Cytoreductive nephrectomy for metastatic renal cell carcinoma with nonclear cell histology

The Evolving Landscape of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma

The role of cytoreductive nephrectomy in metastatic renal cell carcinoma (RCC) has been studied intensively over the past few decades. Interestingly, the opinion with regard to the importance of this procedure has switched from a recommendation as a standard of care to an almost complete refutation. However, no definitive agreement on cytoreductive nephrectomy, including the pros and cons of the procedure, has been reached, and the topic remains highly controversial. With the advent of immune checkpoint inhibitors, we have experienced a paradigm shift, with immunotherapy playing a crucial role in the treatment algorithm. Nevertheless, obtaining results from prospective clinical trials on the role of cytoreductive nephrectomy requires time, and once some data have been gathered, the standards of systemic therapy may be different, and we stand again at the beginning. This review summarizes current knowledge on the topic in the light of newly evolving treatment strategies. The crucial point is to recognize who could be an appropriate candidate for immediate cytoreductive surgery that may facilitate the effect of systemic therapy through tumor debulking, or who might benefit from deferred cytoreduction in the setting of an objective response of the tumor. The role of prognostic factors in management decisions as well as the technical details associated with performing the procedure from a urological perspective are discussed. Ongoing clinical trials that may bring new evidence for transforming therapeutic paradigms are listed.

The Role of Cytoreductive Nephrectomy in Renal Cell Carcinoma with Sarcomatoid Histology: A Case Series and Review of the Literature

Background: Renal cell carcinoma with sarcomatoid dedifferentiation represents a rare histological entity characterized by aggressive behavior, limited efficacy of tyrosine kinase inhibitors or mTOR inhibitors, and poor outcome. The immune checkpoint inhibitor therapy regimen combining ipilimumab with nivolumab represents a new standard of care for this patient population due to a hitherto unprecedented response rate and overall survival. On the other hand, the role of cytoreductive nephrectomy in metastatic renal cell carcinoma, in particular, with sarcomatoid histology, remains controversial. Patient and Methods: In the present case series, we report six patients with locally advanced or synchronous metastatic sarcomatoid renal cell carcinoma and intermediate or poor International Metastatic RCC Database Consortium (IMDC) risk score, five of whom were successfully subjected to cytoreductive nephrectomy. Results: All six patients received the combination regimen of ipilimumab with nivolumab. Five of these patients underwent upfront cytoreductive nephrectomy followed by systemic treatment without any significant delay, with a durable treatment outcome. Notably, two patients with poor prognostic features achieved a long-term major partial response to therapy. We also performed a review of the literature on optimal treatment strategies for patients with sarcomatoid renal cell carcinoma. Conclusion: Herein, we highlight the feasibility of performing cytoreductive nephrectomy in patients with intermediate/poor prognosis metastatic renal cell carcinoma with sarcomatoid dedifferentiation followed by immunotherapy with ipilimumab and nivolumab. To enhance the chances of immunotherapy success, cytoreductive nephrectomy should also be considered for patients presenting with a disease with adverse prognostic parameters.

Surgical Insights for the Management of Variant Histology in Renal Cell Carcinoma

PURPOSE

To review the current literature regarding variant (non-clear) histology of renal cell carcinoma (RCC) and the clinical management of these renal tumors.

MATERIAL AND METHODS

A PubMed database search was performed in May 2020 focusing on variant RCC, its diagnosis and associated syndromes, tumor characteristics, and options for management.

RESULTS

A broad range of pathological, clinical and diagnostic characteristics amongst non-ccRCC variants were found to have an impact on the overall management of these tumors. The imaging modalities, frequency of surveillance, and timing for intervention were found to be dependent on the type of genetic alterations, type of histology, and tumor growth rates. The timing and type of surgery as well as the systemic therapy are tailored to the specific tumor type and patient.

CONCLUSION

The findings of this review suggest that clinical management should be considered and adjusted for patients with non-ccRCC histological variants based on tumor subtype and genetic alterations.

Dissecting Outcomes: Should Cytoreductive Nephrectomy Be Performed for Patients With Metastatic Renal Cell Carcinoma With Sarcomatoid Dedifferentiation?

Background

It is highly contested whether cytoreductive nephrectomy for treating advanced renal cell carcinoma (RCC) with sarcomatoid features (sRCC) benefits overall survival. Patients with sRCC are known to have a poor prognosis, and these tumors have a more aggressive biology than those without sarcomatoid features.

Methods

Patients with clear cell RCC or non–clear cell RCC underwent cytoreductive nephrectomy in efforts to improve overall survival (OS). Patients were stratified by presence or absence of histologic sarcomatoid features within tumor samples.

Results

Of 167 patients who underwent cytoreductive nephrectomy, 127 had clear cell RCC, of whom 14 had sarcomatoid features, and 40 had non–clear cell RCC, of whom 13 had sarcomatoid features. Median age of the cohort was 62 years (range, 56.5–69 years). The cohort included 119 male (71.3%) and 48 (28.7%) female patients. Among all patients with advanced RCC, having sRCC had a significantly worse OS after cytoreductive nephrectomy (30 vs 8 months; hazard ratio [HR], 2.88; P <0.0001). Additionally, favorable-risk patients had significantly longer OS compared to intermediate- or poor-risk patients (56 vs 30 vs 10 months; HR, 0.21; P =0.00016). For patients with clear cell RCC, having sRCC conferred a significantly poorer survival (30 vs 9 months; HR, 2.82; P=0.0035). Patients with non–clear cell sRCC also had significantly worse outcomes compared to patients whose tumors did not have sarcomatoid features (30 vs 6.5 months; HR, 3; P =0.009). When patients with sRCC were stratified by whether there was >10% or ≤10% sarcomatoid features present within the sample, there was no significant difference in OS (8 vs 8.5 months; P =0.32).

Conclusions

Sarcomatoid features within tumor histology confer significantly poor prognosis. Patients with sRCC, regardless of clear cell vs non–clear cell histology, have significantly shorter OS. Even among patients with 10% or less sarcomatoid features, there was no OS benefit to cytoreductive nephrectomy. Based on our findings, there appears to be a limited to no role of cytoreductive nephrectomy if sRCC is identified on pretreatment biopsy. The role of radiomics and pre-operative biopsies may confer significant benefit in this patient population.

Imaging guided percutaneous renal biopsy: do it or not?

Since its first reported application, renal biopsy became an important part of the diagnostic algorithm, considered advantages and risks, to better manage therapeutic options. The biopsy can be performed with different techniques (open, laparoscopic, transjugular, transurethral and percutaneous). Currently, the percutaneous approach is the modality of choice. Percutaneous biopsy can be performed under CT or US guidance, but critical benefits and disadvantages have to be considered. Core needle biopsy is usually preferred to fine-needle aspiration because of the sample quality, usually obtaining multiple cores, especially in heterogeneous tumors. Principal complications are hematuria (1-10%), perinephric hematoma (10-90%), pneumothorax (0,6%), clinically significant pain (1,2%).

Association Between Systemic Therapy and/or Cytoreductive Nephrectomy and Survival in Contemporary Metastatic Non-clear Cell Renal Cell Carcinoma Patients

BACKGROUND

Optimal management of metastatic non-clear cell renal cell carcinoma (non-ccmRCC) remains largely unknown.

OBJECTIVE

To test the effect of systemic therapy (ST) and/or cytoreductive nephrectomy (CNT) on overall mortality (OM) in patients with non-ccmRCC.

DESIGN, SETTING, AND PARTICIPANTS

Within the Surveillance, Epidemiology and End Results (SEER) registry (2006-2015), we identified patients with papillary, chromophobe, sarcomatoid, and collecting duct metastatic renal cell carcinoma (mRCC).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Temporal trends (estimated annual percentage change [EAPC]), Kaplan-Meier plots, and multivariable Cox regression models were used.

RESULTS AND LIMITATIONS

Of 1573 patients with non-ccmRCC, 22%, 25%, 25%, and 28% underwent no treatment, ST, CNT, and CNT with ST, respectively. Between 2006 and 2015, rates of CNT and the combination of CNT and ST decreased (EAPC: -6.3% and -3.2%, respectively). Conversely, rates of no treatment and ST increased over time (EAPC: 4.6% and 7.5%, respectively). In multivariable Cox regression models, relative to no treatment, ST (hazard ratio [HR]: 0.5; p < 0.001), CNT (HR: 0.4; p < 0.001), and CNT with ST (HR: 0.3; p < 0.001) were associated with lower OM. Histological subtypes were associated with OM, relative to papillary renal cell carcinoma (RCC): chromophobe (HR: 0.7; p < 0.01), sarcomatoid (HR: 2.1; p < 0.001), and collecting duct RCC (HR: 1.9; p < 0.001). Limitations include the impossibility to stratify patients according to mRCC risk groups.

CONCLUSIONS

Most non-ccmRCC patients are treated with a combination of CNT and ST or CNT alone or ST alone. The rates of ST alone are increasing. Conversely, the rates of combined CNT and ST and CNT alone are decreasing. These observed temporal patterns of treatment rates are counterintuitive with respect to associated OM benefits, where combination of CNT and ST, as well as CNT alone, resulted in the lowest absolute OM, relative to ST alone, or, even worse, no treatment.

PATIENT SUMMARY

We investigated the effect of treatment modalities on survival of patients with metastatic non-clear cell renal cell carcinoma. The combination of cytoreductive nephrectomy and systemic therapy confers greater benefit with respect to single treatments alone.

Clinicopathologic features associated with survival after cytoreductive nephrectomy for nonclear cell renal cell carcinoma

OBJECTIVES

To report the overall survival (OS) outcomes of patients with nonclear cell renal cell carcinoma (nccRCC) treated at our institution with a cytoreductive nephrectomy (CN) and better understand the clinical and pathological characteristics of the patients that respond best.

MATERIAL AND METHODS

We queried our prospectively maintained database for patients who underwent CN for nccRCC between 1989 and 2018. Histology was reviewed by an expert genitourinary pathologist, and nccRCC tumors were subdivided into papillary, unclassified, chromophobe, and other histology. Baseline clinicopathology, treatments, and survival outcomes were recorded. Preoperative hematological parameters including the neutrophil-to-lymphocyte ratio (NLR) were analyzed. Significant univariate predictors of OS were tested in a multivariate model.

RESULTS

There were 100 nccRCC patients treated with CN. Median age was 61 years (IQR: 48-69) and 65% were male. There were 79 patient deaths with a median OS of 13.7 months (10.8-27.2). Estimated 2- and 5-year survival was 40.1% and 12.2%, respectively. Median follow-up of survivors was 13 months (IQR: 3-30). On multivariate analysis, increasing NLR (hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.14-1.40, P < 0.001) and sarcomatoid features (HR 2.18; 95% CI 1.19-3.97, P = 0.014) conferred worse OS and the presence of papillary features were a favorable prognostic feature (HR 0.37; 95% CI 0.21-0.65, P < 0.001).

CONCLUSIONS

OS outcomes in patients with nccRCC who underwent a CN are consistently modest throughout the study period. Patients with papillary features and a lower preoperative NLR may be better candidates for a CN.

Reassessing the Role of Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma in 2019

Cytoreductive nephrectomy (CRN) has long been considered a standard of care in the management of mRCC. This is largely based on randomized trials in the era of interferon (IFN) that demonstrate an improvement in overall survival (OS). With the advent of targeted therapies, the role of CRN has been questioned and multiple retrospective analyses have shown a potential benefit, particularly in intermediate-risk disease. Two long-awaited prospective trials have been published in the past year that explore the role of CRN. The CARMENA trial randomly assigned patients to therapy with sunitinib with or without CRN, showing noninferiority of sunitinib alone versus sunitinib plus CRN with a median OS of 18.4 months versus 13.9 months, respectively (hazard ratio [HR] for mortality, 0.89; 95% CI, 0.71-1.1). The SURTIME trial randomly assigned patients to immediate CRN followed by sunitinib versus a deferred CRN after three cycles of sunitinib. Analysis is limited by early termination as a result of low accrual. Although there was no difference in progression-free survival (PFS), median OS was significantly improved among patients in the deferred CRN arm (HR, 0.57; 95% CI, 0.34-0.95; p = .032). Early systemic therapy is paramount, but there are patients who may derive benefit by incorporating the removal of the primary tumor in their multimodal therapy, perhaps in a deferred setting. As systemic treatment paradigms shift and immunotherapy again moves to the frontline setting with the potential for novel therapeutic approaches, the role of CRN will continue to evolve with the potential to offer surgical interventions with minimal, if any, delay in systemic treatment.

Surgical Management of Advanced and Metastatic Renal Cell Carcinoma: A Multidisciplinary Approach

The past decade has seen a rapid proliferation in the number and types of systemic therapies available for renal cell carcinoma. However, surgery remains an integral component of the therapeutic armamentarium for advanced and metastatic kidney cancer. Cytoreductive surgery followed by adjuvant cytokine-based immunotherapy (predominantly high-dose interleukin 2) has largely given way to systemic-targeted therapies. Metastasectomy also has a role in carefully selected patients. Additionally, neoadjuvant systemic therapy may increase the feasibility of resecting the primary tumor, which may be beneficial for patients with locally advanced or metastatic disease. Several prospective trials examining the role of adjuvant therapy are underway. Lastly, the first immune checkpoint inhibitor was approved for metastatic renal cell carcinoma (mRCC) in 2015, providing a new treatment mechanism and new opportunities for combining systemic therapy with surgery. This review discusses current and historical literature regarding the surgical management of patients with advanced and mRCC and explores approaches for optimizing patient selection.

Collecting duct carcinoma of the kidney: Disease characteristics and treatment outcomes from the National Cancer Database

OBJECTIVE

To use a large population-level database to assess survival outcomes for collecting duct renal cell carcinoma (CDRCC).

MATERIALS AND METHODS

The National Cancer Database was queried for all cases of CDRCC and clear cell renal cell carcinoma (CCRCC) from 2004 to 2013. After removing patients with other cancer diagnoses, the analytic cohort was composed of 201,686 CCRCC and 577 CDRCC cases. Kaplan-Meier and cox proportional hazards analysis were employed to model survival.

RESULTS

Compared to CCRCC, patients with CDRCC presented with higher grade and stage, node positive, and metastatic disease (70.7% vs. 30.0% with metastasis; P<0.001). Overall median survival for CDRCC was 13.2 months (95% CI: 11.0-15.5) compared to the 122.5 months (95% CI: 121.0-123.9) for CCRCC. On multivariate analysis of the CDRCC cohort, increasing T stage, high-grade disease, and metastasis were predictors of mortality. Of 184 patients with metastatic CDRCC, 113 underwent cytoreductive nephrectomy (CNx) whereas the rest were treated with chemo/radiation or observed. Survival outcomes were improved in patients who received both CNx with chemo/radiation compared to CNx alone (hazard ratio = 0.51, 95% CI: 0.32-0.79) or chemo/radiation alone (hazard ratio = 0.57, 95% CI: 0.37-0.89) on multivariate analysis.

CONCLUSION

CDRCC is an aggressive subtype of renal cell carcinoma. Median survival is 13 months after diagnosis, drastically lower than for CCRCC. More than 70% of patients have metastatic disease at diagnosis. Chemo/radiation in addition to CNx is associated with a survival benefit over single mode therapy.

Percutaneous biopsy in large, locally advanced or metastatic renal tumors

INTRODUCTION

The role of percutaneous biopsy to characterize large, locally advanced and metastatic primary renal tumors has not been well described. The goal of this article is to describe the potential advantages of biopsy for preoperative evaluation of patients with large renal tumors and advanced disease.

METHODS

Literature was reviewed for percutaneous biopsy and for locally advanced and metastatic renal tumors.

RESULTS

Multiple studies have confirmed that percutaneous biopsy is safe, and the cost is minimal relative to the cost of surgical operation. Biopsy of large masses should obtain multiple core samples from several sites with tumors to decrease error from sampling heterogeneous tumors.

CONCLUSIONS

Potential advantages of biopsy for large renal masses include identification of patients for retroperitoneal lymph node dissection who may have occult lymph node metastasis. In patients with metastatic renal cell carcinoma, biopsy characterizes tumors for patients who may not benefit from cytoreductive surgical operation. The role of biopsy is likely to expand in the future with the development of advanced molecular tools for risk stratification.

Cytoreductive surgery in the era of targeted molecular therapy

Cytoreductive nephrectomy (CN) was regarded standard of care for patients with metastatic renal cell carcinoma (mRCC) in the immunotherapy era. With the advent of targeted molecular therapy (TMT) for the treatment of mRCC, the routine use of CN has been questioned. Up to date evidence continues to suggest that CN remains an integral part of treatment in appropriately selected patients. This review details the original context in which the efficacy of CN was established and rationale for the continued use of cytoreductive surgery in the era of TMT.

Surgical considerations for patients with metastatic renal cell carcinoma

Among patients with renal cell carcinoma (RCC), 25-30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials.

Metastatic non-clear cell renal cell carcinoma: an evidence based review of current treatment strategies

Much progress has been made in the treatment of metastatic renal cell carcinoma (RCC) over the last decade, with the development of agents that block the vascular endothelial growth factor (VEGF) pathway or the mammalian target of rapamycin (mTOR) pathway. The incorporation of these agents into treatment algorithms has been the result of carefully conducted clinical trials leading to Food and Drug Administration (FDA) approval and subsequent adoption as the current standard of care. These trials, however, were dominated by patients with clear cell renal cell carcinoma (ccRCC), and little data are currently available on the treatment of non-clear cell renal cell carcinoma (nccRCC). nccRCC encompasses a biologically heterogeneous group of kidney tumors that portend very diverse prognoses and responses to therapy. This review is a pathway based approach that highlights the current systemic treatment strategies for metastatic nccRCC.

[Radical cancer surgery of renal cell and prostate carcinoma with hematogenous metastasis: benefits]

The therapeutic role of cytoreductive surgery for urogenital malignancies is controversially discussed in the literature. The current article critically reflects the potential impact of cytoreductive surgery in patients with renal cell cancer and prostate cancer with locoregional lymph node or systemic metastases based on a review of the literature and personal experience.Even in the era of molecular targeted therapies in metastatic renal cell cancer, cytoreductive radical nephrectomy seems to exert survival benefit when compared to systemic therapy alone if (1) patients demonstrate a good ECOG performance status, (2) exhibit good or intermediate prognosis according to the Heng criteria, (3) cerebral metastases have been excluded, and (4) >90% of the total cancer volume can be eliminated. Preliminary clinical studies suggest that neoadjuvant systemic treatment might be associated with a significantly reduced 1-year mortality rate.For prostate cancer cytoreductive radical prostatectomy is one of the guideline-recommended treatment options for men with intrapelvic lymph node metastases resulting in survival benefit when compared to androgen deprivation as monotherapy. Cytoreductive radical prostatectomy should be performed (1) in the presence of limited intrapelvic lymph node metastasis without bulky disease, (2) if complete resectability of the primary cancer and its metastasis can be achieved by extended radical prostatectomy and extended pelvic lymphadenectomy, (3) if the patient is included in a multimodality approach, and (4) if the life expectancy is > 10 years.The role of cytoreductive radical prostatectomy in men with osseous metastases remains unclear due to the lack of large clinical trials. Despite the presence of the first promising studies, it is not justified to perform cytoreductive radical prostatectomy outside clinical trials. Preliminary results from small studies indicate that patients with minimal metastatic burden, PSA decrease < 1.0 ng/ml following neoadjuvant ADT for 6 months and complete resectability of the tumor exhibit the best prognosis to benefit from this new surgical approach.

Clinicopathologic characteristics and prognostic factors of sarcomatoid renal cell carcinoma

OBJECTIVES

We seek to summarize the clinicopathologic characteristics and prognostic factors of sarcomatoid renal cell carcinoma (SRCC), an uncommon type of renal cell carcinoma.

METHODS AND MATERIALS

Between 2004 and 2012, 23 patients with SRCC were treated at a large urology center in south central China. We collect patient's clinicopathologic features from medical records to assess diagnosis, prognostic factors and efficacy of systemic therapy. Clinical data were absent in 3 cases, and 20 patients were enrolled in the final study.

RESULTS

Immunohistochemically, almost all SRCC expressed cytokeratin (91%), epithelial membrane antigen (87%) and vimentin (100%). Sarcomatoid differentiation occurs in various kinds of subtypes of RCC with almost the same probability. The median tumor size was 10.5 cm. The CT findings of these tumors revealed low-density (n = 5; 25%) or mixed (n = 15; 75%) masses with necrotic areas and often showed an infiltrative morphology (n = 15; 75%). All 20 cases demonstrated heterogeneous enhancement, and eleven (55%) cases demonstrated >50% necrosis. Six cases complicated with calculus and hydronephrosis. Sixteen (80%) patients demonstrated invasions of tissues localized in Gerota's fascia, and 8 (40%) tumors invaded beyond Gerota's fascia. Fifteen (75%) patients demonstrated lymph node metastasis, and sixteen (80%) patients had distant metastasis. Five patients received systemic therapy, and one patient given high-dose interferon-α had a completely response, and one patient received chemotherapy based on gemcitabine had partial response. The median overall survival of all patients was 5.8 months. Patients without distant metastasis had a median overall survival of 35 months compared with 3 months of those with distant metastasis (P < 0.002). The percentage of the sarcomatoid components did not have an obvious influence to the prognosis (P = 0.197).

CONCLUSIONS

Heterogeneity, hugeness, infiltration and necrosis are typical image features of SRCC. The prognosis of SRCC is poor and clinic stage especially the existence of distant disease is the important factor influencing prognosis.

Surgical management of metastatic renal cell carcinoma in the era of targeted therapies

BACKGROUND

Cytoreductive nephrectomy (CN) has been considered standard management for patients with metastatic renal cell carcinoma (mRCC) for over a decade. This practice, based on evidence from the immunotherapy era, has now come into question with the dramatic shift in management of mRCC patients due to the development and approval of several targeted molecular therapies (TMT).

METHODS

A comprehensive English language literature review was performed using MEDLINE/PubMed to identify articles and guidelines pertinent to CN in mRCC.

RESULTS

Retrospective studies have demonstrated improved survival for patients who underwent CN compared to those that did not; however, these studies suffer from heavy selection bias. Furthermore, the optimal timing of TMT, before or after surgery is not known. Pre-surgical TMT has the advantage of early treatment of metastases, downsizing of the primary, and may be an effective 'litmus test' for the selection of patients for CN based on response to TMT. The results of two ongoing phase III trials (CARMENA and SURTIME) will address much of the controversy on the role of CN and the timing of systemic therapy in the TMT era. In this review, we aim to present the evidence that lead to adoption of CN in the era of immunotherapies as well as the available data about the oncologic benefit of CN in patients with mRCC who receive TMT as their primary systemic therapy.

CONCLUSION

There seems to be an important role for CN in the era of TMT, mostly in patients with favorable risk and where a high percentage of tumor burden can be removed by cytoreductive surgery.

MRI phenotype in renal cancer: is it clinically relevant?

Renal cell carcinoma (RCC) is most commonly diagnosed as an incidental finding on cross-sectional imaging and represents a significant clinical challenge. Although most patients have a surgically curable lesion at the time of diagnosis, the variability in the biologic behavior of the different histologic subtypes and tumor grade of RCC, together with the increasing array of management options, creates uncertainty for the optimal clinical approach to individual patients. State-of-the-art magnetic resonance imaging (MRI) provides a comprehensive assessment of renal lesions that includes multiple forms of tissue contrast as well as functional parameters, which in turn provides information that helps to address this dilemma. In this article, we review this evolving and increasingly comprehensive role of MRI in the detection, characterization, perioperative evaluation, and assessment of the treatment response of renal neoplasms. We emphasize the ability of the imaging "phenotype" of renal masses on MRI to help predict the histologic subtype, grade, and clinical behavior of RCC.

Cytoreductive nephrectomy in patients with metastatic non-clear-cell renal cell carcinoma (RCC)

OBJECTIVE

To determine whether patients with metastatic non-clear-cell renal cell carcinoma (RCC) benefit from cytoreductive nephrectomy (CN).

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) programme to identify a population-based sample of 4914 patients diagnosed with metastatic RCC between 2000 and 2009. Of the 4914 patients, 591 had non-clear-cell histology. The median follow-up was 20 months. The primary outcome measure was RCC-specific mortality.

RESULTS

Approximately 64% of patients underwent CN. Patients with non-clear-cell histology who underwent CN had lower RCC-specific and all-cause mortality than those who did not (P < 0.001 in both cases). After adjustment for age, gender, race, marital status, year of diagnosis, geographical location and histology, the associations between CN and lower RCC-specific mortality (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.48-0.80, P < 0.001) and between CN and all-cause mortality (HR 0.45, 95% CI 0.37-0.55, P < 0.001) remained highly significant. Among patients diagnosed between 2006 and 2009 (targeted therapy era), the results remained unchanged (HR 0.50, 95% CI 0.34-0.72, P < 0.001 and HR 0.43, 95% CI 0.31-0.59, P < 0.001, respectively). An interaction model found lower all-cause mortality for all histologies after CN.

CONCLUSIONS

Patients from the SEER programme with metastatic non-clear-cell RCC, including those treated in the targeted therapy era, appear to derive a survival benefit from CN, an association which remained significant regardless of histological subtype. This observation suggests that CN should remain standard in patients with advanced RCC who are deemed to be surgical candidates.

The impact of histology on survival for patients with metastatic renal cell carcinoma undergoing cytoreductive nephrectomy

OBJECTIVE

To evaluate the impact of histology on cancer-specific and overall survival for patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN).

MATERIALS AND METHODS

We retrospectively reviewed the data of 505 patients with mRCC who underwent CN at Mayo Clinic, Rochester, MN, USA, between 1970 and 2008. All specimen were re-reviewed by a single genitourinary pathologist. Survival was estimated using the Kaplan-Meier method and compared according to histology with the log-rank test. Cox proportional hazard regression models were used to evaluate the association of histology with outcome.

RESULTS

Forty (8%) patients with non-clear cell histology and 465 (92%) patients with clear cell histology were identified. The median follow-up was 7.8 years. Metastatic non-clear cell histology was associated with a significantly older median age at nephrectomy (66 vs. 60 years; P = 0.002), larger median tumor size (11.5 vs. 9.2 cm; P = 0.02), and higher rate of lymph node involvement (50% vs. 16%; P < 0.001). No significant difference in 3-year cancer-specific survival (25% vs. 22%; P = 0.50) was noted between patients with clear cell and non-clear cell histology. On multivariate analysis, non-clear cell histology was not significantly associated with patients' risk of death from cancer (HR 0.96; 95% CI 0.61, 1.51; P = 0.85).

CONCLUSIONS

Non-clear cell histology was not independently associated with adverse survival for patients with mRCC undergoing CN. As such, we advocate that surgical resection should continue to be considered in the multimodal treatment approach to these patients, while additional efforts to risk stratify and optimize management in this setting remain necessary.

The impact of histology on clinicopathologic outcomes for patients with renal cell carcinoma and venous tumor thrombus: a matched cohort analysis

OBJECTIVE

To evaluate the impact of tumor histology on clinicopathologic outcomes for patients with renal cell carcinoma (RCC) and venous tumor thrombus (VTT).

METHODS

We identified 807 patients with RCC and VTT who underwent nephrectomy at our institution between 1970 and 2008. All pathologic specimens were re-reviewed by a single urologic pathologist. Patients with non-clear cell RCC (non-ccRCC, n = 56) were matched 1:2 to patients with clear cell RCC (ccRCC) VTT based on symptoms at presentation, regional lymph node involvement, distant metastases, tumor thrombus level, nuclear grade, and sarcomatoid differentiation. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

The 56 patients with non-ccRCC VTT included 26 papillary, 11 chromophobe, 5 collecting duct tumors, and 14 RCCs not otherwise specified. Compared to unmatched patients with ccRCC VTT (n = 751), patients with non-ccRCC VTT presented with larger tumor size (P = .02), higher nuclear grade (P = .04), and more frequent sarcomatoid differentiation (P <.001) and lymph node invasion (P <.001). However, when patients with non-ccRCC were matched to patients with ccRCC, no significant differences were noted with regard to 5-year metastases-free survival (41% vs 34%, P = .24) or cancer-specific survival (25% vs 27%, P = .97).

CONCLUSION

Non-ccRCC VTT is associated with a high rate of adverse pathologic features. Nevertheless, when matched to patients with ccRCC, patients with non-ccRCC VTT did not have increased rate of recurrence or adverse survival. Aggressive surgical resection represents the mainstay of treatment in these cases, whereas continued efforts to optimize a multimodal management approach to such patients remain necessary.

Selecting patients for cytoreductive nephrectomy in advanced renal cell carcinoma: who and when

Renal cell carcinoma presents with metastatic disease in approximately 30% of patients at the time of diagnosis. Cytoreductive nephrectomy (CN) of the primary tumor in the face of metastatic disease is part of a multimodality approach including systemic therapy that is based on evidence from randomized trials in the cytokine era. Data from the pretargeted therapy era showed that CN had a clear role in metastatic renal cell carcinoma, increasing life expectancy by approximately 6 months. The substantial improvement in outcomes reported for targeted therapy has challenged the previous role of CN. However, despite the absence of data from Phase III trials, available evidence suggests that some patients may benefit substantially from CN in the era of targeted therapy. This review summarizes current arguments for CN and how to best select patients for surgery. Ongoing trials are key in generating evidence towards a personalized approach to debulking nephrectomy.

Type II papillary histology predicts poor outcome in patients with renal cell carcinoma and vena cava thrombus

What's known on the subject? and What does the study add? In patients with pRCC, the presence of venous tumour thrombus is known to be a predictor of poorer outcomes. However, a paucity of data is available regarding the prognostic significance of histology in patients with RCC and IVC thrombus. In our series, we found that patients with type II pRCC had significantly poorer outcomes when compared to those with cRCC. Although the lack of effective treatment for patients with metastatic pRCC may have contributed to these adverse outcomes, type II papillary histology was independent predictor not only of CSS but also of RFS.

OBJECTIVE

• To analyze the prognostic impact of papillary histology on oncological outcomes in patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus.

PATIENTS AND METHODS

• We reviewed the medical records of 74 patients who underwent radical nephrectomy and IVC thrombectomy between 1990 and 2010 for clear cell or papillary RCC. • We compared the clinicopathological features and clinical outcomes of 62 patients with clear cell RCC (cRCC) and 12 with papillary RCC (pRCC). • All cases of pRCC were subdivided into type I or type II. • The prognostic role of papillary histology on recurrence-free survival (RFS) and cancer-specific survival (CSS) was estimated using Cox's regression models.

RESULTS

• Upon reclassification of the pRCC subtype, all 12 patients with pRCC had type II tumours. • Patients with type II pRCC were significantly younger (P=0.028) and were more probably women (P=0.025) than those with cRCC • The 2- and 5-year CSS rates were 81.1% and 53.6% in cRCC patients, and 28.1% and 0% in type II pRCC patients, respectively. All eight patients with non-metastatic type II pRCC developed disease recurrence at a median interval of 6 months after surgery, whereas 25 of 44 (56.8%) patients with non-metastatic cRCC experienced such recurrence at a median interval of 10 months after surgery. • Patients with type II pRCC showed significantly lower CSS (P<0.001) and RFS (P=0.002) than those with cRCC. • On multivariate analysis, type II papillary histology was an independent predictor of CSS (hazard ratio, 3.73; P=0.003) and RFS (hazard ratio, 3.15; P=0.015).

CONCLUSIONS

• Type II papillary histology appears to be predominant in cases of pRCC with IVC thrombus. •  Patients with type II pRCC who presented with IVC thrombus had significantly worse outcomes than those with cRCC, and histology is an important prognostic factor in patients with RCC and IVC thrombus.

Characteristics and outcomes of tumors arising from the distal nephron

OBJECTIVE

To compare the characteristics and predictors of cancer-specific survival (CSS) of 2 rare distal nephron tumors--medullary renal cell carcinoma (MRCC) and collecting duct carcinoma (CDC).

METHODS

All cases of histologically verified MRCC and CDC reported to The Surveillance, Epidemiology and End Results (SEER) database between 1995 and 2007 were considered. A number of characteristics were compared by tumor histology. Subset analyses were performed for metastatic patients and those managed surgically. CSS was analyzed using Cox proportional hazard models.

RESULTS

Overall, 21 cases of MRCC and 227 cases of CDC met the criteria for analysis. Patients with MRCC were younger (median 24 vs 63 years, P < .001), more often black (71.4% vs 22.7%, P < .001), metastatic at presentation (71.4% vs 27.8%, P < .001), and less likely to undergo surgery (61.9% vs 85.6%, P = .015) compared with patients with CDC. Tumor size was similar between MRCC and CDC (median 6 vs 5 cm, P = .70). Median survival was 5 months for MRCC and 30 months for CDC (P < .001). In metastatic MRCC and CDC patients, surgery predicted CSS (HR 4.61 and 2.24, both P ≤.05) despite having larger primary tumors than those managed nonsurgically (median 7.5 vs 5.0 cm, P < .01).

CONCLUSION

Patients with MRCC present younger, at a later stage, and are more often black than patients with CDC. The stage migration toward localized kidney cancer is not apparent for these tumors. Although both cancers have a poor prognosis, the clinical and survival characteristics are distinct. Patients selected for cytoreductive surgery have improved survival.

Cytoreductive nephrectomy for pT3b-T4 M1 renal cell carcinoma in 39 patients: single center analysis

We reviewed cytoreductive nephrectomy for pT3b-T4 renal cell carcinoma with metastasis and evaluated the prognostic factors for cancer-specific survival. A total of 39 patients who underwent cytoreductive nephrectomy for renal cell carcinoma with pathological T3b-T4 (2009 Union for International Cancer Control consensus) from 1986 to 2011 in our hospital were the participants in this study. Prognostic factors for cancer-specific survival were analyzed. The median patient age was 64 years (range 31-84). Pathological T3b, T3c and T4 were found in 24 (61%), one (3%) and 14 (36%) patients, respectively. The distribution of the histological type was clear cell type in 34 (87%), papillary type in two (5%) and any type of renal cell carcinoma with a sarcomatoid component in three patients (8%). The median overall and cancer-specific survival was 7.5 and 7.6 months, respectively. Low-grade performance status, regional lymph node metastasis, higher pT stage and histological type were prognostic factors for cancer-specific survival on univariate analysis. On multivariate analysis, lymph node metastasis, higher pT stage and histological type (non-clear cell or sarcomatoid component) were significant predictors for cancer-specific survival. With cytoreductive nephrectomy for patients with pT4, lymph node metastasis and non-clear cell histology, we have to be particularly careful in terms of cancer control.

Limitations of preoperative biopsy in patients with metastatic renal cell carcinoma: comparison to surgical pathology in 405 cases

Study Type--Diagnostic (cohort) Level of Evidence: 2b. What's known on the subject? and What does the study add? Although there have been many investigations of biopsy for small renal masses, there are scant data on the accuracy of biopsy in the setting of metastatic renal cell carcinoma (mRCC). We report a large series of biopsies and compare with nephrectomy pathology in patients with mRCC. The present study highlights the inaccuracy of biopsy in the setting of metastatic disease, which is related to sampling error because of heterogeneity within the tumour and among metastases. These limitations are important to realize when designing trials that depend on pathological findings from biopsy and not nephrectomy. In addition, we found that biopsy of primary tumours were more likely than biopsy of metastatic sites to be diagnostic of RCC. Future studies with multiquadrant biopsies of primary tumours could yield the most accurate pathological results for future studies.

OBJECTIVE

• To evaluate the ability of preoperative biopsy to identify high-risk pathological features by comparing pathology from preoperative metastatic site and primary tumour biopsies with nephrectomy pathology in patients with metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

•  We reviewed clinical and pathological data from patients who underwent biopsy before cytoreductive nephrectomy for mRCC at MD Anderson Cancer Center (MDACC) from 1991 to 2007. • Percutaneous biopsy techniques included fine-needle aspiration, core needle biopsy or a combination of both techniques.

RESULTS

• The pathology of 405 preoperative biopsies (239 metastatic site, 166 primary tumour) from 378 patients was reviewed at MDACC before cytoreductive nephrectomy. • The biopsy and nephrectomy specimens had the same histological subtype in 96.0% of clear-cell renal cell carcinomas (RCCs) and 72.7% of non-clear-cell RCCs. • Of 76 nephrectomy specimens where sarcomatoid de-differentiation was identified, only seven (9.2%) were able to be identified from the preoperative biopsy. • In 38.3% of patients, the same Fuhrman grade was identified in both the biopsy and nephrectomy specimens. • A definitive diagnosis of RCC was more likely to be reported in primary tumour biopsies than in metastatic site biopsies. (P < 0.001).

CONCLUSIONS

• Preoperative biopsy has limited ability to identify non-clear-cell histological subtype, Fuhrman grade or sarcomatoid features. • When surgical pathology is not available, a biopsy obtaining multiple samples from different sites within the primary tumour should be recommended rather than limited metastatic site biopsy to identify patients for clinical trials.

Surgical management of large renal tumors

The surgical management of patients with renal cell carcinoma has undergone many changes. With equivalent oncologic outcomes and appreciation of the importance of renal functional preservation, the utilization of nephron-sparing partial nephrectomy has increased in recent years. Nevertheless, tumors of larger size continue to be preferentially treated with radical nephrectomy. Here, we present evidence that improvements in techniques and durability of oncologic outcomes has justified the use of nephron sparing to accomplish renal functional preservation even in patients with large renal tumors. In addition, surgical technical considerations when managing such tumors are discussed. Finally, we discuss cytoreductive surgery and the evolving role of systemic targeted therapies in the management of advanced metastatic disease.

The impact of cytoreductive nephrectomy on survival of patients with metastatic renal cell carcinoma receiving vascular endothelial growth factor targeted therapy

PURPOSE

Vascular endothelial growth factor targeted therapy is a standard of care in patients with metastatic renal cell carcinoma. The role of cytoreductive nephrectomy in the era of novel agents remains poorly defined.

MATERIALS AND METHODS

We retrospectively reviewed baseline characteristics and outcomes of 314 patients with anti-vascular endothelial growth factor therapy naïve, metastatic renal cell carcinoma from United States and Canadian cancer centers to study the impact of cytoreductive nephrectomy on overall survival.

RESULTS

Patients who underwent cytoreductive nephrectomy (201) were younger (p < 0.01), and more likely to have a better Karnofsky performance status (p < 0.01), more than 1 site of metastasis (p = 0.04) and lower corrected calcium levels (p < 0.01) compared to those who did not undergo cytoreductive nephrectomy (113). On univariable analysis cytoreductive nephrectomy was associated with a median overall survival of 19.8 months compared to 9.4 months for patients who did not undergo cytoreductive nephrectomy (HR 0.44; 95% CI 0.32, 0.59; p < 0.01). On multivariable analysis and adjusting for established prognostic risk factors the overall survival difference persisted (adjusted HR 0.68; 95% CI 0.46, 0.99; p = 0.04) in favor of the cytoreductive nephrectomy group. In subgroup analyses stratified for favorable/intermediate/poor risk criteria, patients in the poor risk group had a marginal benefit (p = 0.06). Similarly patients with Karnofsky performance status less than 80% also had a marginal survival benefit (p = 0.08).

CONCLUSIONS

In this retrospective study cytoreductive nephrectomy was independently associated with a prolonged overall survival of patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor targeted agents, although the benefit is marginal in those patients with poor risk features.

Percutaneous biopsy of primary tumor in metastatic renal cell carcinoma to predict high risk pathological features: comparison with nephrectomy assessment

PURPOSE

As treatment options evolve for metastatic renal cell carcinoma, there is a need for predictive information to help guide therapy. We assessed the accuracy of percutaneous primary tumor biopsy for metastatic renal cell carcinoma by comparing biopsy findings to final nephrectomy pathology in patients undergoing cytoreductive nephrectomy.

MATERIALS AND METHODS

Using an institutional database we reviewed the records of patients who underwent percutaneous primary tumor biopsy before cytoreductive nephrectomy. In patients who underwent biopsy elsewhere pathology findings were re-reviewed at our institution. Differences in accuracy based on biopsy technique, imaging modality and biopsy period were determined by chi-square analysis.

RESULTS

We identified 166 patients who underwent percutaneous biopsy of the primary tumor before cytoreductive nephrectomy between 1991 and 2007, and had data available for review. Median pathological tumor size was 9.1 cm (range 3 to 32). Median time from biopsy to surgery was 46 days (range 6 to 717). Of 104 patients in whom biopsy was assigned a Fuhrman nuclear grade 33 (31.7%) had the same grade in the nephrectomy specimen, including 74 of 109 (67.9%) when considering only high or low grade. Grade change by more than 2 points was seen in 18 of 104 patients (17.3%). Sarcomatoid features were present in 34 of 166 nephrectomy specimens (20.5%) but only 4 (11.8%) were identified preoperatively.

CONCLUSIONS

In patients with metastatic renal cell carcinoma percutaneous renal biopsy has poor accuracy to assess Fuhrman nuclear grade or sarcomatoid features. Physicians should use caution when using biopsy data to guide therapy.

Can we better select patients with metastatic renal cell carcinoma for cytoreductive nephrectomy?

BACKGROUND

The benefits of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) should outweigh surgical morbidity. Even when the generally agreed upon selection criteria for CN are met, some patients do poorly after surgery. The objective of this study was to identify preoperative factors that were prognostic of outcome in patients who were being considered for CN.

METHODS

The authors conducted a retrospective study to investigate the overall survival (OS) of patients who underwent CN using the OS of patients with mRCC who did not undergo CN as a referent group. Patients who underwent CN were divided into 2 groups based on when their OS diverged from that of nonsurgical patients. Chi-square analysis was used to identify variables that differed between the 2 surgical groups. Multivariate Cox proportional hazards regression was used to analyze those variables for the entire CN cohort. Risk factors were defined as preoperative variables that remained significant on multivariate analysis. The median OS and the overall risk of death were calculated based on the number of risk factors.

RESULTS

From 1991 to 2007, 566 patients who were eligible for or received systemic therapy underwent CN, and 110 patients received medical therapy alone. On multivariate analysis, independent preoperative predictors of inferior OS in surgical patients included a lactate dehydrogenase level greater than the upper limit of normal, an albumin level less than the lower limit of normal, symptoms at presentation caused by a metastatic site, liver metastasis, retroperitoneal adenopathy, supradiaphragmatic adenopathy, and clinical tumor classification>or=T3. Inferior OS and an increased risk of death were correlated positively with the number of risk factors. Surgical patients who had >or=4 risk factors did not appear to benefit from CN.

CONCLUSIONS

The authors of this report identified 7 preoperative variables that permitted them to identify patients who were unlikely to benefit from CN.

Targeted therapies for non-clear renal cell carcinoma

The treatment of advanced and metastatic kidney cancer has been revolutionized by the development of targeted systemic therapies. Despite the growing number of available agents approved for use against clear cell renal cell carcinoma, patients with non-clear histologies, constituting approximately 1 in 4 cases of kidney cancer, have not received the same attention. The majority of clinical trials testing novel targeted therapies have excluded non-clear subtypes, providing limited therapeutic options for patients with these diagnoses and their oncologists. This review will focus on the use of targeted therapies against the non-clear histologic subtypes of renal cell carcinoma: papillary I and II, chromophobe, and collecting duct. The unique genetic and molecular profiles of each distinct non-clear kidney cancer subtype will be described, as these differences are integral to the development and effectiveness of the novel agents used to treat them. Trials focusing on non-clear kidney cancer, or those that treated clear cell tumors along with significant numbers of non-clear subtypes, will be discussed. The role of cytoreductive nephrectomy and the use of neoadjuvant and adjuvant targeted therapy will be reviewed. Lastly, areas of future research will be highlighted.

Role of surgery in advanced/metastatic renal cell carcinoma

Metastatic renal cell cancer (RCC) is a malignant disease without curative treatment. These patients are usually symptomatic and desperate for effective palliative treatment. Radiotherapy, chemotherapy, and hormonal therapy are not effective in these patients. A multimodal approach consisting of cytoreductive nephrectomy, systemic therapy (which includes cytokines or targeted molecules), and metastasectomy have been shown to be useful in prolonging the survival and improving the quality of life in a select group of patients with metastatic renal cancer. Patients with oligometastatic disease, good performance status, and delayed presentation of the secondaries have better results following this integrated approach. Although there is some controversy regarding the order in which nephrectomy and systemic therapy are to be instituted, well-controlled studies like the South West Oncology Group and European organization research and treatment of cancer have shown that upfront nephrectomy gives better survival compared to neoadjuvant systemic therapy followed by nephrectomy. This order is the standard presently. Of late, with better understanding of the genetic basis and the biology of the various subtypes of renal cell carcinoma, targeted molecular therapies have emerged as an equally effective alternative therapy to cytokines. Recent reports have proven that targeted therapy is more effective with comparable side effects. Metastasectomy in a subgroup of patients improves survival and quality of life specifically in those with lung secondaries and painful bone metastases.

Impact of tyrosine kinase inhibitors and cytoreductive nephrectomy in patients with metastatic renal cell carcinoma

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Role of cytoreductive nephrectomy in renal cell carcinoma

Cytoreductive nephrectomy prior to cytokine therapy has a well-established role in the treatment of appropriately selected patients with metastatic renal cell carcinoma (RCC). Recent use of novel molecular targeted agents in the management of metastatic RCC has challenged the current dogma of treatment with regards to the necessity, patient selection for and timing of cytoreductive nephrectomy. Current evidence suggests that cytoreductive nephrectomy still plays an integral part in the multimodal paradigm of management for metastatic RCC. This review highlights the role of cytoreductive nephrectomy, and discusses controversial issues surrounding cytoreductive nephrectomy in the treatment of metastatic RCC, in the context of immunotherapy and also in the new era of targeted therapy. It also gives updates on the changing concepts of surgical approaches to cytoreductive nephrectomy in metastatic RCC.

Cytoreductive nephrectomy for metastatic RCC in the era of targeted therapy

Metastatic renal cell carcinoma (RCC) has traditionally been associated with a poor prognosis with few effective treatments. In the multimodal treatment of metastatic RCC, cytoreductive nephrectomy (CN) became the standard of care after two randomized trials demonstrated a benefit in overall survival in patients who received CN prior to treatment with interferon. More recently, several agents (sunitinib, sorafenib, temsirolimus, everolimus and bevacizumab) have been developed that target angiogenesis and the cellular growth pathways involved in metastatic RCC. These targeted agents have demonstrated improved outcomes compared to cytokine therapy, and have transformed metastatic RCC treatment. Targeted agents are being used as a first-line systemic treatment in patients with metastatic RCC with unprecedented success, and many studies are now focusing on the role of CN in combination with these agents for patients with metastatic RCC.