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Wang X, Qian L, Qian Z, Wu Q, Cheng D, Wei J, Song L, Huang S, Chen X, Wang P, Weng G. Therapeutic options for different metastatic sites arising from renal cell carcinoma: A review. Medicine (Baltimore) 2024; 103:e38268. [PMID: 38788027 PMCID: PMC11124732 DOI: 10.1097/md.0000000000038268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Renal cell carcinoma (RCC) stands among the top 10 malignant neoplasms with the highest fatality rates. It exhibits pronounced heterogeneity and robust metastatic behavior. Patients with RCC may present with solitary or multiple metastatic lesions at various anatomical sites, and their prognoses are contingent upon the site of metastasis. When deliberating the optimal therapeutic approach for a patient, thorough evaluation of significant risk factors such as the feasibility of complete resection, the presence of oligometastases, and the patient's functional and physical condition is imperative. Recognizing the nuanced differences in RCC metastasis to distinct organs proves advantageous in contemplating potential treatment modalities aimed at optimizing survival outcomes. Moreover, discerning the metastatic site holds promise for enhancing risk stratification in individuals with metastatic RCC. This review summarizes the recent data pertaining to the current status of different RCC metastatic sites and elucidates their role in informing clinical management strategies across diverse metastatic locales of RCC.
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Affiliation(s)
- Xue Wang
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
| | - Lin Qian
- Department of Urologic Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, China
| | - Zengxing Qian
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
| | - Qihang Wu
- Department of Clinical Laboratory, Ningbo Yinzhou No. 2 Hospital, Ningbo, China
| | - Dongying Cheng
- Department of community, Ningbo Yinzhou No. 3 Hospital, Ningbo, China
| | - Junjun Wei
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
| | - Lingmin Song
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
| | - Shuaihuai Huang
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
| | - Xiaodong Chen
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
| | - Ping Wang
- Department of Clinical Laboratory, Ningbo Yinzhou No. 2 Hospital, Ningbo, China
| | - Guobin Weng
- Zhejiang Key Laboratory of Pathophysiology, Ningbo University, Ningbo, China
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Oza B, Frangou E, Smith B, Bryant H, Kaplan R, Choodari-Oskooei B, Powles T, Stewart GD, Albiges L, Bex A, Choueiri TK, Davis ID, Eisen T, Fielding A, Harrison D, McWhirter A, Mulhere S, Nathan P, Rini B, Ritchie A, Scovell S, Shakeshaft C, Stockler MR, Thorogood N, Parmar MKB, Larkin J, Meade A. RAMPART: A phase III multi-arm multi-stage trial of adjuvant checkpoint inhibitors in patients with resected primary renal cell carcinoma (RCC) at high or intermediate risk of relapse. Contemp Clin Trials 2021; 108:106482. [PMID: 34538402 PMCID: PMC8520913 DOI: 10.1016/j.cct.2021.106482] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND 20-60% of patients with initially locally advanced Renal Cell Carcinoma (RCC) develop metastatic disease despite optimal surgical excision. Adjuvant strategies have been tested in RCC including cytokines, radiotherapy, hormones and oral tyrosine-kinase inhibitors (TKIs), with limited success. The predominant global standard-of-care after nephrectomy remains active monitoring. Immune checkpoint inhibitors (ICIs) are effective in the treatment of metastatic RCC; RAMPART will investigate these agents in the adjuvant setting. METHODS/DESIGN RAMPART is an international, UK-led trial investigating the addition of ICIs after nephrectomy in patients with resected locally advanced RCC. RAMPART is a multi-arm multi-stage (MAMS) platform trial, upon which additional research questions may be addressed over time. The target population is patients with histologically proven resected locally advanced RCC (clear cell and non-clear cell histological subtypes), with no residual macroscopic disease, who are at high or intermediate risk of relapse (Leibovich score 3-11). Patients with fully resected synchronous ipsilateral adrenal metastases are included. Participants are randomly assigned (3,2:2) to Arm A - active monitoring (no placebo) for one year, Arm B - durvalumab (PD-L1 inhibitor) 4-weekly for one year; or Arm C - combination therapy with durvalumab 4-weekly for one year plus two doses of tremelimumab (CTLA-4 inhibitor) at day 1 of the first two 4-weekly cycles. The co-primary outcomes are disease-free-survival (DFS) and overall survival (OS). Secondary outcomes include safety, metastasis-free survival, RCC specific survival, quality of life, and patient and clinician preferences. Tumour tissue, plasma and urine are collected for molecular analysis (TransRAMPART). TRIAL REGISTRATION ISRCTN #: ISRCTN53348826, NCT #: NCT03288532, EUDRACT #: 2017-002329-39, CTA #: 20363/0380/001-0001, MREC #: 17/LO/1875, ClinicalTrials.gov Identifier: NCT03288532, RAMPART grant number: MC_UU_12023/25, TransRAMPART grant number: A28690 Cancer Research UK, RAMPART Protocol version 5.0.
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Affiliation(s)
- Bhavna Oza
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK.
| | - Eleni Frangou
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Ben Smith
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Hanna Bryant
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Rick Kaplan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Babak Choodari-Oskooei
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Tom Powles
- St Bartholomew's Hospital, W Smithfield, London EC1A 7B, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Laurence Albiges
- Institut Gustave Roussy, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Axel Bex
- Royal Free London NHS Foundation Trust UCL Division of Surgery and Interventional Science, Pond Street, London NW3 2QG; Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Toni K Choueiri
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, United States
| | - Ian D Davis
- Monash University Eastern Health Clinical School, Level 2, 5 Arnold Street, Box Hill, VIC 3128, Australia; Department of Medical Oncology, Eastern Health, Melbourne, Australia; ANZUP Cancer Trials Group, Sydney, Australia
| | - Tim Eisen
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus Hill's Road, Cambridge CB2 0QQ, UK
| | - Alison Fielding
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - David Harrison
- University of St Andrews, North Haugh, St Andrews KY16 9TF, UK
| | - Anita McWhirter
- Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, UK
| | - Salena Mulhere
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Paul Nathan
- Mount Vernon Cancer Centre, Rickmansworth Rd, Northwood HA6 2RN, UK
| | - Brian Rini
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, United States
| | - Alastair Ritchie
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Sarah Scovell
- St Bartholomew's Hospital, W Smithfield, London EC1A 7B, UK
| | - Clare Shakeshaft
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Martin R Stockler
- ANZUP Cancer Trials Group, Sydney, Australia; NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW 2006, Australia
| | - Nat Thorogood
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - James Larkin
- Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, UK
| | - Angela Meade
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
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Kalapara AA, Frydenberg M. The role of open radical nephrectomy in contemporary management of renal cell carcinoma. Transl Androl Urol 2020; 9:3123-3139. [PMID: 33457285 PMCID: PMC7807349 DOI: 10.21037/tau-19-327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.
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Affiliation(s)
| | - Mark Frydenberg
- Department of Surgery, Monash University, Melbourne, Australia.,Cabrini Institute, Cabrini Health, Melbourne, Australia
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Eich C, Giessing M. [Radical nephrectomy and partial nephrectomy]. Aktuelle Urol 2020; 51:441-449. [PMID: 32722827 DOI: 10.1055/a-1190-3102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Renal cell carcinoma is the 2nd most frequent urological malignancy in women and the third most frequent in men, with an age peak in the seventh decade of life. If detected early in a local non-metastatic stage, options for complete recovery are excellent. While two decades ago, even locally limited cancers of the kidney were cured by radical nephrectomy, treatment today mostly consists of local treatment for locally confined cancers. Guidelines today recommend local surgical excision (open or minimally-invasive) or - in selected cases - topical energy application (radio-frequency ablation, cryoablation). The surgeon's expertise is most important in the selection of the appropriate kind of surgery and different guidelines have slightly different recommendations.Treatment decisions should be made on an individual basis in due consideration of an individual's age and co-morbidities. This may lead to the recommendation that, due to low perioperative morbidity, even localised carcinomas should be treated by (minimally-invasive) radical nephrectomy instead of nephron-sparing surgery and, in other cases, a non-interventional, active surveillance strategy may be pursued without compromising the patient's life expectancy. For higher-grade renal cell carcinomas, there is usually an indication for radical nephrectomy, as long as no metastases are detected. This also applies to carcinomas with venous thrombi extending into the atrium of the heart. Complications in the treatment of renal carcinomas are usually rare and easily treatable in most cases.
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Affiliation(s)
| | - Markus Giessing
- Universitätsklinikum Düsseldorf, Klinik für Urologie, Düsseldorf
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Daza J, Beksac AT, Kannappan M, Chong J, Abaza R, Hemal A, Sfakianos JP, Badani KK. Identifying tumor-related risk factors for simultaneous adrenalectomy in patients with cT1-cT2 kidney cancer during robotic assisted laparoscopic radical nephrectomy. Minerva Urol Nephrol 2019; 73:72-77. [PMID: 31166101 DOI: 10.23736/s2724-6051.19.03440-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In some cases, preservation of adrenal gland could be at risk in patients with cT1 and cT2 RCC. The aim of this study was to evaluate tumor-related factors that can potentially increase the risk of simultaneous adrenalectomy during robotic-assisted laparoscopic radical nephrectomy (RALRN) in patients with cT1-cT2 disease and the impact of performing such procedure on recurrence-free survival (RFS) and complication rates. METHODS We used a multi-institutional kidney cancer database where we identified patients who underwent RALRN with or without adrenalectomy. We evaluated the tumor-related characteristics that could potentially increase the risk of adrenal gland resection of these patients. We also reported RFS at 12-24 months of follow-up, which was compared with an inverse probability of treatment weighted (IPTW) multivariable cox proportional hazards regression model and postoperative complications, which was compared with an IPTW multivariable logistic regression model. RESULTS Tumor size, cT stage, pT stage, histologic subtype, sarcomatoid differentiation, BMI, lymph node involvement, metastatic disease, Fuhrman grade do not increase the risk of simultaneous adrenalectomy during RALRN. Moreover, RALRN with adrenalectomy had no significant benefit in RFS. No differences in post-operative complications were noted. CONCLUSIONS Our evaluated tumor-related characteristics did not show to impact the incidence of simultaneous adrenalectomy. Adrenal gland resection T does not provide significant benefit in recurrence-free survival. We consider that RALRN with adrenalectomy should be reserved only for patients with adrenal compromise as stated previously regardless that it has shown to be a safe procedure.
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Affiliation(s)
- Jorge Daza
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA -
| | - Alp Tuna Beksac
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muthumeena Kannappan
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Julio Chong
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronney Abaza
- Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Columbus, OH, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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7
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Klatte T, Shariat SF, Briganti A, Giannarini G, Catto JW. Adrenal Lesions: Progress on All Fronts. Eur Urol Focus 2016; 1:215-216. [PMID: 28723389 DOI: 10.1016/j.euf.2015.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/01/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Tobias Klatte
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Alberto Briganti
- Department of Urology, Urological Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - Gianluca Giannarini
- Urology Unit, Academic Medical Centre Hospital "Santa Maria della Misericordia," Udine, Italy
| | - James W Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
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