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Rossi SH, Klatte T, Usher-Smith JA, Fife K, Welsh SJ, Dabestani S, Bex A, Nicol D, Nathan P, Stewart GD, Wilson ECF. A Decision Analysis Evaluating Screening for Kidney Cancer Using Focused Renal Ultrasound. Eur Urol Focus 2021; 7:407-419. [PMID: 31530498 DOI: 10.1016/j.euf.2019.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/19/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Screening for renal cell carcinoma (RCC) has been identified as a key research priority; however, no randomised control trials have been performed. Value of information analysis can determine whether further research on this topic is of value. OBJECTIVE To determine (1) whether current evidence suggests that screening is potentially cost-effective and, if so, (2) in which age/sex groups, (3) identify evidence gaps, and (4) estimate the value of further research to close those gaps. DESIGN, SETTING, AND PARTICIPANTS A decision model was developed evaluating screening in asymptomatic individuals in the UK. A National Health Service perspective was adopted. INTERVENTION A single focused renal ultrasound scan compared with standard of care (no screening). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Expected lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER), discounted at 3.5% per annum. RESULTS AND LIMITATIONS Given a prevalence of RCC of 0.34% (0.18-0.54%), screening 60-yr-old men resulted in an ICER of £18 092/QALY (€22 843/QALY). Given a prevalence of RCC of 0.16% (0.08-0.25%), screening 60-yr-old women resulted in an ICER of £37327/QALY (€47 129/QALY). In the one-way sensitivity analysis, the ICER was <£30000/QALY as long as the prevalence of RCC was ≥0.25% for men and ≥0.2% for women at age 60yr. Given the willingness to pay a threshold of £30000/QALY (€37 878/QALY), the population-expected values of perfect information were £194 million (€244 million) and £97 million (€123 million) for 60-yr-old men and women, respectively. The expected value of perfect parameter information suggests that the prevalence of RCC and stage shift associated with screening are key research priorities. CONCLUSIONS Current evidence suggests that one-off screening of 60-yr-old men is potentially cost-effective and that further research into this topic would be of value to society. PATIENT SUMMARY Economic modelling suggests that screening 60-yr-old men for kidney cancer using ultrasound may be a good use of resources and that further research on this topic should be performed.
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Affiliation(s)
- Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Tobias Klatte
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Department of Urology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kate Fife
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Sarah J Welsh
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Saeed Dabestani
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Lund, Sweden
| | - Axel Bex
- The Royal Free London NHS Foundation Trust, Specialist Centre for Kidney Cancer, UK; Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Amsterdam, The Netherlands
| | - David Nicol
- Department of Urology, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK
| | - Paul Nathan
- Department of Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.
| | - Edward C F Wilson
- Cambridge Centre for Health Services Research, University of Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge, UK; Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK.
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Xue J, Chen W, Xu W, Xu Z, Li X, Qi F, Wang Z. Patterns of distant metastases in patients with clear cell renal cell carcinoma--A population-based analysis. Cancer Med 2020; 10:173-187. [PMID: 33247630 PMCID: PMC7826458 DOI: 10.1002/cam4.3596] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 12/11/2022] Open
Abstract
We developed this study to describe the patterns of distant metastasis (DM) and explore the predictive and prognostic factors of DM in clear cell renal cell carcinoma (ccRCC) patients. We collected the eligible patients from the Surveillance, Epidemiology, and End Result (SEER) database from 2010 to 2015. Then, comparisons of baseline characteristics between patients in different metastatic patterns were made. In addition, proportional mortality ratios (PMRs) and proportion trends of different patterns were calculated. Afterward, survival outcomes were explored by Kaplan–Meier (KM) analyses. Finally, predictive and prognostic factors of DM were investigated. A total of 33,449 ccRCC patients were eventually identified, including 2931 patients with DM and 30,518 patients without DM. 8.76% of patients suffered DM at their initial diagnosis, 35.01% of them had multiple metastases. Generally, lung (6.19%) was the most common metastatic site in patients with DM, and brain (1.20%) was the least frequent metastatic organ. The proportion trends of different metastatic patterns tended to be stable between 2010 and 2015. Moreover, higher tumor grade, T stage, and N stage were identified as risk factors of DM. Finally, age at diagnosis, grade, T stage, N stage, the administration of surgery, the number of metastatic sties, marital status, and household income were found to be significantly associated with prognosis. Lung was the most common metastatic site in ccRCC patients. Different survival outcomes and prognostic factors were identified for different metastatic patterns. Hence, our study would have great value for clinical practice in the future.
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Affiliation(s)
- Jianxin Xue
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Urology, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, the Second Hospital of Nanjing, Nanjing, China
| | - Wensun Chen
- First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Wenbo Xu
- Department of Surgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zicheng Xu
- Department of Urologic Surgery, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao Li
- Department of Urologic Surgery, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Qi
- Department of Urologic Surgery, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Zengjun Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Lyon TD, Gershman B, Shah PH, Thompson RH, Boorjian SA, Lohse CM, Costello BA, Cheville JC, Leibovich BC. Risk prediction models for cancer-specific survival following cytoreductive nephrectomy in the contemporary era. Urol Oncol 2018; 36:499.e1-499.e7. [PMID: 30228096 DOI: 10.1016/j.urolonc.2018.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/26/2018] [Accepted: 08/13/2018] [Indexed: 01/28/2023]
Abstract
INTRODUCTION To develop a risk-stratification model for cancer-specific survival (CSS) following cytoreductive nephrectomy (CN) in the contemporary era. MATERIALS AND METHODS A retrospective review was performed of 313 patients who underwent CN for M1 renal cell carcinoma (RCC) from 1990 to 2010. To account for the introduction of targeted therapies, timing of surgery was classified as immunotherapy era (1990-2004) or contemporary era (2005-2010). Risk scores were developed to predict CSS using Cox proportional hazards regression models. RESULTS A total of 215 (69%) and 98 (31%) patients were treated in the immunotherapy and contemporary eras, respectively. Median follow-up among survivors was 9.6 years, during which time 291 patients died, including 279 from RCC. On multivariable analysis limited to preoperative features, age ≥ 75, (hazard ratio [HR] 1.9), female sex (HR 1.9), constitutional symptoms (HR 1.61), radiographic lymphadenopathy (HR 1.59), and IVC tumor thrombus (HR 1.65) were significantly associated with CSS. On multivariable analysis including pathologic features, the features above as well as coagulative necrosis (HR 1.51) and sarcomatoid differentiation (HR 1.44) were significantly associated with CSS (all P < 0.05). Risk scores were developed for each model and used to predict CSS according to era. Decision curve analysis revealed that the preoperative risk score conferred a net benefit over a treat-all or treat-none approach beyond a 1-year cancer-specific mortality threshold of 25%. CONCLUSIONS We developed risk scores to predict CSS for patients treated with CN in the contemporary era. Patients with poor predicted survival may consider avoiding CN as initial management.
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Affiliation(s)
| | - Boris Gershman
- Warren Alpert Medical School of Brown University, Providence, RI; Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | - Paras H Shah
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - John C Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Patel MI, Beattie K, Bang A, Gurney H, Smith DP. Cytoreductive nephrectomy for metastatic renal cell carcinoma: inequities in access exist despite improved survival. Cancer Med 2017; 6:2188-2193. [PMID: 28834281 PMCID: PMC5633591 DOI: 10.1002/cam4.1137] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 01/28/2023] Open
Abstract
The use of cytoreductive nephrectomy (CRN) in the targeted therapy era is still debated. We aimed to determine factors associated with reduced use of CRN and determine the effect of CRN on overall survival in patients with metastatic renal cell carcinoma (RCC). All advanced RCC diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment and death were electronically linked. Follow-up was to the end of 2011. Multivariable logistic regression analysis was used to determine factors associated with the receipt of CRN. Cox proportional hazards model was used to determine factors associated with survival. A total of 1062 patients were identified with metastatic RCC of whom 289 (27%) received CRN. There was no difference in the use of CRN over the time period of the study. Females (OR 0.68 (95% CI: 0.48-0.96)), unmarried individuals (OR 0.68 (95% CI: 0.48-0.96)), treatment in a nonteaching hospital (OR 0.26 (95% CI: 0.18-0.36)) and individuals without private insurance (OR 0.29 (95% CI: 0.20-0.41)) all had reduced likelihood of receiving CRN. On multivariable analysis, not receiving CRN resulted in a 90% increase in death (HR 1.90 (95% CI: 1.61-2.25)). In addition, increasing age (P < 0.001), increasing Charlson comorbidity status (P = 0.002) and female gender also had a significant independent association with death. Despite a strong association with improved survival, individuals who are elderly, female, have treatment in a nonteaching facility or have no private insurance have a reduced likelihood of receiving CRN.
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Affiliation(s)
- Manish I Patel
- Discipline of Surgery, Westmead Hospital, University of Sydney, Sydney, Australia.,Department of Urology, Westmead Hospital, Westmead, Australia
| | - Kieran Beattie
- Department of Urology, Westmead Hospital, Westmead, Australia
| | - Albert Bang
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | - Howard Gurney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - David P Smith
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia.,Menzies Health Institute Queensland, Griffith University, Nathan, Australia
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Minnillo BJ, Tabayoyong W, Francis JJ, Maurice MJ, Zhu H, Kim S, Abouassaly R. Cytoreductive nephrectomy in the modern era: Predictors of use, morbidity, and survival. Can Urol Assoc J 2017; 11:E184-E191. [PMID: 28503232 DOI: 10.5489/cuaj.4137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To determine tumour, patient, and provider factors associated with cytoreductive nephrectomy (CN) use and to identify those factors that predicted short-term and long-term surgical outcomes. METHODS We performed a retrospective review (1998-2011) of the National Cancer Database, a U.S. population-based oncology outcomes database. The review included 36 549 patients with metastatic renal cell carcinoma (mRCC). We assessed predictors of CN use, length of stay (LOS), 30-day readmission, and 30-day mortality using multivariable logistic regression. The Cox proportional hazards model assessed predictors of overall survival (OS). RESULTS Overall, 10 809 (29.6%) patients received CN, increasing from 15.2% to 36.1% over time. Private insurance (odds ratio [OR] 1.26; 95% confidence interval [CI] 1.16-1.37) and academic facilities (OR 1.83; 95% CI 1.68-1.99) were associated with receiving CN (p<0.0001). Charlson score ≥2 and older age group were less likely to undergo surgery (p<0.0001). Median LOS was five days (inter-quartile range [IQR] 3-7), while 30-day readmission and 30-day mortality were 5.3% and 3.3%, respectively. Undergoing CN (hazard ratio [HR] 0.48; 95% CI 0.44-0.52; p<0.0001) and treatment at academic centres (HR 0.88; 95% CI 0.81-0.95; p=0.001) were independently associated with improved OS. Limitation includes retrospective design with possible selection bias. CONCLUSIONS Increased CN use continues in the modern era, with relatively low surgical morbidity. Further study is required to determine if the finding of lower all-cause mortality in patients treated at academic centres is due to improved care or unmeasured confounders.
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Affiliation(s)
- Brian J Minnillo
- Urological Institute, University Hospitals Case Medical Centre, Case Western Reserve University, Cleveland, OH, United States
| | - William Tabayoyong
- Urological Institute, University Hospitals Case Medical Centre, Case Western Reserve University, Cleveland, OH, United States
| | - John J Francis
- Urological Institute, University Hospitals Case Medical Centre, Case Western Reserve University, Cleveland, OH, United States
| | - Matthew J Maurice
- Urological Institute, University Hospitals Case Medical Centre, Case Western Reserve University, Cleveland, OH, United States
| | - Hui Zhu
- Urology Section/Surgery Service, Louis Stokes Cleveland Veterans Affairs Medical Centre, Cleveland, OH, United States
| | - Simon Kim
- Urological Institute, University Hospitals Case Medical Centre, Case Western Reserve University, Cleveland, OH, United States
| | - Robert Abouassaly
- Urological Institute, University Hospitals Case Medical Centre, Case Western Reserve University, Cleveland, OH, United States
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Khochikar MV. Cytoreductive Surgery in the Management of Renal Tumours: Rationale, Current Evidence and Future Perspectives. Indian J Surg Oncol 2017; 8:33-38. [PMID: 28127180 PMCID: PMC5236027 DOI: 10.1007/s13193-016-0592-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022] Open
Abstract
Renal cell carcinoma accounts for 3% of adult solid malignant tumours. Approximately 25% of the patients present with metastatic disease at presentation. In the era of immunotherapy (interferon alpha-2b and interleukin-2), studies showed significant survival benefit with cytoreductive nephrectomy (CRN) followed by interferon alpha-2b than interferon alpha 2-b alone. Introduction of targeted therapies (vascular endothelial growth factor receptor-tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors) in 2005 generated a great interest in the management of metastatic renal cell carcinoma (mRCC) as these drugs exhibited tumour shrinkage in the primary tumour as well as in the metastatic site/s. Though there is no level 1 evidence, many studies have shown the usefulness of cytoreductive nephrectomy along with targeted therapy as against to targeted therapy alone. This review is aimed at the rationale behind the cytoreductive nephrectomy in mRCC, the current evidence and what is in store for the future. A detailed search on the management of mRCC was carried out on MEDLINE, Embase, CANCERLIT and Cochrane Library databases using the key words "cytoreductive nephrectomy", "immunotherapy" and "targeted therapy" since 1980 till 2015. Original articles, review articles, monograms, book chapters on metastatic renal cancer and textbooks on urologic oncology, oncology and urology were reviewed. Various international guidelines on this issue were also studied. An identical search was performed using the American Society of Clinical Oncology Abstract database. Trials in the progress or recently completed that were relevant to this paper were identified through clinicaltrials.gov. The latest information for new articles ahead of publication was last accessed in November 2015. CRN has remained an integral part to the management of metastatic renal cell carcinoma mainly for the patients with good performance status, life expectancy of more than 12 months and in the absence of adverse prognostic factors. It had shown measurable survival benefit in the era of immunotherapy (CRN + immunotherapy vs. immunotherapy alone). In the era of targeted therapy, many studies have shown significant survival benefit with CRN + targeted therapy. However, there is no clear level 1 evidence to support this. The ongoing trials (CARMENA and European Organisation for Research and Treatment of Cancer SURTIME) would perhaps guide us in the way in which we should manage mRCC disease in the future. Maybe we may find some answers on the issues of the effectiveness of targeted therapy, the timing of CRN and sequencing these treatment arms once the results of these ongoing and future trials are through.
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Obara W, Karashima T, Takeda K, Kato R, Kato Y, Kanehira M, Takata R, Inoue K, Katagiri T, Shuin T, Nakamura Y, Fujioka T. Effective induction of cytotoxic T cells recognizing an epitope peptide derived from hypoxia-inducible protein 2 (HIG2) in patients with metastatic renal cell carcinoma. Cancer Immunol Immunother 2016; 66:17-24. [PMID: 27757561 PMCID: PMC5222936 DOI: 10.1007/s00262-016-1915-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 10/11/2016] [Indexed: 12/22/2022]
Abstract
Purpose Through genome-wide expression profile analysis, hypoxia-inducible protein 2 (HIG2) has previously been identified as an oncoprotein involved in development/progression of renal cell carcinoma (RCC). We subsequently identified a highly immunogenic HLA-A*0201/0206-restricted epitope peptide (HIG2-9-4) corresponding to a part of HIG2 and applied it as a therapeutic vaccine. We conducted a phase I clinical trial using the HIG2-9-4 peptide for patients with advanced RCC. Materials and Methods Nine patients having HLA-A*0201 or HLA-A*0206 with metastatic or unresectable RCC after failure of the cytokine and/or tyrosine kinase inhibitor therapies were enrolled in this study. The patients received subcutaneous administration of the peptide as an emulsion form with Montanide ISA-51 VG once a week in a dose-escalation manner (doses of 0.5, 1.0, or 3.0 mg/body, 3 patients for each dose). The primary endpoint was safety, and the secondary endpoints were immunological and clinical responses. Results Vaccinations with HIG2-9-4 peptide could be well tolerated without any serious systemic adverse events. Peptide-specific cytotoxic T lymphocyte (CTL) responses were detected in eight of the nine patients. Doses of 1.0 or 3.0 mg/body seemed to induce a CTL response better than did a dose of 0.5 mg/body, although the number of patients was too small to draw a firm conclusion. The disease control rate (stable disease for ≥4 months) was 77.8 %, and the median progression-free survival time was 10.3 months. Conclusions HIG2-9-4 peptide vaccine treatment was tolerable and effectively induced peptide-specific CTLs in RCC patients. This novel peptide vaccine therapy for RCC is promising.
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Affiliation(s)
- Wataru Obara
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan.
| | | | - Kazuyoshi Takeda
- Division of Cell Biology, Biomedical Research Center, Graduated School of Medicine, Juntendo University, Tokyo, Japan
- Department of Biofunctional Micribiota, Graduated School of Medicine, Juntendo University, Tokyo, Japan
| | - Renpei Kato
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Yoichiro Kato
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Mitsugu Kanehira
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Ryo Takata
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Keiji Inoue
- Department of Urology, Kochi Medical School, Kochi, Japan
| | - Toyomasa Katagiri
- Division of Genome Medicine, Institute for Genome Research, Tokushima University Graduate School, Tokushima, Japan
| | - Taro Shuin
- Department of Urology, Kochi Medical School, Kochi, Japan
| | - Yusuke Nakamura
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Tomoaki Fujioka
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
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Xiao WJ, Zhu Y, Dai B, Zhang HL, Ye DW. Assessment of survival of patients with metastatic clear cell renal cell carcinoma after radical cytoreductive nephrectomy versus no surgery: a seer analysis. Int Braz J Urol 2015; 41:288-95. [PMID: 26005970 PMCID: PMC4752092 DOI: 10.1590/s1677-5538.ibju.2015.02.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 06/06/2014] [Indexed: 11/22/2022] Open
Abstract
PURPOSES To examine the factors related to the choice of cytoreductive nephrectomy (CN) for patients with metastatic clear cell renal cell carcinoma (mCCRCC), and compare the population-based survival rates of patients treated with or without surgery in the modern targeted therapy era. MATERIALS AND METHODS From 2006 to 2009, patients with mCCRCC were identified from SEER database. The factors that affected patients to be submitted to CN were examined and propensity scores for each patient were calculated. Then patients were matched based upon propensity scores. Univariable and multivariable cox regression models were used to compare survival rates of patients treated with or without surgery. Finally, sensitivity analysis for the cox model on a hazard ratio scale was performed. RESULTS Age, race, tumor size, T stage and N stage were associated with nephrectomy univariablely. After the match based upon propensity scores, the 1-, 2-, and 3-year cancer-specific survival rate estimates were 45.1%, 27.9%, and 21.7% for the no-surgery group vs 70.6%, 52.2%, and 41.7% for the surgery group, respectively (hazard ratio 0.42, 95%CI: 0.35-0.52, log-rank P<0.001). In multivariable Cox proportional hazard regression model, race, T stage, N stage and median household income were significantly associated with survival. Sensitivity analysis on a hazard ratio scale indicated that the hazard ratio might be above 1.00 only when the unknown factor had an opposite effect on survival which was 3-fold than CN. CONCLUSION The results of our study showed that CN significantly improves the survival of patients with metastatic CCRCC even in the targeted therapy era.
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Affiliation(s)
- Wen-Jun Xiao
- Department of Urology, Fudan University Shanghai Cancer Centre, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yao Zhu
- Department of Urology, Fudan University Shanghai Cancer Centre, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Bo Dai
- Department of Urology, Fudan University Shanghai Cancer Centre, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Hai-Liang Zhang
- Department of Urology, Fudan University Shanghai Cancer Centre, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Ding-Wei Ye
- Department of Urology, Fudan University Shanghai Cancer Centre, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
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Gershman B, Moreira DM, Boorjian SA, Lohse CM, Cheville JC, Costello BA, Leibovich BC, Thompson RH. Comprehensive Characterization of the Perioperative Morbidity of Cytoreductive Nephrectomy. Eur Urol 2015; 69:84-91. [PMID: 26044802 DOI: 10.1016/j.eururo.2015.05.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/12/2015] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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10
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Culp SH, Karam JA, Wood CG. Population-based analysis of factors associated with survival in patients undergoing cytoreductive nephrectomy in the targeted therapy era. Urol Oncol 2014; 32:561-8. [DOI: 10.1016/j.urolonc.2013.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/09/2013] [Accepted: 12/12/2013] [Indexed: 02/03/2023]
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Conti SL, Thomas IC, Hagedorn JC, Chung BI, Chertow GM, Wagner TH, Brooks JD, Srinivas S, Leppert JT. Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era. Int J Cancer 2014; 134:2245-52. [PMID: 24135850 DOI: 10.1002/ijc.28553] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 11/06/2022]
Abstract
We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of CN occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing CN increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of CN. CN was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34–0.43). Median survival among patients receiving CN increased in the targeted therapy era (19 vs. 13 months), while median survival among patients not receiving CN increased only slightly (4 vs. 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received CN in the targeted therapy era. Despite decreased utilization in the targeted therapy era, CN remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of CN among patients with metastatic RCC treated with novel targeted therapies.
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Thorstenson A, Bergman M, Scherman-Plogell AH, Hosseinnia S, Ljungberg B, Adolfsson J, Lundstam S. Tumour characteristics and surgical treatment of renal cell carcinoma in Sweden 2005–2010: a population-based study from the National Swedish Kidney Cancer Register. Scand J Urol 2014; 48:231-8. [DOI: 10.3109/21681805.2013.864698] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Aizer AA, Urun Y, McKay RR, Kibel AS, Nguyen PL, Choueiri TK. Cytoreductive nephrectomy in patients with metastatic non-clear-cell renal cell carcinoma (RCC). BJU Int 2014; 113:E67-74. [PMID: 24053727 DOI: 10.1111/bju.12442] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Ayal A Aizer
- Harvard Radiation Oncology Program, Brigham and Women's Hospital, Boston, MA, USA
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Tsao CK, Small AC, Kates M, Moshier EL, Wisnivesky JP, Gartrell BA, Sonpavde G, Godbold JH, Palese MA, Hall SJ, Oh WK, Galsky MD. Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis. World J Urol 2012; 31:1535-9. [PMID: 23223962 DOI: 10.1007/s00345-012-1001-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 11/27/2012] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Two randomized trials published in 2001 provided level 1 evidence for the use of cytoreductive nephrectomy (CyNx) for the treatment of metastatic renal cell carcinoma (mRCC). However, the regulatory approval of vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) in 2005 has left an "evidence void" regarding the use of CyNx. We evaluated the patterns in the use of CyNx in the cytokine and VEGFR-TKI eras, and the patient characteristics associated with the use of CyNx. METHODS The Surveillance, Epidemiology, and End Results registry was used to identify patients with histologically or cytologically confirmed stage IV RCC between 2001 and 2008. Patients were classified as treated during the cytokine (2001-2005) or VEGFR-TKI (2006-2008) eras. A multivariate logistic regression analysis was performed to calculate the odds of undergoing CyNx according to treatment era and socioeconomic characteristics. RESULTS Overall, 1,112 of 2,448 patients (45%) underwent CyNx. CyNx use remained stable between 2001 and 2005 (50%), but decreased to 38% in 2008. Logistic regression analysis revealed that older age (OR 0.82, 95% CI: 0.68, 0.99), black race (OR 0.64, 95% CI: 0.46, 0.91), Hispanic ethnicity (OR 0.71, 95% CI: 0.54, 0.93), and treatment in the VEGFR-TKI era (OR 0.82, 95% CI: 0.68, 0.99) were independently associated with decreased use of CyNx. CONCLUSIONS Use of CyNx in the United States has declined in the VEGFR-TKI era. Older patients and minorities are less likely to receive CyNx. Results of ongoing phase III trials are needed to refine the role of this treatment modality.
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Affiliation(s)
- Che-kai Tsao
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Mount Sinai School of Medicine, 1 Gustave L Levy Place, New York, NY, 10029, USA
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Trends in the use of cytoreductive nephrectomy in the United States. Clin Genitourin Cancer 2012; 10:159-63. [PMID: 22651971 DOI: 10.1016/j.clgc.2012.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 03/14/2012] [Accepted: 03/21/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Two randomized trials published in 2001 established CyNx for patients with metastatic renal carcinoma (mRCC) as a treatment standard in the cytokine era. However, first-line systemic therapy for mRCC changed in 2005 with FDA approval of VEGFR TKIs. We evaluated the patterns of use of CyNx from 2000 to 2008. MATERIALS AND METHODS The National Cancer Database was queried for patients diagnosed with mRCC. Patients who underwent CyNx were identified and were further categorized by pre-VEGFR versus VEGFR TKI era, race, insurance status, and hospital. For these subcategories, prevalence ratios (PRs) were generated using the proportion of patients with mRCC undergoing CyNx versus those not undergoing CyNx. RESULTS Of the 47,417 patients (pts) identified with mRCC, the prevalence of cytoreductive nephrectomy increased 3% each year from 2000 to 2005 (P < .0001), then decreased 3% each year from 2005 to 2008 (P = .0048), with a significant difference between the eras (0.97 vs. 1.025; P < .0001). Black and Hispanic pts were less likely than Caucasian pts to undergo CyNx. Pts with Medicaid, Medicare, and no insurance were less likely than pts with private insurance to undergo CyNx. Pts diagnosed at community hospitals were significantly less likely than pts at teaching hospitals to undergo CyNx. CONCLUSION The use of CyNx has declined in the VEGFR-TKI era. In addition, racial and socioeconomic disparities exist in the use of CyNx. The results of pending randomized trials evaluating the role of CyNx in the VEGFR-TKI era are awaited to optimize use of this modality and address potential disparities.
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Crispen PL, Blute ML. Role of cytoreductive nephrectomy in the era of targeted therapy for renal cell carcinoma. Curr Urol Rep 2012; 13:38-46. [PMID: 22105577 DOI: 10.1007/s11934-011-0225-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
With the advent of targeted therapy for the treatment of metastatic renal cancer, the routine use of cytoreductive nephrectomy has been questioned. However, available data suggest that cytoreductive nephrectomy remains an integral part of treatment in properly selected patients. This review details the rationale for the continued use of cytoreductive nephrectomy in acceptable surgical candidates in the era of targeted therapy.
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Affiliation(s)
- Paul L Crispen
- Department of Surgery, University of Kentucky, Lexington, KY 40513, USA
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Lawson KA, Morris DG. Oncolytic virotherapy for renal cell carcinoma: a novel treatment paradigm? Expert Opin Biol Ther 2012; 12:891-903. [DOI: 10.1517/14712598.2012.685713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yap SA, Horovitz D, Alibhai SMH, Abouassaly R, Timilshina N, Finelli A. Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy - a population-based study. BJU Int 2012; 110:1283-8. [PMID: 22500493 DOI: 10.1111/j.1464-410x.2012.11125.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
UNLABELLED Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Surgical volume has been well established as a predictor of outcomes for several complex surgical procedures, yet few studies have evaluated this relationship with regards to radical nephrectomy with either renal vein or inferior vena cava thrombectomy. In addition, most published literature consists of single-institution series from centres of excellence. We performed a population-level analysis and identified surgeon volume as a significant predictor of short-term mortality for this procedure. Such findings have potential implications regarding future policy and regionalization of care. OBJECTIVE • To study the short-term mortality associated with radical nephrectomy with renal vein or inferior vena cava thrombectomy and the variables associated with this adverse outcome. METHODS • Using the Ontario Cancer Registry, we identified 433 patients in the province of Ontario, Canada undergoing radical nephrectomy with venous thrombectomy between 1995 and 2004. • We determined mortality rates at postoperative days 30 and 90. • Other variables analysed include pathological tumour characteristics, surgeon graduation year, hospital/surgeon academic status, surgery year and hospital/surgeon volume. • We used multivariable logistic regression to assess outcomes. RESULTS • Overall mortality was 2.8% (30-day) and 5.8% (90-day). • Surgeons performing a single nephrectomy with venous thrombectomy performed 14% of the cases and had the highest 30-day (6.7%) and 90-day (10%) mortality. The mortality rate for surgeons performing more than one surgery was 2.1% (30-day) and 5.1% (90-day). • In recent years, this procedure was performed more commonly by the highest volume surgeons - 67% of cases in 2004 vs 40% in 1995. • Significant predictors of 30-day mortality included procedure year and low surgeon volume. • Significant predictors of 90-day mortality included procedure year, low surgeon volume, left-sided tumour and increasing hospital volume. CONCLUSIONS • For radical nephrectomy with venous thrombectomy, surgeon volume predicts short-term mortality, emphasizing the importance of experience in patient outcome. • Despite a shift towards high-volume surgeons, 13.8% of cases continued to be performed by low-volume providers. • If these results are confirmed in other jurisdictions, radical nephrectomy with venous thrombectomy should be regionalized and performed by surgeons who manage these cases regularly.
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Affiliation(s)
- Stanley A Yap
- Division of Urologic Oncology, Princess Margaret Hospital and Department of Health Policy, University of Toronto, Toronto, Ontario, Canada
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Macfarlane R, Heng DYC, Xie W, Knox JJ, McDermott DF, Rini BI, Kollmannsberger C, Choueiri TK. The impact of kidney function on the outcome of metastatic renal cell carcinoma patients treated with vascular endothelial growth factor-targeted therapy. Cancer 2011; 118:365-70. [DOI: 10.1002/cncr.26201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 03/15/2011] [Accepted: 03/24/2011] [Indexed: 11/09/2022]
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Abdollah F, Sun M, Thuret R, Schmitges J, Shariat SF, Perrotte P, Montorsi F, Karakiewicz PI. Mortality and Morbidity After Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma: A Population-Based Study. Ann Surg Oncol 2011; 18:2988-96. [DOI: 10.1245/s10434-011-1715-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Indexed: 11/18/2022]
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Aben KKH, Heskamp S, Janssen-Heijnen ML, Koldewijn EL, van Herpen CM, Kiemeney LA, Oosterwijk E, van Spronsen DJ. Better survival in patients with metastasised kidney cancer after nephrectomy: a population-based study in the Netherlands. Eur J Cancer 2011; 47:2023-32. [PMID: 21459570 DOI: 10.1016/j.ejca.2011.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 02/22/2011] [Accepted: 03/01/2011] [Indexed: 01/12/2023]
Abstract
AIM Cytoreductive nephrectomy is considered beneficial in patients with metastasised kidney cancer but only a minority of these patients undergo cytoreductive surgery. Factors associated with nephrectomy and the independent effect of nephrectomy on survival were evaluated in this study. METHODS Patients were selected from the population-based cancer registry and detailed data were retrieved from clinical files. Factors associated with nephrectomy were evaluated by logistic regression analyses. Cox proportional hazard regression analysis was performed to evaluate factors associated with survival; a propensity score reflecting the probability of being treated surgically was included in order to adjust for confounding by indication. RESULTS 37.5% of 328 patients diagnosed with metastatic kidney cancer between 1999 and 2005 underwent nephrectomy. Patients with a low performance score, high age, ≥2 comorbid conditions, ≥2 metastases, low or high BMI, weight loss, elevated lactate dehydrogenase, elevated alkaline phosphatase, female gender and liver or bone metastases were less likely to be treated surgically. Three year survival was 25% and 4% for patients with and without nephrectomy, respectively (p<0.001). After adjustment for other prognostic factors including the propensity score, nephrectomy remained significantly associated with better survival (Hazard ratio: 0.52, 95% Confidence interval: 0.37-0.73). CONCLUSIONS Even after accounting for prognostic profile, patients still benefit from a nephrectomy; an approximately 50% reduction in mortality was observed. It is, therefore, recommended that patients with metastasised disease receive cytoreductive surgery when there is no contraindication. Trial results on cytoreductive surgery combined with targeted molecular therapeutics are awaited for.
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Affiliation(s)
- K K H Aben
- Department of Cancer Registry and Research, Comprehensive Cancer Centre East, Nijmegen, The Netherlands.
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Thuret R, Maurin C, Sun M, Perrotte P, Karakiewicz P. Traitement du carcinome rénal métastatique. Prog Urol 2011; 21:233-44. [DOI: 10.1016/j.purol.2010.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 11/25/2010] [Indexed: 12/23/2022]
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Whitson JM, Reese AC, Meng MV. Factors associated with surgery in patients with renal cell carcinoma and venous tumor thrombus. BJU Int 2010; 107:729-734. [DOI: 10.1111/j.1464-410x.2010.09593.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sun M, Lughezzani G, Perrotte P, Karakiewicz PI. Treatment of metastatic renal cell carcinoma. Nat Rev Urol 2010; 7:327-38. [DOI: 10.1038/nrurol.2010.57] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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