Potential role of nephrectomy in the treatment of metastatic renal cell carcinoma: a retrospective analysis

The use of cytoreductive nephrectomy in patients with renal cell carcinoma

INTRODUCTION

The systemic options for managing metastatic renal cell carcinoma (mRCC) have expanded considerably over the past decade. Initially limited to cytokines, clinicians may now choose from several classes of targeted therapies and, most recently, immune checkpoint inhibitors. Areas covered: In this review, we discuss the role and timing of cytoreductive nephrectomy (CN) and its evolution starting with cytokines, and then alongside the emergence of targeted therapy and novel immunotherapy with immune checkpoint inhibitors. Patient selection remains the most critical determinant in offering CN, and the anticipated survival benefits of CN must be weighed against the surgical morbidity and potential delay to receipt of systemic therapies. Expert opinion: Proper patient selection is key for decision-making in mRCC. Prospective data is urgently needed to define the role of CN in the contemporary immunotherapy era, with greater personalization of prognostic models.

Effect of renal embolization in patients with synchronous metastatic renal cell carcinoma: a retrospective comparison of cytoreductive nephrectomy and systemic medical therapy

Objective

To compare survival outcomes for renal embolization (RE) to cytoreductive nephrectomy (CN) and no primary renal treatment (NT) among patients with synchronous metastatic renal cell carcinoma (mRCC) treated using either targeted therapy (TT) or immunotherapy (IT).

Results

The median follow-up duration was 81.3 months, with a duration of first-line treatment of 3.5 months. Among the 211 patients, the median PFS and OS were 4.4 and 10.6 months. Specifically for patients receiving TT (124 patients), the PFS and OS were 5.5 and 12.0 months. An intervention effect was identified only for OS, with a median OS of 20.1, 8.8 and 9.3 months for CN, RE and NT, respectively. After stratification by risk classification, CN provided a significant benefit on OS, compared to RE and NT, for patients with an intermediate risk (MSKCC). For those with a poor risk (Heng criteria), NT provided better survival than PFS (p=0.003), and a comparable survival to RE (p > 0.05).

Materials and Methods

Retrospective analysis of 211 patients, 87 treated with IT and 124 with TT, retrieved from our RCC database. Patients' risk factors for survival was evaluated using the Heng and MSKCC criteria, with only patients with an intermediate or poor survival risk included in the analysis. Between-group comparisons were evaluated with respect to progression-free survival (PFS) and overall survival (OS).

Conclusions

The differential effect of CN and RE on OS appears to be modulated by risk classification. In patients with a poor risk, RE should be implemented after careful consideration of comorbidities and life expectancy.

Role of embolization in the treatment of renal masses

Renal arterial embolization (RAE) performed for the treatment of renal masses has been proven to be a safe and effective technique, with several decades of experience. RAE is well tolerated with few complications, particularly if the time interval from embolization to surgery is reduced to less than 48 hours. Review of the literature suggests that RAE is also extremely effective for palliation of symptoms in the setting of nonoperative advanced stage renal cell carcinoma. In addition, this technique plays a large role in the management of angiomyolipomas that are symptomatic or at risk of spontaneous rupture. To date, RAE has not been evaluated in a randomized controlled setting, which has contributed to its underutilization. All of these potential benefits warrant the need for prospective studies for further validation.

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.

Ethanol ablation of renal cell carcinoma for palliation of symptoms in advanced disease

The aim of this study was to evaluate the efficacy of transarterial alcohol ablation of renal cell carcinoma (RCC) with distant metastasis for control of symptoms caused by primary disease. This was a retrospective study consisting of eight patients having stage IV RCC. The primary indication for embolization was hematuria in seven patients and flank pain in one patient. All eight patients underwent renal artery embolization with ethanol and gelatin sponge pledgets. After embolization periodic evaluation was done every 3 months up to 1 year. Patients treated for hematuria did not complain of hematuria at 3- and 6-month follow-up except one who died of disease after 5 months. At 9-month follow-up five patients were free of hematuria while one developed hematuria after 6 months of treatment and died after 8 months. After 1 year three patients had no hematuria. One patient who developed hematuria at 9 months died after 11 months, another patient died of cardiac arrest at 10 months. The only patient who was treated for flank pain did not complain of pain up to 1-year follow-up. To conclude, transarterial embolization of renal tumor using ethanol is very effective in controlling local symptoms such as hematuria and pain. Thus, it may be an alternative treatment offered to symptomatic patients who are either not fit for surgery or not willing to undergo surgery.

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.

Does Radical Nephrectomy with Immunochemotherapy Have Any Superiority over Embolization Alone in Metastatic Renal Cell Carcinoma?

INTRODUCTION

We evaluated the results and effects of radical nephrectomy followed by immunochemotherapy and embolization alone on the survival of patients with metastatic renal cell carcinoma.

PATIENTS AND METHODS

The study included 20 patients with histologically confirmed renal cell carcinoma. Ten patients were in the combined therapy group and the other 10 patients who were unable to undergo nephrectomy because of poor performance status or unresectable tumor were in the embolization group. Radical nephrectomy was performed on patients with good performance status (WHO criteria 0-1). Immunochemotherapy (interferon alpha 2a and 5-fluorouracil) was started within 1 month after surgery. A dose of 9 x 10(6) U/day interferon alpha 2a was subcutaneously administered 3 times a week. A dose of 750 mg/m2 5-fluorouracil was administered intravenously during 4 h in the first 5 days of treatment. 5-Fluorouracil therapy was converted to weekly intervals after the first 12 days. Combined therapy was continued for 3 months. Ethanol was used for transarterial embolization. The main renal arteries and parasitic arteries of the tumor were embolized.

RESULTS

There were no significant differences in age distribution, sex, affected side, tumor size and T stage between the groups. After completion of the combined therapy, 6 patients showed progression at the first control. Only 1 patient (10 %) had stable disease throughout the 10 months after combined therapy. One patient died of myocardial infarction on the 4th day in the embolization group. While progressive disease within the first 3 months was detected in 6 patients, the other 3 patients (30%) had stable disease for 14, 17 and 55 months, respectively. There was no complete response in any group and no patient was alive (died of renal cell carcinoma) at the time of the analysis of the study data. Whereas the median survival time was 11 months (1-80) (mean +/- SE: 22.2 +/- 9.1) in the combined group, this time was a median of 1 month (1-74) (mean +/- SE: 17.5 +/- 8.6) in the embolization group. There was no statistically significant difference in survival time between the groups (p > 0.05).

CONCLUSION

In this preliminary report, the clinical findings in embolization-group patients were definitively worse than the nephrectomy plus immunochemotherapy-group patients. In spite of these differences, combination therapy using radical nephrectomy and immunochemotherapy could not show superiority to embolization alone, especially in terms of survival time.

Renal artery embolisation in the palliative treatment of renal carcinoma

The aim of this study is to review the role and technique of renal artery embolisation (RAE), and assess its effectiveness in the palliative treatment of unresectable or inoperable renal cell carcinoma (RCC) in our institution. The study group consisted of 19 consecutive patients (16 male, 3 female; age range 47-87 years) who underwent palliative RAE for the treatment of renal carcinoma between January 2000 and December 2005. Unresectable disease was present in 11 patients (3 stage IVa, 8 stage IVb). Potentially resectable disease was present in 8 patients (4 stage II, 1 stage IIIa, 1 stage IIIb, 2 stage IIIc); however, these patients were unfit for surgery for other reasons. 13 patients presented with haematuria, which was gross in 7 patients. Nine patients complained of flank pain. RAE was performed using polyvinyl alcohol or embosphere particles, metallic coils and, in some cases, absolute alcohol was necessary. At the time of analysis, 12 patients had died while 7 patients were still alive, with an overall median survival for the study group of 6 months. In the 7 patients with transfusion dependant gross haematuria, there was stabilization of the haemoglobin level post-embolisation. In the 9 patients who presented with flank pain, symptoms improved or resolved in 8 patients. The median length of hospital stay for the 18 patients who were discharged was 5.0 days. RAE is a safe and tolerable management option for patients with inoperable or unresectable renal carcinoma as a means of palliation of local symptoms and improving clinical status, with low morbidity and shorter hospital stay.

Immuno-chemotherapy in metastatic renal cell carcinoma: long-term results from the rambam and linn medical centers, Haifa, Israel

Nephrectomy, immuno-chemotherapy and resection of residual disease have been the treatment of choice for patients with metastatic renal cell carcinoma during the past decades. The aim of this study was to report the long-term results of this treatment approach. Sixty-two patients with metastatic renal cell carcinoma participated in a Phase II study. At diagnosis, 32 patients had localized disease, 30 had metastatic disease and 53 underwent nephrectomy. Metastatic sites were lungs, lymph nodes, bones and liver. Immuno-chemotherapy consisted of: interleukin-2, interferon alpha, 5-fluorouracil and vinblastine. All patients were evaluated for toxicity and response to treatment. CR was achieved in 4 patients and PR in 14. Seven patients, with maximum response to immuno-chemotherapy underwent resection of residual tumor and reached CR. Therefore, CR was achieved in 11 patients (18%) with a median survival of +67 months. Flu-like symptoms were the common side effects. Performance status and histology type significantly affected survival. Nephrectomy, immuno-chemotherapy and resection of residual disease are recommended for patients with metastatic renal cell carcinoma.

Renal cell carcinoma with tumor thrombus extending above diaphragm: Avoiding cardiopulmonary bypass

OBJECTIVES

Renal cell carcinoma with a tumor thrombus extending into the supradiaphragmatic inferior vena cava (IVC) and right atrium represents a challenge to the surgical team. We describe a technique that can be used to resect these tumors safely through a transabdominal approach without recourse to cardiopulmonary bypass (CPB) or entry into the thoracic cavity.

METHODS

Between May 1997 and August 2004, 59 patients (mean age 61 years) underwent surgical resection of a renal tumor extending into the IVC by techniques developed with the intention to avoid sternotomy and CPB. In 7 patients (12%), the tumor thrombus extended into the supradiaphragmatic IVC and right atrium. Complete surgical resection was successful through a transabdominal approach without CPB in all 7 of these patients.

RESULTS

In the 7 patients who underwent the described technique, the median age was 71 years (range 51 to 80). The mean operative time was 7 hours, 47 minutes. The mean estimated blood loss was 2514 mL (range 500 to 6000). The mean number of blood units transfused was 4.7 (range 0 to 11). One patient died in the immediate postoperative period of cardiac arrhythmia. The median follow-up was 11.1 months, and 5 patients were disease free.

CONCLUSIONS

In select cases, renal cell carcinoma extending into the supradiaphragmatic IVC and right atrium can be resected without the use of CPB. We describe our technique.

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.

Combination of surgery and immunotherapy in metastatic renal cell carcinoma

The treatment of choice for non-disseminated renal cell cancer (RCC) is surgery. However, the 5-year survival rates for all stages do not exceed 60%, even in contemporary series. Further improvement will most likely have to await the development of a more effective systemic therapy and the application of combined treatment modalities to counter the relatively high number of patients presenting with advanced stages. Whereas textbook belief up to the 1990s suggested refraining from surgical antitumor-therapy in the case of metastatic RCC, current strategies clearly advocate debulking tumor nephrectomy in the context of modern immunotherapies. This dramatic change of attitude stemmed from two randomized phase III trials conducted by EORTC and SWOG, including a combined analysis of both studies, in which cytoreductive tumor nephrectomy conveyed a significant survival benefit over immunotherapy alone. Concepts and progress in this field appear to be of major interest for modern oncologic urologists following the advent of immunotherapeutic strategies that require surgical intervention at some stage of the treatment cascade.

Nephrectomy for metastatic renal cell carcinoma: Indiana University experience

OBJECTIVES

To report on the short-term morbidity of radical nephrectomy in 32 patients with poorer performance status and more advanced primary renal cell carcinoma (RCC). Nephrectomy followed by immunotherapy has been shown to improve survival in selected, good performance status patients with metastatic RCC.

METHODS

We report on 32 patients who underwent radical nephrectomy (20 open procedures and 12 laparoscopic) in the setting of metastatic RCC at Indiana University between 1999 and 2002. The study group included patients with advanced primary tumors (inferior vena cava involvement, large size, and involvement of adjacent structures). The patients' performance status score ranged from 0 to 2.

RESULTS

The average hospital stay was 5.1 days. No significant intraoperative complications were encountered, and postoperative complications occurred in 6 patients, including one perioperative death. At 4 weeks postoperatively, 21 (72.4%) of 29 assessable patients had a performance status equal to, or better than, their preoperative status, including 4 patients who converted from a preoperative performance status of 2 to 0 or 1 postoperatively. Eleven patients (34.4%) went on to receive postoperative immunotherapy.

CONCLUSIONS

The results of our study demonstrated that radical nephrectomy in the setting of metastatic RCC has a low morbidity and acceptable recovery in these patients with advanced primary tumors and poorer performance status.

Prognostic factors of renal cell carcinoma

PURPOSE

Determination of prognostic factors is essential for the management of renal cell carcinoma. Stage, histological grade and type, and performance status are now well known and commonly used. During the last decade numerous predictors of patient outcome were tested. This review summarizes the most important studies, explores and compares the results, and tries to respond to the question, "Today, what do we expect of clinical, molecular and genetic factors concerning survival of patients with renal cell carcinoma?"

MATERIALS AND METHODS

Based on MEDLINE literature searches we comprehensively reviewed the literature on the prognostic factors associated with the tumor, the patient and the treatment.

RESULTS

During the last decades numerous factors have been studied but few of them maintained independent significance in terms of overall survival as assessed by multivariate analysis. Results are more often controversial from one series to another. No known molecular or cytogenetic tumor marker has been identified to help diagnose, manage or confirm renal cell carcinoma remission, progression or relapse.

CONCLUSIONS

The classical prognostic factors remain histological grade, histological type, performance status, patient age, number and location(s) of metastatic sites, time to appearance of metastases and prior nephrectomy. The only striking advancement during the last few years has been the proven contribution of radical nephrectomy for metastatic disease in patients with good performance status.

Multimodality treatment of metastatic renal cell carcinoma

The treatment of choice for nondisseminated disease is surgery. However, the 5-year survival rates for all stages do not exceed 60%, even in contemporary series. Further improvement will most likely have to await the development of a more effective systemic therapy and the application of combined treatment modalities to counter the relatively high number of patients presenting with advanced stages. Treatment options in metastatic disease include nephrectomy, sometimes in combination with metastasectomy in selected cases, alone or cytoreductive surgery followed by immunotherapy. Alternatively, one may initially apply immunotherapy and perform adjuvant nephrectomy in the case of a response, or proceed to immunotherapy as a monotherapy. Nevertheless, long-term survival ranges from merely 5 to 10% depending strongly on patient selection criteria. Concepts and progress in this field appear to be of major interest for modern uro-oncologists following the advent of immunotherapeutic strategies that require a surgical intervention at some stage of the treatment cascade.

Interleukin-2, interferon-alpha, 5-fluorouracil, and vinblastine in the treatment of metastatic renal cell carcinoma: a prospective phase II study: the experience of Rambam and Lin Medical Centers 1996-2000

BACKGROUND

The current study evaluated the efficacy and toxicity of interleukin-2 (IL-2), interferon-alpha (IFN-alpha), 5-fluorouracil (5-FU), and vinblastine (VBL) in the treatment of metastatic renal cell carcinoma (MRCC).

METHODS

Sixty-two MRCC patients, median age 63 years, received immunochemotherapy. Eastern Cooperative Oncology Group performance status was 1 for 45 patients and 2 for 17 patients. Fifty-four patients underwent nephrectomy prior to treatment. Sites of disease were lungs, lymph nodes, bone, kidney, and liver. Treatment consisted of IL-2 10 MIU/m(2) subcutaneous (SC), three times per week, Weeks 1-4; IFN-alpha 6 MIU/m(2) SC, once per week, Weeks 1-4 and 9 MIU/m(2), three times per week, Weeks 5-7; 5-FU 600 mg/m(2) and VBL 6 mg/m(2), intravenous bolus, Day 1 of Weeks 5 and 7.

RESULTS

In a median followup of 34 months, 62 patients were evaluated for tumor response. Four patients achieved complete response for 26+, 34+, 51+, and 56+ months, respectively; 14 patients achieved partial response for a median of 14 months; and 20 patients achieved stable disease for a median of 9 months. Seven patients (5 partial response, 2 stable disease) underwent complete resection of residual tumor. Five patients remained alive with no evidence of disease for 27, 32, 36, 42, and 48 months, respectively. Nine patients achieved long-term complete response for a median of 36 months. Three-year survival rate for the entire group and for 11 complete responders was 88%. Common side effects were flu-like symptoms, nausea, headache, and depression. Four patients were excluded because of treatment intolerance, and one patient died after nephrectomy.

CONCLUSIONS

Immunochemotherapy is effective and well-tolerated by patients with MRCC. Surgical intervention for resection of residual disease is justified.

Principles of nephrectomy for malignant disease

For many years the prevailing belief was to advocate'radical' nephrectomy via a transperitoneal approach as the standard surgical procedure for renal cell carcinoma (RCC). because the early control of the renal vessels before manipulating the kidney should minimize the likelihood of disseminating tumour cells during surgery. This philosophy was based on retrospective data which were never confirmed in a controlled trial. Since then,evidence has accumulated that some patients maybe better served by an extraperitoneal (translumbar)approach, providing similar oncological efficacy with the added advantage of reduced morbidity. However,these results are again either retrospective or statistically insignificant, and therefore do not allow firm conclusions. Nevertheless, if there is any difference in the possible intraoperative dissemination of tumour, depending on the type of surgical approach, it will be small, requiring analysis in a large randomized multicentre trial. The treatment of choice for disease that is not disseminated is surgery, although the 5-year survival rates for all stages do not exceed 60%, even in contemporary series. Further improvements will probably have to rely on the development of more effective systemic therapy and the application of combined treatments to counter the relatively many patients presenting with advanced stages. Concepts and progress in this field appear to be of major interest for modern uro-oncologists after the advent of immunotherapeutic strategies that require a surgical intervention at some stage of the treatment cascade.

Prognostic factors in patients with renal cell carcinoma: retrospective analysis of 675 cases

OBJECTIVES

To identify independent predictors of cause-specific survival in patients affected by renal cell carcinoma (RCC).

MATERIAL AND METHODS

We evaluated retrospectively 675 patients who underwent in our department from 1976 to 1999 radical nephrectomy for RCC. Pathological stage of the primary tumor (TNM, 1997) was pT1 in 326 cases (48%), pT2 in 133 (20%), pT3a in 66 (10%), pT3b in 138 (20%) and pT4 in 12 (2%). According to TNM classification (Union International Contre le Cancer (UICC), 1997) the pathological stage was I in 303 cases (45%), II in 119 (18%), III in 150 (22%) and IV in 103 (15%). Histological grading was assigned according to Fuhrman's classification in only 333 cases: G1 in 25%, G2 in 35%, G3 in 33% and G4 in 7%.

RESULTS

Cause-specific survival was 77% at 5 years, 69% at 10 years, 64% at 15 years and 57% at 20 years. Five and 10 year cause-specific survival was, respectively 91.4 and 88.5% in pT1 tumors, 84.8 and 72.7% in pT2, 57.4 and 35.6% in pT3a, 47.2 and 33.6% in pT3b-c, and 29.6% in pT4 (P < 0.0001). In relation to the pathological stage according to TNM classification, 5 and 10 year cause-specific survival was, respectively 94 and 91.6% in stage I tumors, 89.7 and 78% in stage II, 63.4 and 46.4% in stage III and 28 and 16.3% in stage IV (P < 0.0001). In relation to the nuclear grade of the primary tumor 5 and 10 year cause-specific survival was, respectively 94 and 88% in G1 tumors, 86 and 75% in G2, 59 and 40% in G3 and 31% in G4 (P < 0.0001). At multivariate analysis pathological stage of the primary tumor, lymph nodes involvement, presence of distant metastases at diagnosis and nuclear grading resulted all independent predictors of cause-specific survival in patients with RCC.

CONCLUSION

Pathological stage of primary tumors, lymph nodes involvement, presence of distant metastases at diagnosis and nuclear grading according to Fuhrman resulted all independent predictors of cause-specific mortality in patients with RCC.

Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial

BACKGROUND

Surgery is the main treatment for localised renal cell carcinoma, but use of radical nephrectomy for metastatic disease is highly controversial. We aimed to establish whether radical nephrectomy done before interferon-alfa-based immunotherapy improved time to progression and overall survival (primary endpoints) compared with interferon alfa alone.

METHODS

We included 85 patients from June, 1995, to July, 1998: two (one per group) were ineligible. 42 of the 83 participants were randomly assigned combined treatment (study group) and 43 immunotherapy alone (controls). All patients had metastatic renal-cell carcinoma that had been histologically confirmed and was progressive at entry. In study patients, surgery was done within 4 weeks of randomisation, and immunotherapy (5x10(6) IU/m(2) subcutaneously three times per week) started 2-4 weeks later. In controls, immunotherapy was started within 1 working day of randomisation. Follow-up visits were monthly. All analyses were by intention to treat.

FINDINGS

40 (53%) of 75 patients received at least 16 weeks of interferon-alfa treatment, which was also the median duration of treatment. Time to progression (5 vs 3 months, hazard ratio 0.60, 95% CI 0.36-0.97) and median duration of survival were significantly better in study patients than in controls (17 vs 7 months, 0.54, 0.31-0.94). Five patients responded completely to combined treatment, and one to interferon alfa alone. Dose modification was necessary in 32% of patients, most commonly because of non-haematological side-effects.

INTERPRETATION

Radical nephrectomy before interferon-based immunotherapy might substantially delay time to progression and improve survival of patients with metastatic renal cell carcinoma who present with good performance status.

Prognostic evaluation of transcatheter arterial embolization for unresectable renal cell carcinoma with distant metastasis

OBJECTIVE

To evaluate the efficacy of transcatheter arterial embolization (TAE) in patients with unresectable renal cell carcinoma (RCC) and distant metastasis at the time of diagnosis.

PATIENTS AND METHODS

The study included 54 patients with histologically defined RCC (by biopsy in 28 and autopsy in 26) who were unable to undergo nephrectomy mainly because their performance status was poor (score > or = 2). The patients were classified into two groups; 24 patients who underwent TAE with ethanol and 30 patients who did not. The two groups were compared for several clinical factors, mainly focusing on the prognosis.

RESULTS

There were no significant differences in the clinical factors, including performance status, tumour diameter, vascular invasion, lymph node involvement, adjuvant therapy, metastatic organs or the number of metastases between the groups. However, the proportion of patients with para-neoplastic signs in those undergoing TAE was greater than that in those not, and the difference was significant (chi squared 0.35, P < 0.05). The median survival of the two groups was 229 days (TAE) and 116 days (no TAE). The 1-, 2- and 3-year survival rates in the TAE group were 29%, 15% and 10%, respectively, and in those not undergoing TAE were 13%, 7% and 3%, respectively. Those undergoing TAE had a significantly better prognosis than those who did not (P = 0.019). The adverse effects in patients undergoing TAE with ethanol included fever, back pain on the affected side, nausea and vomiting, but all the patients recovered from these adverse effects.

CONCLUSION

TAE with ethanol is a safe and effective treatment for patients with unresectable disseminated RCC and a poor performance status; TAE with ethanol not only induces ablation of the primary tumour, but also prolongs survival.