Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma

[Oncological principles for local control of primary tumor]

OBJECTIVE

Review of the databases of carcinogenesis and the principles of local control of the primary tumor in order to decrease the risk of tumor progression and predict metastatic behavior.

MATERIALS AND METHODS

Review of the literature using Medline databases based on scientific relevance. Research was centered on the characteristics of solid tumor development, the basics of local control of the primary tumor, latest advance in genomics and the oncological principles applied on prostate cancer surgery.

RESULTS

The cornerstone in order to cure a local or locally advanced cancer is to eradicate the primary tumor. This should be done using effective methods that can assure local control, decrease the risk of progression and metastasis. The oncological surgery is the most important step in order to have this tumor control, beside radiotherapy and systemic therapy associated. In localized prostate cancer, surgery remains the gold standard between the multiple therapeutic modalities proposed.

CONCLUSION

The local control of solid malignant tumor is primordial in order to change the natural history of the disease and decrease its risk of progression. This is the goal of oncological surgery, and starting from these principles radical prostatectomy was favored.

Comprehensive Characterization of the Perioperative Morbidity of Cytoreductive Nephrectomy

BACKGROUND

Although cytoreductive nephrectomy (CN) has been associated with perioperative morbidity, data are lacking regarding the risk of prolonged length of stay (pLOS) and delay to receipt of systemic therapy (ST).

OBJECTIVE

To evaluate the association of clinicopathologic features with postoperative complications, pLOS, and time to receipt of ST.

DESIGN, SETTING, AND PARTICIPANTS

We evaluated 294 patients with M1 renal cell carcinoma treated between 1990 and 2009.

INTERVENTIONS

CN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic and Cox regressions were used to evaluate associations of clinicopathologic features with 30-d postoperative complications, pLOS (LOS ≥75th percentile), and time to receipt of ST.

RESULTS AND LIMITATIONS

Fifteen (5%) patients experienced at least one Clavien grade ≥3 early complication. Among patients for whom postsurgical ST was recommended, 61% did not receive ST within 60 d, but the delay was surgery-related in only 11%. In multivariable models limited to preoperative features, liver metastases were associated with complications (odds ratio [OR] 3.73, p=0.004) and pLOS (OR 2.46, p=0.03), while a laparoscopic approach was associated with earlier administration of ST (hazard ratio [HR] 5.05, p<0.001). In multivariable models incorporating operative features, intraoperative transfusion was associated with complications (OR 1.14, p<0.001) and pLOS (OR 1.22, p<0.001), while pN1 disease was associated with pLOS (OR 2.12, p=0.049) and delay to ST (HR 0.38, p=0.004). Limitations include the retrospective design and surgical selection bias.

CONCLUSIONS

Overall, 61% of CN patients did not receive timely ST, but only 5% of patients experienced Clavien grade ≥3 complications and the delay to ST was surgery-related in 11%. Liver metastases, intraoperative transfusion, and pN1 disease were independently associated with perioperative morbidity.

PATIENT SUMMARY

We evaluated the morbidity of cytoreductive nephrectomy and identified predictors of unfavorable perioperative outcomes. Although 61% of patients did not receive timely systemic therapy, the rates of complications and surgery-related delay to systemic therapy were low.