Multi-modal treatment for metastatic renal cancer: the role of surgery

Reply to De Luca et al. Comment on "Marra et al. Metastatic Renal Cell Carcinoma to the Soft Tissue 27 Years after Radical Nephrectomy: A Case Report. Medicina 2023, 59, 150"

We appreciated the comments of De Luca and colleagues [...].

Modified vein clamping technique for renal cell carcinoma complicated with level I-II IVC thrombi: a study at a single centre

Objectives

To share our initial experience with the modified vein clamping technique for the treatment of renal cell carcinoma complicated with level I–II IVC thrombi.

Methods

From March 2018 to April 2021, 11 patients with renal cell carcinoma (RCC) involving an IVC tumour thrombus were admitted to our hospital. They all underwent laparoscopic radical nephrectomy and IVC thrombectomy (LRN-IVCTE) using a modified vein clamping technique.

Results

All procedures were successfully completed without conversion to open surgery. The median operative time was 185.00 min (145.00–216.00 min); the median estimated blood loss was 200.00 ml (155.00–300.00 ml), and four patients received an intraoperative transfusion. In addition, the median IVC clamping time was 18.00 min (12.00–20.00 min); the median postoperative hospital stay was 6.00 days (4.00–7.00 days), while the median follow-up period was 28.00 months (4.00–34.00 months).

Conclusions

The modified vein clamping technique for the treatment of renal cell carcinoma complicated with level I–II IVC thrombi may be a safe and technically feasible alternative technique.

Experience with management of renal cell carcinoma with inferior vena cava/right atrial tumor thrombus

Introduction:

We aimed to present our experience in managing renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus.

Methods:

Records of all patients aged 18 years and older, with a diagnosis of primary renal masses with IVC thrombus, presenting to our institute from January 2012 to August 2020 were retrospectively reviewed. Patients with tumor thrombus limited only to renal vein were excluded from the analysis. Their hospital course and outcomes were recorded and evaluated for predictors of survival.

Results:

During the study period, we treated 61 patients with a renal mass and concurrent IVC thrombus and 56 of these underwent surgery. 7 of them had level III and 6 had level IV thrombus. A total of six patients received neoadjuvant tyrosine kinase inhibitor (TKI) therapy and all of them showed a decrease in size and level of tumor thrombus and cardiopulmonary bypass was safely avoided. Fourteen patients had distant metastasis and underwent cytoreductive surgery and of these 12 patients received TKI therapy after surgery with a mean survival of 26.8 months. The overall survival at 2 and 5 years of nonmetastatic group was 81.1% and 47.5% respectively and in metastatic group was 35.1% and 0%, respectively. Poor performance status, distant metastasis, higher T stage, higher thrombus levels, and positive surgical margins were all predictors of decreased survival.

Conclusions:

Complete surgical resection in both nonmetastatic and metastatic RCC with IVC thrombus has long-term survival benefits. Neoadjuvant TKI therapy, with adequate preoperative planning, helps in decreasing the size of the thrombus and in safely avoiding bypass in level III and IV IVC thrombi.

Nomogram Predicting Survival to Assist Decision-Making of Metastasectomy in Patients With Metastatic Renal Cell Carcinoma

The survival benefit of metastasectomy (MSX) in patients with metastatic renal cell carcinoma (mRCC) remains unclear. A reliable model to predict an individuals’ risk of cancer-specific mortality (CSM) and to identify optimal candidates for MSX is needed. We identified 2,911 mRCC patients who underwent cytoreductive nephrectomy from the Surveillance, Epidemiology, and End Results database (2010–2015). Based on the Fine and Gray competing risks analyses, we created a nomogram to predict the survival of mRCC patients. Decision tree analysis was useful for patient stratification. The impact of MSX was assessed among three different subgroups. Overall, 579 (19.9%) cases underwent MSX. In the entire patients, the 1-, 2-, and 3-year cumulative incidence of CSM were 32.8, 47.2, and 57.9%, respectively. MSX was significantly associated with improved survival (hazard ratio [HR] = 0.875, 95% confidence interval [CI] 0.773–0.991; P = 0.015). Based on risk scores, patients were divided into three risk groups using decision tree analysis. In the low-risk group, MSX was significantly associated with a 12.8% risk reduction of 3-year CSM (HR = 0.689, 95% CI 0.507–0.938; P = 0.008), while MSX was not associated with survival in intermediate- and high-risk groups. We proposed a novel nomogram and patient stratification approach to identify suitable patients for MSX. The newly identified patient subgroup with a low-risk of CSM might benefit more from aggressive surgery. These results should be further validated and improved by the prospective trials.

Prognostic impact of metastasectomy in renal cell carcinoma in the postcytokine therapy era

OBJECTIVES

To explore the real-world data regarding survival following metastasectomy (MS) for renal cell carcinoma (RCC) in the postcytokine therapy era.

PATIENTS AND METHODS

Patients diagnosed with metastatic renal cell carcinoma (mRCC) between January 2008 and December 2018 at our institutions were retrospectively evaluated. The patients were classified into three groups according to their MS status: (1) complete MS (cMS), (2) incomplete MS (icMS), and (3) without MS (nonMS). Factors for overall survival (OS) after diagnosis were analyzed.

RESULTS

Overall, 314 patients were evaluated. During the follow-up period (median: 25.3 months), a total of 98 patients (31.2%) underwent at least one MS. The cMS group (n = 45, 14.3%) had a significantly longer OS (median: not reached [N.R.]) than the icMS (n = 53, 16.9%) (81.5 months, P= 0.0042) and nonMS groups (28.1 months, P< 0.0001). The icMS group had a significantly longer OS than the nonMS group did (P= 0.0010). Multivariate analysis showed that the MS status was an independent factor for OS (cMS vs. nonMS: P= 0.0004; icMS vs. nonMS: P= 0.0176), together with histopathological type, International Metastatic Renal Cell Carcinoma Database Consortium risk, liver metastasis status, and prior nephrectomy status (all, P< 0.05). In addition, the OS was comparable throughout the eras of systemic therapy (early molecular-targeted therapy, late molecular-targeted therapy, and immune checkpoint inhibitor eras) in the MS group (median: 121.9 vs. N.R. vs. N.R. months, P= 0.948).

CONCLUSIONS

MS, especially cMS improved survival in selected patients with mRCC in the postcytokine therapy era. In addition, MS still plays a significant role in the current systemic therapy.

Clinical response to sodium glucose co-transporter 2 inhibitor ipragliflozin in a patient with metastatic renal cell carcinoma

Introduction

Sodium glucose co‐transporter 2 inhibitors constitute a new class of antidiabetic medication. Sodium glucose co‐transporter 2 inhibitors have been shown to exert anticancer effects. However, the clinical value of these drugs as anticancer agents is yet to be evaluated.

Case presentation

A 72‐year‐old man presented to our hospital with frequent cough and dyspnea. Contrast‐enhanced computed tomography revealed renal cell carcinoma cT3bN0M1. Ipragliflozin, a sodium glucose co‐transporter 2 inhibitor, treatment was initiated to control blood glucose levels. Two years after diagnosis, computed tomography revealed remarkable tumor regression without any systemic therapy other than ipragliflozin.

Conclusion

Sodium glucose co‐transporter 2 inhibitors are potentially applicable as anticancer agents among patients with metastatic renal cell carcinoma.

Dual Combined Laparoscopic Approach for Renal-Cell Carcinoma with Renal Vein and Level I-II Inferior Vena Cava Thrombus: Our Technique and Initial Results

OBJECTIVE

To present our technique and initial results of dual combined retroperitoneal and transperitoneal laparoscopic approach for the treatment of renal-cell carcinoma (RCC) with level 0-II venous tumor thrombus.

PATIENTS AND METHODS

We included nine consecutive patients with RCC and level 0-II inferior vena cava (IVC) thrombus who underwent laparoscopic radical nephrectomy and IVC thrombectomy using dual combined laparoscopic approach in our department between January 2016 and June 2017.

RESULTS

The mean operative time was 150 minutes when cavotomy was not performed and 240 minutes when cavotomy with thrombectomy was required. The mean IVC clamping time was 24 minutes and the mean blood loss was 300 mL. We encountered no major intraoperative or postoperative complications (Clavien III-IV). The patients were discharged a mean of 7 days after the procedure. At the 6-month follow-up, all patients were alive. One patient presented a retroperitoneal enlarged lymph node and started systemic treatment.

CONCLUSIONS

The dual combined laparoscopic approach for kidney tumors with level 0-II IVC thrombus is feasible, reproducible, and especially useful in patients with complex renal pedicle. The technique provides early arterial control by retroperitoneal approach, which reduces the blood flow through the renal vein and has the advantage of minimal mobilization of the thrombus-bearing renal vein; it therefore lowers the risk of tumor embolism and intraoperative hemorrhage.

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.

Treatment of Advanced Renal Cell Carcinoma: Recent Advances and Current Role of Immunotherapy, Surgery, and Cryotherapy

Renal cell carcinoma (RCC) is the 10th most common cancer in Western countries. The prognosis of metastatic disease is unfavorable but may be different according to several risk factors, such as histology and clinical features (Karnofsky performance status, time from nephrectomy, hemoglobin level, neutrophils and thrombocytes count, lactate dehydrogenase and calcium serum value, sites and extension of the disease). In this review, we focused on some recent developments in the use of immunotherapy, surgery and cryotherapy in the treatment of advanced disease. While RCC is unresponsive to chemotherapy, recent advances have emerged with the development of targeted agents and innovative immunotherapy-based treatments. Surgical resection remains the standard of care for patients with small renal lesions but in patients with significant comorbidities ablative therapies such as cryoablation and radiofrequency ablation may lead to local cancer control and avoid surgical complications and morbidity. In the setting of metastatic RCC, radical nephrectomy, or cytoreductive nephrectomy, is considered a palliative surgery, usually part of a multimodality treatment approach that requires systemic treatments.

The value of hepatic resection in metastasic renal cancer in the Era of Tyrosinkinase Inhibitor Therapy

BACKGROUND

The value of liver-directed therapy (LDT) in patients with metastasic renal cell carcinoma (MRCC) is still an active field of research, particularly in the era of tyrosinkinase inhibitor (TKI) therapy.

METHODS

The records of 35 patients with MRCC undergoing LDT of metastasic liver lesions between 1992 and 2015 were retrospectively analyzed. Immediate postoperative TKI was given in a subgroup of patients after LDT for metastasic lesions. Uni- and multivariate models were applied to assess overall survival (OS), progression-free survival (PFS) and disease-free survival (DFS).

RESULTS

Following primary tumor (renal cell cancer) resection and LDT, respectively, median OS was better for a total of 16 patients (41 %) receiving immediate postoperative TKI with 151 and 98 months, when compared to patients without TKI therapy with 61 (p = 0.003) and 40 months (p = 0.032). Immediate postoperative TKI was associated with better median PFS (47 months versus 19 months; p = 0.023), whereas in DFS only a trend was observed (51 months versus 19 months; p = 0.110).

CONCLUSIONS

LDT should be considered as a suitable additive tool in the era of TKI therapy of MRCC to the liver. In this context, postoperative TKI therapy seems to be associated with better OS and PFS, but not DFS.

A unique presentation of a renal clear cell carcinoma with atypical metastases

INTRODUCTION

Renal cancer is a relatively common neoplasia with renal clear cell carcinoma being the most frequent histological type. This tumor has a strong tendency to metastasize virtually to all organs. Today, new diagnostic tools allow physicians to distinguish between those patients with "incidental findings" and those with advanced metastatic disease.

PRESENTATION OF CASE

A 70-year-old male with multiple indolent subcutaneous masses underwent colonoscopy after a positive fecal screening test for colorectal carcinoma. A rectal lesion was discovered but biopsy was negative. CT scan revealed advanced renal cancer involving the peritoneal cavity, retroperitoneum and lung. Biopsy of subcutaneous masses confirmed the suspected metastases. The patient underwent surgery (an open left nephrectomy with rectosigmoid resection and metastases debulking) because of a high risk of bowel obstruction and increasing anemia. After three years of multi-targeted therapy and follow-up, the patient is still asymptomatic and in good general condition.

DISCUSSION

Treatment of metastatic renal cancer is still controversial even if more than 30% of patients have metastasis at the time of diagnosis. Recently introduced targeted therapies are encouraging but still present problems with side effects and an unlimited period of efficacy. Although there is no consensus, several studies and guidelines consider metastasectomy to be a valid option.

CONCLUSION

Recent series highlight surgery as a key-point in the management of advanced renal clear cell carcinoma. Our case demonstrates the validity of a surgical strategy supported by a multidisciplinary approach.

Laparoscopic Radical Nephrectomy and Inferior Vena Cava Thrombectomy in the Treatment of Renal Cell Carcinoma

BACKGROUND

Radical nephrectomy with inferior vena cava (IVC) thrombectomy is the preferred treatment for renal cell carcinoma (RCC) with IVC thrombus. However, IVC thrombectomy using a laparoscopic approach has not been reported for high-level thrombi.

OBJECTIVE

To describe the surgical technique for laparoscopic IVC thrombectomy in patients with different thrombus levels and to assess its safety and feasibility.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of medical records for 11 patients with right-side RCC, including six patients with level II IVC thrombus and five patients with level IV thrombus.

SURGICAL PROCEDURE

Laparoscopic thrombectomy for level II thrombus was performed after clamping the infrarenal IVC, left renal vein, and infrahepatic IVC. Laparoscopic thrombectomy and thoracoscope-assisted open atriotomy for level IV thrombus were performed after establishing cardiopulmonary bypass and clamping the infrarenal IVC, left renal vein, and hepatoduodenal ligament.

MEASUREMENTS

The intraoperative variables, postoperative complications, and surgical outcomes were assessed.

RESULTS AND LIMITATIONS

The median operative time was 210min. The median IVC clamping time for patients with level II and level IV thrombus was 16.5 and 31min, respectively. The median estimated blood loss was 510ml, and no major intraoperative or postoperative complications occurred. One patient with level IV thrombus died of brain metastasis 6 mo after the operation, and the remaining ten patients had no local recurrence or distant metastasis during a median follow-up period of 31 mo.

CONCLUSIONS

Laparoscopic IVC thrombectomy for level II thrombus and well-selected level IV thrombus may be a safe and technically feasible alternative to open surgery.

PATIENT SUMMARY

We studied the treatment of patients with an inferior vena cava thrombus at different levels using a laparoscopic approach. This technique was safe and feasible in well-selected patients.

Open mini-flank partial nephrectomy: an essential contemporary operation

Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.

The association between statin medication and progression after surgery for localized renal cell carcinoma

PURPOSE

Evidence suggests that statins may influence pathways of renal cell carcinoma proliferation, although to our knowledge no study has examined the influence of statin medications on the progression of renal cell carcinoma in humans.

MATERIALS AND METHODS

We identified 2,608 patients with localized renal cell carcinoma who were treated surgically between 1995 and 2010 at our tertiary referral center. Competing risks Cox proportional hazards models were used to evaluate the relationship between statin use and time to local recurrence or progression (metastases or death from renal cell carcinoma) and overall survival. Statin use was modeled as a time dependent covariate as a sensitivity analysis. Models were adjusted for clinical and demographic features.

RESULTS

Of 2,608 patients 699 (27%) were statin users at surgery. Statin users had similar pathological characteristics compared to nonusers. At a median followup of 36 months there were 247 progression events. Statin use was associated with a 33% reduction in the risk of progression after surgery (HR 0.67, 95% CI 0.47-0.96, p = 0.028) and an 11% reduction in overall mortality that was not significant (HR 0.89, 95% CI 0.71-1.13, p = 0.3). Modeling statin use as a time dependent covariate attenuated the risk reduction in progression to 23% (HR 0.77, p = 0.12) and augmented the risk reduction in overall survival (HR 0.71, p = 0.002).

CONCLUSIONS

In our cohort statin use was associated with a reduced risk of progression and overall mortality, although this effect was sensitive to the method of analysis. If validated in other cohorts, this finding warrants consideration of prospective research on statins in the adjuvant setting.

Metastatic renal cell carcinoma: update on epidemiology, genetics, and therapeutic modalities

The treatment of advanced renal cell carcinoma (RCC) remains a major therapeutic challenge for clinicians. Despite advances in the understanding of the immunobiology of RCC and the availability of several novel targeted agents, there has been little improvement in the survival of patients with metastatic RCC. This review will focus on the recent understanding of risk factors and treatment options and outcomes of metastatic RCC, in particular, targeted therapeutic agents that inhibit vascular endothelial growth factor and mammalian target of rapamycin pathways. Prospective studies are required to determine whether sequential targeted therapy will further improve progression-free survival in RCC. Ongoing research to develop novel agents with better tolerability and enhanced efficacy in the treatment of metastatic RCC is required.

Rare case of renal cell carcinoma with mandibular swelling as primary presentation

Introduction. Renal cell carcinoma accounts for approximately 3% of adult malignancies and 90–95% of neoplasms arising from the kidney. This disease is characterized by a lack of early warning signs, diverse clinical manifestations, and resistance to radiation and chemotherapy. Approximately one-third of patients with renal cell carcinoma have metastatic disease at initial presentation. Fifteen percent of patients with renal cell carcinoma are said to present with metastases in the head and neck region. Most of the metastases from RCC to the head and neck involve the thyroid gland. The head and neck are unusual sites for metastases, but skin, skeletal muscle, thyroid gland, nasal cavity and paranasal sinus metastases have been reported. Case Report. The following report describes a rare case where the patient presented with mandibular swelling of short duration as the primary complaint without any symptom or sign pertaining to urinary tract and was found to have renal cell carcinoma on further workup. Conclusion. Metastatic renal cell carcinoma is a diagnostic dilemma especially when there is no pointer historically towards renal cell carcinoma as was in our case. An unusual vascular osteolytic lesion in head and neck in a middle-aged person should be dealt with high index of suspicion with renal cell carcinoma at the back of the mind.

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.

Patient and caregiver knowledge and utilization of partial versus radical nephrectomy: results of a national kidney foundation survey to assess educational needs of kidney cancer patients and caregivers

BACKGROUND

In response to requests from patients, caregivers, and physicians for information on kidney cancer, the National Kidney Foundation (NKF) conducted a survey to assess the educational needs of the kidney cancer community. Key areas of assessment were patient and caregiver knowledge of risk factors for chronic kidney disease (CKD), including kidney cancer and nephrectomy, and of kidney-sparing surgical options.

STUDY DESIGN

Survey to assess educational needs of patients with kidney cancer and caregivers.

SETTING & PARTICIPANTS

Respondents were invited through physician referrals and online sources and included 365 adult patients with kidney cancer and 52 caregivers.

PREDICTOR

Age, geographic region, and cancer stages 1-2 versus 3-4.

OUTCOMES & MEASUREMENTS

Survey responses were descriptively analyzed, with data compared and weighted to the population age and geographic characteristics of the general kidney cancer population.

RESULTS

83% of 181 early-stage patients, 92% of 123 late-stage patients, and 86% of 113 patients who did not know their stage received radical nephrectomy. Although 62% agreed that radical nephrectomy for cancer treatment is a risk factor for CKD, only 40% agreed that losing part or all of 1 kidney from injury or a disease other than cancer is a risk factor for CKD. 56% agreed that kidney cancer can be related to CKD.

LIMITATIONS

We did not have patient medical records to validate responses and we do not know the number of people who were invited to take the survey but declined.

CONCLUSIONS

There is a lack of patient awareness that kidney cancer and radical nephrectomy are risk factors for CKD. Only a minority of patients underwent partial nephrectomy or were given it as an option for their early-stage kidney cancer. This suggests a knowledge deficit among physicians, surgeons, patients, and caregivers alike that there is a bidirectional relationship between kidney cancer and CKD and that kidney-sparing surgery is preferable when feasible.

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.

C-reactive protein in patients with advanced metastatic renal cell carcinoma: usefulness in identifying patients most likely to benefit from initial nephrectomy

Objective

C-reactive protein (CRP) is considered a useful serum marker for patients with RCC. However, its clinical utility in advanced metastatic renal cell carcinoma (AM-RCC), particularly in deciding whether to perform nephrectomy at the onset, is not well studied.

Patients and methods

We retrospectively evaluated 181 patients with AM-RCC, including 18 patients underwent potentially curative surgery, 111 underwent cytoreductive nephrectomy, and 52 received medical treatment only. CRP cutoff points were determined by receiver operating characteristic (ROC) curve analysis. Kaplan-Meier and Cox regression analyses were used for survival tests.

Results

ROC analysis suggested that grouping patients according to 3 CRP ranges was a rational model. Patients with highly elevated CRP (≥67.0 mg/L) presented remarkably poor prognosis despite treatment (nephrectomy or medical treatment only). Cox regression models demonstrated that risk factors of overall survival for patients who underwent nephrectomy were the CRP ranges defined in this study (≤18.0 mg/L, >18.0 and <67.0 mg/L, and ≥67.0 mg/L), ECOG PS (0, 1, and ≥2), and number of metastatic organ sites (0–1 and ≥2). The retrospective design is a limitation of this study.

Conclusion

Our study demonstrated that the serum CRP level is a statistically significant prognostic parameter for patients with AM-RCC. The data also indicated that pretreatment serum CRP level provides useful prognostic information that helps in deciding whether to perform initial nephrectomy for patients with AM-RCC.

Role of cytoreductive nephrectomy in the era of targeted therapy for renal cell carcinoma

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.

Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC)

Study Type - Harm (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Radical nephrectomy for patients with metastatic renal cell carcinoma results in greater rates of morbidity than for those with less advanced disease. This study systematically characterizes complications associated with nephrectomy for metastatic RCC and identifies patient and disease characteristics that are associated with a greater risk of developing complications. Overall complications were relatively frequent, but major complications (grade 3 or greater) were rare. Increasing age and worsening performance status were associated with increased probability of complications. When complications were sustained, patients were less likely to receive systemic therapy in a timely fashion. These observations may influence the timing or patient selection for surgery or systemic therapy.

OBJECTIVE

• To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

• We identified patients with mRCC who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1989 and 2009. • Postoperative complications were characterised using a modified version of the Clavien-Dindo classification system. • Patient and disease characteristics, including a previously validated MSKCC risk-stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models. • The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10-fold cross validation.

RESULTS

• Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥ 2 complications within 8 weeks of surgery. • Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting. • In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications. • Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12-0.86; P= 0.024). • A multivariable model containing KPS (OR 14.5; 95%CI 4.34-48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01-1.08; P= 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63-0.80) for postoperative complications.

CONCLUSIONS

• Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS. • These complications are important because they may delay or deny receipt of subsequent systemic therapy.

Defining an individualized treatment strategy for metastatic renal cancer

Treatment of metastatic renal cell carcinoma (mRCC) has evolved dramatically within the past 10 years with the advent of therapy targeting the angiogenesis and mammalian target of rapamycin (mTOR) pathways. These therapies rapidly supplanted immunotherapy as a first-line systemic treatment option. Response rates, however, continue to vary, largely due to mRCC's clinical and molecular heterogeneity. This article reviews current understanding of mRCC biology and available treatments, discusses novel biomarkers that improve prognostication and may be able to predict response, and integrates available literature on surgical and systemic therapies into an individualized strategy.

3rd Pavia international symposium on advanced kidney cancer

Kidney cancers' natural history has radically changed in the past few years, due to the development of novel targeted agents. Despite these improvements, several unanswered questions still remain on the table, regarding the best first-line treatment, the ideal sequence of treatments, the management of specific subgroups of patients (e.g., elderly patients or those with comorbidities) and the relevance of prognostic factors, among many others. To foster discussions among clinicians and investigators working in this field, and to exchange different viewpoints concerning the newest advances in kidney cancer pathogenesis and treatment, the 3rd Pavia International Symposium on Advanced Kidney cancer was held in Pavia (Italy) between 30 June and 1 July 2011. The aim of this report is to summarize the most significant advances in the different disciplines applied to advanced kidney cancer, which were presented and discussed during the meeting, and how these advances will be changing the perspective of patients with this disease.

Delivering preventive, predictive and personalised cancer medicine for renal cell carcinoma: the challenge of tumour heterogeneity

Recent years have seen major advances in the management of metastatic renal cell carcinoma (mRCC). The tyrosine kinase and mammalian target of rapamycin inhibitors have resulted in disease control and improved survival for many patients with mRCC, but they have not led to preventive, predictive or personalised medicine (PPPM). Failure to achieve this rests ultimately with inadequate knowledge of tissue and molecular heterogeneity; discovery of these drugs was based upon identification of pathogenic molecular pathways in RCC, but research into molecular factors which underpin drug response, resistance and selection of therapy for individual patients has lagged well behind clinical trials of drug development. This review will provide an overview of the development of targeted drug therapies for mRCC, will discuss the challenges which currently impede the delivery of PPPM, including identification of biomarkers, drug resistance and molecular heterogeneity, and will propose research methodologies and technologies required to overcome these obstacles.

Role of immunohistochemistry in the evaluation of needle core biopsies in adult renal cortical tumors: an ex vivo study

Multiple therapeutic options for renal tumors that are now available have put pathologists under increasing pressure to render diagnosis on limited material. Results on biopsies by hematoxylin and eosin (H&E) have historically not been encouraging. Currently, multiple immunohistochemical markers with differential expression in these renal tumors are available. We studied the utility of such markers on needle biopsies that were obtained ex vivo. After nephrectomy, two 18-guage cores were obtained and processed routinely. Expressions of carbonic anhydrase (CA) IX, CD117, α-methylacyl-CoA racemase (AMACR), cytokeratin 7 (CK7), and CD10 were evaluated. Results, with or without immunostaining, were compared with the final nephrectomy diagnosis. We studied 145 tumors, including 119 renal cell carcinomas (83 clear cell, 18 papillary, 14 chromophobe, and 4 type unclassified), 11 oncocytomas, and 15 miscellaneous tumors. Adequate evaluable material was present in 123 (85%) cases. In such biopsies, 81% of cases were correctly classified by H&E alone, with correct diagnosis in 90% of cases in the most common tumor subtypes (clear cell, papillary and chromophobe renal cell carcinoma, and oncocytoma). By adding immunostains, the accuracy was 90% overall and 99% among the 4 most common subtypes. The following extent and patterns of immuneexpression were highly useful in the diagnoses: diffuse, membranous CAIX expression in clear cell renal cell carcinoma, diffuse positivity for AMACR in papillary renal cell carcinoma, distinct peripheral cytoplasmic accentuation for CD117 in chromophobe renal cell carcinoma, widespread and intense positivity for CK7 in chromophobe and papillary renal cell carcinoma, and diffuse membranous reactivity in clear cell and patchy/luminal in papillary renal cell carcinoma for CD10. In conclusion, utilizing immunostains improves classification of renal tumors on needle biopsy, which may be of particular help for pathologists with limited experience. Both extent and patterns must be considered for a definitive diagnosis.

ICUD-EAU International Consultation on Kidney Cancer 2010: treatment of metastatic disease

CONTEXT

Until the development of novel targeted agents directed against angiogenesis and tumour growth, few treatment options have been available for the treatment of metastatic renal-cell carcinoma (mRCC).

OBJECTIVE

This review discusses current targeted therapies for mRCC and provides consensus statements regarding treatment algorithms.

EVIDENCE ACQUISITION

Medical literature was retrieved from PubMed up to April 2011. Additional relevant articles and abstract reviews were included from the bibliographies of the retrieved literature.

EVIDENCE SYNTHESIS

Targeted treatment for mRCC can be categorized for the following patient groups: previously untreated patients, those refractory to immunotherapy, and those refractory to vascular endothelial growth factor (VEGF)-targeted therapy. Sunitinib and bevacizumab combined with interferon alpha are generally considered first-line treatment options in patients with favourable or intermediate prognoses. Temsirolimus is considered a first-line treatment option for poor-risk patients. Either sorafenib or sunitinib may be valid second-line treatments for patients who have failed prior cytokine-based therapies. For patients refractory to treatment with VEGF-targeted therapy, everolimus is now recommended. Pazopanib is a new treatment option in the first- and second-line setting (after cytokine failure). Sequential and combination approaches, and the roles of nephrectomy and tumour metastasectomy will also be discussed.

CONCLUSIONS

Increasing clinical evidence is clarifying appropriate first- and second-line treatments with targeted agents for patients with mRCC. Based on phase 2 and 3 trials, a sequential approach is most promising, while combination therapy is still investigational. The role of nephrectomy in mRCC is being evaluated in ongoing phase 3 clinical trials.

The role of surgery in the management of early-stage renal cancer

There were an estimated 58,240 new cases and 13,040 deaths from kidney cancer in the United States in 2010. The increased treatment and cure of small, incidentally discovered renal tumors, most of which are nonlethal in nature, has not offset the increased mortality caused by advanced and metastatic tumors. In this article, the optimum approach to the surgical management of localized renal tumors and its impact on renal function are discussed.