The Role of Metastasectomy in Patients with Renal Cell Carcinoma with Sarcomatoid Dedifferentiation: A Matched Controlled Analysis

Surgical metastasectomy for metastatic renal cell carcinoma in the era of targeted and immune therapy: a narrative review

PURPOSE

Metastatic renal cell carcinoma (mRCC) still harbours a big propensity for future metastasis. Combinations of immune and targeted therapies are currently the cornerstone of management with a less clear role for surgical metastasectomy (SM).

METHODS

We performed a narrative review of literature searching for the available evidence on the yield of surgical metastasectomy in the era of targeted and immune therapies. The review consisted of a PubMed search of relevant articles using the Mesh terms:" renal cell carcinoma", "surgery», «resection", "metastasectomy", "molecular targeted therapies", "immune checkpoint inhibitors" alone or in combination.

RESULTS

In this review, we exposed the place of surgical metastasectomy within a multimodal treatment algorithm for mRCC Also, we detailed the patient selection criteria that yielded the best results when SM was performed. Finally, we discussed the feasibility and advantages of SM per organ site.

CONCLUSION

Our work was able to show that SM could be proposed as a consolidation treatment to excise residual lesions that were deemed unresectable prior to a combination of systemic therapies. Contrastingly, it can be proposed as an upfront treatment, leaving systemic therapies as an alternative in case of future relapse. However, patient selection regarding their performance status, metastatic sites, number of lesions and tumorous characteristics is of paramount importance.

Clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with sarcomatoid dedifferentiation: A PRISMA-compliant systematic review and meta-analysis

Background

There are still differences in the prognostic factors of renal cell carcinoma with sarcomatoid dedifferentiation (sRCC). The aim of this study was to evaluate important predictors of survival in patients with sRCC.

Patients and methods

A comprehensive search of PubMed, Embase, and Cochrane Library was conducted to identify eligible studies. The endpoints embraced overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS). Hazard ratios (HRs) and related 95% confidence intervals (CIs) were extracted.

Results

A total of 13 studies were included for analyses. The pooled results showed that high European Cooperative Oncology Group performance score (HR 2.39, 95% CI 1.32–4.30; P = 0.004), high T stage (HR 2.18, 95% CI 1.66–2.86; P < 0.001), positive lymph node (HR 1.54, 95% CI 1.40–1.69; P < 0.001), distant metastasis (HR 2.52, 95% CI 1.99–3.21; P < 0.001), lung metastases (HR 1.45, 95% CI 1.16–1.80; P < 0.001), liver metastases (HR 1.71, 95% CI 1.30–2.25; P < 0.001), tumor necrosis (HR 1.78, 95% CI 1.14–2.80; P = 0.010), and percentage sarcomatoid ≥50% (HR 2.35, 95% CI 1.57–3.52; P < 0.001) were associated with unfavorable OS. Positive lymph node (HR 1.57, 95% CI 1.33–1.85; P < 0.001) and high neutrophil to lymphocyte ratio (HR 1.16, 95% CI 1.04–1.29; P = 0.008) were associated with unfavorable CSS. High T stage (HR 1.93 95% CI 1.44–2.58; P < 0.001) was associated with unfavorable progression-free survival.

Conclusions

A meta-analysis of available data identified important prognostic factors for CSS, OS, and PFS of sRCC, which should be systematically evaluated for patient counseling, risk stratification, and treatment selection.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=249449.

Pulmonary metastasectomy in renal cell carcinoma: a mainstay of multidisciplinary treatment

Renal cell carcinoma (RCC) remains a public health issue and seems to be increasing. A significant proportion of RCC patients will develop pulmonary metastasis at some point in their evolution. In this review, we aimed to update the surgical management of pulmonary metastases as well as systemic therapy, including targeted therapies, according to recent data in the literature. We retrospectively reviewed studies evaluating the benefit of pulmonary metastasectomy in RCC patients and evaluating the place of different chemotherapies, targeted therapies and immunotherapies through November 1, 2019. Several retrospective studies have shown the benefit of pulmonary metastasectomy in metastatic RCC (mRCC), most in a situation with only pulmonary metastases. According to the prognostic criteria of the IMDC risk model, the patient is classified into a prognostic group to identify the best systemic treatment. With the development of targeted therapies, the modalities are multiple and may involve tyrosine kinase inhibitors/checkpoint inhibitors and soon vaccine therapy or CAR-T cells. At the local level, in patients who cannot benefit from surgery, stereotactic radiotherapy or radiofrequency has a place to be considered. Although there is a lack of a randomized study, pulmonary metastasectomy appears to be feasible and effective. The place and modalities of systemic therapies in the era of targeted therapies remain to be more clearly defined.

Prognostic Significance of Sarcomatoid Differentiation in Patients With Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Background

To date, the prognostic value of sarcomatoid differentiation in patients having metastatic renal cell carcinoma (mRCC) remains inconclusive. A systematic review and meta-analysis were conducted.

Materials and Methods

Relevant literatures were obtained from PubMed, Embase, and Cochrane Library published prior to May, 2020. All patients were diagnosed with mRCC and treated with surgery, cytokine therapy, targeted therapy, and immunotherapy. Sarcomatoid differentiation in the pathological specimens was identified. Each endpoint [overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS)] was assessed using a multivariable adjusted hazard ratio (HR) and 95% confidence interval (CI).

Results

Fifteen observational studies having 5,828 patients with mRCC were included. The merged results showed that patients presenting sarcomatoid differentiation had a significantly inferior OS (HR: 2.26, 95% CI: 1.82-2.81; P < 0.001), PFS (HR: 2.28, 95% CI: 1.63-3.19; P < 0.001), and CSS (HR: 2.27, 95% CI: 1.51-3.40; P < 0.001) compared to those without sarcomatoid differentiation. Subgroup analysis based on publication year, patient population, country, number of cases, and NOS score did not change the direction of results. A significant publication bias was identified for OS, but no publication bias was identified for PFS. Moreover, sensitivity analysis also verified the robustness of the results.

Conclusion

This study suggested that sarcomatoid differentiation was correlated to unfavorable clinical outcomes in mRCC and may be a poor prognostic factor incorporating to prognostic models for mRCC patients.

Sarcomatoid renal cell carcinoma: biology, natural history and management

Sarcomatoid dedifferentiation is an uncommon feature that can occur in most histological subtypes of renal cell carcinomas (RCCs) and carries a decidedly poor prognosis. Historically, conventional treatments for sarcomatoid RCCs (sRCCs) have shown little efficacy, and median survival is commonly 6–13 months. Despite being first described in 1968, the mechanisms driving sarcomatoid dedifferentiation remain poorly understood, and information and treatment options available to physicians and patients are limited. When diagnosed at an early stage, surgical intervention remains the treatment of choice. However, preoperative identification through routine imaging or biopsy is unreliable and most patients present with advanced disease and systemic symptoms. For these patients, the role of cytoreductive nephrectomy is disputed. The expansion of immunotherapies approved for RCCs has generated a search for biomarkers that might be indicative of treatment response in sRCCs, although a proven effective systemic agent remains elusive. PDL1 expression is increased in sarcomatoid dedifferentiated renal tumours, which suggests that patients with sRCCs could benefit from PD1 and/or PDL1 immune checkpoint blockade therapy. Treatment outcomes for sarcomatoid tumours have remained relatively consistent compared with other RCCs, but further investigation of the tumour–immune cell microenvironment might yield insights into further therapeutic possibilities.

In this Review, Blum et al. summarize the current knowledge on sarcomatoid renal cell carcinoma, a diagnosis characterized by the presence of sarcomatoid dedifferentiation and a poor prognosis. They discuss the origin, presentation, molecular biology and treatment of this disease.

Sarcomatoid dedifferentiation is not considered to be a unique histological subtype of renal cell carcinomas (RCCs); rather, it can be present within any subtype of RCCs.

Sarcomatoid dedifferentiation appears in ~4% of all RCCs, but is present in ~20% of all metastatic RCCs. According to WHO guidelines, any RCC with sarcomatoid dedifferentiation is a WHO–International Society of Urological Pathology grade 4 lesion.

Sarcomatoid dedifferentiation is often heterogeneously present within RCCs, making routine imaging and biopsy unreliable for preoperative detection. Surgical resection for localized disease is the standard of care, with subsequent close monitoring of patients following surgery.

In patients with metastatic disease, conventional therapies such as surgery and systemic agents have been ineffective and overall 5-year survival remains at 23.5–33%.

Previous genomic analyses have failed to identify definitive mutational drivers of disease. However, sarcomatoid RCCs (sRCCs) have been shown to have higher PD1 and PDL1 expression than other subtypes of RCCs. Newer combinations of immune checkpoint inhibitor immunotherapies could yield improved responses and outcomes.

Studies investigating sRCCs are limited by patient numbers owing to the low incidence of sRCCs and their advanced stage at presentation. Multi-institutional efforts to establish a consensus on treatment recommendations based on highly powered data are essential.

Recurrent metastatic clear cell renal carcinoma with sarcomatoid dedifferentiation treated with surgery and Cabozantinib

Renal cell carcinoma with sarcomatoid dedifferentiation is an entity of RCC that has undergone an anaplastic transformation with both a carcinomatous and a sarcomatous component. The standard treatment in metastatic patients is immunotherapy.

The aim of this article is to describe our case of metastatic recurrent RCC with sarcomatoid dedifferentiation in a 59 year old male patient treated with nephrectomy and multiple metastasectomies followed by Cabozantinib.

Consecutive PET-CT scans showed no evidence of recurrence, three years after the last metastasectomy, and the patient is having currently a normal life.

Sarcomatoid dedifferentiation remains a poor prognosis factor in RCC. Surgery for metastases followed by Cabozantinib may be a therapeutic option in metastatic young patients. However, a prospective randomized trial would be the best option to validate this approach.

Clinicopathologic features and prognostic factors in patients with renal cell carcinoma with sarcomatoid differentiation

Renal cell carcinoma with sarcomatoid differentiation (RCCs) is rare, accounting for 1-8% of all RCC histological subtypes. In this study, we examined 139 patients with RCCs and aimed to explore their clinicopathologic features and prognostic factors. From January 2007 to January 2019, patients who were pathologically diagnosed with RCCs were included in this retrospective study. Data on clinicopathologic features and overall survival were collected. The expression of CK, vimentin, CK7, and CD10 in the sarcomatoid regions of RCCs was detected. The Kaplan-Meier curves and log-rank tests were used to describe the effect of clinicopathologic characteristics on overall survival. A Cox regression model was used to evaluate risk factors for prognosis. A total of 139 patients with RCCs were identified. The median age at diagnosis was 60 years. The median survival time of all patients was 39 months. The three- and five-year survival rates were 50.2% and 44.0%, respectively. A high pathologic T stage (pT3 and pT4), microvascular invasion, and lymph node metastasis were significant predictors of prognosis. Pathologic T4 stage and lymph node metastasis were independent prognostic factors for overall survival in patients with RCCs. Furthermore, the expression of CD10 was a prognostic factor for overall survival. In this study, a relatively large cohort of patients with RCCs was analyzed. We summarized the clinicopathologic features of RCCs and explored the risk factors for prognosis. Our findings may provide valuable prediction for clinical strategy.

The Role of Cytoreductive Nephrectomy for Sarcomatoid Renal Cell Carcinoma: A 29-Year Institutional Experience

OBJECTIVE

To assess which patients respond best following cytoreductive nephrectomy for renal cell carcinoma (RCC) with sarcomatoid dedifferentiation (sRCC) and whether outcomes are improving over time.

METHODS

We identified 562 patients with metastatic RCC treated between 1989 and 2018 with cytoreductive nephrectomy. We reviewed baseline clinical and pathologic characteristics, including the presence of sRCC, and metastatic sites at time of nephrectomy. The primary study endpoint was overall survival (OS). Univariate and multivariate Cox-regression analyses were used to identify significant predictors of OS.

RESULTS

The study cohort had 192 sRCC patients, with a median age of 59 years. Frequently involved metastatic locations were lung (n = 115), retroperitoneal nodes (n = 63), and axial skeleton (n = 43). Lung metastasis were more prevalent in clear cell histology (P = .0017) whereas nodal involvement was associated with nonclear cell subtypes (P = .0064). Median follow-up was 14 months. Estimated 2- and 5-year OS were 34.1% and 14.8%, respectively. On multivariate analysis, metastases to the liver (HR = 1.64; 95% CI 1.02-2.63; P = .04), lung (HR = 1.50; 95% CI 1.05-2.14; P = .03), retroperitoneal nodes (HR = 1.52; 95% CI 1.03-2.25; P = 0.04) and nonclear cell histology (HR = 1.61; 95% CI 1.10-2.35; P = .01) were associated with worse OS in the sRCC cohort.

CONCLUSION

OS after cytoreductive nephrectomy for sRCC and non-sRCC is improving over time. In patients with sRCC, presentations with unifocal metastasis not involving the liver or lung, clear cell histology and node negative disease have better outcomes following cytoreductive nephrectomy and may yield greater benefit from the procedure.

Primitive neuroectodermal tumour with synchronous ipsilateral clear cell carcinoma of the kidney

We report the first case of a synchronous ipsilateral primitive neuroectodermal tumour (PNET) and clear cell renal cell carcinoma of the kidney. A 37-year-old man presented to the emergency department with a 24-hour history of colicky abdominal pain and visible haematuria. He had no relevant surgical or medical history. Physical examination was unremarkable apart from mild left flank tenderness. Triphasic CT of the abdomen and pelvis showed two solid lesions in the left kidney. Further staging CT of the chest showed no evidence of local or distal metastasis. He subsequently underwent laparoscopic radical nephrectomy. Pathological analysis of the kidney showed two synchronous renal tumours, a clear cell carcinoma and PNET of the kidney. The patient received adjuvant chemotherapy according to Ewing's sarcoma chemotherapy protocol. Surveillance CT scans at 3, 6 and 12 months showed no evidence of disease recurrence or metastasis.

Ki-67 index and percentage of sarcomatoid differentiation were two independent prognostic predictors in sarcomatoid renal cell carcinoma

Purpose

To identify whether and which of pathological features of sarcomatoid differentiation (SD) in renal cell carcinoma (RCC) can be used as independent predictors associated with overall survival (OS).

Materials and methods

After institutional review board approval, patients with a diagnosis of sarcomatoid RCC (sRCC), spindled RCC, or RCC with the presence of spindle cells between 2003 and 2017 were further selected and re-examined. The primary pathological features including histological subtypes, tumor necrosis, Ki-67 index of SD, and the percent of SD (%SD) were included into analysis. Histological subtypes were categorized into clear-cell RCC and nonclear-cell RCC. Ki-67 index of SD was confirmed by immunohistochemical staining. %SD was estimated through reviewing all of the tumor sections microscopically and then giving an approximate %SD within the entire tumor. The clinical relevant prognostic predictor's association with OS was analyzed within Cox proportional hazards regression models. Survival curves were generated using the Kaplan-Meier method, and OS differences were compared using the log-rank test.

Results

A total of 2,089 consecutive patients of RCC were referred to our department, of whom 62 (3.0%) patients were identified with histological element of SD after re-examining the available slides of suspicious cases. Finally, 53 patients were included into survival analysis after excluding 9 patients without adequate information. Thirty-eight (71.7%) patients died at last follow-up. The median OS for all patients was 11.0 months from the date of surgery. In patients with clinical distant metastasis (cM₁), the median OS was only 3 compared with 21 months for patients with no clinical distant metastasis (cM₀). Tumor stage, status of clinical distant metastasis, Ki-67 index, and %SD were independent predictors of multivariate analysis in overall 53 patients. However, in the cohort of cM₀ patients, we found that only %SD and Ki-67 index were two independent predictors of OS in multivariate analysis.

Conclusion

Patients with sRCC are associated with very poor prognosis. Ki-67 index of SD and %SD were identified as the two most important independent predictors particularly for nonmetastatic patients. The limitations of our study were also observed, and further studies are needed.

Surgical Metastasectomy in Renal Cell Carcinoma: A Systematic Review

CONTEXT

The benefit of surgical metastasectomy (SM) for patients with metastatic renal cell carcinoma (mRCC) remains controversial because of the lack of high-level evidence on the role of SM in terms of survival benefit in the era of systemic therapy.

OBJECTIVE

To perform a systematic review of the literature on the role of SM in the treatment of mRCC and discuss key issues in the SM decision-making process.

EVIDENCE ACQUISITION

A systematic search of the Embase and Medline databases was carried out and a systematic review of the role of SM in mRCC was performed. A total of 56 studies were finally included in the evidence synthesis.

EVIDENCE SYNTHESIS

All the studies included were retrospective and mostly noncomparative. Median overall survival (OS) ranged from 36 to 142mo for those undergoing SM, compared to 8-27mo for no SM. SM was associated with a lower risk of all-cause mortality compared to no SM (pooled adjusted hazard ratio 2.37, 95% confidence interval 2.03-2.87; p<0.001). Morbidity and mortality were similar for SM and primary tumor surgery. The most important prognostic factor for OS was complete resection of metastases. Other prognostic factors included disease free-survival from nephrectomy, primary tumor features (T stage ≥3, high grade, sarcomatoid features, and pathological nodal status), the number of metastases, and performance status. Lung metastasectomy seemed to show the best survival benefit.

CONCLUSIONS

Although no randomized clinical data are available, published studies support the role of SM in selected patients in the modern era. Complete SM allows sustained survival free of systemic treatment. Integration of SM and systemic therapy in a multimodal approach remains a valid option for some patients.

PATIENT SUMMARY

Surgical resection of metastases originating from renal cell carcinoma may play a role in prolonging survival and avoiding systemic therapy when complete resection is achievable. This strategy is an option for selected patients with a limited number of metastases who still have good general health status.

The prognostic value and clinicopathological features of sarcomatoid differentiation in patients with renal cell carcinoma: a systematic review and meta-analysis

Background and purpose

Numerous studies have demonstrated that sarcomatoid differentiation is linked to the risk of renal cell carcinoma (RCC). However, its actual clinicopathological impact remains inconclusive. Therefore, we undertook a meta-analysis to evaluate the pathologic and prognostic impacts of sarcomatoid differentiation in patients with RCC by assessing cancer-specific survival, overall survival, recurrence-free survival, progression-free survival, and cancer-specific mortality.

Materials and methods

In accordance with the preferred reporting items for systematic reviews and meta-analysis statement, relevant studies were collected systematically from PubMed, Embase, and Web of Science to identify relevant studies published prior to January 2018. The pooled effects (hazard ratios, odds ratios, and standard mean differences) and 95% confidence intervals were calculated to investigate the association of sarcomatoid differentiation with cancer prognosis and clinicopathological features.

Results

Thirty-five studies (N=11,261 patients [n=59-1,437 per study]) on RCC were included in this meta-analysis. Overall, the pooled analysis suggested that sarcomatoid differentiation was significantly associated with unfavorable cancer-specific survival (HR=1.46, 95% CI: 1.26-1.70, p<0.001), overall survival (HR=1.59, 95% CI: 1.42-1.78, p<0.001), progression-free survival (HR=1.61, 95% CI: 1.35-1.91, p<0.001), recurrence-free survival (HR=1.60, 95% CI: 1.29-1.99, p<0.001), and cancer-specific mortality (HR=2.36, 95% CI: 1.64-3.41, p<0.001) in patients with RCC. Moreover, sarcomatoid differentiation was closely correlated with TNM stage (III/IV vs I/II: OR=1.84, 95% CI: 1.12-3.03, p=0.017), Fuhrman grade (III/IV vs I/II: OR=8.37, 95% CI: 2.92-24.00, p<0.001), lymph node involvement (N1 vs N0: OR=1.88, 95% CI: 1.08-3.28, p=0.026), and pathological types (clear cell RCC-only vs mixed type: OR=0.48, 95% CI: 0.29-0.80, p=0.005), but was not related to gender (male vs female, OR=0.86, 95% CI: 0.58-1.28, p=0.464) and average age (SMD=-0.02, 95% CI: -0.20-0.17, p=0.868).

Conclusion

This study suggests that sarcomatoid differentiation in histopathology is associated with poor clinical outcome and advanced clinicopathological features in RCC and could serve as a poor prognostic factor for RCC patients.

Epidemiology, biology and treatment of sarcomatoid RCC: current state of the art

Long recognized to confer an extremely poor prognosis, sarcomatoid dedifferentiation of renal cell carcinoma (sRCC) is a tumor phenotype that is finally beginning to be better understood on the molecular and genetic levels. With an overall incidence that ranges from 1 to 32% depending on associated RCC subtype, the survival of sarcomatoid RCC patients rarely exceeds 2 years. The main reasons for its poor outcome include its aggressive biology, its tendency to present at an advanced or metastatic stage at the time of diagnosis, its high rate of tumor recurrence after nephrectomy, and its limited response to systemic therapies. Molecular pathology studies suggest that sarcomatoid dedifferentiation originates from a focal epithelial-mesenchymal transition (EMT) arising in the carcinomatous component of the tumor. It is hoped that the growing understanding of the molecular biology of sRCC will soon make it possible to adapt treatments based on the identification of actionable tumor alterations. The deliberate inclusion of these patients in the multicenter clinical trials of immune, targeted and combination therapies is a necessary next step in pioneering future treatment strategies.

Role of metastasis-directed treatment in kidney cancer

Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.

Sarcomatoid renal cell carcinoma: Biology and treatment advances

Sarcomatoid transformation in renal cell carcinoma, so called sacromatoid RCC (sRCC), is associated with an aggressive behavior and a poor prognosis. Current therapeutic approaches are largely ineffective. Recent studies looking into the genomic and molecular characterization of sRCCs have provided insights into the biology and pathogenesis of this entity. These advances in molecular signatures may help development of effective treatment strategies. We herein present a review of recent developments in the pathology, biology, and treatment modalities in sRCC.

Clinical outcomes of the sequential use of pazopanib followed by everolimus for the treatment of metastatic renal cell carcinoma: A multicentre study in Korea

INTRODUCTION

The aim of this study was to investigate the real-world clinical outcomes of first-line pazopanib and second-line everolimus in Korean patients with metastatic renal cell carcinoma (mRCC).

METHODS

Data of patients who had mRCC with clear-cell component between 2001 and 2015 at multiple institutions were collected retrospectively. To be included in the analysis, patients had to meet the following criteria: age ≥18 years; received first-line targeted therapy with pazopanib; and received second-line targeted therapy with everolimus. The primary outcomes included overall survival (OS), progression-free survival (PFS), and adverse events (AEs).

RESULT

A total of 36 patients were included in the analysis. The median followup period was 33.5 months (range 17-49.5). The median PFS was eight months (95% confidence interval [CI] 6.4-9.6) after treatment with pazopanib and three months (95% CI 1.9-4.1) with everolimus. The median OS was 27 months (95% CI 16.6-37.4). The median treatment duration was seven months (range 4.3-10.8) after treatment with pazopanib and 3.5 months (range 3-4) with everolimus. Multivariate analysis revealed that the Heng risk criteria were independently associated with OS (p<0.001). Almost every patient experienced some form of AE, the majority of which were mostly mild or moderate in severity. The most common AEs were diarrhea (50%), hypertension (44.4%), and fatigue (41.7%) after treatment with pazopanib, and anemia (47.2%), stomatitis (41.7%), and fatigue (38.9%) with everolimus.

CONCLUSIONS

The outcomes for the patients treated with pazopanib followed by everolimus in Korea as observed by us were consistent with those reported by previous studies. The Heng risk criteria were significantly associated with the prognosis of patients with mRCC. AEs were mainly mild to moderate and readily managed.

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.

[Is surgical treatment ever indicated in metastatic renal cell carcinoma and if so, based on which scientific rationale?]

BACKGROUND

Metastasis is a common event in renal cell carcinoma. Surgical resection of metastases may be feasible in two scenarios: aiming at palliation, which may be feasible due to reduced radiosensitivity of renal cell cancer, and aiming at prolonging survival, which may be feasible given the rather good prognosis of some patterns of metastasis.

OBJECTIVE

This review intends to reflect on current evidence for surgical resection of metastases in both scenarios. The literature was searched in PubMed and respective guidelines were reviewed.

RESULTS AND CONCLUSIONS

Palliative resection is mainly feasible to control symptoms like spinal compression; adjuvant radiation is advisable. Resection is markedly feasible, however, for improvement of cancer-specific survival in probably all resectable patterns of metastasis-solitary, multiple, syn- and metachronous, and in all organs-provided complete resection can be achieved. A fairly good prognosis is seen in solitary pulmonary metastasis without concomitant hilar or mediastinal lymph node metastasis and a metachronous appearance following long recurrence-free survival after tumor nephrectomy; complete resection may be considered curative in certain cases. Neo- or adjuvant medical therapy or radiation is not established. In cases lacking complete resectability, stereotactic radiation may be considered as an alternative.