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Dahm P, Ergun O, Uhlig A, Bellut L, Risk MC, Lyon JA, Kunath F. Cytoreductive nephrectomy in metastatic renal cell carcinoma. Cochrane Database Syst Rev 2024; 6:CD013773. [PMID: 38847285 PMCID: PMC11157663 DOI: 10.1002/14651858.cd013773.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
BACKGROUND Nephrectomy is the surgical removal of all or part of a kidney. When the aim of nephrectomy is to reduce tumor burden in people with established metastatic disease, the procedure is called cytoreductive nephrectomy (CN). CN is typically combined with systemic anticancer therapy (SACT). SACT can be initiated before or immediately after the operation or deferred until radiological signs of disease progression. The benefits and harms of CN are controversial. OBJECTIVES To assess the effects of cytoreductive nephrectomy combined with systemic anticancer therapy versus systemic anticancer therapy alone or watchful waiting in newly diagnosed metastatic renal cell carcinoma. SEARCH METHODS We performed a comprehensive search in the Cochrane Library, MEDLINE, Embase, Scopus, two trial registries, and other gray literature sources up to 1 March 2024. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated SACT and CN versus SACT alone or watchful waiting. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. Primary outcomes were time to death from any cause and quality of life. Secondary outcomes were time to disease progression, treatment response, treatment-related mortality, discontinuation due to adverse events, and serious adverse events. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS Our search identified 10 records of four unique RCTs that informed two comparisons. In this abstract, we focus on the results for the two primary outcomes. Cytoreductive nephrectomy plus systemic anticancer therapy versus systemic anticancer therapy alone Three RCTs informed this comparison. Due to the considerable heterogeneity when pooling across these studies, we decided to present the results of the prespecified subgroup analysis by type of systemic agent. Cytoreductive nephrectomy plus interferon immunotherapy versus interferon immunotherapy alone CN plus interferon immunotherapy compared with interferon immunotherapy alone probably increases time to death from any cause (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.51 to 0.89; I²= 0%; 2 studies, 326 participants; moderate-certainty evidence). Assuming 820 all-cause deaths at two years' follow-up per 1000 people who receive interferon immunotherapy alone, the effect estimate corresponds to 132 fewer all-cause deaths (237 fewer to 37 fewer) per 1000 people who receive CN plus interferon immunotherapy. We found no evidence to assess quality of life. Cytoreductive nephrectomy plus tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone We are very uncertain about the effect of CN plus tyrosine kinase inhibitor (TKI) therapy compared with TKI therapy alone on time to death from any cause (HR 1.11, 95% CI 0.90 to 1.37; 1 study, 450 participants; very low-certainty evidence). Assuming 574 all-cause deaths at two years' follow-up per 1000 people who receive TKI therapy alone, the effect estimate corresponds to 38 more all-cause deaths (38 fewer to 115 more) per 1000 people who receive CN plus TKI therapy. We found no evidence to assess quality of life. Immediate cytoreductive nephrectomy versus deferred cytoreductive nephrectomy One study evaluated CN followed by TKI therapy (immediate CN) versus three cycles of TKI therapy followed by CN (deferred CN). Immediate CN compared with deferred CN may decrease time to death from any cause (HR 1.63, 95% CI 1.05 to 2.53; 1 study, 99 participants; low-certainty evidence). Assuming 620 all-cause deaths at two years' follow-up per 1000 people who receive deferred CN, the effect estimate corresponds to 173 more all-cause deaths (18 more to 294 more) per 1000 people who receive immediate CN. We found no evidence to assess quality of life. AUTHORS' CONCLUSIONS CN plus SACT in the form of interferon immunotherapy versus SACT in the form of interferon immunotherapy alone probably increases time to death from any cause. However, we are very uncertain about the effect of CN plus SACT in the form of TKI therapy versus SACT in the form of TKI therapy alone on time to death from any cause. Immediate CN versus deferred CN may decrease time to death from any cause. We found no quality of life data for any of these three comparisons. We also found no evidence to inform any other comparisons, in particular those involving newer immunotherapy agents (programmed death receptor 1 [PD-1]/programmed death ligand 1 [PD-L1] immune checkpoint inhibitors), which have become the backbone of SACT for metastatic renal cell carcinoma. There is an urgent need for RCTs that explore the role of CN in the context of contemporary forms of systemic immunotherapy.
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Affiliation(s)
- Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Onuralp Ergun
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Annemarie Uhlig
- Department of Urology, University Medical Center, Goettingen, Germany
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - Laura Bellut
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael C Risk
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Jennifer A Lyon
- Library Services, Children's Mercy Hospital, Kansas City, Missouri, USA
- Center for Evidence-Based Policy, Portland, Oregon, USA
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Medizinische Fakultät am Medizincampus Oberfranken, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Urology and Pediatric Urology, Klinikum Bayreuth GmbH, Bayreuth, Germany
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Choudhary D, Naik M, Vageesh BG, Agarwal A. A case report of liver infiltration from a large renal cell carcinoma: Diagnostic and management enigma. Int J Surg Case Rep 2024; 114:109045. [PMID: 38039569 PMCID: PMC10730738 DOI: 10.1016/j.ijscr.2023.109045] [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: 10/02/2023] [Revised: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Renal cell carcinoma is the most lethal malignancy of urinary tract. Invasion of right lobe of liver by Renal cell carcinoma is rare and possess a treatment challenge. Simultaneous nephrectomy with right hepatectomy has been proposed as a part of multi-modality treatment approach. But its safety and feasibility is not well established. CASE PRESENTATION We herein discuss a case of 30-year old female patient who underwent simultaneous nephrectomy with right hepatectomy along with single peritoneal metastasectomy for a huge Renal cell carcinoma of right kidney and infiltrating the right lobe of liver. Intra-operatively a single peritoneal nodule was present which came positive for malignancy on frozen section. Considering young age, good performance status and oligometastatic disease definitive procedure in the form of combined right nephrectomy and right hepatectomy was performed. She was discharged from the hospital on 6th post-operative day with an uneventful post-operative course. CLINICAL DISCUSSION The patients with locally advanced Renal cell carcinoma with involvement of adjacent organs require en block surgical resection in combination with targeted therapy and immunotherapy. The surgical management of patients with direct liver infiltration requires a right nephrectomy with some form of liver resection based on the extent of liver involvement to achieve a margin negative resection. In our case a plan of formal right hepatectomy was made as the tumor was infiltrating into segment VI, VII, and VIII. CONCLUSION The combined nephrectomy and right hepatectomy is safe and feasible for this type of huge RCC invading right hepatic lobe.
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Affiliation(s)
- Devendra Choudhary
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India.
| | - Maktum Naik
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India
| | - B G Vageesh
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India
| | - Anil Agarwal
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India
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Das A, Shapiro DD, Craig JK, Abel EJ. Understanding and integrating cytoreductive nephrectomy with immune checkpoint inhibitors in the management of metastatic RCC. Nat Rev Urol 2023; 20:654-668. [PMID: 37400492 DOI: 10.1038/s41585-023-00776-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 07/05/2023]
Abstract
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.
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Affiliation(s)
- Arighno Das
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel D Shapiro
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Juliana K Craig
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - E Jason Abel
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Prognostic model of upfront cytoreductive nephrectomy in patients with metastatic renal cell carcinoma treated with immune checkpoint inhibitors and/or targeted agents. Int Urol Nephrol 2022; 54:1225-1232. [PMID: 35314918 DOI: 10.1007/s11255-022-03157-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/19/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to investigate prognostic factors and to establish a prognostic model using them for upfront cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitor (ICI) and/or tyrosine kinase inhibitor (TKI). MATERIALS AND METHODS Two hundred eleven patients who were diagnosed as mRCC at initial diagnosis and were treated with TKI and/or ICI were classified into 2 groups: those undergoing CN (upfront CN group, 117 cases) and those who initially underwent systemic therapy (non-upfront CN group, 94 cases). In the upfront CN group, the patients' background and overall survival (OS) were compared with those in the other two groups, and prognostic factors were analyzed. A prognostic model of the upfront CN group was established. RESULTS The median of the observation period for the upfront CN group was 25 months. The rates of patients with clear cell histology, with a Karnofsky performance status (KPS) of ≥ 80%, with a single metastatic organ, with a normal pretreated C-reactive protein level, and with an intermediate risk according to the International mRCC Database Consortium (IMDC) model were significantly higher than those in the non-upfront CN group (87.2% and 30.9%, p < 0.0001; 92.3% and 77.7%, p = 0.0025; 41.9% and 24.5%, p = 0.0080; 47.9% and 13.8%, p < 0.0001; 66.7% and 45.7%, p = 0.0023, respectively). The 50% OS in the upfront CN group was 33.1 months, significantly better than that in the non-upfront CN group (11.1 months, p < 0.0001), and these results were consistent regardless of their prognostic risk level. Multivariate analysis showed that multiple metastatic organs and a KPS of < 80% were independent predictive factors for OS (hazard ratio: 1.653 and 2.995, p = 0.0339 and 0.0054, respectively). Using these two parameters to stratify the upfront CN group, the 50% OSs in cases with no risk factors, in those with one factor, and in those with two factors were 43.4 months, 29.1 months, and 7.7 months, respectively (p < 0.0001). CONCLUSION The upfront CN group was able to be stratified by our prognostic model into three subgroups with different prognoses. This model can provide useful information for making decisions in consideration of upfront CN in patients with mRCC.
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Marchioni M, Kriegmair M, Heck M, Amiel T, Porpiglia F, Ceccucci E, Campi R, Minervini A, Mari A, Van Bruwaene S, Linares E, Hevia V, Musquera M, D'Anna M, Derweesh I, Bradshaw A, Autorino R, Guruli G, Veccia A, Roussel E, Albersen M, Pavan N, Claps F, Antonelli A, Palumbo C, Klatte T, Erdem S, Mir MC. Development of a Novel Risk Score to Select the Optimal Candidate for Cytoreductive Nephrectomy Among Patients with Metastatic Renal Cell Carcinoma. Results from a Multi-institutional Registry (REMARCC). Eur Urol Oncol 2020; 4:256-263. [PMID: 33384274 DOI: 10.1016/j.euo.2020.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved. OBJECTIVE To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN. DESIGN, SETTING, AND PARTICIPANTS We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model's discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores. RESULTS AND LIMITATIONS The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (<80%) and those with more than three metastases had also higher OM rates (p = 0.026 and 0.040, respectively). The C-index of the REMARCC model was higher than that of the MSKCC and IMDC models (66.4% vs 60.4% vs 60.3%). After stratification, 113 (22.0%) patients were classified to have a favorable (no risk factors), 202 (39.5%) an intermediate (one or two risk factors), and 197 (38.5%) a poor (more than two risk factors) prognosis. Moreover, 72 (17.2%) and 51 (13.9%) patients classified as having an intermediate and a poor prognosis according to MSKCC and IMDC categories, respectively, would be reclassified as having a good prognosis according to the REMARCC score. CONCLUSIONS Our findings confirm the relevance of tumor and patient features for the risk stratification of mRCC patients and clinical decision-making regarding CN. Further prospective external validations are required for the scoring system proposed herein. PATIENT SUMMARY Current stratification systems for selecting patients for kidney removal when metastatic disease is shown are controversial. We suggest a system that includes tumor and patient features besides the systems already in use, which are based on blood tests.
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Affiliation(s)
- Michele Marchioni
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. D'Annunzio" Chieti-Pescara, Chieti, Italy; Department of Urology, SS Annunziata Hospital, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | | | - Mathias Heck
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Thomas Amiel
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Francesco Porpiglia
- Department of Urology, School of Medicine, University of Turin-San Luigi Gonzaga Hospital, Turin, Italy
| | - Enrico Ceccucci
- Department of Urology, School of Medicine, University of Turin-San Luigi Gonzaga Hospital, Turin, Italy
| | - Riccardo Campi
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
| | - Andrea Minervini
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
| | - Andrea Mari
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
| | | | | | - Vital Hevia
- Department of Urology, Hospital Ramon y Cajal, Madrid, Spain
| | | | | | - Ithaar Derweesh
- Department of Urology, UC San Diego Moores Cancer Center, University of California San Diego School of Medicine, Louisiana Jolla, CA, USA
| | - Aaron Bradshaw
- Department of Urology, UC San Diego Moores Cancer Center, University of California San Diego School of Medicine, Louisiana Jolla, CA, USA
| | | | - Georgi Guruli
- Division of Urology, VCU Medical Center, Richmond, VA, USA
| | | | - Eduard Roussel
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Nicola Pavan
- Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Francesco Claps
- Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, AOUI Verona Hospital, Verona, Italy
| | - Carlotta Palumbo
- Department of Urology, University of Verona, AOUI Verona Hospital, Verona, Italy
| | - Tobias Klatte
- Department of Urology, Royal Bournemouth Hospital, University Hospitals Dorset, Bournemouth, UK
| | - Selcuk Erdem
- Department of Urology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Maria Carmen Mir
- Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain.
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Cytoreductive Nephrectomy in Patients Presenting With Advanced Disease: Have We Finally Answered the Question? ACTA ACUST UNITED AC 2020; 26:382-389. [PMID: 32947306 DOI: 10.1097/ppo.0000000000000470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Determining the appropriate patients for cytoreductive nephrectomy (CN) has evolved with the integration of more effective systemic therapies for patients with metastatic renal cell carcinoma (mRCC). While previously considered to be first-line therapy for mRCC, CN has not demonstrated a significant survival advantage over systemic therapy in more recent randomized trials when compared with targeted therapy. Conversely, multiple observational studies demonstrate a therapeutic benefit for CN. This review synthesizes the current literature regarding patient selection for CN and further evaluates the role of CN in the current era of immune checkpoint inhibitor therapy. With careful patient selection, CN maintains an important role in the management of mRCC patients.
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Silagy AW, Duzgol C, Marcon J, DiNatale RG, Mano R, Blum KA, Reznik E, Voss MH, Motzer RJ, Coleman JA, Russo P, Akin O, Hakimi AA. An evaluation of the role of tumor load in cytoreductive nephrectomy. Can Urol Assoc J 2020; 14:E625-E630. [PMID: 32569570 DOI: 10.5489/cuaj.6350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION New radiological tools can accurately provide preoperative three-dimensional spatial assessment of metastatic renal cell carcinoma (RCC). We aimed to determine whether the distribution, volume, shape, and fraction of RCC resected in a cytoreductive nephrectomy associates with survival. METHODS We retrospectively reviewed 560 patients undergoing cytoreductive nephrectomy, performing a comprehensive volumetric analysis in eligible patients of all detectable primary and metastatic RCC prior to surgery. We used Cox regression analysis to determine the association between the volume, shape, fraction resected, and distribution of RCC and overall survival (OS). RESULTS There were 62 patients eligible for volumetric analysis, with similar baseline characteristics to the entire cohort, and median survivor followup was 34 months. Larger primary tumors were less spherical, but not associated with different metastatic patterns. Increased primary tumor volume and tumor size, but not the fraction of tumor resected, were associated with inferior survival. The rank of tumors based on unidimensional size did not completely correspond to the rank by primary tumor volume, however, both measurements yielded similar concordance for predicted OS. Larger tumor volume was not associated with a longer postoperative time off treatment. CONCLUSIONS Primary tumor volume was significant for predicting OS, while the fraction of disease resected did not appear to impact patient outcomes. Although rich in detail, our study is potentially limited by selection bias. Future temporal studies may help elucidate whether the primary tumor shape is associated with tumor growth kinetics.
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Affiliation(s)
- Andrew W Silagy
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Department of Surgery, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - Cihan Duzgol
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Julian Marcon
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Renzo G DiNatale
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kyle A Blum
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ed Reznik
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martin H Voss
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Robert J Motzer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Oguz Akin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - A Ari Hakimi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Nizam A, Schindelheim JA, Ornstein MC. The role of active surveillance and cytoreductive nephrectomy in metastatic renal cell carcinoma. Cancer Treat Res Commun 2020; 23:100169. [PMID: 32126518 DOI: 10.1016/j.ctarc.2020.100169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 01/22/2020] [Accepted: 02/01/2020] [Indexed: 12/14/2022]
Abstract
Treatment of metastatic renal cell carcinoma (mRCC) has been revolutionized by an expanding armamentarium of systemic therapies, which have resulted in improved patient outcomes. Multimodal approaches that include cytoreductive nephrectomy (CN), immunotherapy, and targeted therapy are necessary to optimize clinical care. Active surveillance (AS) and CN are two cornerstones of treatment in mRCC, which require reexamination in the context of new systemic therapies. Herein, we review the data and provide a practical approach for the incorporation of AS and CN in the management of mRCC.
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Affiliation(s)
- Amanda Nizam
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, United States
| | - Jonah A Schindelheim
- Department of Medicine, Touro College of Osteopathic Medicine, Middletown, NY, United States
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, United States.
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DiNatale RG, Xie W, Becerra MF, Silagy AW, Attalla K, Sanchez A, Mano R, Marcon J, Blum KA, Benfante NE, Voss MH, Motzer RJ, Coleman J, Choueiri TK, Reznik E, Russo P, Heng DYC, Hakimi AA. The Association Between Small Primary Tumor Size and Prognosis in Metastatic Renal Cell Carcinoma: Insights from Two Independent Cohorts of Patients Who Underwent Cytoreductive Nephrectomy. Eur Urol Oncol 2019; 3:47-56. [PMID: 31735646 DOI: 10.1016/j.euo.2019.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/29/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND One of the main challenges in the management of renal cell carcinoma (RCC) is risk-stratifying patients who present with metastatic disease. Tumor size is an important predictor of survival in the localized setting; however, this feature has not been explored fully in patients presenting with M1 RCC. OBJECTIVE To assess the impact of tumor size on survival in patients with metastatic RCC who underwent cytoreductive nephrectomy (CN). DESIGN, SETTING, AND PARTICIPANTS We queried the Memorial Sloan Kettering (MSK) nephrectomy database for patients who presented with M1 disease and underwent CN between 1989 and 2016 (n=304). Primary tumor size was obtained from pathology reports. Data from the International Metastatic Database Consortium (IMDC) were used for validation purposes (n=778). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Overall survival (OS) estimates were computed using the Kaplan-Meier method. Cox regressions were used to test the association between tumor size and OS in univariate and multivariable analyses. Tumors ≤4cm were compared with larger masses. Secondary analyses were performed to assess the robustness of these findings. RESULTS AND LIMITATIONS Clear cell tumors ≤4cm were significantly associated with improved OS in both the MSK (hazard ratio [HR]: 0.35, 0.17-0.72, p= 0.004) and IMDC (HR 0.54, 0.36-0.83, p= 0.004) cohorts. The association was observed even after adjusting for known prognostic factors (HR 0.40, 0.14-1.14, p= 0.09 and HR: 0.54, 0.33-0.90, p= 0.02 in the MSK and IMDC cohorts, respectively). Limitations of this study include the absence of patients who were considered poor surgical candidates as well as potential selection bias. CONCLUSIONS The primary tumor size ≤4cm was independently associated with improved OS in patients with metastatic clear cell RCC who underwent CN. Additionally, the association between primary size and survival was found to be nonlinear. These findings suggest that there is a group of small metastatic RCCs that can convey a better overall prognosis. The potential role of primary tumor size when risk stratifying patients with M1 RCC should be explored further to determine its utility during clinical decision making. PATIENT SUMMARY We evaluated the impact of small tumor size on prognosis in patients with metastatic kidney cancer who undergo removal of the primary tumor. Very small masses (≤4cm) were associated with better prognosis in patients with clear cell tumors.
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Affiliation(s)
- Renzo G DiNatale
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Immunogenomics and Precision Oncology Platform, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wanling Xie
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria F Becerra
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Andrew W Silagy
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Surgery, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - Kyrollis Attalla
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alejandro Sanchez
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julian Marcon
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, University Hospital of Munich, Munich, Germany
| | - Kyle A Blum
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Immunogenomics and Precision Oncology Platform, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole E Benfante
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin H Voss
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Motzer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Toni K Choueiri
- Department of Medicine, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ed Reznik
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel Y C Heng
- Department of Medicine, Tom Baker Cancer Center, Calgary, AB, Canada
| | - A Ari Hakimi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Immunogenomics and Precision Oncology Platform, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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10
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Soares A, Maia MC, Vidigal F, Marques Monteiro FS. Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma: How to Apply New Evidence in Clinical Practice. Oncology 2019; 98:1-9. [PMID: 31514196 DOI: 10.1159/000502778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 11/19/2022]
Abstract
Cytoreductive nephrectomy (CN) followed by systemic therapy had been considered the standard of care for metastatic renal cell carcinoma (mRCC) patients since two clinical trials established its role during the cytokines era. With introduction of new and effective drugs, such as vascular endothelial growth factor-targeted therapies, the role of CN started to be challenged. Retrospective studies conducted during the targeted therapy era pointed to better outcomes when CN was associated with systemic treatment, although certain patients with poor risk features did not seem to benefit. Therefore, prospective clinical trials supporting CN were needed. Recently, with the publication of two randomized trials evaluating CN in the targeted therapy era, it has been made clear that patient selection and multidisciplinary discussion are of paramount importance in order to achieve the best outcomes. We reviewed the available literature on the role of CN among mRCC patients, commenting on how to apply the new evidence into clinical practice and providing future perspectives.
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Affiliation(s)
- Andrey Soares
- Department of Medical Oncology, Hospital Israelita Albert Einstein, São Paulo, Brazil, .,Department of Medical Oncology, Centro Paulista de Oncologia, São Paulo, Brazil, .,Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil,
| | - Manuel C Maia
- Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil.,Department of Medical Oncology, Centro de Oncologia do Paraná, Curtiba, Brazil
| | - Fernando Vidigal
- Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil.,Department of Medical Oncology, Hospital Sírio Libanês - Unidade Brasília, Brasília, Brazil
| | - Fernando Sabino Marques Monteiro
- Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil.,Hospital Santa Lúcia, Brasília, Brazil.,Hospital Universitário de Brasília, Universidade Nacional de Brasília, Brasília, Brazil
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11
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Individualised Indications for Cytoreductive Nephrectomy: Which Criteria Define the Optimal Candidates? Eur Urol Oncol 2019; 2:365-378. [DOI: 10.1016/j.euo.2019.04.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/08/2019] [Accepted: 04/16/2019] [Indexed: 12/12/2022]
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12
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Mason RJ, Wood L, Kapoor A, Basappa N, Bjarnason G, Boorjian SA, Breau RH, Cagiannos I, Jewett MA, Karakiewicz PI, Kassouf W, Kollmannsberger C, Lalani AKA, Lattouf JB, Lavallée LT, Pautler S, Power N, Richard P, So A, Tanguay S, Rendon RA. Kidney Cancer Research Network of Canada (KCRNC) consensus statement on the role of cytoreductive nephrectomy for patients with metastatic renal cell carcinoma. Can Urol Assoc J 2019; 13:166-174. [PMID: 31199235 PMCID: PMC6570591 DOI: 10.5489/cuaj.5786] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ross J. Mason
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Lori Wood
- Division of Medical Oncology, Dalhousie University, Halifax, NS, Canada
| | - Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Naveen Basappa
- Division of Medical Oncology, University of Alberta, Edmonton, AB, Canada
| | - George Bjarnason
- Division of Medical Oncology, University of Toronto, Toronto, ON, Canada
| | | | - Rodney H. Breau
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Wassim Kassouf
- Division of Urology, McGill University, Montreal, QC, Canada
| | | | | | | | | | | | - Nicholas Power
- Division of Urology, Western University, London, ON, Canada
| | - Patrick Richard
- Division of Urology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Alan So
- Department of Urologic Sciences, University of British Colombia, Vancouver, BC, Canada
| | - Simon Tanguay
- Division of Urology, McGill University, Montreal, QC, Canada
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13
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Teishima J, Inoue S, Hayashi T, Matsubara A. Current status of prognostic factors in patients with metastatic renal cell carcinoma. Int J Urol 2019; 26:608-617. [PMID: 30959579 DOI: 10.1111/iju.13956] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/03/2019] [Indexed: 12/12/2022]
Abstract
In recent years, the induction of novel agents, including molecular-targeted agents and immune checkpoint inhibitors, have dramatically changed therapeutic options and their outcomes for metastatic renal cell carcinoma. Several prognostic models based on the data of patients with metastatic renal cell carcinoma treated with targeted agents or cytokine therapy have been useful in real clinical practice. Serum or peripheral blood markers related to inflammatory response have been reported to be associated with their prognosis or therapeutic efficacy. In addition to them, investigation for novel predictive factors that represent the efficacy of agents, the risk of adverse events and the prognosis are required for the advance of therapeutic strategies. The present review discusses the conventional prognostic models and clinical factors, and recent advances of the identification of some of the most promising molecules as novel biomarkers for metastatic renal cell carcinoma.
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Affiliation(s)
- Jun Teishima
- Department of Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shogo Inoue
- Department of Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tetsutaro Hayashi
- Department of Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akio Matsubara
- Department of Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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14
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The role of metastatic burden in cytoreductive/consolidative radical cystectomy. World J Urol 2019; 37:2691-2698. [PMID: 30864005 DOI: 10.1007/s00345-019-02693-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/18/2019] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To describe our institutional experience with cytoreductive/consolidative radical cystectomy (CCRC) for metastatic urothelial carcinoma (UC) and to investigate clinicopathologic features predicting prolonged cancer specific survival (CSS) following CCRC. METHODS We performed IRB-approved review of our cystectomy database, and identified 43 patients with metastatic UC who underwent CCRC. Baseline demographics, chemotherapy regimen, clinicopathologic features, and perioperative complications were collected. Progression-free survival (PFS) and CSS were estimated from the time of CCRC. Univariate and multivariate Cox regression models were used to identify predictors of improved CSS after CCRC. RESULTS Of the 43 patients, 32 (74.4%) had clinical evidence of distant metastases, while 11 harbored occult metastases on the surgical specimen. The most common site of metastasis was the retroperitoneal lymph nodes, found in 30 patients. Solitary metastases were found in 22 patients (51.1%). Forty-one (95%) patients received chemotherapy prior to CCRC. Disease progression was detected in 35 patients after CCRC (median PFS 5.9 months), and 34 died of metastatic cancer (median CSS 12.3 months). On multivariate analysis, patients with solitary metastases were found to have improved CSS compared to those with multiple metastases (HR 2.62, 95% CI 1.16-5.90, p = 0.02), with median CSS of 26.0 months vs. 7.9 months (p < 0.001). Median postoperative length of stay was 10 days. Overall, 56% suffered postoperative complications, including one perioperative mortality. CONCLUSIONS CCRC is feasible in the setting of metastatic UC. Patients with solitary metastasis demonstrated longer CSS than those with multiple metastases, and should be considered candidates for future trials evaluating the role of CCRC for metastatic UC.
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15
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Systematic Review of the Role of Cytoreductive Nephrectomy in the Targeted Therapy Era and Beyond: An Individualized Approach to Metastatic Renal Cell Carcinoma. Eur Urol 2019; 75:111-128. [DOI: 10.1016/j.eururo.2018.09.016] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/10/2018] [Indexed: 01/02/2023]
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16
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Krabbe LM, Woldu SL, Sanli O, Margulis V. Metastatic Surgery in Advanced Renal Cell Carcinoma. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Teishima J, Ohara S, Shinmei S, Inoue S, Hayashi T, Mochizuki H, Mita K, Shigeta M, Matsubara A. Normalization of C-reactive protein levels following cytoreductive nephrectomy in patients with metastatic renal cell carcinoma treated with tyrosine kinase inhibitors is associated with improved overall survival. Urol Oncol 2018; 36:339.e9-339.e15. [DOI: 10.1016/j.urolonc.2018.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/03/2018] [Accepted: 04/16/2018] [Indexed: 10/14/2022]
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18
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Abstract
PURPOSE OF REVIEW Although novel targeted therapies for metastatic renal cell carcinoma (RCC) are emerging, metastasectomy still remains the only potentially curable intervention and plays an important role both in disease control, cancer-specific survival (CSS) and overall survival (OS). A systematic review was conducted in 2014 by the European Association of Urology RCC guidelines panel to summarize evidence on the subject at hand. The purpose of this review is to update the current evidence base. RECENT FINDINGS A total of 17-19% of initially nonmetastatic patients with later RCC metastasis are potentially curable. Complete metastasectomy still remains the sole curative option, continues to show improved OS and CSS and is suggested to defer time to palliative targeted therapy. Resectability, long time to recurrence, good performance status and oligometastatic disease have better benefit of metastasectomy. Stereotactic radiotherapy remains an excellent option for local tumor control and symptom control in patients with RCC brain and bone metastases. Minimal-invasive options such as thermal ablation are evolving, albeit the evidence base is small. Novel trials are investigating sequencing of metastasectomy and targeted therapy with results pending. SUMMARY Metastasectomy continues to be supported as beneficial for OS, CSS and progression-free survival in patients with good prognostic factors.
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19
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Reaume MN, Basappa NS, Wood L, Kapoor A, Bjarnason GA, Blais N, Breau RH, Canil C, Cheung P, Conter HJ, Hotte SJ, Jeldres C, Jewett MAS, Karakiewicz PI, Kollmannsberger C, Patenaude F, So A, Soulières D, Venner P, Violette P, Zalewski P, Chappell H, North SA. Management of advanced kidney cancer: Canadian Kidney Cancer Forum (CKCF) consensus update 2017. Can Urol Assoc J 2017; 11:310-320. [PMID: 29382441 DOI: 10.5489/cuaj.4769] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- M Neil Reaume
- Division of Medical Oncology, Ottawa Hospital Cancer Centre and University of Ottawa, Ottawa, ON, Canada
| | - Naveen S Basappa
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, Canada
| | - Lori Wood
- Department of Medicine and Urology, Dalhousie University, Halifax, NS, Canada
| | - Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON, Canada.,The Kidney Cancer Research Network of Canada, Toronto, ON, Canada
| | - Georg A Bjarnason
- Division of Medical Oncology/Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Normand Blais
- Division of Medical Oncology/Hematology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program and Division of Urology, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Christina Canil
- Division of Medical Oncology, Ottawa Hospital Cancer Centre and University of Ottawa, Ottawa, ON, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Claudio Jeldres
- Centre hospitalier de l'Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Pierre I Karakiewicz
- Service d'urologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Christian Kollmannsberger
- Division of Medical Oncology, British Columbia Cancer Agency-Vancouver Cancer Centre, and University of British Columbia, Vancouver, BC, Canada
| | - Francois Patenaude
- Department of Medicine, Hematology Service and Department of Oncology, Sir Mortimer B. Davis Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Alan So
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Denis Soulières
- Division of Medical Oncology/Hematology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Peter Venner
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, Canada
| | | | - Pawel Zalewski
- R.S. McLaughlin Durham Regional Cancer Centre, Oshawa, ON, Canada
| | | | - Scott A North
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, Canada
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20
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Shinder BM, Rhee K, Farrell D, Farber NJ, Stein MN, Jang TL, Singer EA. Surgical Management of Advanced and Metastatic Renal Cell Carcinoma: A Multidisciplinary Approach. Front Oncol 2017; 7:107. [PMID: 28620578 PMCID: PMC5449498 DOI: 10.3389/fonc.2017.00107] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022] Open
Abstract
The past decade has seen a rapid proliferation in the number and types of systemic therapies available for renal cell carcinoma. However, surgery remains an integral component of the therapeutic armamentarium for advanced and metastatic kidney cancer. Cytoreductive surgery followed by adjuvant cytokine-based immunotherapy (predominantly high-dose interleukin 2) has largely given way to systemic-targeted therapies. Metastasectomy also has a role in carefully selected patients. Additionally, neoadjuvant systemic therapy may increase the feasibility of resecting the primary tumor, which may be beneficial for patients with locally advanced or metastatic disease. Several prospective trials examining the role of adjuvant therapy are underway. Lastly, the first immune checkpoint inhibitor was approved for metastatic renal cell carcinoma (mRCC) in 2015, providing a new treatment mechanism and new opportunities for combining systemic therapy with surgery. This review discusses current and historical literature regarding the surgical management of patients with advanced and mRCC and explores approaches for optimizing patient selection.
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Affiliation(s)
- Brian M Shinder
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Kevin Rhee
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Douglas Farrell
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Nicholas J Farber
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Mark N Stein
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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21
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Blute ML, Ziemlewicz TJ, Lang JM, Kyriakopoulos C, Jarrard DF, Downs TM, Grimes M, Shi F, Mann MA, Abel EJ. Metastatic Tumor Burden Does Not Predict Overall Survival Following Cytoreductive Nephrectomy for Renal Cell Carcinoma: a Novel 3-Dimensional Volumetric Analysis. Urology 2017; 100:139-144. [DOI: 10.1016/j.urology.2016.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/01/2016] [Accepted: 09/08/2016] [Indexed: 01/30/2023]
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22
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Leveridge M. Rethinking lymph node metastasis and cytoreductive nephrectomy. Can Urol Assoc J 2017; 10:396-397. [PMID: 28096913 DOI: 10.5489/cuaj.4252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael Leveridge
- Departments of Urology and Oncology, Queen's University, Kingston, ON, Canada
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23
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Qi N, Wu P, Chen J, Li T, Ning X, Wang J, Gong K. Cytoreductive nephrectomy with thrombectomy before targeted therapy improves survival for metastatic renal cell carcinoma with venous tumor thrombus: a single-center experience. World J Surg Oncol 2017; 15:4. [PMID: 28056988 PMCID: PMC5217450 DOI: 10.1186/s12957-016-1066-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Nienie Qi
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, Beijing, China
| | - Pengjie Wu
- Department of Urology, Beijing Hospital, Beijing, China
| | - Jinchao Chen
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, Beijing, China
| | - Teng Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, Beijing, China
| | - Xianghui Ning
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, Beijing, China
| | - Jin Wang
- Department of cardiac surgery, Peking University First Hospital, Beijing, China
| | - Kan Gong
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University; National Urological Cancer Center, No. 8, Xishiku St., Xicheng Dist, Beijing, 100034, China.
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24
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Metastatic Surgery in Advanced Renal Cell Carcinoma. Urol Oncol 2017. [DOI: 10.1007/978-3-319-42603-7_65-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Brehmer B, Kauffmann C, Blank C, Heidenreich A, Bex A. Resection of metastasis and local recurrences of renal cell carcinoma after presurgical targeted therapy: probability of complete local control and outcome. World J Urol 2016; 34:1061-6. [DOI: 10.1007/s00345-016-1865-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 05/23/2016] [Indexed: 12/22/2022] Open
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26
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Li P, Wong Y, Armstrong K, Haas N, Subedi P, Davis‐Cerone M, Doshi JA. Survival among patients with advanced renal cell carcinoma in the pretargeted versus targeted therapy eras. Cancer Med 2016; 5:169-81. [PMID: 26645975 PMCID: PMC4735783 DOI: 10.1002/cam4.574] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/28/2015] [Accepted: 09/28/2015] [Indexed: 11/06/2022] Open
Abstract
Between December 2005 and October 2009, FDA approved six targeted therapies shown to significantly extend survival for advanced renal cell carcinoma (RCC) patients in clinical trials. This study aimed to examine changes in survival between the pretargeted and targeted therapy periods in advanced RCC patients in a real-world setting. Utilizing the 2000-2010 SEER Research files, a pre-post study design with a contemporaneous comparison group was employed to examine differences in survival outcomes for patients diagnosed with advanced RCC (study group) or advanced prostate cancer (comparison group, for whom no significant treatment innovations happened during this period) across the pretargeted therapy era (2000-2005) and the targeted therapy era (2006-2010). RCC patients diagnosed in the targeted therapy era (N = 6439) showed improved survival compared to those diagnosed in the pretargeted therapy era (N = 7231, hazard ratio (HR) for all-cause death: 0.86, P < 0.01), while the change between the pre-post periods was not significant for advanced prostate cancer patients (HR: 0.97, P = 0.08). Advanced RCC patients had significantly larger improvements in overall survival compared to advanced prostate cancer patients (z = 4.31; P < 0.01). More detailed year-to-year analysis revealed greater survival improvements for RCC in the later years of the posttargeted period. Similar results were seen for cause-specific survival. Subgroup analyses by nephrectomy status, age, and gender showed consistent findings. Patients diagnosed with advanced RCC during the targeted therapy era had better survival outcomes than those diagnosed during the pretargeted therapy era. Future studies should examine the real-world survival improvements directly associated with targeted therapies.
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Affiliation(s)
- Pengxiang Li
- Division of General Internal MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
- Leonard Davis Institute of Health EconomicsPhiladelphiaPennsylvania
| | | | | | - Naomi Haas
- Hospital of the University of PennsylvaniaPhiladelphiaPennsylvania
| | | | | | - Jalpa A. Doshi
- Division of General Internal MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
- Leonard Davis Institute of Health EconomicsPhiladelphiaPennsylvania
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27
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Alam R, Tosoian JJ, Pierorazio PM, Johnson MH. Distant Metastases From a Small Renal Cell Carcinoma: A Case Report. Urol Case Rep 2016; 4:59-60. [PMID: 26793584 PMCID: PMC4719795 DOI: 10.1016/j.eucr.2015.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/02/2015] [Indexed: 11/29/2022] Open
Abstract
Renal cell carcinoma (RCC) less than 3 cm in diameter rarely metastasizes. In this report, we present the case of a metastatic RCC in which the primary tumor was 1.6 cm. We further review the relevant literature to highlight this rare but important clinical presentation.
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Affiliation(s)
- Ridwan Alam
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Jeffrey J Tosoian
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Michael H Johnson
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
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28
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Adibi M, Thomas AZ, Borregales LD, Matin SF, Wood CG, Karam JA. Surgical considerations for patients with metastatic renal cell carcinoma. Urol Oncol 2015; 33:528-37. [PMID: 26546481 DOI: 10.1016/j.urolonc.2015.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 09/26/2015] [Accepted: 10/05/2015] [Indexed: 02/06/2023]
Abstract
Among patients with renal cell carcinoma (RCC), 25-30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials.
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Affiliation(s)
- Mehrad Adibi
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arun Z Thomas
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Leonardo D Borregales
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Lee D, Lee C, Kwon T, You D, Jeong IG, Hong JH, Ahn H, Kim CS. Clinical features and prognosis of prostate cancer with high-grade prostatic intraepithelial neoplasia. Korean J Urol 2015; 56:565-71. [PMID: 26279825 PMCID: PMC4534430 DOI: 10.4111/kju.2015.56.8.565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 06/16/2015] [Indexed: 11/30/2022] Open
Abstract
Purpose To evaluate the clinical features and biochemical recurrence (BCR) in prostate cancer (PCa) with high-grade prostatic intraepithelial neoplasia (HGPIN). Materials and Methods We retrospectively analyzed the medical records of 893 patients who underwent a radical prostatectomy for PCa between 2011 and 2012 at Asan Medical Center; 752 of these patients who did not receive neoadjuvant or adjuvant therapy and were followed up for more than 1 year were included. The cohort was divided into two groups-patients with and without HGPIN-and their characteristics were compared. The Cox proportional hazards model was used to analyze factors affecting BCR. Results In total, 652 study patients (86.7%) had HGPIN. There were no significant differences in preoperative factors between the two groups, including age (p=0.369) and preoperative prostate-specific antigen concentration (p=0.234). Patients with HGPIN had a higher Gleason score (p=0.012), more frequent multiple tumor (p=0.013), and more perineural invasion (p=0.012), but no other postoperative pathologic characteristics were significantly different between the two groups. There were no significant differences in BCR (13.0% vs. 11.5%, p=0.665) and HGPIN was not associated with BCR (p=0.745). In multivariate analysis, only the T stage (p<0.001) was associated with BCR. Conclusions PCa patients with HGPIN have a higher Gleason score, more frequent multiple tumors, and more perineural invasion than those without HGPIN. The presence of HGPIN is not an independent predictor of BCR.
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Affiliation(s)
- Donghyun Lee
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chunwoo Lee
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taekmin Kwon
- Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dalsan You
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Gab Jeong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanjong Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Choung-Soo Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Heidenreich A, Pfister D, Porres D. [Radical cancer surgery of renal cell and prostate carcinoma with hematogenous metastasis: benefits]. Urologe A 2015; 53:823-31. [PMID: 24824471 DOI: 10.1007/s00120-014-3519-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The therapeutic role of cytoreductive surgery for urogenital malignancies is controversially discussed in the literature. The current article critically reflects the potential impact of cytoreductive surgery in patients with renal cell cancer and prostate cancer with locoregional lymph node or systemic metastases based on a review of the literature and personal experience.Even in the era of molecular targeted therapies in metastatic renal cell cancer, cytoreductive radical nephrectomy seems to exert survival benefit when compared to systemic therapy alone if (1) patients demonstrate a good ECOG performance status, (2) exhibit good or intermediate prognosis according to the Heng criteria, (3) cerebral metastases have been excluded, and (4) >90% of the total cancer volume can be eliminated. Preliminary clinical studies suggest that neoadjuvant systemic treatment might be associated with a significantly reduced 1-year mortality rate.For prostate cancer cytoreductive radical prostatectomy is one of the guideline-recommended treatment options for men with intrapelvic lymph node metastases resulting in survival benefit when compared to androgen deprivation as monotherapy. Cytoreductive radical prostatectomy should be performed (1) in the presence of limited intrapelvic lymph node metastasis without bulky disease, (2) if complete resectability of the primary cancer and its metastasis can be achieved by extended radical prostatectomy and extended pelvic lymphadenectomy, (3) if the patient is included in a multimodality approach, and (4) if the life expectancy is > 10 years.The role of cytoreductive radical prostatectomy in men with osseous metastases remains unclear due to the lack of large clinical trials. Despite the presence of the first promising studies, it is not justified to perform cytoreductive radical prostatectomy outside clinical trials. Preliminary results from small studies indicate that patients with minimal metastatic burden, PSA decrease < 1.0 ng/ml following neoadjuvant ADT for 6 months and complete resectability of the tumor exhibit the best prognosis to benefit from this new surgical approach.
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Affiliation(s)
- A Heidenreich
- Klinik für Urologie, Universitätsklinikum Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland,
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Krabbe LM, Haddad AQ, Westerman ME, Margulis V. Surgical management of metastatic renal cell carcinoma in the era of targeted therapies. World J Urol 2014; 32:615-22. [PMID: 24700309 DOI: 10.1007/s00345-014-1286-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/19/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cytoreductive nephrectomy (CN) has been considered standard management for patients with metastatic renal cell carcinoma (mRCC) for over a decade. This practice, based on evidence from the immunotherapy era, has now come into question with the dramatic shift in management of mRCC patients due to the development and approval of several targeted molecular therapies (TMT). METHODS A comprehensive English language literature review was performed using MEDLINE/PubMed to identify articles and guidelines pertinent to CN in mRCC. RESULTS Retrospective studies have demonstrated improved survival for patients who underwent CN compared to those that did not; however, these studies suffer from heavy selection bias. Furthermore, the optimal timing of TMT, before or after surgery is not known. Pre-surgical TMT has the advantage of early treatment of metastases, downsizing of the primary, and may be an effective 'litmus test' for the selection of patients for CN based on response to TMT. The results of two ongoing phase III trials (CARMENA and SURTIME) will address much of the controversy on the role of CN and the timing of systemic therapy in the TMT era. In this review, we aim to present the evidence that lead to adoption of CN in the era of immunotherapies as well as the available data about the oncologic benefit of CN in patients with mRCC who receive TMT as their primary systemic therapy. CONCLUSION There seems to be an important role for CN in the era of TMT, mostly in patients with favorable risk and where a high percentage of tumor burden can be removed by cytoreductive surgery.
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Affiliation(s)
- Laura-Maria Krabbe
- Department of Urology, UT Southwestern Medical Center, J8.148, 5235 Harry Hines Boulevard, Dallas, TX, 75390-9110, USA
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Galazi M, Rodriguez-Vida A, Josephides E, Chau NM, Chowdhury S. Cytoreductive nephrectomy: past, present and future. Expert Rev Anticancer Ther 2014; 14:271-7. [PMID: 24392671 DOI: 10.1586/14737140.2014.864240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cytoreductive nephrectomy (CN) is an integral part of the treatment of patients with metastatic renal cell carcinoma. Improved survival has been shown with CN and IFN-α. The introduction of targeted therapy for metastatic renal cell carcinoma has raised important questions regarding the role of CN. The majority of patients who were enrolled in the Phase III studies of targeted therapies had undergone prior nephrectomy. Thus, the benefit of these agents has largely been demonstrated in a nephrectomized population. CARMENA and SURTIME, important Phase III studies examining the role and timing of CN, are ongoing. Until new evidence is available, CN is a reasonable approach in selected patients with a resectable primary tumor and good performance status.
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Affiliation(s)
- Myria Galazi
- Department of Medical Oncology, Guy's Hospital, London, SE1 9RT, UK
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La Rochelle J, Wood C, Bex A. Refining the Use of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma. Semin Oncol 2013; 40:429-35. [DOI: 10.1053/j.seminoncol.2013.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Margulis V, Shariat SF, Rapoport Y, Rink M, Sjoberg DD, Tannir NM, Abel EJ, Culp SH, Tamboli P, Wood CG. Development of accurate models for individualized prediction of survival after cytoreductive nephrectomy for metastatic renal cell carcinoma. Eur Urol 2012; 63:947-52. [PMID: 23273681 DOI: 10.1016/j.eururo.2012.11.040] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 11/15/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited evidence to guide patient selection for cytoreductive nephrectomy (CN) following the diagnosis of metastatic renal cell carcinoma (mRCC). OBJECTIVE Given the significant variability in oncologic outcomes following surgery, we sought to develop clinically relevant, individualized, multivariable models for the prediction of cancer-specific survival at 6 and 12 mo after CN. The development of this nomogram will better help clinicians select patients for cytoreductive surgery. DESIGN, SETTING, AND PARTICIPANTS We identified 601 consecutive patients who underwent CN for kidney cancer at a single tertiary cancer center. INTERVENTION CN for mRCC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The development cohort was used to select predictive variables from a large group of candidate predictors. The discrimination, calibration, and decision curves were corrected for overfit using 10-fold crossvalidation that included stepwise variable selection. RESULTS AND LIMITATIONS With a median follow-up of 65 mo (range: 6-199) for the entire cohort, 110 and 215 patients died from kidney cancer at 6 and 12 mo after surgery, respectively. For the preoperative model, serum albumin and serum lactate dehydrogenase were included. Final pathologic primary tumor stage, nodal stage, and receipt of blood transfusion were added to the previously mentioned parameters for the postoperative model. Preoperative and postoperative nomograms demonstrated good discrimination of 0.76 and 0.74, respectively, when applied to the validation data set. Both models demonstrated excellent calibration and a good net benefit over large ranges of threshold probabilities. The retrospective study design is the major limitation of this study. CONCLUSIONS We have developed models for accurate prediction of cancer-specific survival after CN, using either preoperative or postoperative variables. While these tools need validation in independent cohorts, our results suggest that the models are informative and can be used to aid in clinical decision making.
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Affiliation(s)
- Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 77030, USA
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Capitanio U, Abdollah F, Matloob R, Salonia A, Suardi N, Briganti A, Carenzi C, Rigatti P, Montorsi F, Bertini R. Effect of number and location of distant metastases on renal cell carcinoma mortality in candidates for cytoreductive nephrectomy: Implications for multimodal therapy. Int J Urol 2012; 20:572-9. [DOI: 10.1111/iju.12004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 10/14/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Umberto Capitanio
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Firas Abdollah
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Rayan Matloob
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Andrea Salonia
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Nazareno Suardi
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Alberto Briganti
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Cristina Carenzi
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Patrizio Rigatti
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Francesco Montorsi
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
| | - Roberto Bertini
- Department of Urology; San Raffaele Scientific Institute; University Vita-Salute San Raffaele; Milan; Italy
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Bex A, Powles T. Selecting patients for cytoreductive nephrectomy in advanced renal cell carcinoma: who and when. Expert Rev Anticancer Ther 2012; 12:787-97. [PMID: 22716495 DOI: 10.1586/era.12.54] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Renal cell carcinoma presents with metastatic disease in approximately 30% of patients at the time of diagnosis. Cytoreductive nephrectomy (CN) of the primary tumor in the face of metastatic disease is part of a multimodality approach including systemic therapy that is based on evidence from randomized trials in the cytokine era. Data from the pretargeted therapy era showed that CN had a clear role in metastatic renal cell carcinoma, increasing life expectancy by approximately 6 months. The substantial improvement in outcomes reported for targeted therapy has challenged the previous role of CN. However, despite the absence of data from Phase III trials, available evidence suggests that some patients may benefit substantially from CN in the era of targeted therapy. This review summarizes current arguments for CN and how to best select patients for surgery. Ongoing trials are key in generating evidence towards a personalized approach to debulking nephrectomy.
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Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Sfoungaristos S, Perimenis P. Implication of high grade intraepithelial neoplasia in adverse pathology after radical prostatectomy. Prague Med Rep 2012; 113:156-65. [PMID: 22691286 DOI: 10.14712/23362936.2015.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The implication of high grade prostatic intraepithelial neoplasia (HGPIN) to prostate cancer aggressiveness and prognosis is conflicted. The aim of the present study was to evaluate the role of HGPIN in prediction of adverse pathology in patients undergoing a radical prostatectomy. We retrospectively analysed patients who underwent a radical prostatectomy between January 2005 and December 2010. The relationship between HGPIN and the presence of upgrade, positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and lymph node invasion (LNI) was analysed. HGPIN predictive ability was estimated by using receiver operating characteristic curves. HGPIN was found in 160 (53.3%) specimens. A statistically significant correlation was found between HGPIN and preoperative prostate specific antigen (p=0.020) and patients' age (p=0.025). No significant differences were found, regarding the presence of adverse pathological findings, between the patients with or without HGPIN, irrespective of the preoperative risk stratification. HGPIN did not reach significance for the prediction of upgrade, PSM, ECD, SVI and LNI. The presence of concomitant HGPIN and prostate cancer found not to be related with tumor aggressiveness in patients undergoing a radical prostatectomy and should not be considered as a parameter for the operative outcome prediction.
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Affiliation(s)
- S Sfoungaristos
- Department of Urology, University Hospital of Patras, Patras, Greece.
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Dall'Oglio MF, Sousa-Canavez JM, Tanno FY, Tiseo BC, Crippa A, Dos Reis ST, Leite KRM, Srougi M. Early experience with targeted therapy and dendritic cell vaccine in metastatic renal cell carcinoma after nephrectomy. Int Braz J Urol 2012; 37:180-5; discussion 185-6. [PMID: 21557834 DOI: 10.1590/s1677-55382011000200004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2010] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Metastatic renal cell carcinoma (RCC) is one of the most treatment-resistant malignancies and nephrectomy, isolated or combined with systemic chemotherapy typically has limited or no effectiveness. We report our initial results in patients treated with the association of molecular targeted therapy, nephrectomy, and hybrid dendritic-tumor cell (DC) vaccine. MATERIALS AND METHODS Two male patients diagnosed with metastatic RCC were selected for the study. They were treated with the triple strategy, in which sunitinib (50 mg per day) was given for 4 weeks, followed by radical nephrectomy after two weeks. DC vaccine was initiated immediately after surgery and repeated monthly. Sunitinib was restarted daily after 2 to 3 weeks of surgery with a 7-day interval every 4 weeks. RESULTS Both patients had complete adherence to the proposed treatment with DC vaccine therapy combined with sunitinib. Follow-up in these patients at 9 and 10 months demonstrated a stable disease in both, as shown by imaging and clinical findings, with no further treatment required. CONCLUSION The immune response obtained with DC vaccine combined with the antiangiogenic effect of sunitinib and the potential benefits of cytoreductive nephrectomy in advanced disease could represent a new option in the treatment of metastatic RCC. Further prospective trials are needed not only to elucidate the ideal dosing and schedule, but also to better define the proof-of-concept proposed in this report and its role in clinical practice.
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Affiliation(s)
- Marcos F Dall'Oglio
- Division of Urology, Medical School, University of Sao Paulo, Sao Paulo, Brazil.
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Reese AC, Whitson JM, Meng MV. Natural history of untreated renal cell carcinoma with venous tumor thrombus. Urol Oncol 2012; 31:1305-9. [PMID: 22237466 DOI: 10.1016/j.urolonc.2011.12.006] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 12/08/2011] [Accepted: 12/08/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The natural history of untreated renal cell carcinoma (RCC) with venous tumor thrombus (VTT) is poorly characterized. We aimed to describe the natural history of this disease, and to identify prognostic factors associated with disease-specific survival. MATERIALS AND METHODS We identified patients in the Surveillance, Epidemiology, and End Results (SEER) database with untreated renal cell carcinoma and venous tumor thrombi. Disease-specific median and 1-year survival rates were determined, and disease-free survival curves were plotted using the Kaplan-Meier method. Multivariable Cox regression analyses were performed to identify factors associated with disease-specific and overall survival in this patient group. RESULTS Of 2,265 patients with RCC and VTT, 390 (17%) underwent no treatment; 278 (71%) patients died during follow-up; of these, 243 deaths (87%) were due to RCC. Median and 1-year disease-specific survival for this group was 5 months and 29%, respectively. On multivariable analysis, the extent of tumor thrombus (HR 1.7 for T3c vs. T3b, 95% CI 1.0-2.7) and the presence of metastases (HR 3.1 for M+ vs. M0, 95% CI 1.7-5.5) were most strongly associated with disease-specific mortality. CONCLUSIONS Prognosis is poor for the majority of untreated patients with RCC and VTT. Supradiaphragmatic thrombi and distant metastases are adverse prognostic factors in this patient group. This information is important when counseling patients as to the risk and benefits of surgical vs. nonoperative management of RCC and VTT.
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Affiliation(s)
- Adam C Reese
- Department of Urology, University of California San Francisco, San Francisco, CA 94143, USA.
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Shinohara N, Abe T, Sazawa A, Maruyama S, Shindo J, Sato S, Suzuki S, Nonomura K. Interferon-α-based immunotherapy in metastatic renal cell carcinoma patients with the primary tumor in situ. Jpn J Clin Oncol 2011; 42:113-9. [PMID: 22131341 DOI: 10.1093/jjco/hyr176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We reviewed the outcomes of metastatic renal cell carcinoma patients with the primary tumor in situ who initially underwent interferon-α-based immunotherapy to evaluate the effect of this therapy on metastatic sites as well as primary kidney tumor and survival. METHODS Thirty-one patients, for whom upfront cytoreductive nephrectomy was considered to be inappropriate because of poor performance status and far-advanced disease, were the subject of the present study. Tumor response and reduction in the size of metastatic sites and primary kidney tumor were assessed. Overall survival distributions were estimated using the Kaplan-Meier method with the significance determined using the log-rank test. RESULTS Partial response was observed in 11 patients, yielding an overall response rate of 35%. Seventeen patients had regression or stabilization of metastatic sites, while progression of metastatic sites was observed in the remaining 14 patients. Regarding the maximum response of primary kidney tumor, a reduction in kidney primary tumor size was observed in 42% of the patients and the mean reduction rate in these patients was 18.2% (range: 3-36%). Furthermore, the reduction in the size of metastatic sites was significantly associated with that in the size of primary kidney tumor (R(2)= 0.432, P< 0.0001). The median survival for the 31 patients was 17 months. The median survival was 42 months in patients with regression or stabilization of metastatic sites and 7 months in those without (P< 0.001). CONCLUSIONS The present study suggests that metastatic sites as well as primary kidney tumor respond to interferon-α-based immunotherapy in metastatic renal cell carcinoma patients with primary tumor in situ.
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Affiliation(s)
- Nobuo Shinohara
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Vourganti S, Shuch B, Bratslavsky G. Surgical management of large renal tumors. Expert Rev Anticancer Ther 2011; 11:1889-900. [PMID: 22117156 DOI: 10.1586/era.11.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The surgical management of patients with renal cell carcinoma has undergone many changes. With equivalent oncologic outcomes and appreciation of the importance of renal functional preservation, the utilization of nephron-sparing partial nephrectomy has increased in recent years. Nevertheless, tumors of larger size continue to be preferentially treated with radical nephrectomy. Here, we present evidence that improvements in techniques and durability of oncologic outcomes has justified the use of nephron sparing to accomplish renal functional preservation even in patients with large renal tumors. In addition, surgical technical considerations when managing such tumors are discussed. Finally, we discuss cytoreductive surgery and the evolving role of systemic targeted therapies in the management of advanced metastatic disease.
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Affiliation(s)
- Srinivas Vourganti
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892-1107, USA
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Jung JH, Lee JW, Arkoncel FRP, Cho NH, Yusoff NAM, Kim KJ, Song JM, Kim SJ, Rha KH. Significance of perineural invasion, lymphovascular invasion, and high-grade prostatic intraepithelial neoplasia in robot-assisted laparoscopic radical prostatectomy. Ann Surg Oncol 2011; 18:3828-32. [PMID: 21660497 DOI: 10.1245/s10434-011-1790-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recently, more detailed histopathological variables such as perineural invasion (PNI), lymphovascular invasion (LVI), and high-grade prostatic intraepithelial neoplasia (HGPIN) have been investigated as prognostic factors for adverse pathologic findings on the radical prostatectomy specimen. We aim to determine whether these pathological factors are associated with adverse pathologic features after robot-assisted laparoscopic radical prostatectomy (RALP). METHODS All 407 patients who underwent RALP with pelvic lymphadenectomy between July 2005 and December 2009 were analyzed, retrospectively. We investigated the association of these three pathological parameters with adverse pathological findings in RALP specimen and biochemical recurrence using Kaplan-Meier analysis with log-rank test and a multivariate Cox proportional hazard model. RESULTS The PNI and LVI were significantly associated with a higher pathological stage, a higher pathological Gleason score, a higher tumor volume in RALP specimen, a higher frequency of positive surgical margins, and a higher frequency of seminal vesicle invasion. In addition, PNI correlated with preoperative PSA, clinical stage, and Gleason score on needle biopsy. However, the HGPIN was not significantly associated with the clinicopathological characteristics studied. Using log-rank test, presence of PNI (P < 0.001) increases the probability of biochemical recurrence. On multivariate analysis, all three pathological parameters were not significantly correlated with biochemical recurrence. CONCLUSION Although presence of PNI and LVI in RALP specimen correlated with multiple adverse clinicopathological factors, it did not predict biochemical recurrence, thus limiting its clinical usefulness. HGPIN was not significantly associated with the clinicopathological characteristics studied.
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Affiliation(s)
- Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
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Choueiri TK, Xie W, Kollmannsberger C, North S, Knox JJ, Lampard JG, McDermott DF, Rini BI, Heng DYC. The impact of cytoreductive nephrectomy on survival of patients with metastatic renal cell carcinoma receiving vascular endothelial growth factor targeted therapy. J Urol 2010; 185:60-6. [PMID: 21074201 DOI: 10.1016/j.juro.2010.09.012] [Citation(s) in RCA: 257] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Indexed: 12/16/2022]
Abstract
PURPOSE Vascular endothelial growth factor targeted therapy is a standard of care in patients with metastatic renal cell carcinoma. The role of cytoreductive nephrectomy in the era of novel agents remains poorly defined. MATERIALS AND METHODS We retrospectively reviewed baseline characteristics and outcomes of 314 patients with anti-vascular endothelial growth factor therapy naïve, metastatic renal cell carcinoma from United States and Canadian cancer centers to study the impact of cytoreductive nephrectomy on overall survival. RESULTS Patients who underwent cytoreductive nephrectomy (201) were younger (p < 0.01), and more likely to have a better Karnofsky performance status (p < 0.01), more than 1 site of metastasis (p = 0.04) and lower corrected calcium levels (p < 0.01) compared to those who did not undergo cytoreductive nephrectomy (113). On univariable analysis cytoreductive nephrectomy was associated with a median overall survival of 19.8 months compared to 9.4 months for patients who did not undergo cytoreductive nephrectomy (HR 0.44; 95% CI 0.32, 0.59; p < 0.01). On multivariable analysis and adjusting for established prognostic risk factors the overall survival difference persisted (adjusted HR 0.68; 95% CI 0.46, 0.99; p = 0.04) in favor of the cytoreductive nephrectomy group. In subgroup analyses stratified for favorable/intermediate/poor risk criteria, patients in the poor risk group had a marginal benefit (p = 0.06). Similarly patients with Karnofsky performance status less than 80% also had a marginal survival benefit (p = 0.08). CONCLUSIONS In this retrospective study cytoreductive nephrectomy was independently associated with a prolonged overall survival of patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor targeted agents, although the benefit is marginal in those patients with poor risk features.
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Affiliation(s)
- Toni K Choueiri
- Kidney Cancer Center, Dana Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Grover S, Srivastava A, Tan G, Sooriakumaran P, John M, Mudaliar K, El-Douaihy Y, Leung R, Shevchuk M, Tewari AK. Clinicopathological Strategies to Identify Contralateral Prostate Cancer Involvement in Potential Candidates for Focal Therapy. Int J Surg Pathol 2010; 18:499-507. [DOI: 10.1177/1066896910379479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To identify the magnitude and possible predictors of contralateral lobe involvement and contralateral extraprostatic extension (EPE) in prostatic biopsy—defined localized unilateral cancers. Patients and Methods: Between January 2005 and August 2009, 1861 patients underwent robotic-assisted radical prostatectomy at the authors’ institution. A total of 1114 had unilateral disease on preoperative biopsy. Final histopathology reports of these patients were reviewed. Results: Of the 1114 patients with unilateral disease on biopsy, 867 (77.9%) had contralateral or bilateral disease on final histopathology. EPE was found in 132 patients (11.9%). Twenty patients (1.8%) had contralateral EPE involvement. High-grade prostatic intraepithelial neoplasm (HGPIN) on biopsy was the significant predictor of contralateral lobe involvement on both univariate ( P = .02; odds ratio [OR] = 1.791) and multivariate analysis ( P = .004; OR = 2.677). Clinical stage T2 was the significant predictor of contralateral EPE on both univariate ( P = .012; OR = 5.250) and multivariate analysis ( P = .007; OR = 8.656). Conclusion: HGPIN on biopsy significantly predicts for contralateral lobe involvement and should be considered an exclusion criterion for focal therapy in prostate cancer patients. Patients with palpable tumor on digital rectal examination should be advised in favor of radical treatment as these patients may harbor more aggressive tumors involving the contralateral side despite the biopsy findings.
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Affiliation(s)
- Sonal Grover
- Weill Cornell Medical College, New York, NY, USA
| | | | - Gerald Tan
- Weill Cornell Medical College, New York, NY, USA
| | | | - Majnu John
- Weill Cornell Medical College, New York, NY, USA
| | | | | | - Robert Leung
- Weill Cornell Medical College, New York, NY, USA
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Algaba F, Montironi R. Impact of prostate cancer multifocality on its biology and treatment. J Endourol 2010; 24:799-804. [PMID: 20367408 DOI: 10.1089/end.2009.0462] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Any focal therapy requires correct localization of the lesion; consequently, much effort is now devoted to accurate characterization of the spatial distribution of the tumor within the prostate. One of the greatest difficulties in the localization of prostate cancer is its frequent multifocality, but prostate cancer is unifocal in 13% to 43.7% of cases and unilateral in 19.2%. In cases of multifocality, it seems that the index tumor is the biologic driving force behind the malignant potential of prostate cancer. Not only is the Gleason score of the secondary nodes lower than that of the index node, but 80% of the secondary nodes are smaller than 0.5 cc and almost all extraprostatic extensions are associated with the largest cancers. While current evaluation with 12 to 18 core biopsies may be adequate to determine the index lesion, transperineal three-dimensional mapping biopsy of the prostate should be undertaken if greater accuracy is needed.
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Affiliation(s)
- Ferran Algaba
- Fundació Puigvert, Pathology Section, Universitat Autónoma de Barcelona, Barcelona, Spain.
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Barbastefano J, Garcia JA, Elson P, Wood LS, Lane BR, Dreicer R, Campbell SC, Rini BI. Association of percentage of tumour burden removed with debulking nephrectomy and progression-free survival in patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor-targeted therapy. BJU Int 2010; 106:1266-9. [PMID: 20346042 DOI: 10.1111/j.1464-410x.2010.09323.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yezhelyev M, Master V, Egnatashvili V, Kooby DA. Combined nephrectomy and major hepatectomy: indications, outcomes, and recommendations. J Am Coll Surg 2009; 208:410-8. [PMID: 19318003 DOI: 10.1016/j.jamcollsurg.2008.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 12/03/2008] [Accepted: 12/04/2008] [Indexed: 01/12/2023]
Abstract
BACKGROUND Simultaneous nephrectomy with major hepatectomy (NMH) is uncommon. We reviewed our experience with NMH. STUDY DESIGN Records of patients who underwent NMH at Emory Hospital between January 1995 and May 2008 were examined. Patients undergoing resection of three or more liver segments at the same setting as a total nephrectomy were included. Indications and outcomes were assessed. RESULTS Twenty patients underwent NMH. Mean (+/- SD) age was 59.9+/-12.8 years, 6 (30%) were women, and 15 (75%) presented with comorbidities. Most kidney neoplasms were renal cell carcinomas of the right kidney (n=16, 80%) with a mean diameter of 10.0+/-6.1 cm. Eight patients (40%) also underwent thrombectomy for inferior vena cava tumor thrombus. The most common indications for hepatectomy were direct liver invasion in eight patients (40%) and distant hepatic metastases in nine (45%); liver tumors were 4.2+/-3.3 cm (mean +/- SD) in diameter. Mean (+/- SD) operative time was 8.3+/-2.6 hours. Liver resections included 15 (75%) right hepatectomies and 5 (25%) left hepatectomies. In all cases, tumor negative hepatic margins were achieved. Median operative blood loss was 1,700 mL (range 200 to 8,000 mL). Ten patients (50%) suffered complications in the postoperative period; three of these suffered major complications, resulting in one perioperative death (5%). Mean hospital stay was 12+/-8.8 days. Overall survival was 25 months (range 0 to 34 months). CONCLUSIONS In this large series of nephrectomy with simultaneous major hepatectomy, morbidity and mortality were acceptable. In specialized centers NMH may be considered in properly selected patients for combined resection for synchronous neoplasms of the kidney and liver.
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Affiliation(s)
- Maksym Yezhelyev
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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Neoadjuvant sunitinib for surgically complex advanced renal cell cancer of doubtful resectability: initial experience with downsizing to reconsider cytoreductive surgery. World J Urol 2009; 27:533-9. [PMID: 19145434 DOI: 10.1007/s00345-008-0368-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 12/15/2008] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To evaluate neoadjuvant sunitinib in patients with synchronous metastatic renal cell cancer (mRCC) to downsize surgically complex tumours and reconsider cytoreductive surgery. PATIENTS AND METHODS Retrospective analysis of ten consecutive mRCC patients treated with sunitinib in an expanded access program who presented with surgically complex primary tumours or bulky locoregional metastases. Surgery-limiting tumour sites (SLTSs) were defined as primary or retroperitoneal lesions with direct invasion of adjacent organs or encasement of vital structures on imaging. Patients received sunitinib 50 mg/day for 4 weeks on and 2 weeks off to be followed by cytoreductive surgery after downsizing and individual reassessment. Response was measured according to Response Evaluation Criteria in Solid Tumours (RECIST). RESULTS Six out of ten SLTSs revealed a reduction of tumour size with a median of 14% according to RECIST. None of the ten SLTSs had a partial response (PR), whilst at distant metastatic sites one complete remission and two PRs occurred. Downsizing of SLTSs appeared most prominent in the first 2-4 months, which resulted in reconsidering cytoreductive nephrectomy in three patients. These three tumours invaded the liver on imaging and were reduced by 11, 18 and 20%. CONCLUSIONS In this patient group with mRCC and surgically complex primary tumours or locoregional metastases, downsizing of SLTSs by neoadjuvant sunitinib was limited. Cytoreductive surgery was reconsidered in three patients. Given the overall reduction in tumour burden by sunitinib alone, further investigation to define the role of cytoreductive surgery is warranted.
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