Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: an institutional review

Understanding and integrating cytoreductive nephrectomy with immune checkpoint inhibitors in the management of metastatic RCC

Cytoreductive nephrectomy became accepted as standard of care for selected patients with metastatic renal cell carcinoma (mRCC) because of improved survival observed in patients treated with cytoreductive nephrectomy in combination with interferon-α in two randomized clinical trials published in 2001. Over the past two decades, novel systemic therapies have shown higher treatment response rates and improved survival outcomes compared with interferon-α. During this rapid evolution of mRCC treatments, systemic therapies have been the primary focus of clinical trials. Results from multiple retrospective studies continue to suggest an overall survival benefit for selected patients treated with nephrectomy in combination with systemic mRCC treatments, with the notable exception of one debated clinical trial. The optimal timing for surgery is unknown, and proper patient selection remains crucial to improving surgical outcomes. As systemic therapies continue to evolve, clinicians have an increasing need to understand how to incorporate cytoreductive nephrectomy into the management of mRCC.

Thyroid gland metastasis from renal cell carcinoma: a case series and literature review

BACKGROUND

Renal cell carcinoma (RCC) is the most common malignancy that metastasises to the thyroid. This study aims to better understand the clinical characteristics of patients with thyroid metastasis from RCC.

METHODS

A retrospective case series of patients with thyroid metastasis from RCC between 2008 and 2020 from two tertiary centres were examined. MEDLINE and PubMed database searches were performed to retrieve the relevant literature.

RESULTS

Fifteen patients (eight males) were identified, with a median age of 57.0 (interquartile range (IQR) 51.0-63.0) at time of RCC diagnosis. Median time to thyroid metastasis was 92.0 months (IQR 40.0-156.0), with 12 (80.0%) patients undergoing thyroidectomy within 2 months of diagnosis. No patients developed post-operative complications or local thyroid recurrence. The two most common non-thyroid metastatic sites in this case series are lungs and bone (five patients, respectively; 33.3%) and pancreas (four patients; 26.7%). Ten (66.6%) patients underwent systemic chemotherapy, and five (33.4%) patients underwent radiotherapy for other sites of metastasis. Median survival following thyroid metastasis was 54.0 months (IQR 15.0-100.0). The literature review was conducted through MEDLINE and PubMed database searches, and 30 papers were considered relevant to this review. Results from our study are comparable to those reported in the literature.

CONCLUSION

Thyroid metastases can occur long after nephrectomy and portends a better prognosis. To prevent development of central neck disease, thyroidectomy should be considered.

The Role of Metastasectomy in Urothelial Carcinoma: Where Are We in 2020?

Systemic therapy is the mainstay of treatment for metastatic urothelial carcinoma (UC). Responses to first-line platinum-based therapy tend to be short-lived with potential toxicity. Despite the approval of checkpoint inhibitors, the long-term prognosis for patients with metastatic UC remains dismal. Herein we report the case of a patient with a solitary pulmonary metastatic lesion of urothelial origin as the only site of metastatic disease who remained free of disease for more than 2 years without systemic therapy after metastasectomy. We review the literature discussing the role of combined surgical and medical management of oligometastatic UC. As our case illustrates, a growing body of evidence suggests a potential role for a multimodal approach in patients with oligometastatic UC.

Metachronous metastasis to contralateral retroperitoneal adipose tissue after radical nephrectomy: a case report and review of the literature

Renal cell carcinoma (RCC) metastasis to the adrenal gland, perirenal adipose tissue, and ureter on the contralateral side is rare. We report a case of solitary metachronous clear cell renal cell carcinoma (ccRCC) metastasis to the contralateral retroperitoneal adipose tissue, which was identified after radical nephrectomy. A patient had undergone retroperitoneal laparoscopic radical nephrectomy for RCC in the right kidney in December 2012. Postoperative pathological analysis showed Fuhrman grade I ccRCC, T_1bN₀M₀. Three years after surgery, a solitary tumor of 1.0 × 1.0 cm was identified by an abdominal computed tomographic scan inside the retroperitoneal fat pad in front of the left posterior abdominal wall, without adhesion to the abdominal wall. The tumor was then completely resected by retroperitoneal laparoscopic resection. Pathological analysis showed that it was a metastasized lesion from a previous tumor. Nine months after surgery, there was no sign of recurrence confirmed by radiographic follow-up. Findings from this case indicate the unpredictability of dissemination of RCC. Our findings support a follow-up regimen that includes regular postoperative computed tomographic scans to identify early metastasis. To the best of our knowledge, this is the first reported case of contralateral retroperitoneal adipose metastasis after laparoscopic tumorectomy.

Thyroid Gland Hemorrhage in a Patient with Past Medical History of Renal Clear Cell Carcinoma: Report of a Very Rare Case

BACKGROUND The incidence of metastasis to the thyroid gland is extremely rare, with hemorrhage being a particularly uncommon manifestation of metastatic thyroid disease. CASE REPORT A 68-year-old man who underwent a right nephrectomy for RCC 8 years ago was referred to the Emergency Department (ED) complaining of upper-chest pain radiating to the left shoulder, tachycardia, and increased dysphonia. An enhanced computed tomography (CT) scan suggested a thyroid mass originating from both thyroid lobes, with right deviation of the trachea due to active bleeding. The patient underwent an emergency total thyroidectomy. The postoperative course was uneventful. The histopathological analysis of the surgical specimen revealed metastasis of an RCC. CONCLUSIONS Active bleeding of the thyroid gland is a formal indication for emergency surgical management. In patients with a history of cancer, especially in cases of RCC, metastatic disease should be suspected, although in most cases the final diagnosis can only be made after surgery.

Role of metastasis-directed treatment in kidney cancer

Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.

Characteristics of Metastasis as a Prognostic Factor for Immunotherapy in Metastatic Renal Cell Carcinoma

Aims and background

This study aimed to evaluate the significance of characteristics of metastasis as prognostic factors in metastatic renal cell carcinoma (RCC).

Patients and methods

A total of 148 patients who had received immunotherapy were included in the study. Patients were categorized in various ways according to the characteristics of metastasis, including a synchronous metastasis group (n = 77) vs a metachronous metastasis group (n = 71), and a solitary metastasis group (n = 93) vs a multiple metastases group (n = 55).

Results

In the synchronous and metachronous metastasis groups, median progression-free survival was 4.3 months (95% confidence interval [CI] 2.9-5.7) and 11.1 months (95% CI 6.7-15.5), respectively (P = 0.004). Median overall survival was 17.1 months (95% CI 9.5-24.7) and 54.8 months (95% CI 38.3-71.3) in the two groups (P = 0.019). In the solitary and multiple metastasis groups, median progression-free survival was 11.0 months (95% CI 6.6-15.5) and 3.9 months (95% CI 2.6-5.2), respectively (P <0.001). Median overall survival was 55.2 months (95% CI 50.7-59.7) and 15.6 months (95% CI 10.9-20.3) in the two groups (P <0.001). Multivariate Cox proportional hazards model analysis using the clinical variables showed that T stage (P = 0.026), number of metastatic sites (P = 0.009) and time to metastasis (P = 0.019) were independent predictors of progression-free survival. Using the same variables, only the number of metastatic sites was an independent prognostic predictor of overall survival (P = 0.014).

Conclusions

Our findings suggest that the time to metastasis and the number of metastases are important prognostic factors in metastatic RCC.

Lung metastasectomy following kidney tumors: outcomes and prognostic factors from a single-center experience

Background

The lung is one of the sites most frequently affected by metastatic renal cell carcinoma (mRCC). Nonsurgical therapy for mRCC has limited efficacy, while the 5-year survival rates data published in literature after pulmonary surgery for metastasectomy, emphasize the role of surgery as the treatment that guarantees the best effectiveness in pulmonary resectable metastases.

Methods

From January 2000 to March 2016, 27 patients underwent pulmonary metastasectomy for metastatic renal cancer was retrospectively reviewed. Primary renal cancer was controlled in all patients and there was no other metastatic site in addition to the lung, at the time of metastasectomy. The aim of the study was to identify outcomes and prognostic factors in association with survival after complete pulmonary resection of metastases in a subgroup of patients with isolated pulmonary metastases from RCC.

Results

Five- and 10-year overall survival (OS) from first pulmonary metastasectomy was 75% and 59%, respectively. Independent prognostic factor influencing survival were: dimension of pulmonary metastases ≥2 cm (3-year survival: 67% vs. 100%; P=0.014) and disease free interval (DFI) ≥5 years (3-year survival: 94% vs. 28%; P=0.05). The only independent prognostic factors affecting DFI was the dimension of pulmonary metastases ≥2 cm (5-year DFI: 67% vs. 89%; P=0.03) at univariate analysis.

Conclusions

Considering the good results based on high long-term efficacy and low morbidity after metastases surgical resection, we always recommend metastasectomy in patients with technically resectable metastases, especially in case of long DFI and reduced dimension of pulmonary lesions.

22-year survival following radical nephrectomy and several metastasectomies in a case of renal cell carcinoma

Renal cell carcinoma (RCC) is a common malignancy. Metastases can be seen both synchronously, at the time of diagnosis, and metachronously during follow-up. At the time of diagnosis, 23% of the patients have metastatic disease. and 25% of patients will develop metastasis during follow-up period after nephrectomy. Nearly 80% of them develop within the first 5 years. However late metastasis of RCC have been also reported within the postoperative 10 years in the literature. For metastatic lesions, if surgically feasible, metastasectomy, and targeted pharmaceutical agents have been recommended. However any randomized controlled study which aimed to determine treatment protocol in patients who develop multiple metastases has not been cited in the literature. Herein, we are presenting a case with renal cell carcinoma in whom within 22 years of follow-up after 10 years of survival multiple metastases in different organs were detected which were managed with surgical, and medical treatments. As far as we know, this case is the first patient with the longest survival whose non-pulmonary metastases had been treated with more than one surgical interventions.

Outcomes Following Complete Surgical Metastasectomy for Patients with Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

PURPOSE

The benefit of complete surgical metastasectomy for patients with metastatic renal cell carcinoma remains controversial due to limited outcome data. We performed a systematic review and meta-analysis to determine whether complete surgical metastasectomy confers a survival benefit compared to incomplete or no metastasectomy for patients with metastatic renal cell carcinoma.

MATERIALS AND METHODS

Ovid Embase®, MEDLINE®, Cochrane and Scopus® databases were searched for studies evaluating complete surgical metastasectomy for metastatic renal cell carcinoma through January 19, 2016. Only comparative studies reporting adjusted hazard ratios (aHRs) for all cause mortality of incomplete surgical metastasectomy vs complete surgical metastasectomy were included in the analysis. Generic inverse variance with random effects models was used to determine the pooled aHR. Risk of bias was assessed with the Newcastle-Ottawa Scale.

RESULTS

Eight published cohort studies with a low or moderate potential for bias were included in the final analysis. The studies reported on a total of 2,267 patients (958 undergoing complete surgical metastasectomy and 1,309 incomplete surgical metastasectomy). Median overall survival ranged between 36.5 and 142 months for those undergoing complete surgical metastasectomy, compared to 8.4 to 27 months for incomplete surgical metastasectomy. Complete surgical metastasectomy was associated with a reduced risk of all cause mortality compared with incomplete surgical metastasectomy (pooled aHR 2.37, 95% CI 2.03-2.87, p <0.001), with low heterogeneity (I² = 0%). Complete surgical metastasectomy remained independently associated with a reduction in mortality across a priori subgroup and sensitivity analyses, and regardless of whether we adjusted for performance status.

CONCLUSIONS

Complete surgical metastasectomy for metastatic renal cell carcinoma is associated with improved survival compared with incomplete surgical metastasectomy based on meta-analysis of observational data. Consideration should be given to performing complete surgical metastasectomy, when technically feasible, in patients with metastatic renal cell carcinoma who are surgical candidates.

Complete metastasectomy for renal cell carcinoma: Comparison of five solid organ sites

BACKGROUND AND OBJECTIVES

Patients with metastatic RCC can undergo metastasectomy to improve survival time. Our goal was to provide and compare characteristics and oncological outcomes of RCC patients who underwent complete metastasectomy at a single organ site.

METHODS

A total of 138 RCC patients were identified as undergoing complete metastasectomy at a single organ site including adrenal, lung, liver, pancreas, or thyroid. Competing risk regression analysis was used to assess RFS and CSS adjusting for several covariates.

RESULTS

In this highly selected cohort, RFS and CSS was 27% and 84% at 5 years following metastasectomy, respectively. Univariate analysis revealed that removal of multiple tumors, younger age, and a shorter interval between nephrectomy and metastasis was associated with worse RFS. Larger tumors and sarcomatoid histology at nephrectomy was associated with worse CSS. We found no evidence that metastases at the time of RCC diagnosis influenced recurrence or survival. Tumor size, number of metastases resected, and time from nephrectomy to first recurrence was significantly different, but recurrence rates were not found to be significantly different, when compared across all organ sites.

CONCLUSIONS

These findings inform clinical and surgical management of select RCC patients with isolated metastasis to one of several organ sites. J. Surg. Oncol. 2016;114:375-379. © 2016 Wiley Periodicals, Inc.

The Role of Metastasectomy in Patients with Renal Cell Carcinoma with Sarcomatoid Dedifferentiation: A Matched Controlled Analysis

PURPOSE

Management of metastatic renal cell carcinoma with sarcomatoid dedifferentiation remains a therapeutic challenge with no standard treatment strategies. We evaluated whether metastasectomy has any survival benefit in patients with metastatic sarcomatoid dedifferentiation treated with radical nephrectomy.

MATERIALS AND METHODS

From an institutional database of 273 patients with sarcomatoid dedifferentiation treated with nephrectomy we matched 80 with synchronous and asynchronous metastases for age, ECOG (Eastern Cooperative Oncology Group) performance status, histology and lymph node status. Matched pairs were then retained only if patients who did not undergo metastasectomy were alive at metastasectomy comparable to matched surgical patients to decrease the bias of survival outcomes. Overall survival from nephrectomy was studied using univariable and multivariable proportional hazards regression.

RESULTS

Median overall survival was 8.3 (95% CI 6.5-10.5) and 18.5 months (95% CI 11.5-42.9) in patients with synchronous and asynchronous metastases, respectively. Overall survival in patients who underwent metastasectomy for synchronous metastasis compared to nonsurgical patients was 8.4 and 8.0 months (p = 0.35), respectively. Similarly, overall survival in patients with asynchronous metastases treated with metastasectomy compared to the nonsurgical group was 36.2 and 13.7 months, respectively (p = 0.29). On multivariable analysis positive lymph nodes at nephrectomy were associated with an increased risk of death in the synchronous and asynchronous patient subgroups (HR 2.1, 95% CI 1.1-4.0, p = 0.03 and HR 3.3, 95% CI 1.2-9.2, p = 0.02, respectively).

CONCLUSIONS

In the current study there was no clear evidence of benefit in patients with sarcomatoid dedifferentiation who underwent metastasectomy after nephrectomy. Particularly, the group of patients with pathological lymph node positive disease at nephrectomy had considerably worse survival.

Renal cell cancer metastases to esophagus and stomach successfully treated with radiotherapy and pazopanib

Renal cell cancer has been rarely reported as a cause of gastric or esophageal metastases. They usually present with gastrointestinal bleeding and most cases have been managed surgically or endoscopically. We report the case of a 38-year-old man with a 4-year history of metastatic renal cell carcinoma admitted to the emergency room with melena and anemia. At endoscopy, three esophageal polypoid lesions (middle and distal thirds) and a 7 cm mass in the gastric fundus were identified. Biopsy revealed esophageal mucosa infiltrated by renal cell carcinoma. Radiotherapy was administered (30 Gy in 10 fractions), followed by pazopanib, with excellent tolerance and without new bleeding episodes. Computed tomography scan showed complete disappearance of the esophageal and fundic lesions at 3 months follow-up. Twenty-four months after being initiated on pazopanib, there is no radiological evidence of disease. This is the first reported case showing complete remission of gastric and esophageal metastases after treatment with radiotherapy and pazopanib.

Challenging the treatment paradigm for advanced renal cell carcinoma: a review of systemic and localized therapies

The current standard of care for the management of advanced renal cell carcinoma (RCC) revolves around systemic therapy with molecularly targeted agents. Over the last decade, a total of seven targeted drugs have been approved but, altogether, only exploit two molecular targets in this disease: the vascular endothelial growth factor (VEGF) axis and the mammalian target of rapamycin (mTOR). Introduction of these agents has markedly improved outcomes compared with those in the cytokine era, yet comparatively little progress has been made since registration of the first targeted therapeutics occurred 10 years ago. In this article, we review efforts to improve on this current treatment paradigm. We discuss novel targets in this disease and corresponding new agents under investigation. The article dedicates particular attention to targeted immunotherapeutics, which are rapidly emerging as a new category of interest in this disease. Last, we review current data supporting the use of surgical interventions to improve outcomes in patients with metastatic disease.

THYROID METASTASIS FROM CLEAR CELL CARCINOMA OF THE KIDNEY 16 YEARS AFTER NEPHRECTOMY

The thyroid gland is one of the most vascularized organs in the body. However, metastatic disease to the thyroid gland is rare. When it does occur kidney is the most common primary tumor site, followed by melanoma, lung, breast, esophagus, uterus and colon carcinoma. We describe the case of an isolated thyroid metastasis from clear cell renal carcinoma occurring 16 years after nephrectomy. An 82 years-old woman presented for the recent growth of a right thyroid nodule, diagnosed 3 years before, when a fine needle aspiration biopsy found a benign cytology suggesting a well-differentiated follicular thyroid adenoma. Her medical history included type 2 diabetes mellitus, atrial fibrillation and a right nephrectomy for a clear cell renal carcinoma done 16 years before. The patient has lost weight but she was otherwise asymptomatic. The right lobe goiter was painless, firm, and mobile with deglutition, without signs of local compression or latero-cervical lymphadenopathy. Thyroid ultrasonography revealed an enlarged (9.9 cm) macronodular right lobe, with multiple cystic areas, with normal left lobe and a thrombus in the right internal jugular vein. Thyroid function tests were normal. The patient was suspected of thyroid carcinoma and underwent a near total thyroidectomy. Histopathological examination revealed a metastasis of clear cell renal carcinoma in the right thyroid gland lobe (8.5/5/5 cm). Further imaging showed no primary tumor or other metastases. Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of operated renal cell carcinoma, since it can occur up to 25 years after nephrectomy.

Gallbladder's clear cell renal carcinoma metastasis: A case report

•

Contribute to the comprehension of rare mestatic disease in clear cell renal carcinoma.

•

Underline that non only primary tumors develop in the gallbladder.

•

Increasing suspect of metastatic disease in patients with renal cell carcinoma will improve medical care of this patients.

Introduction

Clear cell renal cell carcinoma (ccRCC) is well known for its propensity to metastasize to unusual sites, even after 10 years. Gallbladder metastases are extremely rare, being found in approximately 0.6% of cases, at autopsy.

Case presentation

A 51-year-old man with a history of right ccRCC underwent total nephrectomy with extended lymphadenectomy, in another Hospital. Three years later, he was hospitalized at our Hospital, with gallbladder metastasis detected during a follow-up CT scan. At clinical examination, the patient did not present any symptoms or signs of gallbladder disease. Several imaging tests were performed to better characterize the lesion. A successful cholecystectomy and hepatic resection of 4b segment were performed, obtaining a R0 resection. The clinical course was uneventful, without any complications. After a 7-month follow-up, the patient is free from disease.

Discussion

A typical metastases are those located in a site other than thoracic, skeletal, hepatic, adrenal or encephalic tissue. Cholecystectomy with R0 resection has demonstrated to be the only factor increasing survival, mainly in isolated cases of metastasis, providing an overall 35–60% survival rate at 5 years.

Conclusion

In the follow-up of patients with a positive history of renal cell carcinoma specially clear cell subtype, all new finding should be taken into account as possible metastases. We ought to consider US and CT-scan behavior of gallbladder metastatic disease in order to orientate our diagnosis. Surgery for metastatic gallbladder disease of renal origin seems to be a feasible therapy which is capable of increasing patients’ overall survival.

Survival after renal cell carcinoma metastasis to the thyroid: single center experience and systematic review of the literature

BACKGROUND

Renal cell carcinoma can metastasize to uncommon sites, for example, the thyroid gland where metastases are rarely found. To determine the patient survival and the time between cancer diagnosis and thyroid metastasis, we analyzed a large patient cohort from our hospital records and performed a systematic review.

PATIENTS AND METHODS

Patients diagnosed between 1978 and 2007 with thyroid metastases from renal cell carcinoma were retrospectively identified from the hospital database. A systematic literature search was performed for publications describing at least three cases of thyroid metastasis from renal cell carcinoma. Case data from the identified studies were collected and used to determine the survival data.

RESULTS

We identified 34 patients (19 females) from our hospital records with a mean age of 67 years (range, 33-79) when thyroid metastasis was diagnosed. Median time to primary metastasis after resection of renal cell carcinoma was 6.5 years (range, 0-25) with a single case of synchronous metastasis. Median survival after primary metastasis was 4.7 years (95% confidence interval [CI]: 1.8-7.6). The systematic review included 32 studies with 285 patients. Case data could be extracted for 202 patients. Median time to thyroid metastasis (without synchronous cases) was 8.8 years (95% CI: 7.5-10.1). Median actuarial survival after thyroid metastasis was 3.4 years (95% CI: 2.2-4.6). Total thyroidectomy was not associated with a better survival compared to partial thyroidectomies.

CONCLUSIONS

Time to thyroid metastasis of renal cell carcinoma can be very long, and survival after thyroidectomy is favorable compared to metastasis to other sites.

Local treatments for metastases of renal cell carcinoma: a systematic review

Local treatment of metastases such as metastasectomy or radiotherapy remains controversial in the treatment of metastatic renal cell carcinoma. To investigate the benefits and harms of various local treatments, we did a systematic review of all types of comparative studies on local treatment of metastases from renal cell carcinoma in any organ. Interventions included metastasectomy, radiotherapy modalities, and no local treatment. The results suggest that patients treated with complete metastasectomy have better survival and symptom control (including pain relief in bone metastases) than those treated with either incomplete or no metastasectomy. Nevertheless, the available evidence was marred by high risks of bias and confounding across all studies. Although the findings presented here should be interpreted with caution, they and the identified gaps in knowledge should provide guidance for clinicians and researchers, and directions for further research.

Surgical management of renal cell carcinoma

Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.

Long-term survival after pancreatic resection for renal cell carcinoma metastasis

BACKGROUND

Surgical resection of pancreatic metastasis (PM) is the only reported curative treatment for renal cell carcinoma. However, there is currently little information regarding very long-term survival. The primary objective of this study was to determine the 10-year survival of this condition using the largest surgical series reported to date.

METHODS

Between May 1987 and June 2003, we conducted a retrospective study of 62 patients surgically treated for PM from renal cell carcinoma at 12 Franco-Belgian surgical centers. Follow-up ended on May 31, 2012.

RESULTS

There were 27 male (44 %) and 35 female (56 %) patients with a median age of 54 years [31-75]. Mean disease-free interval from resection of primary tumor to reoperation for pancreatic recurrence was 9.8 years (median 10 years [0-25]). During a median follow-up of 91 months [12-250], 37 recurrences (60 %) were observed. After surgical resection of repeated recurrences, overall median survival time was 52.6 months versus 11.2 months after nonoperative management (p = 0.019). Cumulative 3-, 5-, and 10-year overall survival (OS) rates were 72, 63, and 32 %, respectively. The corresponding disease-free survival rates were 54, 35, and 27 %, respectively. Lymph node involvement and existence of extrapancreatic metastases before PM were associated with poor overall survival.

CONCLUSIONS

Aggressive surgical management of single or multiple PM, even in cases of extrapancreatic disease, should be considered in selected patients to allow a chance of long-term survival.

Systematic lymph node dissection in lung metastasectomy of renal cell carcinoma: an 18 years of experience

BACKGROUND

Pulmonary metastasectomy of renal cell carcinomas (RCC) remains controversial. Thoracic lymph node involvement (LNI) is a known prognostic factor. The aim of our analysis is to evaluate whether patients with LNI, and particularly N2 patients, should be excluded from surgical treatment.

METHODS

We retrospectively reviewed data from 122 patients who underwent operations at two French thoracic surgery departments between 1993 and 2011 for RCC lung metastases.

RESULTS

The population consisted of 38 women and 84 men; the average age at time of metastasectomy was 63.3 years (min: 43, max: 82). LNI was identified as a prognostic factor using univariate and multivariate analysis (median survival: 107 months vs. 37 months, P = 0.003; HR = 0.384 (0.179; 0.825), P = 0.01, respectively). Although differences in survival between metastases at the hilar and mediastinal locations were not significant (median survival: 74 months vs. 32 months, respectively, P = 0.75), length of survival time was associated with disease-free interval less than 12 months (median survival: 23 months vs. 94 months, P < 0.0001; HR = 3.081 (1.193; 7.957), P = 0.02).

CONCLUSION

Although LNI has an adverse effect on survival; long-term survival can be achieved in pN+ patients. Consequently, these patients should not be excluded from surgery. Systematic lymphadenectomy should be performed to obtain more accurate staging and to determine appropriate adjuvant treatment.

The role of surgery for metastatic renal cell carcinoma in the era of targeted therapies

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.

8-year survival in a patient with several recurrences of renal cell carcinoma after radical nephrectomy

We describe the case of a patient with a large renal cell carcinoma (RCC) who underwent cytoreductive nephrectomy utilizing liver mobilization techniques similar to those used in transplantation. Despite recurrent metastases, our patient continues to survive eight years later with several metastasectomies and adjuvant chemotherapy. We report the case of a 48-year-old Hispanic American man who presented with a 4-month history of an enlarging right upper quadrant abdominal mass and hematuria. Computerized tomography revealed a 13 x 14 x 14 centimeter mass suspicious of RCC with possible metastasis to the lungs. The patient subsequently underwent radical nephrectomy. Pathological analysis confirmed the mass as RCC. Over the following eight years, the patient developed metastases to the pulmonary lobes, buccal mucosa, thoracic spine, and second rib, which were all treated with metastasectomy. The patient continues to survive today with a reasonable quality of life. Palliative measures in patients with large RCC tumors with distant metastases require persistent, aggressive therapeutic modalities.

Metastases of renal cell carcinoma to the larynx and thyroid: Two case reports on metastasis developing years after nephrectomy

Renal cell carcinoma (RCC) has a high metastatic potential due to its hematogen and vascular features. It metastasizes frequently to the lungs, the bones, the liver, the lymph nodes and the brain. Metastasis of RCC to the head and neck region is quite rare. In this case report, two RCC patients with head and neck metastases are presented: one occurring after 5 years and the other occurring 17 years after diagnosis.

Renal cell carcinoma : clinical features and management

In 1999 it was estimated that renal cell carcinoma (RCC) would account for 29,990 new cancer cases diagnosed in the United States (61% in men and 39% in women), and lead to 11,600 deaths. RCC accounts for 2-3% of all malignancies in adults and causes 2.3% of all cancer deaths in the United States annually (1). Approx 4% of all RCC cases are bilateral at some point in the life of the patient. Data from over 10,000 cases of renal cancer entered in the Connecticut Tumor Registry suggests an increase in the incidence of renal cancer from 1935-1989; in women the incidence increased from 0.7 to 4.2 in 100,000, and in men from 1.6 to 9.6 in 100,000 (2). Factors implicated in the development of RCC include cigarette smoking, exposure to petroleum products, obesity, diuretic use, cadmium exposure, and ionizing radiation (3-9).

Survival and impact of clinical prognostic factors in surgically treated metastatic renal cell carcinoma

BACKGROUND

The survival impact of metastasectomy for metastatic renal cell carcinoma (mRCC) is still an active research field, particularly in the multimodal/targeted therapy era.

OBJECTIVE

To determine the survival impact of clinical prognostic factors and their application to stratification of patients according to their prognosis so clinicians may be aided in their management of mRCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, bi-institutional cohort study of 109 consecutive patients (71 male and 38 female; median age: 62 yr (range: 25-82 yr) with renal cell carcinoma (RCC) who underwent partial or radical nephrectomy and at least one metastasectomy for mRCC.

INTERVENTION

Metastasis resection from various anatomic sites with the aim of completely removing detected lesions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariable and multivariable Cox regression models were used to analyse the impact of clinical prognostic factors on cancer-specific survival (CSS). Kaplan-Meier analysis with the log-rank test was used to compare CSS. Receiver operating characteristic (ROC) analysis was performed to test accuracy of prognostic groups. The α error for statistical significance was set at 0.05.

RESULTS AND LIMITATIONS

Multivariable analysis revealed that primary tumour T stage ≥ 3 (hazard ratio [HR]: 2.8; p<0.01), primary tumour Fuhrman grade ≥ 3 (HR: 2.3; p<0.03), nonpulmonary metastases (HR: 3.1; p<0.03), disease-free interval ≤ 12 mo (HR: 2.3; p<0.058), and multiorgan metastases (HR: 2.5; p<0.04) were independent pretreatment prognostic factors. Leuven-Udine (LU) prognostic groups based on these covariates were created and analysed with Kaplan-Meier and log-rank tests. The 2- and 5-yr CSS were significantly different; the respective group A CSS rates were 95.8% and 83.1%; group B, 89.9% and 56.4%; group C, 65.6% and 32.6%; and group D, 24.7% and 0% (p<0.0001). ROC analysis on the accuracy of prognostic grouping revealed respective areas under the curve of 0.87 and 0.88 at 2 and 5 yr. Main limitations to present study are the retrospective design and the presence of different metastasis sites.

CONCLUSIONS

LU prognostic groups could be considered an accurate clinical tool to stratify patients according to prognosis and aid clinicians in the management of mRCC.

Current status of targeted therapy for advanced renal cell carcinoma

The treatment of metastatic renal cell carcinoma (mRCC) has recently evolved from being predominantly cytokine-based treatment to the use of targeted agents, which include sorafenib, sunitinib, bevacizumab (plus interferon alpha [IFN-α]), temsirolimus, everolimus, pazopanib, and most recently, axitinib. Improved understanding of the molecular pathways implicated in the pathogenesis of RCC has led to the development of specific targeted therapies for treating the disease. In Korea, it has been 5 years since targeted therapy became available for mRCC. Thus, we now have broader and better therapeutic options at hand, leading to a significantly improved prognosis for patients with mRCC. However, the treatment of mRCC remains a challenge and a major health problem. Many questions remain on the efficacy of combination treatments and on the best methods for achieving complete remission. Additional studies are needed to optimize the use of these agents by identifying those patients who would most benefit and by elucidating the best means of delivering these agents, either in combination or as sequential single agents. Furthermore, numerous ongoing research activities aim at improving the benefits of the new compounds in the metastatic situation or their application in the early phase of the disease. This review introduces what is currently known regarding the fundamental biology that underlies clear cell RCC, summarizes the clinical evidence supporting the benefits of targeted agents in mRCC treatment, discusses survival endpoints used in pivotal clinical trials, and outlines future research directions.

Twelve-year survival after multiple recurrences and repeated metastasectomies for renal cell carcinoma

Background

Metastatic renal cell carcinoma (RCC) presents a therapeutic challenge for clinicians because of the unpredictable clinical course, resistance to chemotherapy or radiotherapy and the limited response to immunotherapy.

Patients and Methods

We report a case of a 62-year-old woman who underwent nephrectomy for T4N0 RCC, clear cell type, Fuhrman grade 3/4 in 1999. The patinet subsequently had multiple tumor recurrences.

Results

The patient underwent eight metastasectomies, including multiple partial left nephrectomies, right adrenalectomy, a complete left nephrectomy, and distal pancreatectomy. She remains well and tumor free 12 years after initial diagnosis.

Conclusion

Repeated resections after initial metastasectomy can be carried out safely and provide long-term survival in selected patients with recurrent metastasis from RCC. The findings from our case indicate that close follow-up for the early detection of recurrence and complete resection of metastases can improve the results after repeated resection.

Contralateral ureteral metastasis 4 years after radical nephrectomy

INTRODUCTION

Metastasis of renal cell carcinoma to the contralateral ureter is extremely rare. To date, only 50 cases of metastatic RCC to the ureter have been reported, among whom 6 cases occur at the contralateral site. We herein report a rare case of metastatic RCC in the contralateral ureter 4 years after radical nephrectomy.

PRESENTATION OF CASE

A 74-year-old man presented with gross, painless hematuria for one month. Computed tomography scan confirmed that a 1.5 cm × 0.5 cm tumor occurred in the contralateral distal ureter. A 3.5 cm segment of ureter was resected and a uretero-vesical anastomosis with psoas hitch was accomplished.

DISCUSSION

The reappearance of hematuria after radical nephrectomy is the most common manifestation of the metastasis to the bladder or ureter. The mechanism of metastasis is not clear. In pathology, vimentin and cytokeratins might help to differentiate between metastatic clear cell renal cell carcinoma and clear cell transitional cell carcinoma.

CONCLUSION

Metastasis of renal cell carcinoma to the contralateral ureter is rare. Early recognition is extremely important in protecting the remaining renal function and prolonging life-expectancy for post-nephrectomy patients. Complete metastectomy suitable anastomosis have been shown to improve survival.

Evaluation of response to multikinase inhibitor in metastatic renal cell carcinoma by FDG PET/contrast-enhanced CT

PURPOSE

Multikinase inhibitor (MKI) is a promising drug for treatment of metastatic renal cell carcinoma (mRCC). We explained the usefulness of [¹⁸F]-2-fluoro-2-deoxyglucose positron emission tomography/contrast-enhanced computed tomography (FDG PET/CECT) for mRCC in evaluating the early response to MKI and in predicting progression-free survival (PFS).

METHODS

Patients who planned MKI treatment for mRCC were included in this prospective study. FDG PET/CECT was performed before MKI treatment and after one cycle of MKI treatment. Evaluation of the response to MKI was assessed by PET according to the European Organization for Research and Treatment of Cancer, by CT according to the Response Evaluation Criteria in Solid Tumors and appearance of central hypoattenuation (CHA).

RESULTS

Twelve patients were enrolled in the study. Equality of response evaluation between PET and CT was in 8 patients (partial response [PR]: 1, stable disease [SD]: 6, progressive disease [PD]: 1). Among the other 4 patients, PET showed 2 patients with PR and 2 patients with PD, in contrast to the CT finding of SD in all 4 patients. PFS according to PET response showed a statistically significant difference between PR and SD (P < 0.05) and between PR and PD (P < 0.05), but not between PR and SD (P = 0.083). Positive CHA in metastatic lesions after MKI treatment was confirmed in 8 patients. PFS with positive CHA was 233.8 days, while that without CHA was 75.0 days (P < 0.05).

CONCLUSION

FDG PET/CECT shows potential for evaluating early treatment response to MKI in mRCC and for predicting PFS.

Long-term management of patients with metastatic renal cell carcinoma on targeted agents

Therapy for patients with metastatic renal cell carcinoma is becoming increasingly effective. Sustained partial remissions, occasional complete responses and manageable quality of life are seen in a subset of individuals. As we face the prospect of generating an increasingly large number of patients requiring long-term management, the choice and timing of systemic therapy and surgical interventions is becoming increasingly important. In this article, we review the timing and type of cytoreductive nephrectomy, what to do for patients with oligometastatic disease and how to deal with complete responders. In addition, we summarize the major side effects experienced with the commonly used molecularly targeted agents, and provide guidance on how to maximize benefit from these agents while maintaining an acceptable quality of life for patients. As treatment efficacy improves, the optimal integration of systemic therapy, surgery and toxicity management will become a critical aspect of our care for patients with metastatic renal cell carcinoma.

Survival after complete surgical resection of multiple metastases from renal cell carcinoma

BACKGROUND

Although a role for resection of solitary metastases from renal cell carcinoma (RCC) has been described, the utility of surgery in patients with multiple sites of disease has been less well defined. The authors report the survival of patients who underwent complete metastasectomy for multiple RCC metastases.

METHODS

The authors identified 887 patients who underwent nephrectomy for RCC between 1976 and 2006 who developed multiple metastatic lesions. The impact of complete metastasectomy on survival was evaluated controlling for the timing, location, and number of metastases and for patient performance status.

RESULTS

Of 887 patients, 125 (14%) underwent complete surgical resection of all metastases. Complete metastasectomy was associated with a significant prolongation of median cancer-specific survival (CSS) (4.8 years vs 1.3 years; P < .001). Patients who had lung-only metastases had a 5-year CSS rate of 73.6% with complete resection versus 19% without complete resection (P < .001). A survival advantage from complete metastasectomy also was observed among patients with multiple, nonlung-only metastases, who had a 5-year CSS rate of 32.5% with complete resection versus 12.4% without complete resection (P < .001). Complete resection remained predictive of improved CSS for patients who had ≥ 3 metastatic lesions (P < .001) and for patients who had synchronous (P < .001) and asynchronous (P = .002) multiple metastases. Moreover, on multivariate analysis, the absence of complete metastasectomy was associated significantly with an increased risk of death from RCC (hazard ratio, 2.91; 95% confidence interval, 2.17-3.90; P < .001).

CONCLUSIONS

The current results indicated that complete resection of multiple RCC metastases may be associated with long-term survival and should be considered when technically feasible in appropriate surgical candidates.