemporary adjuvant systemic therapy trials, and the rationale supporting the use of neoadjuvant therapy.
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Affiliation(s)
- Marc C Smaldone
- Division of Urologic Oncology, Department of Surgery, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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3
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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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Rendon RA. New surgical horizons: the role of cytoreductive nephrectomy for metastatic kidney cancer. Can Urol Assoc J 2011; 1:S62-8. [PMID: 18542787 DOI: 10.5489/cuaj.69] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Renal cell carcinoma is the most lethal urologic malignancy. Up to 30% of patients with kidney cancer have metastatic disease and 30% of those treated for local or locally advanced disease will progress to metastases. Radical nephrectomy is the standard treatment for the management of nondisseminated kidney cancer, but the role of cytoreductive nephrectomy for patients with metastatic disease is controversial. In this paper, the rationale for cytoreductive nephrectomy is described and the currently available evidence for and against it is evaluated. The different approaches to defining prognostic factors to select which patients will benefit from cytoreductive nephrectomy will also be described. Finally, the role of cytoreductive nephrectomy in the era of new targeted therapies is discussed.
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Affiliation(s)
- Ricardo A Rendon
- Department of Urology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS
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Arroua F, Maurin C, Carcenac A, Ragni E, Rossi D, Bastide C. [Role of surgery (cytoreductive nephrectomy and metastasectomy) in the management of metastatic renal cell carcinoma: a literature review]. Prog Urol 2010; 20:1175-83. [PMID: 21130395 DOI: 10.1016/j.purol.2010.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Revised: 05/29/2010] [Accepted: 06/02/2010] [Indexed: 01/16/2023]
Abstract
Cytoreductive nephrectomy is an established treatment option prior immunotherapy in well-selected patients with metastatic renal cell carcinoma. With the recent introduction of new targeted agents, the role of surgery has been source of controversy. This review examines the role of cytoreductive nephrectomy during the immunotherapy era, then in the new targeted therapies era. This review also summarizes the optimal timing of these treatments, the prognostic factors predicting outcome following cytoreductive nephrectomy, the role of metastasectomy, partial and laparoscopic cytoreductive nephrectomy.
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Affiliation(s)
- F Arroua
- Service d'urologie, CHU Nord de Marseille, chemin des Bourrely, 13915 Marseille cedex 20, France.
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Culp SH, Tannir NM, Abel EJ, Margulis V, Tamboli P, Matin SF, Wood CG. Can we better select patients with metastatic renal cell carcinoma for cytoreductive nephrectomy? Cancer 2010; 116:3378-88. [PMID: 20564061 DOI: 10.1002/cncr.25046] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The benefits of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) should outweigh surgical morbidity. Even when the generally agreed upon selection criteria for CN are met, some patients do poorly after surgery. The objective of this study was to identify preoperative factors that were prognostic of outcome in patients who were being considered for CN. METHODS The authors conducted a retrospective study to investigate the overall survival (OS) of patients who underwent CN using the OS of patients with mRCC who did not undergo CN as a referent group. Patients who underwent CN were divided into 2 groups based on when their OS diverged from that of nonsurgical patients. Chi-square analysis was used to identify variables that differed between the 2 surgical groups. Multivariate Cox proportional hazards regression was used to analyze those variables for the entire CN cohort. Risk factors were defined as preoperative variables that remained significant on multivariate analysis. The median OS and the overall risk of death were calculated based on the number of risk factors. RESULTS From 1991 to 2007, 566 patients who were eligible for or received systemic therapy underwent CN, and 110 patients received medical therapy alone. On multivariate analysis, independent preoperative predictors of inferior OS in surgical patients included a lactate dehydrogenase level greater than the upper limit of normal, an albumin level less than the lower limit of normal, symptoms at presentation caused by a metastatic site, liver metastasis, retroperitoneal adenopathy, supradiaphragmatic adenopathy, and clinical tumor classification>or=T3. Inferior OS and an increased risk of death were correlated positively with the number of risk factors. Surgical patients who had >or=4 risk factors did not appear to benefit from CN. CONCLUSIONS The authors of this report identified 7 preoperative variables that permitted them to identify patients who were unlikely to benefit from CN.
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Affiliation(s)
- Stephen H Culp
- Department of Urology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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7
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Cytoreductive nephrectomy in metastatic renal cell carcinoma: the evolving role of surgery in the era of molecular targeted therapy. Curr Opin Support Palliat Care 2009; 3:157-65. [DOI: 10.1097/spc.0b013e32832e466b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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8
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Polcari AJ, Gorbonos A, Milner JE, Flanigan RC. The role of cytoreductive nephrectomy in the era of molecular targeted therapy. Int J Urol 2009; 16:227-33. [DOI: 10.1111/j.1442-2042.2008.02245.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Renal Cell Cancer. Oncology 2007. [DOI: 10.1007/0-387-31056-8_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lambert EH, Pierorazio PM, Shabsigh A, Olsson CA, Benson MC, McKiernan JM. Prognostic Risk Stratification and Clinical Outcomes in Patients Undergoing Surgical Treatment for Renal Cell Carcinoma with Vascular Tumor Thrombus. Urology 2007; 69:1054-8. [PMID: 17572185 DOI: 10.1016/j.urology.2007.02.052] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 01/19/2007] [Accepted: 02/26/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Approximately 4% to 10% of patients with renal cell carcinoma (RCC) present with vascular tumor thrombus. Often, these patients also present with metastatic disease. This study examined the clinical outcome and morbidity of patients with RCC and vascular tumor thrombus treated with aggressive surgical therapy. METHODS From 1989 to 2006, 118 patients were identified with Stage pT3b or pT3c RCC who had undergone radical nephrectomy and thrombectomy. Disease-specific survival (DSS) and overall survival were measured by Kaplan-Meier statistics with the log-rank test to assess differences in survival stratified by the clinical and pathologic variables. Cox regression techniques were used to identify significant predictors of DSS. RESULTS The median follow-up was 18 months (range 1 month to 13.55 years). Tumor thrombus was at the level of the renal vein in 67 patients (56.8%), the infradiaphragmatic inferior vena cava in 39 (33%), and the supradiaphragmatic inferior vena cava in 12 patients (10%). Of the 118 patients, 42 (35.6%) presented with metastasis. The median tumor size was 8.2 cm. The 5-year overall survival rate was 40.7%. The 5-year DSS rate was 60.3% in those without metastasis and 10% in those with metastasis (P <0.001). The level of tumor thrombus did not significantly affect survival (P = 0.85). When the patients without metastasis were analyzed separately, nodal positivity (P = 0.03) and a tumor diameter greater than 7 cm (P = 0.05) were significant predictors of DSS. CONCLUSIONS Our results support the role of radical nephrectomy and thrombectomy in patients with RCC and vascular tumor thrombus. The absence of significant morbidity makes aggressive radical surgery feasible in the patients with tumor thrombus and metastatic disease. The current TNM staging system may need to be revised, given the evidence that the level of tumor thrombus invasion does not affect the survival outcomes.
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Affiliation(s)
- Erica H Lambert
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York, USA.
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11
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Abstract
For most cases of renal cell carcinoma (RCC), the standard of care is surgical resection as monotherapy or as part of a multimodal approach. In patients with early localized disease, radical nephrectomy is associated with a favorable prognosis, whereas patients with advanced disease are rarely cured. A significant number of patients undergoing surgery for localized RCC experience recurrence, suggesting that there are some individuals in whom surgical excision is necessary but insufficient. In these patients, the development of effective adjuvant strategies is imperative. In this article, we review the prognostic variables and comprehensive staging algorithms for identifying patients at high risk for disease recurrence. Additionally, we review data from completed adjuvant RCC trials and highlight relevant ongoing trials.
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Affiliation(s)
- David A Kunkle
- Department of Urologic Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
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12
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Blanco Díez A, Fernández Rosado E, Suárez Pascual G, Rodríguez Gómez I, Ruibal Moldes ML, Novás Castro S, Gómez Veiga F, Alvarez Castelo L, Barbagelata López A, Ponce Díaz-Reixa J, González Martín M. [Role of nephrectomy in metastatic renal cell carcinoma. Experience of the Department of Urology Juan Canalejo Hospital]. Actas Urol Esp 2005; 29:190-7. [PMID: 15881918 DOI: 10.1016/s0210-4806(05)73222-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We expose our experience in nephrectomy in metastatic renal cell carcinoma, and also show complications, evolution and survival of these patients. MATERIAL AND METHODS We performe a retrospective review of renal cell carcinoma treated at our service in the period between January 1st 1991 and December 31st 2002. We only studied those which presented in a metastatic pattern (31), and divide these in two groups: the ones which were nephrectomized and those which were not. We try to showw the differences between the two groups in order of status performance (E.C.O.G.), associated morbidity and median survival. In the first group we also study complications of surgery and treatment that patients underwent. RESULTS we performed nephrectomy in 19 cases, all of them E.C.O.G. 0-1. Median postoperative stay was 12 days, and complication rate was 11.5%. Of these patients, 45% underwent some type of systemic treatment, and median survival was 31 months. We didn't performed nephrectomy in 12 patients, of which 9 were E.C.O.G. 2-3. Associated co-morbidity was higher in this group. Only in three patients any treatment was offered always with palliative reason. Median survival was 3.8 months. CONCLUSIONS In those patients with good performance status this approach does not represent more morbility nor mortality than in non-metastatic patients, and that is a cornerstone in their management. We also make a literature review in which we see the last pathways in the management of these patients, and that show the needing for a combined approach both quirurgical and inmunotherapical. We have review with special interest the studie's conclusions of SWOG and EORTC groups.
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Affiliation(s)
- A Blanco Díez
- Servicio de Urología, Complejo Hospitalario Universitario Juan Canalejo, La Coruña
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Brinkmann OA, Bruns F, Gosheger G, Micke O, Hertle L. Treatment of bone metastases and local recurrence from renal cell carcinoma with immunochemotherapy and radiation. World J Urol 2005; 23:185-90. [PMID: 15838689 DOI: 10.1007/s00345-004-0479-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Accepted: 11/01/2004] [Indexed: 10/25/2022] Open
Abstract
Immunotherapies using interferons and/or interleukins are currently the treatment of choice for metastatic renal cell carcinoma (RCC). Bone metastases and non-resectable local recurrence are negative predictors for successful immunotherapy and signs of poor prognosis. The present study was designed to evaluate the effectiveness of combined immunochemotherapy (ICT) and radiation therapy (RT) for bone metastases or local recurrence from RCC in a prospective fashion. From September 1997 to September 1999, 20 patients with progressive RCC were treated with a combination of RT and ICT [s.c. interleukin-2a (IL-2), s.c. interferon alpha (IFN-alpha) and i.v. 5-fluorouracil]. RT started in week 2 of ICT. The radiation field was limited to the symptomatic bone metastases (15 patients) or the local recurrence (five patients). The total dosages of the RT ranged between 45 and 50 Gy, administered in fractions of from 1.8 to 2 Gy daily. In case of objective response or stable disease, the patients received up to two further ICT courses. All patients had good pain relief. Three out of 20 achieved complete remission, three had a partial remission, nine were stable and five patients had progressive disease under the combined treatment. Median survival was 21 months, mean survival 24 months (range: 5-59 months). The side effects of the combined treatment are in the same range as with ICT alone (World Health Organisation grade 2 and 3). Of 20 patients, 19 had their pain medication reduced after treatment. The combination of ICT and RT is feasible. There is remarkable pain relief. Our data suggest that the combination of immunochemotherapy and radiation therapy may induce a synergistic antitumor effect for the treatment of bone metastases or local recurrence from RCC compared to data from the literature for ICT or RT alone.
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Affiliation(s)
- Olaf Anselm Brinkmann
- Department of Urology, University Clinic of Muenster, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany.
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14
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Fuchs B, Trousdale RT, Rock MG. Solitary bony metastasis from renal cell carcinoma: significance of surgical treatment. Clin Orthop Relat Res 2005:187-92. [PMID: 15685074 DOI: 10.1097/01.blo.0000149820.65137.b4] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To define the importance of the type of surgical treatment, we retrospectively analyzed the survival rate of 60 patients with solitary bony metastasis from renal cell carcinoma. Thirteen patients had wide resection, 20 had local stabilization, and 27 patients had no surgical treatment, but had adjuvant treatment alone. The 1-, 3-, and 5-year survival rates were 83%, 45%, and 23%, respectively. Patients with surgical treatment (wide or intralesional resection) survived longer compared with patients who had no surgical treatment but had adjuvant treatment modalities. However, there was no survival advantage for patients who had a wide resection of the lesion compared with patients who had intralesional resection or intramedullary stabilization alone. Our results indicate that wide surgical excision of a solitary bony metastasis from renal cell carcinoma is not mandatory to improve survival. However, because three of 20 patients (15%) treated with stabilization alone had local disease progression, wide resection of metastatic lesions and stabilization may be necessary to prevent local disease progression and complications.
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Affiliation(s)
- Bruno Fuchs
- Department of Orthopedics, Mayo Clinic, 200 SW First Street, Rochester, MN 55905, USA.
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Abstract
Up to one third of patients with renal cell carcinoma will present with metastatic disease, and 20 to 40% of those with clinically localized disease will eventually be found to have metastatic involvement. Prognosis continues to be guarded for this population, with a 2-year survival of only 10 to 30%. Although advances are being made in the medical management of renal cell carcinoma, the role of surgery in the treatment algorithm is also being additionally refined. Palliative surgery either via nephrectomy or metastasectomy has a role in certain well-selected patients. There are also data to support total metastasectomy at the time of either nephrectomy or recurrence in a small subset of patients with minimal, resectable metastases. More controversial is the idea of cytoreductive nephrectomy as an adjunct to immunotherapy. Recent phase III trials indicate that nephrectomy may play an important role in management of metastatic renal cell carcinoma in conjunction with cytokine-based immunotherapy. Nephrectomy is also an essential component of tumor-based vaccine and adoptive immunotherapy protocols and may play a role in other novel therapies.
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Affiliation(s)
- Robert C Flanigan
- Department of Urology, Loyola University Medical Center, Maywood, Illinois 60153, USA.
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Wood CG. The role of cytoreductive nephrectomy in the management of metastatic renal cell carcinoma. Urol Clin North Am 2003; 30:581-8. [PMID: 12953756 DOI: 10.1016/s0094-0143(03)00026-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cytoreductive nephrectomy can be an important and effective component of a multidisciplinary treatment approach to metastatic renal cell carcinoma in carefully selected patients. The results of retrospective single institution series and randomized multicenter phase III trials suggest that removal of the primary tumor, even in the setting of metastatic disease, can significantly prolong survival and delay time to progression. It may also enhance the response to systemic therapy in the postoperative period. When employing initial cytoreductive nephrectomy as part of an overall treatment approach, careful patient selection is critical to success. A poor performance status (ECOG performance status less than 1), significant comorbidities that make surgical intervention high risk, or high-volume metastatic disease, and the presence of brain, liver, or bone metastases, or of atypical (sarcomatoid) histology have all been shown to be associated with an extremely poor prognosis. Patients exhibiting these clinical phenotypes should not be considered for initial cytoreductive nephrectomy as part of their treatment paradigm. Instead, they should receive some form of upfront systemic therapy (immunotherapy or novel therapy) and then be considered for delayed nephrectomy as part of a surgical consolidation approach after an interval of treatment if their disease kinetics demonstrate stable or regressing disease in response to systemic therapy. Patients who do not demonstrate these poor prognostic features should be considered for upfront cytoreductive nephrectomy as part of their overall treatment approach because of the potential it offers for palliation from local tumor symptoms, a delay in the time to disease progression, an improved response to systemic therapy, and improved overall survival.
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Affiliation(s)
- Christopher G Wood
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Abstract
Recent randomized prospective trials have suggested that cytoreductive nephrectomy confers a survival advantage in patients with metastatic renal cancer who receive immunotherapy with interferon-alfa-2b. It appears that the patients most benefiting from this approach are those with good performance status, lung-only metastases, and adequate cardiac and pulmonary reserve. Nonrandomized trials have further suggested that this survival advantage may be extended in patients who receive more aggressive interleukin-2-based immunotherapy.
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Affiliation(s)
- Robert C Flanigan
- Department of Urology, Loyola University Stritch School of Medicine, Building 54, Room 237A, 2160 S. First Avenue, Maywood, IL 60153, USA.
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18
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Affiliation(s)
- Paul M Yonover
- Loyola University Stritch School of Medicine, Department of Urology, 2160 S. 1st Avenue, Room 245, Building 54, Maywood, IL 60153-5500, USA
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Yonover PM, Flanigan RC. Should radical nephrectomy be performed in the face of surgically incurable disease? Curr Opin Urol 2000; 10:429-34. [PMID: 11005447 DOI: 10.1097/00042307-200009000-00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The role of cytoreductive nephrectomy in the management of metastatic renal cancer remains controversial. Recent trials, like SWOG 8949 have suggested the usefulness of this approach at least in selected patients with good performance status and other favorable indicators. The timing of cytoreductive nephrectomy has also been controversial and remains so to this time.
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Affiliation(s)
- P M Yonover
- Loyola University Medical Center, Department of Urology, Maywood, Illinois, USA
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20
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Tigrani VS, Reese DM, Small EJ, Presti JC, Carroll PR. Potential role of nephrectomy in the treatment of metastatic renal cell carcinoma: a retrospective analysis. Urology 2000; 55:36-40. [PMID: 10654891 DOI: 10.1016/s0090-4295(99)00395-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To examine the outcomes of patients with newly diagnosed metastatic renal cell carcinoma (RCC) who underwent initial nephrectomy as a component of therapy, because the role of nephrectomy in the treatment of patients with metastatic RCC is uncertain. METHODS A retrospective review of 63 patients who underwent radical nephrectomy with or without additional surgical procedures in the setting of metastatic RCC was performed. Pretreatment characteristics and the type of surgery were examined as predictors of outcome, and the type of systemic therapy received (if any) and overall survival were determined. RESULTS The median patient age was 59 years (range 39 to 79). Thirty-two patients had a single metastatic site, with the most common sites being the lung (n = 33), lymphatics (n = 32), and bone (n = 19). Seventeen patients (27%) also underwent vena cavotomy during surgery. Two patients died perioperatively. Thirty-nine (62%) patients underwent systemic therapy after surgery, and 6 patients (9.5%) were rendered free of disease and elected not to receive systemic treatment. The median survival was 17.8 months. CONCLUSIONS Primary renal surgery may be beneficial for selected patients with metastatic RCC, and most patients will be able to receive postoperative systemic therapy.
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Affiliation(s)
- V S Tigrani
- Department of Urology, University of California, San Francisco, School of Medicine, 94115, USA
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Sawczuk IS, Pollard JC. Renal cell carcinoma: should radical nephrectomy be performed in the presence of metastatic disease? Curr Opin Urol 1999; 9:377-81. [PMID: 10579074 DOI: 10.1097/00042307-199909000-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Metastatic renal cell carcinoma is associated with an unfavorable prognosis and the treatment options are limited. Adjunctive radical nephrectomy, performed either before or after the administration of systemic immunotherapy, has been proposed as a means of improving outcome. The role of nephrectomy for patients with metastatic disease remains controversial. This article reviews the role of nephrectomy in metastatic renal cell carcinoma and the optimal timing for surgery relative to immunotherapy.
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Affiliation(s)
- I S Sawczuk
- Department of Urology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Wagner JR, Walther MM, Linehan WM, White DE, Rosenberg SA, Yang JC. Interleukin-2 based immunotherapy for metastatic renal cell carcinoma with the kidney in place. J Urol 1999; 162:43-5. [PMID: 10379736 DOI: 10.1097/00005392-199907000-00011] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We assessed morbidity, response and survival in patients with metastatic renal carcinoma treated with high dose intravenous interleukin-2 (IL-2) based immunotherapy with the primary renal tumor in place. MATERIALS AND METHODS We retrospectively analyzed the records of patients with metastatic renal carcinoma and the primary kidney tumor in situ who were treated at the surgery branch of the National Cancer Institute. Of the patients 607 were treated with IL-2 based therapy. Patient age, sex, sites of extrarenal disease, morbidity, and response and survival rates were examined. RESULTS From 1986 to 1996, 51 patients with the majority of disease at extrarenal sites were treated with the primary tumor in place. Treatment involved IL-2 based regimens, reflecting the evolution of immunotherapy at the National Institutes of Health. When evaluating only extrarenal sites, response was complete in 1 and partial in 2 of the 51 cases (6%). No responses were noted in the primary renal tumor. Three patients with responses at extrarenal sites underwent nephrectomy. The duration of response in these 3 cases was greater than 88, 11 and 4 months, respectively. Median survival in all 51 patients was 13 months (range 1 to 86). CONCLUSIONS Select patients may be treated with IL-2 based immunotherapy with the primary renal tumors in place with morbidity. A randomized study is needed to assess the role of cytoreductive nephrectomy for treating metastatic renal cell carcinoma.
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Affiliation(s)
- J R Wagner
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Naitoh J, Kaplan A, Dorey F, Figlin R, Belldegrun A. Metastatic renal cell carcinoma with concurrent inferior vena caval invasion: long-term survival after combination therapy with radical nephrectomy, vena caval thrombectomy and postoperative immunotherapy. J Urol 1999; 162:46-50. [PMID: 10379737 DOI: 10.1097/00005392-199907000-00012] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We report our experience using aggressive multimodal therapy in a high risk group of patients with metastatic renal cell carcinoma and concurrent inferior vena caval extension. MATERIALS AND METHODS We retrospectively reviewed the records of all patients in our kidney cancer database who had metastatic renal cell carcinoma and tumor thrombus extension into the inferior vena cava at the initial diagnosis. Patients were included in the study if they underwent radical nephrectomy and inferior venal caval thombectomy, and immunotherapy was planned for the postoperative period. Tumor size and grade, metastatic sites, level of vena caval extension, surgical complications and overall survival were obtained from the medical records. The primary end point analyzed was overall survival. RESULTS We identified 31 cases of metastatic renal cell cancer with extensive disease and vena caval extension. Of the patients 23% had an isolated lung metastasis, and 53% had metastasis in the lung and at other sites. The remaining patients had involvement primarily at nonpulmonary metastatic sites, including lymph node in 38%, soft tissue in 13%, liver in 29% and bone in 10%. Average blood loss during nephrectomy was 3,200 cc (median 2,100) and the rate of major complications was 12%. Of the patients 80% underwent the full course of surgery and postoperative immunotherapy. At a mean followup of 18 months (34 for survivors) 26% of the patients are alive. Actuarial overall 5-year survival of the group was 17%. Tumor thrombus level did not correlate with overall survival, while immunotherapy, tumor grade and metastatic site provided significant prognostic information. In patients with an isolated pulmonary metastasis the 5-year survival rate was 43%, while in those with low grade tumors it was 52%. CONCLUSIONS In contrast to the poor results of surgery only in patients with renal cell carcinoma and concurrent inferior venal caval invasion, reasonable 5-year survival may be achieved after combined aggressive surgery and immunotherapy. Patients in whom metastasis was limited to the lungs and those with grade 1 to 2 tumors had a better prognosis. With careful planning and experienced immunotherapists therapy may be completed in the majority of this high risk group of patients.
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Affiliation(s)
- J Naitoh
- Department of Urology, University of California-Los Angeles, USA
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TIMELY DELIVERY OF BIOLOGICAL THERAPY AFTER CYTOREDUCTIVE NEPHRECTOMY IN CAREFULLY SELECTED PATIENTS WITH METASTATIC RENAL CELL CARCINOMA. J Urol 1998. [DOI: 10.1097/00005392-199804000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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LEVY DAVIDA, SWANSON DAVIDA, SLATON JOELW, ELLERHORST JULIE, DINNEY COLINP. TIMELY DELIVERY OF BIOLOGICAL THERAPY AFTER CYTOREDUCTIVE NEPHRECTOMY IN CAREFULLY SELECTED PATIENTS WITH METASTATIC RENAL CELL CARCINOMA. J Urol 1998. [DOI: 10.1016/s0022-5347(01)63542-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- DAVID A. LEVY
- Departments of Urology and Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - DAVID A. SWANSON
- Departments of Urology and Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - JOEL W. SLATON
- Departments of Urology and Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - JULIE ELLERHORST
- Departments of Urology and Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - COLIN P.N. DINNEY
- Departments of Urology and Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Affiliation(s)
- S Saint
- Department of Medicine, University of Washington, Seattle 98195-7183, USA
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Slaton JW, Balbay MD, Levy DA, Pisters LL, Nesbitt JC, Swanson DA, Dinney CP. Nephrectomy and vena caval thrombectomy in patients with metastatic renal cell carcinoma. Urology 1997; 50:673-7. [PMID: 9372873 DOI: 10.1016/s0090-4295(97)00329-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To report out experience with performing nephrectomy and vena caval thombectomy in patients with metastatic renal cell carcinoma. METHODS A retrospective review was performed of 15 patients who underwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites of metastases included lungs (n = 8), bone (n = 3), bulky retroperitoneal or mediastinal lymph nodes (n = 2), liver (n = 1), and contralateral adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score of 0, 11 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months. RESULTS Median operative time was 6.5 hours and median hospitalization was 10 days. Two patients required re-exploration for postoperative hemorrhage. There were no perioperative deaths. Four patients underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperatively. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 110). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months (range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Ten of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapid progression at 2 and 5 months after surgery and the other 2 at 17 and 42 months. CONCLUSIONS Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furthermore, in patients receiving biologic therapy, nephrectomy may enable a better quality of life and prolonged survival.
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Affiliation(s)
- J W Slaton
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston 77030, USA
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Althausen P, Althausen A, Jennings LC, Mankin HJ. Prognostic factors and surgical treatment of osseous metastases secondary to renal cell carcinoma. Cancer 1997. [DOI: 10.1002/(sici)1097-0142(19970915)80:6<1103::aid-cncr13>3.0.co;2-c] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nastasi G, Porta C, Moroni M, Bobbio-Pallavicini E, Santagati G, Santagati C, Alessiani M. Nephrectomy as a component of systemic treatment for renal cell carcinoma patients. J Surg Oncol 1994; 56:81-2. [PMID: 8007683 DOI: 10.1002/jso.2930560206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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