Infarction-nephrectomy for metastatic renal carcinoma. Southwest oncology group study

Effect of renal embolization in patients with synchronous metastatic renal cell carcinoma: a retrospective comparison of cytoreductive nephrectomy and systemic medical therapy

Objective

To compare survival outcomes for renal embolization (RE) to cytoreductive nephrectomy (CN) and no primary renal treatment (NT) among patients with synchronous metastatic renal cell carcinoma (mRCC) treated using either targeted therapy (TT) or immunotherapy (IT).

Results

The median follow-up duration was 81.3 months, with a duration of first-line treatment of 3.5 months. Among the 211 patients, the median PFS and OS were 4.4 and 10.6 months. Specifically for patients receiving TT (124 patients), the PFS and OS were 5.5 and 12.0 months. An intervention effect was identified only for OS, with a median OS of 20.1, 8.8 and 9.3 months for CN, RE and NT, respectively. After stratification by risk classification, CN provided a significant benefit on OS, compared to RE and NT, for patients with an intermediate risk (MSKCC). For those with a poor risk (Heng criteria), NT provided better survival than PFS (p=0.003), and a comparable survival to RE (p > 0.05).

Materials and Methods

Retrospective analysis of 211 patients, 87 treated with IT and 124 with TT, retrieved from our RCC database. Patients' risk factors for survival was evaluated using the Heng and MSKCC criteria, with only patients with an intermediate or poor survival risk included in the analysis. Between-group comparisons were evaluated with respect to progression-free survival (PFS) and overall survival (OS).

Conclusions

The differential effect of CN and RE on OS appears to be modulated by risk classification. In patients with a poor risk, RE should be implemented after careful consideration of comorbidities and life expectancy.

Effect of Ethanol Induced Occlusion of the Renal Artery in Rabbit Kidney Implanted with VX2 Carcinoma

The effects of injection of absolute ethanol into the renal artery were investigated in 13 rabbit kidneys previously implanted with VX2 carcinoma. Eight rabbits with implanted tumors served as controls. The effects were evaluated by angiography and histology. Three days after implantation, tumors were demonstrated by angiography as relatively hypovascular areas in the subcapsular cortex of the kidneys. Following angiography, absolute ethanol (0.3 ml/kg) was injected into the renal artery. Repeat angiography with barium sulphate was performed after an additional 3 days (10 ethanol treated animals, 2 controls), 10 days (2 treated, 1 control) or 14 days (1 treated, 0 control). In treated animals the tumors were markedly smaller in comparison with those of the control group. The occlusion procedure, however, did not completely eradicate tumor cells. The histologic study of the implanted tumor confirmed the findings previously reported that viable tumor cells still remained in the peripheral portions of infarcted areas. This study demonstrated the beneficial, though not curative, short-term effects of transcatheter renal artery treatment with absolute ethanol in malignant renal tumors.

Role of embolization in the treatment of renal masses

Renal arterial embolization (RAE) performed for the treatment of renal masses has been proven to be a safe and effective technique, with several decades of experience. RAE is well tolerated with few complications, particularly if the time interval from embolization to surgery is reduced to less than 48 hours. Review of the literature suggests that RAE is also extremely effective for palliation of symptoms in the setting of nonoperative advanced stage renal cell carcinoma. In addition, this technique plays a large role in the management of angiomyolipomas that are symptomatic or at risk of spontaneous rupture. To date, RAE has not been evaluated in a randomized controlled setting, which has contributed to its underutilization. All of these potential benefits warrant the need for prospective studies for further validation.

Ethanol ablation of renal cell carcinoma for palliation of symptoms in advanced disease

The aim of this study was to evaluate the efficacy of transarterial alcohol ablation of renal cell carcinoma (RCC) with distant metastasis for control of symptoms caused by primary disease. This was a retrospective study consisting of eight patients having stage IV RCC. The primary indication for embolization was hematuria in seven patients and flank pain in one patient. All eight patients underwent renal artery embolization with ethanol and gelatin sponge pledgets. After embolization periodic evaluation was done every 3 months up to 1 year. Patients treated for hematuria did not complain of hematuria at 3- and 6-month follow-up except one who died of disease after 5 months. At 9-month follow-up five patients were free of hematuria while one developed hematuria after 6 months of treatment and died after 8 months. After 1 year three patients had no hematuria. One patient who developed hematuria at 9 months died after 11 months, another patient died of cardiac arrest at 10 months. The only patient who was treated for flank pain did not complain of pain up to 1-year follow-up. To conclude, transarterial embolization of renal tumor using ethanol is very effective in controlling local symptoms such as hematuria and pain. Thus, it may be an alternative treatment offered to symptomatic patients who are either not fit for surgery or not willing to undergo surgery.

Renal embolization as an alternative to surgical nephrectomy in children

PURPOSE

Complete renal embolization may be an alternative to surgical nephrectomy. The indications for renal embolization do not differ from those for surgical nephrectomy, but the less invasive nature of the technique is a major advantage. Few case reports are available in the pediatric age group. Our experience showed that complete renal embolization was feasible in pediatric patients with results comparable to those obtained in adults.

MATERIALS AND METHODS

Twelve pediatric patients underwent 14 renal embolizations. The indications for embolization were as follows: (1) severe hypertension in 7 patients with end-stage renal failure; in these cases, a unilateral native nephrectomy was recommended prior to renal transplantation; (2) end-stage hydronephrosis in 3 patients with moderate hypertension or recurrent urinary infection; (3) nephrotic syndrome in 1 patient; or (4) ablation of an irreversibly rejected renal allograft in 1 patient. The embolization was performed under epidural anesthesia in 10 patients and under general anesthesia in 2 patients, by means of a polyvinyl alcohol injection with hemostatic gelatin powder and placement of coils. Postembolization course was followed.

RESULTS

The embolization was successful in all 12 patients. In 1 patient, the procedure had to be repeated as a small accessory artery had revascularized the upper pole. In another patient, the procedure was bilateral in 2 separate sessions. In 10 patients, severe flank pain required narcotic analgesia. Two patients had fever. None had hypertension peaks. Median hospital stay was 4 days. At mean follow-up of 16 months, the results were stable.

CONCLUSION

Renal embolization can avoid surgical nephrectomy also in pediatric patients. The advantages are less morbidity and shorter hospital stay. Our results in the short and medium term were equal to those of surgical removal. The procedure appeared to be safe and minimally invasive.

Palliative transarterial embolization of renal tumors in 20 patients

OBJECTIVES

The aim of this study is to evaluate immediate technical and clinical results of palliative transarterial renal embolization in patients with symptomatic renal tumors.

METHODS

Parenchymal embolization of 20 renal tumors was performed in 20 symptomatic patients with hematuria and/or lumbar pain and/or para-neoplastic syndrome. Seven patients were inoperable because of poor general condition, and 15 patients had metastatic lesions.

RESULTS

Immediate technical success was observed, with post-infarction pain in all patients requiring analgesia in 12 cases (which was successful in 90%); 8 patients had transitory fever. With a median follow up of 8.1 (range 4-27) months, recurrent hematuria was noted in two patients for which partial embolization was initially chosen; pain did not recur in any patients.

CONCLUSIONS

Palliative embolization of advanced symptomatic renal tumors is easy to accomplish with low morbidity. It helps to alleviate invalidating symptoms in a multidisciplinary management of advanced renal tumors.

Renal artery embolization: clinical indications and experience from over 100 cases

OBJECTIVE

To review current indications and techniques for renal artery embolization (RAE) and more specifically to review cases of RAE before nephrectomy for treating patients with a large renal mass.

PATIENTS AND METHODS

All RAEs done at our institution between May 1993 and December 2005 were reviewed. Patients were identified using a database assembled by the Division of Cardiovascular Interventional Radiology. Indications, techniques and RAE-related complications were then obtained from a retrospective review of medical records. Additional data for patients undergoing preoperative infarction were acquired, including estimated blood loss (EBL), transfusion requirement, pathological size, subtype, grade, stage, and level of tumour thrombus if present.

RESULTS

In all, there were 121 RAEs, 69 in males and 52 in females (mean age 57.6 years, range 11-89). Metallic microcoils were the most often used embolization agent, followed by acrylic microspheres (embospheres), polyvinyl alcohol particles, absolute ethanol, and Gelfoam (Pharmacia & Upjohn, USA). The most common indication for RAE was infarction before nephrectomy (54.5%). Other indications included symptomatic angiomyolipomas, palliation of unresectable renal cancer, haemorrhage, perinephric bleeding in end-stage renal disease, vascular lesions, malignant hypertension, and sequelae of end-stage renal disease. RAE-associated complications including coil migration, incomplete embolization, and groin haematoma (in 5.0%). Symptoms of post-infarction syndrome were common, with 74.4% of patients having flank pain, nausea, or vomiting; the vast majority of these symptoms were mild and self-limited. In patients having nephrectomy after RAE the median (range) interval from RAE was 2 (0-78) days. The mean tumour size was 11.2 (3.5-25) cm and 46% of patients had tumour thrombus present in either the renal vein or inferior vena cava (IVC). The mean (median) overall EBL in patients having nephrectomy after RAE was 1048 (725) mL. The mean transfusion requirement over the course of hospitalization was 3.9 units of packed red blood cells.

CONCLUSIONS

RAE is a safe and effective therapeutic tool for many urological, renal and vascular conditions. Its use has increased at our institution due to improved techniques, embolization materials, and our increasing use of RAE as an adjuvant procedure for patients requiring nephrectomy with or without IVC thrombectomy. There are many potential operative advantages for patients having RAE before surgery, with minimal morbidity. It is likely that the lack of prospective randomized trials is the primary reason why it is underutilized in the preoperative setting.

Metastatic Prostate Cancer—Does Treatment of the Primary Tumor Matter?

PURPOSE

In recent years there has been increased interest in adjuvant therapy for prostate cancer. This trend has engendered a tendency toward overlooking the issue of therapy to the primary tumor in advanced disease. We reviewed the effect of treating the principal disease bulk on overall treatment outcome in patients with advanced and metastatic cancer. Specifically we evaluated the role of surgical tumor cytoreduction.

MATERIALS AND METHODS

We performed a comprehensive literature review to evaluate the role of surgical debulking on the outcome of advanced cancer, including any published evidence supporting a benefit of this therapy for prostate cancer.

RESULTS

Even in cancers for which adjuvant chemotherapy and radiation are used liberally there is a clear benefit to optimal surgical debulking for local control and survival. The beneficial role of maximal surgical cytoreduction has been clearly demonstrated in advanced ovarian cancer and gastrointestinal carcinomatosis. Maximal debulking of brain, liver and lung metastasis has translated into longer survival. Removal of the primary tumor has been proved to increase survival in randomized trials of metastatic renal cell cancer. It appears that patients with node positive and possibly metastatic prostate cancer have a better response to androgen ablation with surgical removal of the gland.

CONCLUSIONS

Surgical cytoreduction of cancer results in a more favorable and durable response to systemic therapy. It is reasonable to explore aggressive surgical therapy for advanced prostate cancer.

Surgery for metastatic renal cell cancer

Renal cell carcinoma (RCC) often presents in its metastatic form, or progresses after curative treatment. While the management of metastatic RCC has historically been mainly surgical, contemporary approaches often incorporate systemic immunotherapy. This review examines the current indications and scope of surgical treatment of patients with metastatic RCC. Surgery is sometimes indicated for symptom palliation at either the primary or secondary sites. However, other less invasive therapies may be equally effective, and should be considered carefully. Cytoreductive surgery prior to immunotherapy appears to confer a survival advantage, but only selected patients are suitable for this treatment regimen. Primary immunotherapy followed by surgical removal of the tumour in partial responders is an alternative treatment strategy, which has not yet been evaluated as in randomized trials. As immunotherapy develops further, the precise timing and role of surgery in multimodality treatment will need to be carefully evaluated. Occasionally, the complete surgical excision of metastases, and the primary tumour, if present, is feasible and this may prolong survival. Empirically, it would seem that such patients should also be treated with adjuvant immunotherapy, as eventual relapse is frequent. Surgery with the aim of inducing spontaneous tumour regression is not justifiable, given the rarity of this phenomenon.

Nephrectomy in metastatic renal cell carcinoma

Patients presenting with metastatic renal cell carcinoma (RCC) face a dismal prognosis, with a median survival time of only 6 to 12 months and a 2-year survival rate of 10% to 20%. RCC is notoriously chemorefractory, and immunotherapy is associated with total response rates of less than 20% and complete response rates of less than 5%. Therefore, surgery has continued to play a prominent role in the management of patients with metastatic RCC. Recent randomized prospective trials suggest a survival advantage for cytoreductive nephrectomy, and some patients with advanced RCC may also achieve palliation. Patients with limited and resectable metastases should be considered for combined nephrectomy and metastasectomy. The other main option for patients with advanced RCC is systemic immunotherapy followed by assessment for surgical consolidation, but responses in the primary tumor are uncommon and results with this pathway have not been encouraging. Tumor embolization can be a valuable palliative adjunct for some patients with metastatic RCC. Cytoreductive nephrectomy represents the most aggressive pathway for patients with metastatic RCC. Although cytoreductive nephrectomy can extend survival by approximately 50% for many patients, it can be associated with morbidity and delay in administration of systemic therapy. Therefore, patient selection, taking into account performance status and sites and burden of disease, which are well-established prognostic factors for patients with metastatic RCC, is of paramount importance in managing this challenging group of patients.

The role of transarterial embolization in the treatment of renal cell carcinoma

OBJECTIVE

To review the role of transarterial renal embolization in our unit, assessing the indications, tolerability and efficacy of this technique for treating renal cell carcinoma (RCC).

PATIENTS AND METHODS

Thirty patients undergoing transarterial embolization between 1991 and 1999 were identified and 25 case notes analysed retrospectively.

RESULTS

Most patients (14 of 25) presented with less advanced (stage I-III) RCC who were unable or unwilling to undergo radical surgery; the remainder (11) presented with advanced (stage IV) disease. The embolizing agent was ethanol, usually combined with stainless steel coils (85% of cases). Procedural pain and fever was controlled successfully. The median hospital stay associated with the procedure was 4 days. At the time of analysis six of 11 stage IV and 11 of 14 stage I-III patients were alive (median follow-up 27 and 39 months, respectively). Symptoms from the primary tumour were well controlled. Overall, 17 of 25 (68%) of patients reported no problems while three (12%) required brief hospital admission for treatment of persistent haematuria. Fourteen patients were subsequently re-staged; the primary tumour in two had increased, in seven remained unchanged and in five it decreased. No patients without metastases developed them and metastases in two patients regressed.

CONCLUSION

Transarterial embolization is associated with minimal morbidity and complications, and subsequent symptom control is good. The effect of palliative embolization on RCC progression is unknown and requires prospective investigation. Presently, there is no role for cytoreductive embolization; it should be included as a treatment option in clinical trials evaluating such options in patients with metastatic RCC.

The role of resection for patients with renal carcinoma

Metastatic renal cancer is responsive in some cases to immunotherapeutic agents. Indications for nephrectomy in the face of metastatic disease have traditionally included palliation of symptoms caused by the primary tumor, and nephrectomy combined with metastatectomy in patients with resectable metastases. Recent findings from a Southwest Oncology Group trial strongly suggest that cytoreductive nephrectomy, combined with immunotherapy, may also result in improved survival in patients with unresectable metastases.

Prognostic evaluation of transcatheter arterial embolization for unresectable renal cell carcinoma with distant metastasis

OBJECTIVE

To evaluate the efficacy of transcatheter arterial embolization (TAE) in patients with unresectable renal cell carcinoma (RCC) and distant metastasis at the time of diagnosis.

PATIENTS AND METHODS

The study included 54 patients with histologically defined RCC (by biopsy in 28 and autopsy in 26) who were unable to undergo nephrectomy mainly because their performance status was poor (score > or = 2). The patients were classified into two groups; 24 patients who underwent TAE with ethanol and 30 patients who did not. The two groups were compared for several clinical factors, mainly focusing on the prognosis.

RESULTS

There were no significant differences in the clinical factors, including performance status, tumour diameter, vascular invasion, lymph node involvement, adjuvant therapy, metastatic organs or the number of metastases between the groups. However, the proportion of patients with para-neoplastic signs in those undergoing TAE was greater than that in those not, and the difference was significant (chi squared 0.35, P < 0.05). The median survival of the two groups was 229 days (TAE) and 116 days (no TAE). The 1-, 2- and 3-year survival rates in the TAE group were 29%, 15% and 10%, respectively, and in those not undergoing TAE were 13%, 7% and 3%, respectively. Those undergoing TAE had a significantly better prognosis than those who did not (P = 0.019). The adverse effects in patients undergoing TAE with ethanol included fever, back pain on the affected side, nausea and vomiting, but all the patients recovered from these adverse effects.

CONCLUSION

TAE with ethanol is a safe and effective treatment for patients with unresectable disseminated RCC and a poor performance status; TAE with ethanol not only induces ablation of the primary tumour, but also prolongs survival.

Renal cell carcinoma

Renal cell carcinoma (RCC) is characterized by (a) lack of early warning signs, which results in a high proportion of patients with metastases at the time of diagnosis; (b) protean clinical manifestations; and (c) resistance to radiotherapy and chemotherapy. The estimates of new diagnoses and deaths from kidney cancer in the United States during 1996 are 30,600 and 12,000, respectively. RCC occurs nearly twice as often in men as in women. The age at diagnosis is generally older than 40 years; the median age is in the midsixties. The incidence of RCC has been rising steadily. Between 1974 and 1990, there was a 38% increase in the number of patients who had a diagnosis of RCC. This increase was accompanied by a significant improvement in 5-year survival. Both trends are likely the result of improved diagnostic capability. Newer radiographic techniques, including ultrasonography, computed tomography, and magnetic resonance imaging, are detecting kidney tumors more frequently and at a lower disease stage, when tumors can be resected for cure. Surgical treatment is the only curative therapy for localized RCC. Radical nephrectomy remains the mainstay of surgical management, but techniques are being modified. These modifications include partial nephrectomy and resection of vena caval thrombi. In highly selected cases, surgical resection of locally recurrent RCC or of disease at a solitary metastatic site is associated with long-term survival. Metastatic RCC is highly resistant to the many systemic therapies that have been extensively investigated. A minority of patients achieve complete or partial response to interferon, interleukin-2, or both. Response can be dramatic but is rarely durable. Because most patients do not achieve response, these agents are not considered effective treatments for RCC, but the response in some patients indicates the need for continued research on their use. Identification of new agents with better antitumor activity against metastases remains a high priority in clinical investigation of therapy for this refractory disease.

Transcatheter arterial embolization of unresectable renal cell carcinoma with a mixture of ethanol and iodized oil

PURPOSE

The effectiveness of renal transcatheter arterial embolization (TAE) with a mixture of ethanol and iodized oil (Lipiodol) was analyzed retrospectively in 27 patients with unresectable renal cell carcinoma.

METHODS

Symptomatic or permanent palliation by TAE was performed with the intent to achieve total or partial ablation of the kidney with 10-28 ml of embolic material in a 3:1 mixture of ethanol and iodized oil. Clinical, angiographic, and computed tomographic (CT) follow-up were analyzed. Cumulative survival was estimated with the Kaplan-Meier method.

RESULTS

Partial (5) or complete (22) ablation of the embolized kidneys was achieved in all cases. Follow-up CT after 1 month revealed Lipiodol uptake in the tumor area (14/14), decreased size of the tumor (6/14), and gas formation (7/14). Pulmonary metastasis improved significantly in one patient after transcatheter arterial embolization and adjunctive chemotherapy. Overall median survival of the 27 patients was 8.5 months. The median survival was 23 months in 10 patients with stage III, three of whom are still alive, and was 7 months in 15 patients with stage IV tumors.

CONCLUSION

The mixture of ethanol and Lipiodol is not only a convenient embolic material to use, but is also effective for selective or nonselective devascularization for unresectable renal cell carcinoma.

Combined chemo-immuno-hormonotherapy of advanced renal cell carcinoma

Thirty-five patients (pts.) with advanced renal cell carcinoma were treated with a combination of vinblastine (5 mg/m2/IV) plus epirubicin (50 mg/m2/IV) every 3-4 weeks, alpha-2-A-interferon (9 x 10(6) U/IM 3 times in the 1st week, then 18 x 10(6) U/IM 3 times weekly), and medroxyprogesterone acetate (2,000 mg/os/day plus 500 mg IM/week). Thirty-one patients were males and 4 were females with a median age of 63 years (range 35-75) and median performance status of 70% (range 50-90%). We observed nine partial remissions (26%) with median duration of 40 weeks (range 20-232+). Fifteen pts. had no change (43%) while 11 pts. progressed (31%). The main side-effects were: leukopenia (29/35, 83%) with median nadir of 3,100 WBC/mm3 (range 510-3,990) and fever (32/35, 91%). Thrombocytopenia occurred in 4 pts. (11%), anemia in 5 (14%), asthenia in 12 (34%), nausea/vomiting in 12 (34%), alopecia in 8 (23%) and stomatitis in 3 (8.5%). Two patients stopped the therapy with medroxyprogesterone acetate because of muscular cramps. Median survival was 65 weeks (range 6-327+). We conclude that the combination of recombinant alpha 2A-interferon-vinblastine-epirubicin and medroxyprogesterone acetate has modest but definitive activity in patients with advanced renal cell carcinoma.

Progestogens: an occasional review

Progestogens are drugs which share the ability to stimulate the progesterone receptor, but differ in many other aspects. Some of their uses include the regulation of menstrual bleeding, protection of oestrogen-primed endometrium, contraception and as anticancer therapy. However, progesterone physical and psychological side-effects and potentially adverse metabolic effects including lipoprotein changes must be considered. An understanding of these differences will permit appropriate prescribing of these drugs for gynaecological and medical disorders.

Arterial embolization in patients with renal carcinoma

The literature concerning embolization of the renal artery in patients with renal cell carcinoma is reviewed. Based on this review it is concluded that the method is useful in this patient group as it will facilitate the surgical procedure if nephrectomy is performed afterwards. Used as a palliative method, embolization reduces haematuria. It was not possible to draw conclusions concerning survival rates or eventual immuno-stimulating effects of embolization.

Management of primary and metastatic renal cell carcinoma by transcatheter embolization with iodine 125

The long-term results of the management of metastatic renal cell carcinoma by a radioactive interstitial implant seated by a transcatheter embolization technique were evaluated in 85 patients at risk at 2 years and 37 at 5 years. The 2-year survival rate was 33% and the 5-year survival rate was 32%. Patients with isolated skeletal metastases showed the best survival rate (2-year survival rate, 69%; 5-year survival rate, 60%). Isolated pulmonary, other parenchymal, and central nervous system (CNS) metastases showed a lower 2-year survival rate of 15%. Regardless of the site of metastases and the size of the primary, histologic grade appeared to have a substantial impact on the survival of our patients. The beneficial results of interstitial radiation therapy are attributed to reduction of tumor burden and possibly the stimulation of the host immune response that may initiate remission. The noticeably better results in patients with osseous metastases are attributed to the resolute treatment of all osseous metastases by additional interstitial iodine 125 (125I) infarct implants. Conversely, the poor results in patients with CNS and other parenchymal metastases may be based on the inability to treat such metastases with 125I interstitial infarct implants. In addition to clinical observations of weight gain and the cessation of pain and hematuria if present, remissions are heralded by normalization of the erythrocyte sedimentation rate, disappearance of tumor markers if present, and rise of beta interferon levels. The technique is advocated for the management of inoperable renal cell carcinoma with distant metastases.

Renal artery embolization in the palliative treatment of renal adenocarcinoma

Renal artery embolization without subsequent nephrectomy was used to treat renal adenocarcinoma in 25 patients. The tumour had metastasized in 15 cases, and was locally advanced in six cases and localized in four. The aim was palliation of local symptoms in 20 cases. It was achieved in 11 of 14 patients with gross haematuria and in three of six with severe local pain. No prolongation of survival time was evident, and all the patients died of renal adenocarcinoma within 38 months. Regression of metastases was not seen. In one patient, embolization with absolute ethanol was followed by infarction of the left colon and death.