Surgical resection of isolated retroperitoneal lymph node recurrence of renal cell carcinoma following nephrectomy

Lymph node dissection during radical nephrectomy: A Canadian multi-institutional analysis

OBJECTIVES

To determine the association between lymph node dissection (LND) at the time of radical nephrectomy and survival in a large, multi-institutional cohort using a propensity score matching design.

SUBJECTS AND METHODS

The Canadian Kidney Cancer information system was used to identify patients undergoing radical nephrectomy for nonmetastatic renal cell carcinoma. Associations between LND with overall survival , recurrence free survival and cancer specific survival were determined using various propensity score techniques in the overall cohort and in patients with varying probabilities of pN1. Cox models were used to determine association of lymph node removed with outcomes.

RESULTS

Of the 2,699 eligible patients, 812 (30%) underwent LND. Of the LND patients, 88 (10.8%) had nodal metastases. There was no association between LND and improved overall survival, recurrence free survival or cancer specific survival using various propensity score techniques (stratification by propensity score quintile, matched pairs, inverse treatment probability weighting and adjusted for propensity score quintile). There was no association between LND and a therapeutic benefit in patients with increased threshold probabilities of nodal metastases. Increased number of lymph nodes removed was not associated with improved survival outcomes.

CONCLUSIONS

LND at the time of radical nephrectomy for renal cell carcinoma is not associated with improved outcomes. There was no benefit in patients at high risk for nodal metastases, and the number of nodes removed did not correlate with survival. Further studies are needed to determine which high risk patients may benefit from LND.

Understanding the role of salvage lymphadenectomy in node only recurrences after nephrectomy for renal cell carcinoma

PURPOSE

To investigate oncological outcomes and relapse patterns in retroperitoneal lymph node (LN)-only recurrences with salvage retroperitoneal lymph node dissection (S-RPLND).

MATERIALS AND METHODS

We reviewed records of 19 patients undergoing RPLND for RCC recurrences between 2011 and 2018. All patients initially had primary non-metastatic RCC, with subsequent recurrence restricted to the retroperitoneal lymph nodes (LN). LN recurrence sites after nephrectomy and relapses after S-RPLND were assessed. The primary outcomes were post-RPLND Relapse-Free Survival (RFS), and Cancer-Specific Survival (CSS).

RESULTS

The median age of our cohort was 60 years at RPLND. Right and left nephrectomies were performed in 14 (73.7%) and 5 (26.3%), respectively. Clear cell carcinoma was found in 10 (52.6%) patients, followed by papillary in 4(21.1%), chromophobe in 2(10.5%), and 'other' in 3 (15.8%). The extent of lymphadenectomy during nephrectomy and S-RPLND varied based on surgical approach. The median follow-up time after S-RPLND of the entire cohort was 31.53 months, and the median RFS was 9.63 months. Overall, 4 patients died of cancer, of which 3 (75%) were N1 at time of nephrectomy. The CSS after RPLND at 3 and 5 years was 81.5% and 61.1%, respectively. The RFS after RPLND at 2 and 5 years was 44.4% and 29.6%, respectively.

CONCLUSIONS

Our results suggest that aggressive surgical management provides satisfactory CSS with acceptable complication rates. Moreover, we believe this subset of patients with node-only recurrence showed an unpredictable pattern of lymphatic spread, with predilection for regional dissemination warranting surgical resection of LN recurrences in a bilateral template fashion when feasible.

Topographic distribution of first landing sites of lymphatic metastases from patients with renal cancer

INTRODUCTION AND OBJECTIVE

Adjuvant studies with checkpoint inhibitors have attracted new interest in accurate pathological lymph node (LN) staging in renal cell carcinoma. Sentinel lymph node (SN) studies in cN0 patients revealed the pattern of lymphatic radiotracer drainage from renal tumors. The aim of this study was to describe the location of single- or oligometastatic LN and analyze if the topography of these first landing sites matches the drainage pattern observed in SN studies of renal tumors.

MATERIALS AND METHODS

We collected data from 8 referral centers from 1990 to 2018 of all patients with pT1-4 cN0 or cN1 M0 renal cell carcinoma with pathologically confirmed single- or oligometastases in locoregional LN. The location of LN metastases, number, size of metastatic LN, and survival were analyzed using descriptive statistics with SPSS version 22 (IBM, Chicago, IL).

RESULTS

From 3,794 patients with histologically confirmed pN1, a total of 76 patients (2%) with single- or oligometastatic pN1 were identified, of whom 24 (31.6%) and 52 (68.4%) were cN0 and cN1, respectively. On the left side, LN metastases were predominantly located in the para-aortal (48.0%; 95% confidence interval [CI] 29.22-63.12%) and hilar (31.42%; 95% CI 17.4-49.4%) area. On the right side, metastases located in retrocaval (26.82%; 95% CI 14.7-43.2%), hilar (26.82%; 95% CI 14.7-43.2%), interaortocaval (26.82%; 95% CI 14.7-43.2%), and paracaval (17.07%; 95% CI 7.6-32.6%) LNs. These landing sites exactly matched the lymphatic drainage pattern of intratumorally injected radiotracer reported in SN studies for both sides.

CONCLUSIONS

Single- or oligometastatic LNs in renal cancer are mainly located in the hilar, retro-, para, and interaortocaval region on the right side and para-aortal region on the left side. These first landing sites match the drainage pattern reported in SN trials.

Metastatic clear cell renal cell carcinoma in isolated retroperitoneal lymph node without evidence of primary tumor in kidneys: A case report

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) plays a diagnostic, therapeutic, and prognostic role in myriad urologic malignancies, including testicular carcinoma, renal cell carcinoma (RCC), and upper urinary tract urothelial carcinoma. RCC represents 2% of all cancers with approximately 25% of patients presenting with advanced disease. Clear cell RCC (CCRCC) is the most common RCC, accounting for 75%-80% of all RCC.

CASE SUMMARY

A 71-year-old man presented with a history of benign prostatic hypertrophy. He was asymptomatic without any hematuria, pain, or other urinary symptoms. A computed tomography (CT) scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node. There was no evidence of renal pathology. A core biopsy was performed of the left para-aortic lymph node. Although the primary tumor site was unknown, the morphological and immunohistochemical features were most consistent with CCRCC. A RPLND was performed which revealed a single mass 5.5 cm in greatest dimension with extensive necrosis. The retroperitoneal lymph node was most compatible with CCRCC. A nephrectomy was not conducted as a renal mass had not been detected on any prior imaging studies. The patient did not receive any type of adjuvant therapy. The patient underwent surveillance with serial CT scans with contrast of the chest, abdomen, and pelvis for the next 5 years, all of which demonstrated no recurrent or metastatic disease and no evidence of retroperitoneal adenopathy.

CONCLUSION

Our unique case emphasizes the therapeutic role of metastasectomy in metastatic CCRCC even in the absence of primary tumor in the kidneys.

Adverse Effect of Lymph Node Dissection in Metastatic Renal Cell Cancer Patients Treated with Cytoreductive Nephrectomy: A Contemporary Analysis of Survival

Background and objectives: In patients with metastatic renal cell cancer (mRCC), cytoreductive nephrectomy (CN) may occasionally be performed. However, the role of lymph node dissection (LND) for such cases is unknown in era of target therapy. To test the effect of LND at CN on cancer-specific survival (CSS), overall survival (OS) in era of target therapy compared with no LND in patients with mRCC. Methods: A total of 4690 mRCC patients treated with CN were identified within the Surveillance, Epidemiology, and End Result (SEER) database (2006-2015). Survival differences were assessed by Kaplan-Meier estimate and compared using log-rank test. Multivariable Cox regression analysis (MCR) was used to evaluate the effect of LND on CSS and OS. Results: Within the SEER database, 1902 (40.6%) of 4690 mRCC patients underwent LND at CN. MCR analysis showed that LND at CN exhibited lower CSS (hazard ratio [HR] 1.18, 95% confidence interval (CI) 1.09-1.27; p < 0.01) and OS (HR 1.13, 95% CI 1.05-1.21; p < 0.01) compared with non-LND in mRCC patients. The adverse effect of LND on CSS and OS were also detected in metastatic patients with clear cell RCC (ccRCC) and non-ccRCC (all p<0.0001). Additionally, the association of number of resected node with CSS (HR 0.98, 95% CI 0.88-1.10; p = 0.68) and OS (HR 1.00, 95% CI 0.89-1.11; p = 0.93) were not observed in MCR analysis. Conclusion: We are the first to demonstrate that LND at CN is associated with poor CSS and OS in metastatic patients with ccRCC and non-ccRCC. Considering that the current study is retrospective, these findings' impact on clinical practice needs to be further verified in future validation studies.

Systematic Review of the Management of Local Kidney Cancer Relapse

CONTEXT

Management of locally recurrent renal cancer is complex.

OBJECTIVE

In this systematic review we analyse the available literature on the management of local renal cancer recurrence.

EVIDENCE ACQUISITION

A systematic search (PubMed, Web of Science, CINAHL, Clinical Trials, and Scopus) of English literature from 2000 to 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

EVIDENCE SYNTHESIS

The search identified 1838 articles. Of those, 36 were included in the evidence synthesis. The majority of the studies identified were retrospective and not controlled. Local recurrence after thermal ablation (TA) may be managed with repeat TA. Alternatively, salvage nephrectomy is possible. However, a higher rate of complications should be expected than after primary nephrectomy. Salvage nephrectomy and TA represent treatment options for local recurrence after partial nephrectomy. Local retroperitoneal recurrence after radical nephrectomy is ideally treated with surgical resection, for which minimally invasive approaches might be applicable to select patients. For large recurrences, addition of intraoperative radiation may improve local control. Local tumour destruction appears to be more beneficial than systemic therapy alone for local recurrences.

CONCLUSIONS

Management of local renal cancer relapse varies according to the clinical course and prior treatments. The available data are mainly limited to noncontrolled retrospective series. After nephron-sparing treatment, TA represents an effective treatment with low morbidity. For local recurrence after radical nephrectomy, the low-level evidence available suggests superiority of surgical excision relative to systemic therapy or best supportive care. As a consequence, surgery should be prioritised when feasible and applicable.

PATIENT SUMMARY

In renal cell cancer, the occurrence and management of local recurrence depend on the initial treatment. This cancer is a disease with a highly variable clinical course. After initial organ-sparing treatment, thermal ablation offers good cancer control and low rates of complications. For recurrence after radical nephrectomy, surgical excision seems to provide the best long-term cancer control and it is superior to medical therapy alone.

The role of lymph node dissection in the management of renal cell carcinoma: a systematic review and meta-analysis

Our objective was to evaluate the role of retroperitoneal lymph node dissection (LND) in non-metastatic (M0) and metastatic (M1) renal cell carcinoma (RCC). We searched Medline, EMBASE, Web of Science and Scopus from database inception to 29 August 2017 for studies of patients who underwent partial or radical nephrectomy for M0 or M1 RCC. Two investigators independently selected studies for inclusion. Risk of bias was assessed using the Newcastle-Ottawa scale, Cochrane Collaboration tool and National Heart, Lung and Blood Institute Quality Assessment Tool. Random effects meta-analysis was performed for all-cause-mortality. The GRADE approach was used to characterize quality of evidence. A total of 51 unique studies were included in the qualitative systematic review. Risk of bias was low in 41/51 (80%) studies. LND was not associated with all-cause mortality in either M0 (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92-1.12; I² = 0%; four studies), M1 (HR 1.04, 95% CI 0.83-1.29; I² = 0%; two studies), or pooled M0 and M1 settings (HR 1.00, 95% CI 0.92-1.09; I² = 0%; seven studies), with no statistically significant differences according to M stage subgroups (P = 0.50). In the three studies that examined M0 subgroups with a high risk of nodal metastasis, LND was not associated with improved oncological outcomes. Studies on the association of extent of LND with survival reported inconsistent results. Meanwhile, a small proportion of patients with pN1M0 disease demonstrate durable long-term oncological control after surgery, with 10-year cancer-specific survival of 21-31%. Nodal involvement is independently associated with adverse prognosis in both M0 and M1 settings. GRADE quality of evidence was moderate or low for the outcomes examined. Although LND yields independent prognostic information, the existing literature does not support a therapeutic benefit to LND in either M0 or M1 RCC. High-risk M0 patient groups warrant further study, as a subset of patients with isolated nodal metastases experience long-term survival after surgical resection.

The independent oncological role for cytoreductive nephrectomy in metastatic renal cell carcinoma: Prognostic features in the era of targeted therapies

OBJECTIVES

To describe the effects of cytoreductive nephrectomy (CN) on the natural course of metastatic renal cell carcinoma (mRCC). CN appears to stabilize metastatic lesions in mRCC in a subgroup of patients and we hypothesize that systemic treatment might be deferred in these patients with stable disease after CN.

SUBJECTS AND METHODS

Overall, 45 patients with mRCC who underwent CN and subsequent oncologic follow-up were included in this retrospective, single-center analysis. After CN, patients were followed at least every 3 months with clinical evaluation, contrast-enhanced computerized tomography scan of chest and abdomen, with additional imaging if needed. At 3 months, patients were radiographically evaluated and categorized into nonresponders (death or progression) or responders (stable disease or remission). Kaplan-Meier and Cox proportional hazards regression statistics were used to describe prognostic factors for overall survival (OS) and systemic therapy-free survival (STFS).

RESULTS

Median OS was 31(3-121) months. Further, 24 (53.3%) and 21 (46.7%) patients were classified as responders and nonresponders at 3 months, respectively. Responders had a significant better 2-year OS compared with nonresponders (81.7% vs. 26.5%, P = 0.005). Responders also had a better 2-year STFS (40.3% vs. 6.3%, P = 0.005). On Cox regression analysis, worse OS was found to be associated with low preoperative hemoglobin levels, the absence of postoperative radiographical response, and the presence of non-clear cell pathology. The presence of postoperative radiographical response, normal preoperative lactate dehydrogenase levels, the presence of a single metastasis, and performing metastasis-directed therapy was found to be associated with a longer systemic therapy-free period.

CONCLUSION

A beneficial oncologic response is observed in approximately half of the patients undergoing CN. Absence of radiographic progression at 3 months is an important marker for OS and STFS. Therefore, systemic treatment might be postponed in selected patients.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical Management of Local Retroperitoneal Recurrence of Renal Cell Carcinoma after Radical Nephrectomy

PURPOSE

Isolated local retroperitoneal recurrence after radical nephrectomy for renal cell carcinoma poses a therapeutic challenge. We investigated outcomes in patients with localized retroperitoneal recurrence treated with surgical resection.

MATERIALS AND METHODS

This was a retrospective, single institutional study of 102 patients with retroperitoneal recurrence treated with surgery from 1990 to 2014. Demographics, clinical and pathological features, location of retroperitoneal recurrence and perioperative complications are reported using descriptive statistics. We studied recurrence-free and cancer specific survival using univariate and multivariate analyses.

RESULTS

Median age at retroperitoneal recurrence diagnosis was 55 years (IQR 49-64). Cancer was pT3-4 in 62 patients (60.8%) and pN1 in 20 (19.6%). No patients had distant metastatic disease at retroperitoneal recurrence surgery. Median time from nephrectomy to retroperitoneal recurrence diagnosis was 19 months (IQR 5-38.8). The median size of the resected retroperitoneal recurrence was 4.5 cm (IQR 2.7-7). Median followup after recurrence surgery was 32 months (IQR 16-57). Metastatic progression was observed in 60 patients (58.8%) postoperatively. Neoadjuvant and salvage systemic therapy was administered in 46 (45.1%) and 48 patients (47.1%), respectively. On multivariate analysis pathological nodal stage at original nephrectomy and maximum diameter of retroperitoneal recurrence were identified as independent risk factors for cancer specific death.

CONCLUSIONS

Clinicopathological factors at nephrectomy as well as retroperitoneal recurrence surgery are important prognosticators. Aggressive surgical resection offers potential cure in a substantial number of patients with retroperitoneal recurrence with acceptable complications and still has a dominant role in the management of isolated locally recurrent RCC.

The role of lymphadenectomy in the management of renal cell carcinoma

The role of lymphadenectomy in the management of renal cell carcinoma has been established in staging but is less well defined as a therapeutic maneuver. Level one evidence suggests no survival benefit or increased complication rate with lymphadenectomy when performed concurrently with radical nephrectomy. However, several retrospective studies have identified a survival benefit when patients with increased risk of micrometastatic lymph node disease undergo lymphadenectomy. We perform a selective review of the literature and present the historical basis, risk assessment, use and development of nodal templates, and therapeutic benefits associated with the use of lymphadenectomy in the management of renal cell carcinoma.

Percutaneous ablation of lymph node metastases using CT-guided high-dose-rate brachytherapy

OBJECTIVE

To assess the technical feasibility, safety and clinical outcome of CT-guided high-dose-rate brachytherapy (CT-HDRBT) for achieving local tumour control (LTC) in isolated lymph node metastases.

METHODS

From January 2008 to December 2011, 10 patients (six males and four females) with isolated nodal metastases were treated with CT-HDRBT. Five lymph node metastases were para-aortic, three were at the liver hilum, one at the coeliac trunk and one was a left iliac nodal metastasis. The mean lesion diameter was 36.5 mm (range 12.0-67.0 mm). Patients were followed up by either contrast-enhanced CT or MRI 6 weeks and then every 3 months after the end of treatment. The primary end point was LTC. Secondary end points included primary technical effectiveness rate, adverse events and progression-free survival.

RESULTS

The first follow-up examination after 6 weeks revealed complete coverage of all nodal metastases treated. There was no peri-interventional mortality or major complications. The mean follow-up period was 13.2 months (range 4-20 months). 2 out of 10 patients (20%) showed local tumour progression 9 and 10 months after ablation. 5 out of 10 patients (50%) showed systemic tumour progression. The mean progression-free interval was 9.2 months (range 2-20 months).

CONCLUSION

CT-HDRBT is a safe and effective technique for minimally invasive ablation of nodal metastases.

ADVANCES IN KNOWLEDGE

CT-HDRBT of lymph node metastases is feasible and safe. CT-HDRBT might be a viable therapeutic alternative to obtain LTC in selected patients with isolated lymph node metastases.

Lymph node dissection in renal cell carcinoma

CONTEXT

Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most accurate and reliable staging procedure for the detection of lymph node invasion (LNI), its therapeutic benefit in renal cell carcinoma (RCC) still remains controversial.

OBJECTIVE

Review the available literature concerning the role of LND in RCC staging and outcome.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in RCC. Keywords included kidney neoplasms, renal cell cancer, renal cell carcinoma, kidney cancer, lymphadenectomy, lymph node excision, lymphatic metastases, nephrectomy, imaging, and complications. The articles with the highest level of evidence were identified with the consensus of all of the collaborative authors and were critically reviewed. This review is the result of an interactive peer-reviewing process by an expert panel of co-authors.

EVIDENCE SYNTHESIS

Renal lymphatic drainage is unpredictable. The newer available imaging techniques are still immature in detecting small lymph node metastases. Results from the European Organization for Research and Treatment of Cancer trial 30881 showed no benefit in performing LND during surgery for clinically node-negative RCC, but the results are limited to patients with the lowest risk of developing LNI. Numerous retrospective series support the hypothesis that LND may be beneficial in high-risk patients (clinical T3-T4, high Fuhrman grade, presence of sarcomatoid features, or coagulative tumor necrosis). If enlarged nodes are evident at imaging or palpable during surgery, LND seems justified at any stage. However, the extent of the LND remains a matter of controversy.

CONCLUSIONS

To date, the available evidence suggests that an extended LND may be beneficial when technically feasible in patients with locally advanced disease (T3-T4) and/or unfavorable clinical and pathologic characteristics (high Fuhrman grade, larger tumors, presence of sarcomatoid features, and/or coagulative tumor necrosis). Although node-positive patients often harbor distant metastases as well, the majority of retrospective nonrandomized trials seem to suggest a possible benefit of regional LND even for this group of patients. In patients with T1-T2, clinically negative lymph nodes and absence of unfavorable clinical and pathologic characteristics, regional LND offers limited staging information and no benefit in terms of decreasing disease recurrence or improving survival.

Outcomes and clinicopathologic variables associated with late recurrence after nephrectomy for localized renal cell carcinoma

OBJECTIVE

To characterize the incidence and clinicopathologic factors associated with late recurrence after surgical resection for renal cell carcinoma (RCC) because the recurrence patterns >5 years after nephrectomy have been poorly described.

METHODS

We identified 1454 patients treated with nephrectomy for localized RCC from 1970 to 2000 who had remained free of disease for 5 years. Subsequent tumor recurrence was classified as renal recurrence and distant metastasis. The incidence of recurrence >5 years from surgery was estimated using the Kaplan-Meier method. The associations of clinicopathologic variables with late recurrence were analyzed using Cox proportional hazard regression models.

RESULTS

With a median postoperative follow-up of 13.9 years (range 5.1-38.9), 63 patients (4.3%) experienced late renal recurrence at a median of 9.3 years (range 5.1-25.3), and 172 patients (11.8%) developed late distant metastases at a median of 9.6 years (range 5.1-26.6) after surgery. The estimated recurrence-free survival rate at 10 and 15 years was 97.3% and 95.2% for renal recurrence, and 93.1% and 85.9% for distant metastases, respectively. On multivariate analysis, increased tumor size (hazard ratio [HR] 1.12; P < .001) was associated with late renal tumor recurrence, and increased tumor size (HR 1.07; P = .018), clear cell or collecting duct histologic features (HR 3.76; P < .001), and tumor Stage pT1b (HR 2.8; P < .001), pT2a (HR 4.5; P < .001), pT2b (HR 3.4; P = .007), and pT3-pT4 (HR 5.1; P < .001) were associated with distant metastasis.

CONCLUSION

After an initial 5-year postoperative disease-free interval, approximately 5% and 15% of patients will develop renal recurrence and distant metastases, respectively, during the next decade. Therefore, long-term surveillance remains necessary after nephrectomy.

Recent developments in kidney cancer

Renal cell carcinoma (RCC) diagnosis and management have undergone significant shifts in the recent past. The increasing rate of diagnosis of small renal masses, often in patients at high risk of morbidity with operative treatment, has led to studies, trials and discoveries in renal mass biopsy, active surveillance and minimally invasive thermal ablation. At the other end of the disease spectrum, targeted systemic therapies for metastatic RCC have supplanted cytokine-based treatment, with significant benefits to progression and survival. Recent reviews and trials have also cemented the role of partial nephrectomy as standard surgical management for most low-stage masses, and the roles of regional lymphadenectomy and adrenalectomy concomitant with nephrectomy have been clarified. This review aims to highlight recent evidence that has emerged in the management of this complicated oncologic issue.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery

OBJECTIVES

To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management.

METHODS

Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed.

RESULTS

PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 +/- 1.6) in comparison to those with negative surgical margins (3.4 +/- 1.8 cm) (P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality.

CONCLUSIONS

The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.