Nephrectomy for metastatic renal cell carcinoma: Indiana University experience

Dealing with malignancy involving the inferior vena cava in the 21st century

INTRODUCTION

Malignancies involving the inferior vena cava (IVC) have historically been considered not amendable to surgery. More recently, involvement of the IVC by neoplastic processes in the kidney, liver or in the retroperitoneum can be managed successfully.

EVIDENCE ACQUISITION

In this systematic review we summarize the current evidence regarding the surgical management of the IVC in cases of involvement in neoplastic processes. Current literature was searched, and studies selected on the base of the PRISMA guidelines. Evidence was synthesized in narrative form due to heterogeneity of studies.

EVIDENCE SYNTHESIS

Renal cell carcinoma accounts for the greatest proportion of studied patients and can be managed with partial or complete vascular exclusion of the IVC, thrombectomy and direct closure or patch repair with good oncological prognosis. Hepatic malignancies or metastases may involve the IVC, and the joint expertise of hepatobiliary and vascular surgeons has developed various strategies, according to the location of tumor and the need to perform a complete vascular exclusion above the hepatic veins. In retroperitoneal lymph node dissection, the IVC can be excised en-block to guarantee better oncological margins. Also, in retroperitoneal sarcomas not arising from the IVC a vascular substitution may be required to improve the overall survival by clearing all the neoplastic cells in the retroperitoneum. Leiomyoma can have a challenging presentation with involvement of the IVC requiring either thrombectomy, partial or complete substitution, with good oncological outcomes.

CONCLUSIONS

A multidisciplinary approach with specialist expertise is required when dealing with IVC involvement in surgical oncology. Multiple techniques and strategies are required to deliver the most efficient care and achieve the best possible overall survival. The main aim of these procedures must be the complete clearance of all neoplastic cells and achievement of a safe margin according to the perioperative treatment strategy.

Cytoreductive nephrectomy in metastatic renal cell carcinoma

Metastatic renal cell carcinoma is associated with a poor prognosis and a median survival time of only 6-12 months. However, the emergence of immunotherapies has rekindled interest in cytoreductive nephrectomy as a therapeutic option. Phase III randomized trials have demonstrated that cytoreductive nephrectomy significantly improves overall survival in selected patients with metastatic renal cell carcinoma treated with interferon immunotherapy. While cytokine-based immunotherapy may be considered the standard systemic therapy, clinical studies are ongoing to develop molecular biomarkers and new therapies with improved efficacy and tolerability. With further advances in our understanding of the pathogenesis, behavior and molecular biology of renal cell carcinoma, cytoreductive nephrectomy, in combination with molecular targeted therapies, may become the new standard of care for patients with metastatic renal cell carcinoma.

New surgical horizons: the role of cytoreductive nephrectomy for metastatic kidney cancer

Renal cell carcinoma is the most lethal urologic malignancy. Up to 30% of patients with kidney cancer have metastatic disease and 30% of those treated for local or locally advanced disease will progress to metastases. Radical nephrectomy is the standard treatment for the management of nondisseminated kidney cancer, but the role of cytoreductive nephrectomy for patients with metastatic disease is controversial. In this paper, the rationale for cytoreductive nephrectomy is described and the currently available evidence for and against it is evaluated. The different approaches to defining prognostic factors to select which patients will benefit from cytoreductive nephrectomy will also be described. Finally, the role of cytoreductive nephrectomy in the era of new targeted therapies is discussed.

[Role of surgery (cytoreductive nephrectomy and metastasectomy) in the management of metastatic renal cell carcinoma: a literature review]

Cytoreductive nephrectomy is an established treatment option prior immunotherapy in well-selected patients with metastatic renal cell carcinoma. With the recent introduction of new targeted agents, the role of surgery has been source of controversy. This review examines the role of cytoreductive nephrectomy during the immunotherapy era, then in the new targeted therapies era. This review also summarizes the optimal timing of these treatments, the prognostic factors predicting outcome following cytoreductive nephrectomy, the role of metastasectomy, partial and laparoscopic cytoreductive nephrectomy.

Cytoreductive nephrectomy for metastatic RCC in the era of targeted therapy

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

Nefrectomía radical laparoscópica

In this article, we review the different surgical approaches to carry out radical laparoscopic nephrectomy: transperitoneal approach, retroperitoneal approach and hand-assisted approach. We describe the advantages and drawbacks of each alternative and summarize the most important references in the medical literature. In spite of this being a relatively new surgical approach, less than 15 years old, it has become a standard treatment and, today, is considered as the elective surgical treatment for T1 and T2 renal tumours in many centres.

Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?

PURPOSE OF REVIEW

Laparoscopic radical nephrectomy has been developed and applied for patients with renal cell carcinoma since 1992. The number of patients undergoing laparoscopic radical nephrectomy has increased explosively worldwide in recent years, and laparoscopy is now extended to patients with advanced disease. It is very important to clarify the present status of laparoscopic radical nephrectomy among the treatment modalities for patients with renal cell carcinoma.

RECENT FINDINGS

Laparoscopic radical nephrectomy has a minimally invasive nature as well as comparable long-term cancer control in patients with pT1-3a renal cell carcinoma to open surgery. It is technically applicable for N1-2 disease and T3b disease if the tumor thrombus is within the renal vein. Also, it is feasible as a cytoreductive surgery for patients with M1 disease.

SUMMARY

Laparoscopic radical nephrectomy is a standard treatment modality for T1-3a renal cell carcinoma patients. It is also available for treating patients with N1-2 disease, and for patients with M1 disease as a cytoreductive surgery.

Surgery for metastatic renal cell cancer

Renal cell carcinoma (RCC) often presents in its metastatic form, or progresses after curative treatment. While the management of metastatic RCC has historically been mainly surgical, contemporary approaches often incorporate systemic immunotherapy. This review examines the current indications and scope of surgical treatment of patients with metastatic RCC. Surgery is sometimes indicated for symptom palliation at either the primary or secondary sites. However, other less invasive therapies may be equally effective, and should be considered carefully. Cytoreductive surgery prior to immunotherapy appears to confer a survival advantage, but only selected patients are suitable for this treatment regimen. Primary immunotherapy followed by surgical removal of the tumour in partial responders is an alternative treatment strategy, which has not yet been evaluated as in randomized trials. As immunotherapy develops further, the precise timing and role of surgery in multimodality treatment will need to be carefully evaluated. Occasionally, the complete surgical excision of metastases, and the primary tumour, if present, is feasible and this may prolong survival. Empirically, it would seem that such patients should also be treated with adjuvant immunotherapy, as eventual relapse is frequent. Surgery with the aim of inducing spontaneous tumour regression is not justifiable, given the rarity of this phenomenon.

[Role of nephrectomy in metastatic renal cell carcinoma. Experience of the Department of Urology Juan Canalejo Hospital]

OBJECTIVES

We expose our experience in nephrectomy in metastatic renal cell carcinoma, and also show complications, evolution and survival of these patients.

MATERIAL AND METHODS

We performe a retrospective review of renal cell carcinoma treated at our service in the period between January 1st 1991 and December 31st 2002. We only studied those which presented in a metastatic pattern (31), and divide these in two groups: the ones which were nephrectomized and those which were not. We try to showw the differences between the two groups in order of status performance (E.C.O.G.), associated morbidity and median survival. In the first group we also study complications of surgery and treatment that patients underwent.

RESULTS

we performed nephrectomy in 19 cases, all of them E.C.O.G. 0-1. Median postoperative stay was 12 days, and complication rate was 11.5%. Of these patients, 45% underwent some type of systemic treatment, and median survival was 31 months. We didn't performed nephrectomy in 12 patients, of which 9 were E.C.O.G. 2-3. Associated co-morbidity was higher in this group. Only in three patients any treatment was offered always with palliative reason. Median survival was 3.8 months.

CONCLUSIONS

In those patients with good performance status this approach does not represent more morbility nor mortality than in non-metastatic patients, and that is a cornerstone in their management. We also make a literature review in which we see the last pathways in the management of these patients, and that show the needing for a combined approach both quirurgical and inmunotherapical. We have review with special interest the studie's conclusions of SWOG and EORTC groups.