The role of cytoreductive nephrectomy in the management of metastatic renal cell carcinoma

Understanding and integrating cytoreductive nephrectomy with immune checkpoint inhibitors in the management of metastatic RCC

Cytoreductive nephrectomy became accepted as standard of care for selected patients with metastatic renal cell carcinoma (mRCC) because of improved survival observed in patients treated with cytoreductive nephrectomy in combination with interferon-α in two randomized clinical trials published in 2001. Over the past two decades, novel systemic therapies have shown higher treatment response rates and improved survival outcomes compared with interferon-α. During this rapid evolution of mRCC treatments, systemic therapies have been the primary focus of clinical trials. Results from multiple retrospective studies continue to suggest an overall survival benefit for selected patients treated with nephrectomy in combination with systemic mRCC treatments, with the notable exception of one debated clinical trial. The optimal timing for surgery is unknown, and proper patient selection remains crucial to improving surgical outcomes. As systemic therapies continue to evolve, clinicians have an increasing need to understand how to incorporate cytoreductive nephrectomy into the management of mRCC.

The role of cytoreductive nephrectomy in renal cell carcinoma patients with liver metastasis

It is widely accepted that renal cell carcinoma (RCC) with liver metastasis (LM) carries a dismal prognosis. We aimed to explore the value of cytoreductive nephrectomy among these patients. Patients were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. The univariate and multivariate Cox proportional hazards models were conducted to select the prognostic predictors of survival. Patients were divided into nephrectomy and non-nephrectomy groups. Propensity score-matching (PSM) analyses were applied to reduce the above factors' differences between the groups. Overall survival (OS) was compared by Kaplan-Meier analyses. Data from 683 patients were extracted from the database. The univariate Cox regression and multivariate Cox regression revealed that factors including age, histologic type, T and N stages, lung metastasis, brain metastasis, and nephrectomy were significant predictors of survival in the patients. After the PSM analyses, we found that nephrectomy prolonged OS. Nephrectomy can prolong OS in eligible RCC patients with LM.

Benefit of on nephrectomy for treating metastatic renal cell carcinoma

INTRODUCTION

Systemic treatment for metastatic renal cell carcinoma (mRCC) has changed with the new therapies, and it is not clear if nephrectomy (NEP) has a survival benefit in this kind of patients.

OBJECTIVE

To investigate if NEP associated to systemic treatment improves overall survival (OS) and progression-free survival (PFS).

MATERIAL AND METHODS

A retrospective, observational, descriptive study of 45 patients with diagnosis of mRCC between 2006-2014. Advanced cases with only palliative care were excluded, also patients with solitary metastasis who were managed with surgical resection.

RESULTS

Finally 34 patients were treated with systemic treatment. Twenty-six also with surgery associated. Seventy percent were intermediate/low risk at the Motzer classification and>80% Karnofsky performance status. PFS was 7m. NEP improves PFS (10 vs. 4m). High risk Motzer decreased PFS (P<.001). The OS was 11.5m. Patients with Karnofsky performance status>80, intermediate or low risk Motzer treated with NEP and mTOR as second line treatment, increased the OS (14 vs. 3m, P=.0001; 14 vs. 6m, P=.001; and 9 vs. 5m, P=.003, respectively). In the multivariate analysis only NEP (P=0,006; HR 4.5) and intermediate/low risk at the Motzer classification(P=.020; HR 8.9) demonstrated significant improvement in OS.

CONCLUSIONS

Patients treated with NEP associated to systemic treatment and with an intermediate/low risk in the Motzer classification had a better PFS and OS. The OS also improves in patients treated with mTOR in second line, and Karnofsky performance status>80%in the univariate study, but not in the multivariable one.

Cytoreductive nephrectomy with thrombectomy before targeted therapy improves survival for metastatic renal cell carcinoma with venous tumor thrombus: a single-center experience

Background

The aim of the study is to evaluate the role of cytoreductive nephrectomy (CN) with thrombectomy before targeted molecular therapy (TMT) on survival in metastatic renal cell carcinoma (mRCC) with venous tumor thrombus.

Methods

We performed a retrospective analysis of 47 patients treated in our center from April 2008 to October 2014. In the study, 20 patients underwent CN with thrombectomy followed by targeted therapy (group 1); 15 patients received targeted therapy alone (group 2); and 12 patients underwent CN with thrombectomy alone (group 3). The overall survival (OS) and cancer-specific survival (CSS) were calculated according to the Kaplan-Meier survival curve method, and prognostic variables were assessed by Cox regression analyses.

Results

The median follow-up times of group 1, group 2, and group 3 were 24.5, 12, and 6.5 months, respectively. During follow-up, in both group 1 and group 3, 12 patients died. In group 2, 14 patients died. The median OS of group 1, group 2, and group 3 was 22, 12, and 6 months, respectively (P < 0.001). Compared with surgery alone and targeted therapy alone, patients with cytoreductive surgery before targeted therapy had statistically better survival benefits (P < 0.001, P = 0.009, respectively). On univariate analysis, the number of metastatic sites (P = 0.004) was a statistically significant prognostic factor influencing OS.

Conclusions

Our single-center experience showed that CN with thrombectomy before targeted therapy improved the survival of patients with mRCC with venous tumor thrombus. The number of metastatic sites was an independent prognostic factor influencing OS.

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.

Treatment and survival of osseous renal cell carcinoma metastases

BACKGROUND

Renal cell carcinoma is the seventh leading cause of cancer deaths. Studies have shown patients with solitary osseous metastases have a better prognosis; however, methods of resection are not well defined. The purpose of this study was to review factors associated with survival and assess the impact of wide versus intralesional management on function and disease-specific outcomes in patients with renal cell carcinoma metastases.

METHODS

Sixty-nine patients with 86 osseous renal cell metastases were reviewed. Potential factors associated with survival were evaluated with Kaplan-Meier curves. ANOVA was performed to compare means between groups.

RESULTS

One year survival for the group was 77% and 32.5% at 5 years. The absence of metastatic disease at presentation, nephrectomy, and pre-operative status were associated with improved survival. There was a lower rate of local recurrence with wide resection (5%) versus intralesional procedures (27%).

CONCLUSIONS

Improved pre-operative status, nephrectomy, and metachronous lesions had better overall survival. Wide resection results in decreased local recurrence and revision surgeries. However, it did not reliably predict improved survival. Our recommendation is for individual evaluation of each patient with osseous renal cell carcinoma metastases. Wide excision may be used for resectable lesions to prevent local progression and subsequent surgeries.

Downsizing a thrombus of advanced renal cell carcinoma in a presurgical setting with sorafenib

A 53-year-old man presented with fever, 15 kg weight loss, ECOG performance status 0, and 12 × 9.5 cm renal tumor with an associated level II (near level III) tumor thrombus extending into the vena cava. We offered a presurgical targeted therapy to downsize the thrombus and primary tumor, which may reduce the extent of the surgery and operative risk. The patient accepted this approach with administration of sorafenib, resulting in a marked reduction of the primary renal tumor and 43% regression in tumor thrombus. Tumor shrinkage and regression of the thrombus allowed resection of the left kidney. Pathological findings revealed that part of the tumor was necrotic tissue. Two years after initiation of presurgical sorafenib therapy, the patient remains alive without evidence of disease progression.

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.

The value of cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy

PURPOSE

We evaluated the value of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma in the targeted therapy era.

MATERIALS AND METHODS

We reviewed the records of 78 patients treated with targeted therapy for metastatic renal cell carcinoma between 2006 and 2009. A total of 45 patients underwent cytoreductive nephrectomy followed by targeted therapy (cytoreductive nephrectomy group) and 33 were treated with targeted therapy alone (noncytoreductive nephrectomy group). We estimated progression-free and overall survival using Kaplan-Meier curves. The prognostic significance of each variable was estimated with a Cox proportional hazards regression model.

RESULTS

Clinicopathological variables did not differ in the 2 groups except for Karnofsky performance status and sarcomatoid feature. The treatment response rate did not differ in the 2 groups (23.1% vs 30.3%, p = 0.488). Median progression-free survival was 11.7 and 9.0 months in the cytoreductive and noncytoreductive nephrectomy groups (p = 0.270), and median overall survival was 21.6 and 13.9 months, respectively (p = 0.128). On multivariate analysis Karnofsky performance status (HR 2.9, 95% CI 1.4-5.7, p = 0.003) and sarcomatoid features (HR 2.9, 95% 1.3-6.7, p = 0.013) were independent predictors of progression-free survival. Karnofsky performance status (HR 3.3, 95% 1.7-6.5, p = 0.001), sarcomatoid features (HR 2.7, 95% 1.2-6.2, p = 0.021) and liver metastasis (HR 2.7, 95% 1.0-7.1, p = 0.045) were independent predictors of overall survival.

CONCLUSIONS

We found no significant differences in tumor response or survival between the 2 groups. Prospective trials are needed to confirm our results.

[Is the cytoreductive nephrectomy still necessary in case of metastases?]

Cytoredutive nephrectomy is a component of metastatic renal cell carcinoma management. This procedure can induce a spontaneous regression of metastases in a small number of cases. It increases the overall survival of correctly selected patients treated with immunotherapy. However, we still do not know if this benefit remains for patient treated with targeted therapies. In the three main prospective randomized studies evaluating targeted therapies, the majority of included patients have had prior nephrectomy. However, this surgical procedure is not without risk and could delay initiation of medical treatment. Age of patient, comorbidities, histologic pattern and surgical difficulties should be taken into account. Until results of prospective studies, the cytoreductive nephrectomy should be still considered as component of the treatment of metastatic renal cell carcinoma.

Neoadjuvant (presurgical) therapy for renal cell carcinoma: a new treatment paradigm for locally advanced and metastatic disease

BACKGROUND

Although upfront cytoreductive nephrectomy followed by systemic therapy remains the standard of care for metastatic renal cell carcinoma, the addition of novel targeted therapy has prompted a reevaluation of this treatment paradigm. The authors reviewed their experience with neoadjuvant systemic therapy administered before cytoreductive surgery for metastatic, locally recurrent, or regionally advanced renal cell carcinoma.

METHODS

The authors compared patients treated with presurgical targeted therapy (with sunitinib, sorafenib, or bevacizumab) with a contemporary group that underwent up-front cytoreductive surgery.

RESULTS

The authors found no difference in any perioperative surgical parameters indicative of morbidity or mortality between the 2 groups. Laboratory models of renal cell carcinoma treated with systemic targeted therapy demonstrate specific protein expression profiles that correlate with response to therapy and the development of therapy resistance.

CONCLUSIONS

Neoadjuvant (presurgical) targeted therapy before cytoreductive surgery appears safe in the setting of metastatic renal cell carcinoma. It identifies patients who respond to systemic therapy before surgery, thus avoiding highly morbid surgery in patients destined for a poor outcome. Further studies are needed to identify the molecular endpoints associated with treatment response and the development of the resistant phenotype, which will in turn identify novel transduction pathways worthy of therapeutic development.

Preoperative tyrosine kinase inhibition as an adjunct to debulking nephrectomy

OBJECTIVES

Since the introduction of tyrosine kinase inhibitors (TKI), treatment of metastatic renal cell carcinoma (RCC) has undergone dramatic changes. However, the use of TKI therapy in adjunctive settings remains to be defined. We present a single-institution experience of patients who received preoperative TKI before nephrectomy for metastatic or unresectable disease.

METHODS

The records of 9 patients with locally advanced or metastatic RCC treated with TKI therapy before nephrectomy at the University of North Carolina were reviewed. All procedures and radiographic images were performed at 1 institution. The cases were surveyed for the effect of TKI on tumor burden and surgical approach and timing.

RESULTS

The patients received systemic therapy with either sorafenib or sunitinib before proceeding to nephrectomy on clinical trials for metastatic disease or as the standard of care. The surgery was well tolerated by all patients, without an apparent effect from TKI therapy on the surgical technique or complications. Responses were observed in the primary tumor, as well as in the metastatic sites.

CONCLUSIONS

Neoadjuvant TKI therapy can induce responses in the primary tumor and has the potential advantage of cytoreduction when administered before nephrectomy for RCC. This setting also potentially provides an opportunity to evaluate the TKI responsiveness of patients with metastatic disease. However, prospective trials evaluating adjunctive surgical approaches to locally advanced and metastatic RCC are needed to determine the significant benefits of TKI therapy and to define the optimal agent, timing of therapy, and disease stage to derive benefit for preoperative therapy.

Current status of debulking nephrectomy in the era of tyrosine kinase inhibitors

Cytoreductive nephrectomy (CN) has an established role against metastatic renal cell carcinoma (mRCC) in properly selected patients and offers a survival advantage when performed prior to cytokine therapy. With the emergence of new, effective targeted molecular therapies for mRCC, well-designed prospective trials are needed to clarify the biologic effects of CN to determine when and for whom CN should be performed in the context of targeted systemic therapy. Consequently, a thorough characterization of the systemic effects afforded by CN is imperative for developing individualized treatment strategies that effectively address the underlying biology of mRCC while maximizing patient quality of life during therapy. Until then, debulking surgery, which provides a survival benefit for select patients with mRCC, should continue to be used in patients before or after targeted systemic therapy.

Cytoreductive nephrectomy for metastatic renal cell carcinoma with nonclear cell histology

PURPOSE

To our knowledge the benefit of cytoreductive surgery for patients with metastatic renal cell carcinoma with nonclear cell histology is unknown. In this retrospective study we report our experience with cytoreductive nephrectomy for nonclear cell metastatic renal cell carcinoma at M. D. Anderson Cancer Center. We compared the outcomes with those in patients with clear cell metastatic renal cell carcinoma.

MATERIALS AND METHODS

From 1991 to 2006, 606 patients with metastatic renal cell carcinoma underwent cytoreductive nephrectomy and they formed the basis of this report. Of these patients 92 had nonclear cell metastatic renal cell carcinoma. The remaining 514 patients had clear cell metastatic renal cell carcinoma and they formed a comparative group. Multivariate Cox regression analysis was performed to evaluate the relationship between clinical variables and histology (clear cell vs nonclear cell) on disease specific survival.

RESULTS

Compared with patients with clear cell histology those with nonclear cell metastatic renal cell carcinoma were younger (p = 0.0001), and more likely to have nodal metastases (p <0.0001) and sarcomatoid features (23% vs 13%, p = 0.026). On multivariate analysis median disease specific survival in patients with nonclear cell histology was significantly worse than that in patients with clear cell metastatic renal cell carcinoma (9.7 vs 20.3 months, p = 0.0003) even after adjusting for T stage, grade, performance status, age and sarcomatoid features. Sarcomatoid features were a predictor of poor outcome in cases of clear and nonclear cell histology, although even in the absence of sarcomatoid features nonclear cell histology was associated with worse disease specific survival (p = 0.017). Interestingly although there was a significantly higher incidence of positive nodes in patients with nonclear histology (p <0.0001), this phenotype was not associated with a worse disease specific survival, as it was in those with clear cell histology (p = 0.0001). In fact, patients with node negative disease with nonclear cell histology had the worst prognosis overall in the entire group.

CONCLUSIONS

Patients with nonclear cell metastatic renal cell carcinoma were younger and had a higher incidence of nodal metastases, a higher incidence of sarcomatoid features and a worse prognosis than those with clear cell histology who underwent cytoreductive surgery.

Cytoreductive nephrectomy for T4NxM1 renal cell carcinoma: the M.D. Anderson Cancer Center experience

OBJECTIVES

Although cytoreductive nephrectomy may provide a survival benefit in metastatic renal cell carcinoma, patients with locally advanced lesions may be denied cytoreduction because of a perceived worse outcome and increased morbidity. We reviewed our experience with cytoreductive nephrectomy in patients with contiguous organ involvement (Stage T4NxM1) to evaluate the outcome and morbidity.

METHODS

From 1993 to 2004, 498 patients underwent cytoreductive nephrectomy for renal cell carcinoma. Of those, 23 patients had Stage T4NxM1 disease. The analyzed variables included surgical complications, palliation of symptoms, and survival.

RESULTS

The median patient age was 55 years (range 35 to 73), with a median tumor size of 15 cm (range 7 to 30). The median overall and disease-specific survival was 6.8 months (range 1.4 to 25.7). The distribution of the histologic type was conventional in 16, papillary in 2, and unclassified in 5. Sarcomatoid features were present in 9 patients. In 2 patients, surgery was aborted because of unresectable disease. Three patients developed postoperative complications (one wound dehiscence, one pancreatic collection, and one seizure). The median length of stay was 7 days (range 5 to 19). Of the 7 patients with local symptoms, 5 experienced postoperative palliation. Most patients (79%) received postoperative systemic therapy after a median of 39 days (range 24 to 114). Five patients did not receive systemic therapy because of disease progression. The median disease-specific survival for the patients who received systemic therapy was 7.1 months (range 1.4 to 25.7), but only 2.5 months (range 0 to 5.2) for those who had not (P = 0.003).

CONCLUSIONS

Cytoreductive nephrectomy in Stage T4NxM1 renal cell carcinoma is feasible and provides significant palliation in symptomatic patients; however, the survival benefit is unclear. Our retrospective series has demonstrated that the prognosis in these patients is poor.

Cytoreductive nephrectomy in the elderly patient: the M. D. Anderson Cancer Center experience

PURPOSE

Cytoreductive nephrectomy as part of a multidisciplinary approach may be considered in patients with metastatic renal cell carcinoma. The benefit in the elderly population (75 years or older) is unclear. We reviewed our experience to help determine if it is of benefit in this patient population.

MATERIALS AND METHODS

Of 404 patients undergoing cytoreductive nephrectomy from 1995 and 2005 we identified 24 elderly patients. Outcomes in these elderly patients were analyzed and compared to outcomes in the remaining 380 who were younger than 75 years.

RESULTS

Median age in the elderly and younger groups was 77.5 and 57.0 years, respectively. Performance status, sex distribution, and tumor histology, stage, grade and size were comparable. Estimated blood loss, transfusion rates, surgical times and hospital stay were similar in the 2 groups. There were 5 perioperative deaths (21%) in elderly patients compared to 4 (1.1%) in younger patients (p<0.01). Estimated blood loss, units transfused and surgical time were greater in the patients who died perioperatively (p<0.05). Median survival was 16.6 months in the elderly group, which did not differ statistically from the 13.7 months in the younger group.

CONCLUSIONS

Cytoreductive nephrectomy in the elderly population can be associated with the potential for significant morbidity and mortality. Despite this and as part of a multidisciplinary approach it may provide potential survival as well as other benefits, which may justify it in highly select and highly motivated patients who are 75 years or older. However, it must be performed carefully with realistic expectations on behalf of the patient and urologist.

Multimodal approaches in the management of locally advanced and metastatic renal cell carcinoma: combining surgery and systemic therapies to improve patient outcome

Patients with locally advanced renal cell carcinoma are at high risk of metastatic relapse following surgery. Patients with metastatic disease have a poor prognosis and few systemic therapy options. Radiation, chemotherapy, hormonal therapy, vaccines, and immunotherapy have all been tested as adjuvant therapy without benefit. Neoadjuvant therapy in the metastatic setting holds promise as a new treatment paradigm. It can serve as a litmus test to allow proper patient selection for aggressive surgical intervention and may provide limited downstaging of primary tumors in selected cases. It can also provide a histologic assessment of the effect of targeted therapy. Application of this paradigm may have merit in the locally advanced setting as well. Effective adjuvant therapy for renal cell carcinoma remains elusive. The benefit of new targeted therapies has yet to be tested in this setting. Neoadjuvant strategies that integrate aggressive surgical intervention with systemic therapy may hold promise as a treatment paradigm.

Place de la néphrectomie dans la prise en charge des cancers du rein métastatiques

Metastatic kidney cancer is still a devastating disease but it represents a very heterogeneous situation. Some patients will have a median survival limited to some months, while others will live several years. If the initial diagnosis of kidney cancer at metastatic stage is quite uncommon, it raises the question of whether or not performing initial nephrectomy. The point was long debated as it was suggested that initial nephrectomy could result in a spontaneous metastase regression and protect against local complications (hematuria, local pain,...). Today, nephrectomy must not be systematic, as effective alternative treatments are often available. Furthermore spontaneous postoperative metastasis regression is unusual. Two recent prospective randomized trials clarified the impact of initial nephrectomy. It is now accepted that initial surgery prior to systemic immunotherapy results in 30% survival benefit. However this procedure should only be considered for highly selected cases: patients in otherwise good condition (ECOG 0-1), macroscopically complete local resection, no supra-hepatic caval thrombus, and patients suitable for systemic immunotherapy treatment. Several questions remain unanswered, such as lymph node dissection to be performed, and its real survival impact. Furthermore the definition of "suitable" patients for immunotherapy has to be clarified, based on the recent results from the Percy Quatro study. It would probably be more effective to consider only patients with an expected good survival benefit using immunotherapy, such as those classified as "good prognosis" based on the CRECY criteria. Finally the development of new drugs, targeting mainly the angiogenic pathway may lead to different future indications in this setting.

Laparoscopic cytoreductive nephrectomy: the M. D. Anderson Cancer Center experience

OBJECTIVES

Cytoreductive nephrectomy (CN) is an integral component in treating patients with metastatic renal cell carcinoma. Critics of CN argue that perioperative morbidity or postoperative disease progression may preclude patients from receiving systemic therapy. Laparoscopic cytoreductive nephrectomy (LCN) may allow for reduced morbidity and may increase the likelihood of patients receiving systemic therapy.

METHODS

From April 2001 to March 2005, 38 patients underwent LCN at our institution. We evaluated perioperative parameters such as demographics, blood loss, operative time, complications, follow-up time, interval to systemic therapy, and survival. A contemporary open cytoreductive surgery group was evaluated for comparison.

RESULTS

The median patient age was 62 years (range 41 to 82). Most patients had a performance status of 1 or less. The median operative time was 188 minutes, and the median blood loss was 175 mL. All specimens were removed intact. The median tumor size was 8 cm (range 3.5 to 14). The median hospitalization was 3 days. Two major (5.7%) and four minor (11.4%) complications occurred, but no perioperative mortality. Postoperatively, 97.4% of patients were eligible for, or received, systemic therapy at a median of 41 days. The overall median survival was 18.1 months. In contrast to open CN, LCN resulted in decreased blood loss and hospital stay, with no differences in complications, operative time, or interval to systemic therapy.

CONCLUSIONS

LCN is a safe and effective surgical approach for select patients with metastatic renal cell carcinoma. Our results have indicated that with proper patient selection, LCN is feasible, morbidity is minimized, and systemic therapy is delivered in a timely fashion.

Metastatectomy prior to Immunochemotherapy for Metastatic Renal Cell Carcinoma

INTRODUCTION

We reviewed our experiences in performing cytoreductive metastatectomy before initiating systemic immunochemotherapy and tried to investigate potential prognostic factors for such an approach.

PATIENTS AND METHODS

A retrospective analysis of 57 patients who received interleukin-2, interferon-alpha, and 5-fluorouracil immunochemotherapy for metastatic renal cell carcinoma was conducted. Before undergoing immunochemotherapy, 20 of the 57 patients had received metastatectomy along with nephrectomy (metastatectomy group) and the other 37 nephrectomy alone (non-metastatectomy group).

RESULTS

The metastatectomy group demonstrated median disease-specific and progression-free survival of 23 and 13 months, respectively. The patients in the metastatectomy group were identified as having a better performance status and primarily demonstrating pulmonary metastasis compared with those in the non-metastatectomy group. As assessed in the metastatectomy group, factors such as the number of metastatic lesions, completeness of metastatectomy, and location of metastatic lesions (lung only vs. others) were observed to be significantly associated with overall survivals on univariate analysis.

CONCLUSIONS

Metastatectomy may still play a significant therapeutic role for metastatic renal cell carcinoma even in the era of immunochemotherapy as part of a multidisciplinary treatment approach in a selected group of patients in adequate general condition who have pulmonary-limited metastasis that can be completely resected.

Current clinical trials in renal cell carcinoma

The treatment of renal cell carcinoma remains primarily surgical. Consequently, it is not surprising that urologists have been active in the design and operation of clinical trials for patients with kidney cancer. Currently, clinical trial efforts of the urologic community are focused on the adjuvant setting in patients undergoing nephrectomy at high risk for recurrence or metastasis. As newer agents become available and are applied earlier during the course of the disease, the involvement of urologists in clinical trials in renal cell carcinoma will increase. This review highlights several key trials currently available for patients with kidney cancer.

Lessons learned in the surgical management of renal cell carcinoma

Surgical excision, the mainstay of management of renal cell carcinoma (RCC), has evolved significantly over the last 4 decades. Radiological imaging is crucial to the diagnosis and staging of RCC, and technological advances have facilitated more precise preoperative assessment. Additionally, wider use of cross-sectional imaging modalities has led to increasing incidental diagnosis of small, early-stage RCC. Nephron-sparing surgery (NSS), originally developed to treat RCC arising in a solitary functioning kidney, has been demonstrated to be a safe and effective alternative to radical nephrectomy. NSS is now also applicable to tumors of suitable size and anatomy in patients with a normal contralateral kidney, thus facilitating preservation of renal function and management of metachronous contralateral pathology. Laparoscopic and percutaneous approaches have developed over the last decade, thus providing minimally invasive modalities, with shortened convalescence and improved cosmesis. Advanced RCC, involving venous extension or nodal spread, is increasingly amenable to surgical management, although appropriate patient selection is crucial. Furthermore, surgical excision of the primary lesion appears to be an integral part of systemic therapy for metastatic RCC.

MEDICAL AND SURGICAL PALLIATIVE CARE OF PATIENTS WITH UROLOGICAL MALIGNANCIES

PURPOSE

Urological malignancies are relatively common and patients often live many years with disease. There are many effective medical and surgical palliative treatments, although few comprehensive guidelines have been published. We reviewed the various palliative treatments available for the 3 most common urological malignancies, namely prostate cancer, bladder cancer and renal cancer.

MATERIALS AND METHODS

A literature search of the last 15 years was performed using MEDLINE/PubMed. In addition, relevant journals were targeted for specific information related to this review. Our clinical experience was combined with the current literature to create guidelines for palliative care.

RESULTS

Several effective treatments are available for the palliative care of patients with prostate, bladder or renal cancer. Options in palliative care are varied with regard to invasiveness, morbidity, risks and benefits. The algorithms described provide a framework to a sequential approach to achieving palliation. Urologists are central to initiating care and referrals to improve outcomes in these patients.

CONCLUSIONS

Palliative care includes disease directed treatment as well as functional, psychosocial and spiritual support. Disease directed therapy and palliative care should be provided simultaneously throughout illness. Improved quality of care and quality of life as well as physician satisfaction are frequent outcomes of this approach. Supportive care begins at initial diagnosis and it should be flexible to meet the changing needs of patients with cancer and their families.

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.

[Local relapse and single site of metastatic involvement of renal tumour. Prognostic factors and survival]

OBJECTIVE

To evaluate the clinical and pathological characteristics and survival in patients surgically treated for renal tumours that had local recurrence or metastasis to a single site.

MATERIAL AND METHODS

A retrospective study of 321 nephrectomies, evaluating the clinical and pathological variables in patients having local recurrence or metastasis to a single site, and who were treated surgically. Study and comparison of survival in the different groups.

RESULTS

The only factor found to have an independent influence on local recurrence is pathological stage. Local recurrence and the presence of metastasis to a single site have similar survival rates, both being statistically worse than in patients without metastasis at diagnosis, but better than in those having metastasis at diagnosis.

CONCLUSIONS

The presence of local recurrence has the same prognosis as a single excisable metastatic site, the prognosis being better than those initially with metastasis subjected to nephrectomy before receiving systemic treatment.

The role of lymphadenectomy in the surgical management of renal cell carcinoma

After decades of evaluation, the role of lymphadenectomy in the management of renal cell carcinoma remains a controversy. Contemporary series suggest that the true incidence of isolated lymph node metastases in clinically localized disease is small, and the location of such metastases is unpredictable. While several institutional series have suggested a therapeutic benefit for extended lymphadenectomy, there remains a lack of randomized data to support its routine use. Despite this, there remains a role for lymphadenectomy in individuals with high risk of lymph node metastasis or known lymphadenopathy in whom few other options exist for aggressive, potentially curative therapy.

Laparoscopic cytoreductive nephrectomy for metastatic renal cell carcinoma

OBJECTIVE

To critically analyse the results of laparoscopic cytoreductive surgery for renal cell carcinoma (RCC), as phase III evidence supports cytoreductive nephrectomy before immunotherapy, and there is an overall shift towards minimally invasive renal surgery for this disease.

PATIENTS AND METHODS

Since October 2000, 22 patients were treated by laparoscopic cytoreductive nephrectomy for metastatic RCC (group 1). All patients had radiological evidence of metastatic disease, with biopsy confirmation in 10. To put the results into perspective, 25 consecutive contemporary patients with large organ-confined nonmetastatic RCC (>7 cm, clinical stage T2) undergoing laparoscopic radical nephrectomy (group 2) were compared retrospectively. The baseline demographics were comparable between the groups.

RESULTS

The mean tumour size was 8 cm in group 1 and 9.6 cm in group 2 (P = 0.07). Variables during and after surgery were comparable between the groups, with a mean operative duration of 3.1 vs 3.2 h (P = 0.82), blood loss of 285 vs 308 mL (P = 0.79), complications in two vs eight (P = 0.08), morphine sulphate equivalent requirements of 51.7 vs 44.1 mg (P = 0.1) and a median length of hospital stay of 1.7 vs 1.6 days (P = 0.68). In group 1 the median (range) time to immunotherapy was 35 (13-136) days.

CONCLUSIONS

Laparoscopic cytoreductive nephrectomy is safe and effective in selected patients. Currently the procedure is offered to candidates eligible for immunotherapy and with tumours of < or = 15 cm, and no evidence of adjacent organ invasion or inferior vena caval thrombus. Significant perihilar adenopathy and numerous parasitic vessels can increase the complexity of the surgery. Adequate laparoscopic experience is necessary.

Renal cell carcinoma

PURPOSE OF REVIEW

Renal cell carcinoma continues to be a devastating cancer, which currently has few effective treatment options. Recent developments in our understanding of the molecular biology of renal cell carcinoma, particularly clear cell renal cell carcinoma, have led to the development of new agents targeting portions of the hypoxic response pathway.

RECENT FINDINGS

Although high-dose bolus interleukin-2 remains the mainstay of treatment for metastatic disease, the number of patients deriving long-term benefit from this treatment are few, and the use of cytokine therapy in the adjuvant setting has been disappointing. However, the expanding use of minimally invasive surgical techniques has continued to improve patient care. Systemic advances include antibody therapeutics such as bevacizumab, which targets vascular endothelial growth factor signaling, as well as emerging small molecule inhibitors of angiogenesis-related signaling events.

SUMMARY

In addition to progress in surgical techniques and supportive care of patients with renal cell carcinoma, a host of promising targeted therapies for renal cell carcinoma are on the horizon.