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Zarba M, Fujiwara R, Yuasa T, Koga F, Heng DYC, Takemura K. Multidisciplinary systemic and local therapies for metastatic renal cell carcinoma: a narrative review. Expert Rev Anticancer Ther 2024; 24:693-703. [PMID: 38813778 DOI: 10.1080/14737140.2024.2362192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/28/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Systemic and local therapies for patients with metastatic renal cell carcinoma (mRCC) are often challenging despite the evolution of multimodal cancer therapies in the last decade. In this review, we will focus on recent multidisciplinary approaches for patients with mRCC. AREAS COVERED Systemic therapies for patients with mRCC have been garnering attention particularly after the approval of immuno-oncology (IO) agents, including anti-programmed death 1/programmed death-ligand 1. IO combinations have significantly prolonged overall survival in patients with mRCC in the first-line setting. Regarding local therapies, cytoreductive nephrectomy (CN) has become less common in the post-Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques (CARMENA) trial era, even though CN may still benefit selected patients with mRCC. In addition, metastasis-directed local therapies, namely metastasectomy or stereotactic radiotherapy, particularly for oligo-metastatic lesions or brain metastases, may have a prognostic impact. Several ablative techniques are also evolving while maintaining high local control rates with acceptable safety. EXPERT OPINION Multimodal cancer therapies are essential for conquering complex cases of mRCC. Modern systemic therapies including IO-based combination therapy as well as local therapies including CN, metastasectomy, stereotactic radiotherapy, and ablative techniques appear to improve oncologic outcomes of patients with mRCC, although appropriate patient selection is indispensable.
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Affiliation(s)
- Martin Zarba
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
| | - Ryo Fujiwara
- Department of Genitourinary Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Genitourinary Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Daniel Y C Heng
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
| | - Kosuke Takemura
- Department of Genitourinary Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Jiang A, Li J, He Z, Liu Y, Qiao K, Fang Y, Qu L, Luo P, Lin A, Wang L. Renal cancer: signaling pathways and advances in targeted therapies. MedComm (Beijing) 2024; 5:e676. [PMID: 39092291 PMCID: PMC11292401 DOI: 10.1002/mco2.676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 08/04/2024] Open
Abstract
Renal cancer is a highlyheterogeneous malignancy characterized by rising global incidence and mortalityrates. The complex interplay and dysregulation of multiple signaling pathways,including von Hippel-Lindau (VHL)/hypoxia-inducible factor (HIF), phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR), Hippo-yes-associated protein (YAP), Wnt/ß-catenin, cyclic adenosine monophosphate (cAMP), and hepatocyte growth factor (HGF)/c-Met, contribute to theinitiation and progression of renal cancer. Although surgical resection is thestandard treatment for localized renal cancer, recurrence and metastasiscontinue to pose significant challenges. Advanced renal cancer is associatedwith a poor prognosis, and current therapies, such as targeted agents andimmunotherapies, have limitations. This review presents a comprehensiveoverview of the molecular mechanisms underlying aberrant signaling pathways inrenal cancer, emphasizing their intricate crosstalk and synergisticinteractions. We discuss recent advancements in targeted therapies, includingtyrosine kinase inhibitors, and immunotherapies, such as checkpoint inhibitors.Moreover, we underscore the importance of multiomics approaches and networkanalysis in elucidating the complex regulatory networks governing renal cancerpathogenesis. By integrating cutting-edge research and clinical insights, this review contributesto the development of innovative diagnostic and therapeutic strategies, whichhave the potential to improve risk stratification, precision medicine, andultimately, patient outcomes in renal cancer.
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Affiliation(s)
- Aimin Jiang
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Jinxin Li
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Ziwei He
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Ying Liu
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Kun Qiao
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Yu Fang
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
| | - Le Qu
- Department of UrologyJinling HospitalAffiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Peng Luo
- Department of OncologyZhujiang HospitalSouthern Medical UniversityGuangzhouGuangdongChina
| | - Anqi Lin
- Department of OncologyZhujiang HospitalSouthern Medical UniversityGuangzhouGuangdongChina
| | - Linhui Wang
- Department of UrologyChanghai HospitalNaval Medical UniversityShanghaiChina
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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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Kumada N, Iinuma K, Kubota Y, Takagi K, Nakano M, Ishida T, Yokoi S, Sugino F, Kawase M, Takeuchi S, Kawase K, Kato D, Takai M, Tobisawa Y, Ito T, Nakane K, Koie T. Impact of Cytoreductive Nephrectomy in the Management of Metastatic Renal Cell Carcinoma: A Multicenter Retrospective Study. Diseases 2024; 12:122. [PMID: 38920554 PMCID: PMC11202703 DOI: 10.3390/diseases12060122] [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: 03/24/2024] [Revised: 05/04/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
In this study, we aimed to determine the utility of cytoreductive nephrectomy (CN) in real-world clinical practice and investigate whether CN contributes to improved oncological outcomes in patients with metastatic renal cell carcinoma (mRCC). This retrospective multicenter cohort study enrolled patients with mRCC who received systemic therapy at six institutions between May 2005 and May 2023. The patients were divided into those who did not undergo CN (Group I) and those who underwent CN (Group II). The primary endpoints were oncological outcomes, including cancer-specific survival (CSS) and progression-free survival (PFS). Altogether, 137 patients with mRCC were included in this study. The median CSS was 14 months in Group I and 32 months in Group II (p < 0.001). Additionally, the median PFS in Groups I and II was 5 and 13 months, respectively (p = 0.006). A multivariate analysis showed that CN was an independent prognostic factor for CSS and PFS. Hence, CN is a potential treatment modality that can improve oncological outcomes in patients with mRCC.
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Affiliation(s)
- Naotaka Kumada
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
- Department of Urology, Matsunami General Hospital, 185-1 Kasamatsucho, Hashima-gun, Gifu 501-6062, Japan
| | - Koji Iinuma
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Yasuaki Kubota
- Department of Urology, Toyota Memorial Hospital, 1-1 Heiwacho, Toyota 471-8513, Japan;
| | - Kimiaki Takagi
- Department of Urology, Daiyukai Hospital, 1-9-9 Sakura, Ichinomiya 491-8551, Japan;
| | - Masahiro Nakano
- Department of Urology, Gifu Prefectural General Medical Center, 4-6-1 Noisiki, Gifu 500-8717, Japan;
| | - Takashi Ishida
- Department of Urology, Gifu Municipal Hospital, 7-1 Kashimacho, Gifu 500-8513, Japan;
| | - Shigeaki Yokoi
- Department of Urology, Central Japan International Medical Center, Minokamo 505-8510, Japan;
| | - Fumiya Sugino
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Makoto Kawase
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Shinichi Takeuchi
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Kota Kawase
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Daiki Kato
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Manabu Takai
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Yuki Tobisawa
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Takayasu Ito
- Center for Clinical Training and Career Development, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan;
| | - Keita Nakane
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
| | - Takuya Koie
- Department of Urology, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu 501-1194, Japan or (N.K.); (F.S.); (M.K.); (S.T.); (K.K.); (D.K.); (M.T.); (Y.T.); (K.N.); (T.K.)
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Takemura K, Ernst MS, Navani V, Wells JC, Bakouny Z, Donskov F, Basappa NS, Wood LA, Meza L, Pal SK, Szabados B, Powles T, Beuselinck B, McKay RR, Lee JL, Ernst DS, Kapoor A, Yuasa T, Choueiri TK, Heng DYC. Characterization of Patients with Metastatic Renal Cell Carcinoma Undergoing Deferred, Upfront, or No Cytoreductive Nephrectomy in the Era of Combination Immunotherapy: Results from the International Metastatic Renal Cell Carcinoma Database Consortium. Eur Urol Oncol 2024; 7:501-508. [PMID: 37914579 DOI: 10.1016/j.euo.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 09/29/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The role of cytoreductive nephrectomy (CN) has not yet been well characterized in the era of combination immunotherapy. OBJECTIVE To evaluate characteristics and outcomes for patients with metastatic renal cell carcinoma (mRCC) who received immuno-oncology (IO)-based combination therapy according to CN status. DESIGN, SETTING, AND PARTICIPANTS Using the International mRCC Database Consortium (IMDC), patients with mRCC who received frontline IO-based combinations were included. Upfront CN was defined as CN up to 3 mo before diagnosis of metastatic disease but before systemic therapy initiation. Deferred CN was defined as CN after systemic therapy initiation. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS Overall survival (OS) from initiation of systemic therapy was estimated via Cox proportional-hazards regression. A 12-mo landmark time and a time-varying covariate for CN status were used to mitigate potential bias. RESULTS AND LIMITATIONS Of the 385 patients eligible for landmark analysis, 24, 182, and 179 underwent deferred CN, upfront CN, and no CN, respectively. Patients in the no CN subgroup were older (63 yr vs 57 yr in the deferred CN subgroup and 60 yr in the upfront CN subgroup; p = 0.001) and a higher proportion had bone metastases (44% vs 26% in the deferred CN subgroup and 23% in the upfront CN subgroup; p < 0.001). A lower proportion of patients in the upfront CN subgroup had IMDC poor risk (23% vs 43% in the no CN subgroup and 47% in the deferred CN subgroup; p < 0.001). On multivariable analysis, CN receipt was an independent favorable prognostic factor (hazard ratio 0.45, 95% confidence interval 0.26-0.78; p = 0.005). The study is limited by the lack of randomization and its retrospective nature. CONCLUSIONS Despite changes in practice patterns with the advent of novel therapeutic agents, CN may still serve as an effective surgical intervention in carefully selected patients. PATIENT SUMMARY For patients with metastatic kidney cancer, surgery to remove the primary tumor was traditionally the treatment of choice, but immunotherapy drugs are now another option for these patients. We analyzed data for contemporary patients with metastatic kidney cancer who received combination immunotherapy as their first treatment. We found that in selected patients receiving immunotherapy, surgery to remove the primary tumor as well can result in better prognosis.
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Affiliation(s)
- Kosuke Takemura
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Matthew S Ernst
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Vishal Navani
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | | | - Ziad Bakouny
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Frede Donskov
- Aarhus University Hospital, Aarhus, Denmark; University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Naveen S Basappa
- Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Lori A Wood
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Luis Meza
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sumanta K Pal
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | | | - Thomas Powles
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | | | - Rana R McKay
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Jae-Lyun Lee
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D Scott Ernst
- London Regional Cancer Program, Western University, London, ON, Canada
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Takeshi Yuasa
- Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toni K Choueiri
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Daniel Y C Heng
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
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Cardenas LM, Sigurdson S, Wallis CJD, Lalani AK, Swaminath A. Percées dans la prise en charge de l’hypernéphrome. CMAJ 2024; 196:E601-E607. [PMID: 38719217 PMCID: PMC11073830 DOI: 10.1503/cmaj.230356-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Affiliation(s)
- Luisa M Cardenas
- Département d'oncologie (Cardenas, Sigurdson, Lalani, Swaminath), Centre de cancérologie Juravinski, Université McMaster, Hamilton, Ont.; Division d'urologie, Département de chirurgie (Wallis), Université de Toronto; Division d'urologie, Département de chirurgie (Wallis), Hôpital Mont Sinaï; Département de chirurgie oncologique (Wallis), Réseau universitaire de santé, Toronto, Ont
| | - Samantha Sigurdson
- Département d'oncologie (Cardenas, Sigurdson, Lalani, Swaminath), Centre de cancérologie Juravinski, Université McMaster, Hamilton, Ont.; Division d'urologie, Département de chirurgie (Wallis), Université de Toronto; Division d'urologie, Département de chirurgie (Wallis), Hôpital Mont Sinaï; Département de chirurgie oncologique (Wallis), Réseau universitaire de santé, Toronto, Ont
| | - Christopher J D Wallis
- Département d'oncologie (Cardenas, Sigurdson, Lalani, Swaminath), Centre de cancérologie Juravinski, Université McMaster, Hamilton, Ont.; Division d'urologie, Département de chirurgie (Wallis), Université de Toronto; Division d'urologie, Département de chirurgie (Wallis), Hôpital Mont Sinaï; Département de chirurgie oncologique (Wallis), Réseau universitaire de santé, Toronto, Ont
| | - Aly-Khan Lalani
- Département d'oncologie (Cardenas, Sigurdson, Lalani, Swaminath), Centre de cancérologie Juravinski, Université McMaster, Hamilton, Ont.; Division d'urologie, Département de chirurgie (Wallis), Université de Toronto; Division d'urologie, Département de chirurgie (Wallis), Hôpital Mont Sinaï; Département de chirurgie oncologique (Wallis), Réseau universitaire de santé, Toronto, Ont.
| | - Anand Swaminath
- Département d'oncologie (Cardenas, Sigurdson, Lalani, Swaminath), Centre de cancérologie Juravinski, Université McMaster, Hamilton, Ont.; Division d'urologie, Département de chirurgie (Wallis), Université de Toronto; Division d'urologie, Département de chirurgie (Wallis), Hôpital Mont Sinaï; Département de chirurgie oncologique (Wallis), Réseau universitaire de santé, Toronto, Ont.
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7
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Liu Y, Cheng W, Yang Q, Han Y, Jiang Q, Yang Y, Zhang H. Mining and validation of prognosis of various visceral metastasis in renal cell carcinoma: a study based on SEER database. Updates Surg 2024; 76:657-676. [PMID: 38165526 DOI: 10.1007/s13304-023-01703-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024]
Abstract
Our study was aimed to analyze a substantial of renal cell carcinoma (RCC) patients, research the high-risk factors and prognostic factors of metastasis, and thoroughly examine the effects of primary site surgery, lymph node dissection (LND), and chemotherapy on the prognosis of different visceral metastases. The baseline characteristics were characterized, and logistic regression was used to predict the risk factors for metastasis. Prognostic factors of metastatic RCC were assessed using batch univariate and multivariate Cox regression, with adjustments made through PSM. Next, the Kaplan-Meier method was employed to assess OS and create the survival curve. Logistic regression identified risk factors for metastasis: male gender [OR, 1.223; P < 0.001], Hist clear (OR, 9.37; P < 0.001), Hist papillary (OR, 2.49; P < 0.001), and TTX (OR, 23.33; P < 0.001). We found several independent prognostic variables: among which chemotherapy (HR, 0.64), local LND (HR, 0.67), and primary site surgery (HR, 0.97) were associated with better OS. Further study results demonstrated that all kinds of visceral metastasis except for liver metastasis in the operation group had substantially better prognoses than those in the non-operation group (P < 0.05). Regional LND had no discernible impact on survival. Patients with liver, lung, and distant lymph node (LN) metastasis benefited from chemotherapy (P < 0.05), but the bone and brain metastasis did not significantly benefit from treatment (P > 0.05). We recommend primary surgery for different types of visceral metastases except liver metastasis. Routine regional LND is not recommended. Chemotherapy should be considered for patients with lung, distant LN, and liver metastases, but not for those with bone and brain metastases.
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Affiliation(s)
- Yu Liu
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Wenjuan Cheng
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Qin Yang
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yucheng Han
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Qing Jiang
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yuanyuan Yang
- School of Medicine, Tongji University, Shanghai, 200092, China
| | - Haimin Zhang
- School of Medicine, Tongji University, Shanghai, 200092, China.
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, 200072, China.
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Incesu RB, Barletta F, Garcia CC, Scheipner L, Morra S, Baudo A, Assad A, Tian Z, Saad F, Shariat SF, Carmignani L, Longo N, Ahyai S, Chun FKH, Briganti A, Tilki D, Graefen M, Karakiewicz PI. The Effect of Treatment Intensification on Other-Cause Mortality in Clear-Cell Metastatic Renal Cell Carcinoma Patients. Clin Genitourin Cancer 2024; 22:420-425. [PMID: 38307818 DOI: 10.1016/j.clgc.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND The effect of treatment intensification (systemic therapy [ST] + cytoreductive nephrectomy (CN) vs. ST alone) is unknown regarding rates of other-cause mortality (OCM) in clear-cell metastatic renal cell carcinoma (ccmRCC). We hypothesized that intensified treatment (ST + CN) may result in higher OCM, than when ST is used alone. METHODS Within the Surveillance, Epidemiology, and End Results database, all ccmRCC patients treated 2010-2018 either with ST + CN or ST alone were identified. Propensity score matching (PSM), cumulative incidence plots, multivariable competing risks regression analyses and 6 months' landmark analyses addressed OCM and cancer-specific mortality (CSM) according to treatment status. RESULTS Of 2271 ccmRCC patients, 1233 (54%) were treated with ST + CN vs 1038 (46%) with ST alone. After 1:1 PSM, OCM was 5.3 vs. 4.6 % (P = .5) and CSM was 73.4 vs. 88.4% (P < .001) in ST + CN vs. ST alone patients. In multivariable competing risks regression, the combination of ST and CN was not associated with higher OCM (HR 1.3; 95% CI 0.8-2.1; P = .4), vs. ST alone. However, the combination of ST and CN was independently associated with lower CSM (HR 0.5; 95% CI 0.5-0.6; P < .001), vs. ST alone. After 6 months' landmark analyses, these multivariable associations remained unchanged. CONCLUSIONS The current study indicates no OCM-disadvantage in ST + CN ccmRCC patients, relative to their ST alone counterparts. Conversely, a strong association with lower CSM was recorded in ST + CN patients, relative to their ST alone counterparts. These associations are robust and remained unchanged after strictest statistical adjustment including control for immortal time bias.
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Affiliation(s)
- Reha-Baris Incesu
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Francesco Barletta
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Cristina Cano Garcia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Lukas Scheipner
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, Medical University of Graz, Graz, Austria
| | - Simone Morra
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Andrea Baudo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy; Department of Urology, IRCCS Policlinico San Donato, Milan, Italy
| | - Anis Assad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, New York; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Hourani Center of Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Luca Carmignani
- Department of Urology, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy; Department of Urology, IRCCS Policlinico San Donato, Milan, Italy
| | - Nicola Longo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Sascha Ahyai
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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9
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Lai GS, Li JR, Wang SS, Chen CS, Yang CK, Lin CY, Hung SC, Chiu KY, Yang SF. Outcome benefits of upfront cytoreductive nephrectomy for patients with metastatic renal cell carcinoma: An analysis of the TriNetX database. PLoS One 2024; 19:e0299102. [PMID: 38547226 PMCID: PMC10977795 DOI: 10.1371/journal.pone.0299102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 02/05/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND The role of upfront cytoreductive nephrectomy remains debatable in the present era of tyrosine kinase inhibitors and immune checkpoint inhibitors. Here, we aimed to evaluate the outcomes of metastatic renal cell carcinoma patients treated with upfront CN and modern systemic therapies. METHODS Using the TriNetX network database, we identified patients, in the period from 2008 to 2022, who were diagnosed with metastatic renal cell carcinoma, receiving first-line systemic therapies with tyrosine kinase inhibitors or immune checkpoint inhibitors. Their overall survivals were evaluated using the Kaplan-Meier method as well as multivariable regressions. RESULTS We identified 11,094 patients with metastatic renal cell carcinoma. Of them, 2,914 (43%) patients in the tyrosine kinase inhibitor cohort (n = 6,779), and 1,884 (43.7%) in the immune checkpoint inhibitors cohort (n = 4315) underwent upfront cytoreductive nephrectomy. Those receiving upfront cytoreductive nephrectomy showed survival advantages with either tyrosine kinase inhibitor (Hazard ratio 0.722, 95% Confidence interval 0.67-0.73, p<0.001) or immune checkpoint inhibitors (Hazard ratio 65.1, 95% Confidence interval 0.59-0.71, p<0.001). In multivariable analysis, upfront cytoreductive nephrectomy was a factor for improved OS in both cohorts: tyrosine kinase inhibitors (Hazard ratio 0.623, 95% Confidence interval 0.56-0.694, p<0.001) and immune checkpoint inhibitors cohort (Hazard ratio 0.688, 95% Confidence interval 0.607-0.779, p<0.001). CONCLUSIONS Upfront cytoreductive nephrectomy was associated with an improved overall survival for patients with metastatic renal cell carcinoma receiving either first-line tyrosine kinase inhibitors or immune checkpoint inhibitors. Our results support a clinical role of upfront cytoreductive nephrectomy in the modern era.
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Affiliation(s)
- Gu-Shun Lai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
| | - Jian-Ri Li
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
- Department of Medicine and Nursing, Hungkuang University, Taichung, Taiwan
| | - Shian-Shiang Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
- Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan
| | - Chuan-Shu Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
| | - Chun-Kuang Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
| | - Chia-Yen Lin
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
| | - Sheng-Chun Hung
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
| | - Kun-Yuan Chiu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Division of Urology, Taichung Veterans General Hospital, Taichung, Tawan
- Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
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10
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Cardenas LM, Sigurdson S, Wallis CJD, Lalani AK, Swaminath A. Advances in the management of renal cell carcinoma. CMAJ 2024; 196:E235-E240. [PMID: 38408783 PMCID: PMC10896601 DOI: 10.1503/cmaj.230356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Affiliation(s)
- Luisa M Cardenas
- Department of Oncology (Cardenas, Sigurdson, Lalani, Swaminath), Juravinski Cancer Centre, McMaster University, Hamilton, Ont.; Division of Urology, Department of Surgery (Wallis), University of Toronto; Division of Urology, Department of Surgery (Wallis), Mount Sinai Hospital; Department of Surgical Oncology (Wallis), University Health Network, Toronto, Ont
| | - Samantha Sigurdson
- Department of Oncology (Cardenas, Sigurdson, Lalani, Swaminath), Juravinski Cancer Centre, McMaster University, Hamilton, Ont.; Division of Urology, Department of Surgery (Wallis), University of Toronto; Division of Urology, Department of Surgery (Wallis), Mount Sinai Hospital; Department of Surgical Oncology (Wallis), University Health Network, Toronto, Ont
| | - Christopher J D Wallis
- Department of Oncology (Cardenas, Sigurdson, Lalani, Swaminath), Juravinski Cancer Centre, McMaster University, Hamilton, Ont.; Division of Urology, Department of Surgery (Wallis), University of Toronto; Division of Urology, Department of Surgery (Wallis), Mount Sinai Hospital; Department of Surgical Oncology (Wallis), University Health Network, Toronto, Ont
| | - Aly-Khan Lalani
- Department of Oncology (Cardenas, Sigurdson, Lalani, Swaminath), Juravinski Cancer Centre, McMaster University, Hamilton, Ont.; Division of Urology, Department of Surgery (Wallis), University of Toronto; Division of Urology, Department of Surgery (Wallis), Mount Sinai Hospital; Department of Surgical Oncology (Wallis), University Health Network, Toronto, Ont.
| | - Anand Swaminath
- Department of Oncology (Cardenas, Sigurdson, Lalani, Swaminath), Juravinski Cancer Centre, McMaster University, Hamilton, Ont.; Division of Urology, Department of Surgery (Wallis), University of Toronto; Division of Urology, Department of Surgery (Wallis), Mount Sinai Hospital; Department of Surgical Oncology (Wallis), University Health Network, Toronto, Ont.
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11
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Reese SW, Eismann L, White C, Villada JA, Khaleel S, Ostrovnaya I, Vazquez-Rivera K, Carlo MI, Feldman D, Lee CH, Motzer R, Voss MH, Kotecha RR, Matulewicz RS, Goh A, Coleman J, Russo P, Hakimi AA. Surgical outcomes of cytoreductive nephrectomy in patients receiving systemic immunotherapy for advanced renal cell carcinoma. Urol Oncol 2024; 42:32.e9-32.e16. [PMID: 38135627 PMCID: PMC10922785 DOI: 10.1016/j.urolonc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 11/15/2023] [Accepted: 12/02/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE The use of systemic immune checkpoint blockade before surgery is increasing in patients with metastatic renal cell carcinoma, however, the safety and feasibility of performing consolidative cytoreductive nephrectomy after the administration of systemic therapy are not well described. PATIENTS AND METHODS A retrospective review of patients undergoing nephrectomy was performed using our prospectively maintained institutional database. Patients who received preoperative systemic immunotherapy were identified, and the risk of postoperative complications were compared to those who underwent surgery without upfront systemic treatment. Perioperative characteristics and surgical complications within 90 days following surgery were recorded. RESULTS Overall, we identified 220 patients who underwent cytoreductive nephrectomy from April 2015 to December 2022, of which 46 patients (21%) received systemic therapy before undergoing surgery. Unadjusted rates of surgical complications included 20% (n = 35) in patients who did not receive upfront systemic therapy and 20% (n = 9) in those who received upfront systemic immunotherapy. In our propensity score analysis, there was no statistically significant association between receipt of upfront immunotherapy and 90-day surgical complications [odds ratio (OR): 1.82, 95% confidence interval (CI): 0.59-5.14; P = 0.3]. This model, however, demonstrated an association between receipt of upfront immunotherapy and an increased odds of requiring a blood transfusion [OR: 4.53, 95% CI: 1.83-11.7; P = 0.001]. CONCLUSION In our cohort, there was no significant difference in surgical complications among patients who received systemic therapy before surgery compared to those who did not receive upfront systemic therapy. Cytoreductive nephrectomy is safe and with low rates of complications following the use of systemic therapy.
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Affiliation(s)
- Stephen W Reese
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lennert Eismann
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Ludwig-Maximilians University, Geschwister-Scholl-Platz 1, München, Germany
| | - Charlie White
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juan Arroyave Villada
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sari Khaleel
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katiana Vazquez-Rivera
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maria I Carlo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Darren Feldman
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chung-Han Lee
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Motzer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin H Voss
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ritesh R Kotecha
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard S Matulewicz
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alvin Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Ari Hakimi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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12
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Chen YW, Wang L, Panian J, Dhanji S, Derweesh I, Rose B, Bagrodia A, McKay RR. Treatment Landscape of Renal Cell Carcinoma. Curr Treat Options Oncol 2023; 24:1889-1916. [PMID: 38153686 PMCID: PMC10781877 DOI: 10.1007/s11864-023-01161-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
OPINION STATEMENT The treatment landscape of renal cell carcinoma (RCC) has evolved significantly over the past three decades. Active surveillance and tumor ablation are alternatives to extirpative therapy in appropriately selected patients. Stereotactic body radiation therapy (SBRT) is an emerging noninvasive alternative to treat primary RCC tumors. The advent of immune checkpoint inhibitors (ICIs) has greatly improved the overall survival of advanced RCC, and now the ICI-based doublet (dual ICI-ICI doublet; or ICI in combination with a vascular endothelial growth factor tyrosine kinase inhibitor, ICI-TKI doublet) has become the standard frontline therapy. Based on unprecedented outcomes in the metastatic with ICIs, they are also being explored in the neoadjuvant and adjuvant setting for patients with high-risk disease. Adjuvant pembrolizumab has proven efficacy to reduce the risk of RCC recurrence after nephrectomy. Historically considered a radioresistant tumor, SBRT occupies an expanding role to treat RCC with oligometastasis or oligoprogression in combination with systemic therapy. Furthermore, SBRT is being investigated in combination with ICI-doublet in the advanced disease setting. Lastly, given the treatment paradigm is shifting to adopt ICIs at earlier disease course, the prospective studies guiding treatment sequencing in the post-ICI setting is maturing. The effort is ongoing in search of predictive biomarkers to guide optimal treatment option in RCC.
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Affiliation(s)
- Yu-Wei Chen
- Division of Hematology Oncology, University of California San Diego, San Diego, CA, USA
| | - Luke Wang
- Department of Urology, University of California San Diego, San Diego, CA, USA
| | - Justine Panian
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Sohail Dhanji
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ithaar Derweesh
- Department of Urology, University of California San Diego, San Diego, CA, USA
| | - Brent Rose
- Department of Radiation Oncology, University of California San Diego, San Diego, CA, USA
| | - Aditya Bagrodia
- Department of Urology, University of California San Diego, San Diego, CA, USA
| | - Rana R McKay
- Division of Hematology Oncology, University of California San Diego, San Diego, CA, USA.
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13
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Michalak M, Tomczak P, Milecki T, Antczak A. The role of cytoreductive nephrectomy in the treatment of patients with metastatic kidney cancer - review article. Contemp Oncol (Pozn) 2023; 27:132-138. [PMID: 38239866 PMCID: PMC10793623 DOI: 10.5114/wo.2023.133258] [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: 10/17/2023] [Accepted: 11/17/2023] [Indexed: 01/22/2024] Open
Abstract
The role of cytoreductive nephrectomy (CN), i.e. the removal of a kidney involved by cancer in patients with advanced kidney cancer with distant metastases, is the subject of intense debate among urologists and oncologists. For many years, CN has been considered the gold standard in the treatment of patients at this stage of the disease, especially in patients in good general health with no significant contraindications to surgical treatment. The starting point for questioning the validity of CN was the publication of the results of the cancer du rein metastatique nephrectomie et antiangiogéniques and SURTIME clinical trials (2018 and 2019, respectively), which questioned the validity of surgery in some patients with late-stage cancer. Given the complexity of the disease, the role of removing the involved kidney is the subject of much controversy. In recent years, several studies have been conducted to evaluate the efficacy and safety of nephrectomy in patients with metastatic kidney cancer, resulting in conflicting information regarding the eligibility criteria for patients in different risk groups. The aim of this article is to analyse the available data, provide an up-to-date review of the literature, and discuss the controversies and challenges related to CN in patients with metastatic kidney cancer. The present literature review aims to organize and systematize the current state of knowledge, which may help in making clinical decisions regarding qualification for CN in patients with advanced kidney cancer.
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Affiliation(s)
- Maciej Michalak
- Department and Clinic of Urology and Oncological Urology, Poznań University of Medical Sciences, Poznań, Poland
| | - Piotr Tomczak
- Department of Oncology, Poznań University of Medical Sciences, Poznań, Poland
| | - Tomasz Milecki
- Department and Clinic of Urology and Oncological Urology, Poznań University of Medical Sciences, Poznań, Poland
| | - Andrzej Antczak
- Department and Clinic of Urology and Oncological Urology, Poznań University of Medical Sciences, Poznań, Poland
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14
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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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15
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Dong H, Cao Y, Jian Y, Lei J, Zhou W, Yu X, Zhang X, Peng Z, Sun Z. Patients with metastatic renal cell carcinoma who receive immune-targeted therapy may derive survival benefit from nephrectomy. BMC Cancer 2023; 23:943. [PMID: 37803307 PMCID: PMC10557339 DOI: 10.1186/s12885-023-11408-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 09/16/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Nephrectomy, whether in the era of cytokine therapy or targeted therapy, has an important role in the treatment of metastatic renal cell carcinoma. With the advent of immunotherapy, immunotherapy combined with targeted therapy has become the mainstream of systemic therapy, but the role of nephrectomy in metastatic renal cell carcinoma is unclear. In this study, we retrospectively analyzed the impact of nephrectomy on survival in patients with metastatic renal cell carcinoma who received immune-targeted therapy. METHODS Patients with metastatic renal cell carcinoma who received immune-targeted therapy at three centers between May 17, 2019 and August 1, 2022 were collected, who were divided into two groups based on whether nephrectomy was performed or not. Survival, response rate and adverse event were compared between the two groups. The primary end point was progression free survival, Subgroup analysis and univariate and multivariable prognostic analyses were also assessed. RESULTS With a median follow-up time of 29.3 months (95% CI 28.5-30.2), 165 patients were recruited and divided into two groups based on whether they underwent nephrectomy or not. There were 68 patients in the non-nephrectomy group, 97 in the nephrectomy group. Compared to patients treated with immune-targeted therapy, patients treated with immune-targeted therapy plus nephrectomy were able to achieve survival benefits, with a median PFS of 10.8 months (95% CI 8.3-13.3) and 14.4 months (95% CI 12.6-16.2), respectively, as well as an HR of 0.476 (95% CI 0.323-0.701, p = 0.0002). The 12-month and 18-month PFS rates were 30.9% versus 60.8% and 7.4% versus 25.8%, respectively. The objective response rate (ORR) was 52.9% and 60.8%, respectively, in the non-nephrectomy and nephrectomy groups (p = 0.313), and the disease control rate (DCR) was 75% and 83.5%, respectively (p = 0.179). The most common adverse events related to treatment were hypothyroidism, immune-related pneumonitis and rash. Multivariate analysis showed that primary tumor nephrectomy prior to immune-targeted therapy, clear cell renal carcinoma and oligo metastasis were independent prognostic factors. CONCLUSIONS Nephrectomy may provide PFS benefit with tolerable safety for patients with metastatic renal cell carcinoma who receive immune-targeted therapy. In multivariate analysis, nephrectomy, clear cell carcinoma, and oligo-organ metastasis were found to be favorable independent prognostic factors.
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Affiliation(s)
- Hanzhi Dong
- Department of Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Yuan Cao
- Department of Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Yan Jian
- Department of Medical Oncology, Jiangxi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, Jiangxi Clinical Research Center for Cancer,, Nanchang, 330029, China
| | - Jun Lei
- Department of Oncology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China
| | - Weimin Zhou
- Department of Urology, Jiangxi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, Jiangxi Clinical Research Center for Cancer, Nanchang, 330029, China
| | - Xiaoling Yu
- Department of Oncology, Yugan Xinjiang Hospital, Shangrao, 335100, China
| | - Xiquan Zhang
- Department of Oncology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China.
| | - Zhiqiang Peng
- Department of Lymphohematology, Jiangxi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, Jiangxi Clinical Research Center for Cancer, Nanchang, 330029, China.
| | - Zhe Sun
- Department of Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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16
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Adli G, Yogiswara N, Gde Tirta Yoga Yatindra IB, Putra RM, Djatisoesanto W. Impact of statin on renal cell carcinoma patients undergoing nephrectomy. Does it affect cancer progression and improves survival? A Systematic Review and Meta-Analysis. Arch Ital Urol Androl 2023; 95:11672. [PMID: 37791546 DOI: 10.4081/aiua.2023.11672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Renal cell carcinoma (RCC) is regarded as one of the most common malignant tumors. Various concomitant medications in RCC patients undergoing surgery are investigated to explore the potential for improving survival and preventing disease recurrence, including statin. It has been observed that these drugs induce apoptosis, thereby inhibiting tumor growth and angiogenesis. We aimed to perform a systematic review and meta-analysis to enhance the level of evidence for statin in RCC. METHODS A systematic literature search was conducted in several online databases, including PubMed, Scopus, and Sciencedirect, using terms relevant to the use of statins in RCC patients undergoing nephrectomy for publications published up to July 2023, according to a registered review procedure (CRD42023452318). The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias of the included study. Review Manager 5.4 was used for all analyses. RESULTS Seven articles was eligible for our study. The analysis revealed that patients receiving statin had a better overall survival compared to patients who does not receive statin (HR 0.71, 95% CI 0.51-0.97, p = 0.03, I2 = 76%). However, there was insignificant difference in terms of CSS, DFS, and PFS between RCC patients receiving statin and without statin. CONCLUSIONS Statin has substantial benefits for improving OS. Even though the outcomes for CSS, DFS, and PFS were insignificant, the potential role of statins as a supplementary therapy in surgically treated RCC still requires further investigation.
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Affiliation(s)
- Ghazian Adli
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General-Academic Hospital, Surabaya, East Java.
| | - Niwanda Yogiswara
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General-Academic Hospital, Surabaya, East Java.
| | | | - Rheza Maulana Putra
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General-Academic Hospital, Surabaya, East Java.
| | - Wahjoe Djatisoesanto
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General-Academic Hospital, Surabaya, East Java.
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Nolazco JI, Chang SL. Role of Surgery in Metastatic Renal Cell Carcinoma. Hematol Oncol Clin North Am 2023; 37:893-905. [PMID: 37330346 DOI: 10.1016/j.hoc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Surgery has historically been the mainstay of treatment for metastatic renal cell carcinoma (mRCC), but recent clinical trials demonstrated that contemporary systemic therapies alone are non-inferior to cytoreductive nephrectomy (CN). Thus, the current role of surgery is not precisely defined. CN remains an appropriate upfront treatment for the palliation of severe symptoms, select cases of metastatic non-clear cell renal cell carcinoma, for consolidation following systemic therapy, and in the setting of oligometastatic disease. Metastasectomy is ideally utilized to achieve a disease-free state when there is minimal morbidity associated with surgery. Given the heterogenous nature of mRCC, the decision for systemic therapy and surgery should be made through a multidisciplinary approach tailored to each individual patient.
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Affiliation(s)
- José Ignacio Nolazco
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA; Servicio de Urología, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina
| | - Steven Lee Chang
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA.
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18
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Tappero S, Barletta F, Piccinelli ML, Cano Garcia C, Incesu RB, Morra S, Scheipner L, Tian Z, Parodi S, Dell'Oglio P, Palumbo C, Briganti A, De Cobelli O, Chun FKH, Graefen M, Longo N, Ahyai S, Saad F, Shariat SF, Suardi N, Borghesi M, Terrone C, Karakiewicz PI. The Association Between Cytoreductive Nephrectomy and Overall Survival in Metastatic Renal Cell Carcinoma with Primary Tumor Size ≤4 cm. Eur Urol Focus 2023; 9:742-750. [PMID: 36906483 DOI: 10.1016/j.euf.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/26/2023] [Accepted: 02/21/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND It is unknown whether the survival benefit of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) applies to patients with primary tumor size ≤4 cm. OBJECTIVE To test the association between CN on overall survival (OS) of mRCC patients with primary tumor size ≤4 cm. DESIGN, SETTING, AND PARTICIPANTS Within the Surveillance, Epidemiology, and End Results (SEER) database (2006-2018), all mRCC patients with primary tumor size ≤4 cm were identified. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Propensity score matching (PSM), Kaplan-Meier plots, multivariable Cox regression analyses, and 6-mo landmark analyses addressed OS according to CN status. Sensitivity analyses examined specific populations of special interest: systemic therapy exposed versus naïve, clear-cell (ccmRCC) versus non-clear-cell (non-ccmRCC) mRCC histology, historical (2006-2012) versus contemporary (2013-2018), and young (≤65 yr) versus old (>65 yr) patients. RESULTS AND LIMITATIONS Of 814 patients, 387 (48%) underwent CN. After PSM, the median OS was 44 versus 7 mo (Δ = 37 mo; p < 0.001) in CN versus no-CN patients. CN was associated with higher OS in overall population (multivariable hazard ratio [HR]: 0.30; p < 0.001) as well as in landmark analyses (HR: 0.39; p < 0.001). In all sensitivity analyses, CN was independently associated with higher OS: systemic therapy exposed, HR: 0.38; systemic therapy naïve, HR: 0.31; ccmRCC, HR: 0.29; non-ccmRCC, HR: 0.37; historical, HR: 0.31; contemporary, HR: 0.30; young, HR: 0.23; and old, HR: 0.39 (all p < 0.001). CONCLUSIONS The current study validates the association between CN and higher OS in patients with primary tumor size ≤4 cm. This association is robust, controlled for immortal time bias, and valid across systemic treatment exposure, histologic subtypes, years of surgery, and patient age. PATIENT SUMMARY In the current study, we tested the association between cytoreductive nephrectomy (CN) and overall survival in patients with metastatic renal cell carcinoma and small primary tumor size. We found a strong association between CN and survival, which persists even after several significant variations in patient and tumor characteristics.
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Affiliation(s)
- Stefano Tappero
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy.
| | - Francesco Barletta
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Mattia Luca Piccinelli
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Cristina Cano Garcia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Reha-Baris Incesu
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Morra
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Lukas Scheipner
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, Medical University of Graz, Graz, Austria
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Stefano Parodi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Paolo Dell'Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carlotta Palumbo
- Division of Urology, Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Ottavio De Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nicola Longo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Sascha Ahyai
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Nazareno Suardi
- Department of Urology, Spedali Civili of Brescia, Brescia, Italy
| | - Marco Borghesi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Carlo Terrone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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Piening A, Al-Hammadi N, Dombrowski J, Hamilton Z, Teague RM, Swaminath A, Shahi J. Survival in Metastatic Renal Cell Carcinoma Treated With Immunotherapy and Stereotactic Radiation Therapy or Immunotherapy Alone: A National Cancer Database Analysis. Adv Radiat Oncol 2023; 8:101238. [PMID: 37408680 PMCID: PMC10318269 DOI: 10.1016/j.adro.2023.101238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/29/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Immunotherapy (IO) has significantly improved outcomes in metastatic renal cell carcinoma (mRCC). Preclinical evidence suggests that responses to IO may be potentiated via immunomodulatory effects of stereotactic radiation therapy (SRT). We hypothesized that clinical outcomes from the National Cancer Database (NCDB) would demonstrate improved overall survival (OS) in patients with mRCC receiving IO + SRT versus IO alone. Methods and Materials Patients with mRCC receiving first-line IO ± SRT were identified from the NCDB. Conventional radiation therapy was allowed in the IO alone cohort. The primary endpoint was OS stratified by the receipt of SRT (IO + SRT vs IO alone). Secondary endpoints included OS stratified by the presence of brain metastases (BM) and timing of SRT (before or after IO). Survival was estimated using Kaplan-Meier methodology and compared via the log-rank test. Results Of 644 eligible patients, 63 (9.8%) received IO + SRT, and 581 (90.2%) received IO alone. Median follow-up time was 17.7 months (range, 2-24 months). Sites treated with SRT included the brain (71.4%), lung/chest (7.9%), bones (7.9%), spine (6.3%), and other (6.3%). OS was 74.4% versus 65.0% at 1 year and 71.0% versus 59.4% at 2 years for the IO + SRT and IO alone groups, respectively, although this difference did not reach statistical significance (log-rank P = .1077). In patients with BM, however, 1-year OS (73.0% vs 54.7%) and 2-year OS (70.8% vs 51.4%) was significantly higher in those receiving IO + SRT versus IO alone, respectively (pairwise P = .0261). Timing of SRT (before or after IO) did not influence OS (log-rank P = .3185). Conclusions Patients with BM secondary to mRCC had prolonged OS with the addition of SRT to IO. Factors such as International mRCC Database Consortium risk stratification, oligometastatic tumor burden, SRT dose/fractionation, and utilization of doublet therapy should be considered in future analyses to better identify patients who may benefit from combined IO + SRT. Further prospective studies are warranted.
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Affiliation(s)
- Alexander Piening
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Noor Al-Hammadi
- Department of Health and Clinical Outcomes Research, AHEAD Institute, Saint Louis University School of Medicine, St. Louis, Missouri
| | - John Dombrowski
- Department of Radiation Oncology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Zachary Hamilton
- Department of Surgery, Division of Urology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Ryan M. Teague
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Anand Swaminath
- Department of Radiation Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jeevin Shahi
- Department of Radiation Oncology, Saint Louis University School of Medicine, St. Louis, Missouri
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20
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Méndez-Vidal MJ, Lázaro Quintela M, Lainez-Milagro N, Perez-Valderrama B, Suárez Rodriguez C, Arranz Arija JÁ, Peláez Fernández I, Gallardo Díaz E, Lambea Sorrosal J, González-del-Alba A. SEOM SOGUG clinical guideline for treatment of kidney cancer (2022). Clin Transl Oncol 2023; 25:2732-2748. [PMID: 37556095 PMCID: PMC10425490 DOI: 10.1007/s12094-023-03276-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 08/10/2023]
Abstract
Renal cancer is the seventh most common cancer in men and the tenth in women. The aim of this article is to review the diagnosis, treatment, and follow-up of renal carcinoma accompanied by recommendations with new evidence and treatment algorithms. A new pathologic classification of RCC by the World Health Organization (WHO) was published in 2022 and this classification would be considered a "bridge" to a future molecular classification. For patients with localized disease, surgery is the treatment of choice with nephron-sparing surgery recommended when feasible. Adjuvant treatment with pembrolizumab is an option for intermediate-or high-risk cases, as well as patients after complete resection of metastatic disease. More data are needed in the future, including positive overall survival data. Clinical prognostic classification, preferably IMDC, should be used for treatment decision making in mRCC. Cytoreductive nephrectomy should not be deemed mandatory in individuals with intermediate-poor IMDC/MSKCC risk who require systemic therapy. Metastasectomy can be contemplated in selected subjects with a limited number of metastases or long metachronous disease-free interval. For the population of patients with metastatic ccRCC as a whole, the combination of pembrolizumab-axitinib, nivolumab-cabozantinib, or pembrolizumab-lenvatinib can be considered as the first option based on the benefit obtained in OS versus sunitinib. In cases that have an intermediate IMDC and poor prognosis, the combination of ipilimumab and nivolumab has demonstrated superior OS compared to sunitinib. As for individuals with advanced RCC previously treated with one or two antiangiogenic tyrosine-kinase inhibitors, nivolumab and cabozantinib are the options of choice. When there is progression following initial immunotherapy-based treatment, we recommend treatment with an antiangiogenic tyrosine-kinase inhibitor. While no clear sequence can be advocated, medical oncologists and patients should be aware of the recent advances and new strategies that improve survival and quality of life in the setting of metastatic RC.
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Affiliation(s)
- María José Méndez-Vidal
- Medical Oncology Department, Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Martin Lázaro Quintela
- Medical Oncology Department, Hospital Alvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, Pontevedra, Spain
| | - Nuria Lainez-Milagro
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Pamplona, Spain
| | | | | | | | | | | | - Julio Lambea Sorrosal
- Medical Oncology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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21
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Panian J, Saidian A, Hakimi K, Ajmera A, Anderson WJ, Barata P, Berg S, Signoretti S, Lee Chang S, D'Andrea V, George D, Dzimitrowicz H, El Zarif T, Emamekhoo H, Gross E, Kilari D, Lam E, Lashgari I, Psutka S, Rauterkus GP, Shabaik A, Thapa B, Wang L, Weise N, Yim K, Zhang T, Derweesh I, McKay RR. Pathological Outcomes of Patients With Advanced Renal Cell Carcinoma Who Receive Nephrectomy Following Immunotherapy. Oncologist 2023:oyad166. [PMID: 37368355 DOI: 10.1093/oncolo/oyad166] [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: 12/10/2022] [Accepted: 01/31/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Even though cytoreductive nephrectomy (CN) was once the standard of care for patients with advanced renal cell carcinoma (RCC), its role in treatment has not been well analyzed or defined in the era of immunotherapy (IO). MATERIALS AND METHODS This study analyzed pathological outcomes in patients with advanced or metastatic RCC who received IO prior to CN. This was a multi-institutional, retrospective study of patients with advanced or metastatic RCC. Patients were required to receive IO monotherapy or combination therapy prior to radical or partial CN. The primary endpoint assessed surgical pathologic outcomes, including American Joint Committee on Cancer (AJCC) staging and frequency of downstaging, at the time of surgery. Pathologic outcomes were correlated to clinical variables using a Wald-chi squared test from Cox regression in a multi-variable analysis. Secondary outcomes included objective response rate (ORR) defined by response evaluation criteria in solid tumors (RECIST) version 1.1 and progression-free survival (PFS), which were estimated using the Kaplan-Meier method with reported 95% CIs. RESULTS Fifty-two patients from 9 sites were included. Most patients were male (65%), 81% had clear cell histology, 11% had sarcomatoid differentiation. Overall, 44% of patients experienced pathologic downstaging, and 13% had a complete pathologic response. The ORR immediately prior to nephrectomy was stable disease in 29% of patients, partial response in 63%, progressive disease in 4%, and 4% unknown. Median follow-up for the entire cohort was 25.3 months and median PFS was 3.5 years (95% CI, 2.1-4.9). CONCLUSIONS IO-based interventions prior to CN in patients with advanced or metastatic RCC demonstrates efficacy, with a small fraction of patients showing a complete response. Additional prospective studies are warranted to investigate the role of CN in the modern IO-era.
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Affiliation(s)
- Justine Panian
- University of California San Diego, Department of Medicine, Division of Hematology-Oncology La Jolla, CA, USA
| | - Ava Saidian
- University of California San Diego, Department of Urology, La Jolla, CA, USA
| | - Kevin Hakimi
- University of California San Diego, Department of Urology, La Jolla, CA, USA
| | - Archana Ajmera
- University of California San Diego, Department of Medicine, Division of Hematology-Oncology, La Jolla, CA, USA
| | | | - Pedro Barata
- Tulane University, Deming Department of Medicine, New Orleans, LA, USA
| | - Stephanie Berg
- Loyola University Chicago, Department of Cancer Biology and Internal Medicine, Maywood, IL, USA
| | - Sabina Signoretti
- Brigham and Women's Hospital, Department of Pathology, Boston, MA, USA
| | - Steven Lee Chang
- Brigham and Women's Hospital, Division of Urology, Boston, MA, USA
| | - Vincent D'Andrea
- Brigham and Women's Hospital, Division of Urology, Boston, MA, USA
| | - Daniel George
- Duke Cancer Institute, Department of Medicine, Durham, NC, USA
| | | | - Talal El Zarif
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Hamid Emamekhoo
- University of Wisconsin, Department of Medicine, Madison, WI, USA
| | - Evan Gross
- The University of Washington, Department of Urology, Seattle, WA, USA
| | - Deepak Kilari
- Medical College of Wisconsin, Department of Internal Medicine, Milwaukee, WI, USA
| | - Elaine Lam
- University of Colorado Cancer Center, Division of Medical Oncology, Aurora, CO, USA
| | - Isabel Lashgari
- San Diego State University, Department of Cell and Molecular Biology, San Diego, CA, USA
| | - Sarah Psutka
- The University of Washington, Department of Urology, Seattle, WA, USA
| | - Grant P Rauterkus
- Tulane University, Deming Department of Medicine, New Orleans, LA, USA
| | - Ahmed Shabaik
- University of California San Diego, Department of Pathology, La Jolla, CA, USA
| | - Bicky Thapa
- Medical College of Wisconsin, Department of Internal Medicine, Milwaukee, WI, USA
| | - Luke Wang
- University of California San Diego, Department of Urology, La Jolla, CA, USA
| | - Nicole Weise
- University of California San Diego, Department of Medicine, Division of Hematology-Oncology La Jolla, CA, USA
| | - Kendrick Yim
- Brigham and Women's Hospital, Division of Urology, Boston, MA, USA
| | - Tian Zhang
- UT Southwestern, Department of Internal Medicine, Dallas, TX, USA
| | - Ithaar Derweesh
- University of California San Diego, Department of Urology, La Jolla, CA, USA
| | - Rana R McKay
- University of California San Diego, Department of Medicine, Department of Urology, La Jolla, CA, USA
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22
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Ray S, Dason S, Singer EA. Integrating Surgery in the Multidisciplinary Care of Advanced Renal Cell Carcinoma. Urol Clin North Am 2023; 50:311-323. [PMID: 36948674 DOI: 10.1016/j.ucl.2023.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The role of surgery for patients with locally advanced and metastatic renal cell carcinoma (RCC) is not precisely defined in our contemporary era of systemic therapies. Research in this field is focused on the role of regional lymphadenectomy, along with indications and timing of cytoreductive nephrectomy and metastasectomy. As our understanding of the molecular and immunological basis of RCC continues to develop along with the advent of novel systemic therapies, prospective clinical trials will be critical in defining how surgery should be integrated into the treatment paradigm of advanced RCC.
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Affiliation(s)
- Shagnik Ray
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA
| | - Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA
| | - Eric A Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA.
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23
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Chen B, Li J, Huang Y, Tang B, Jiang J, Chen Z, Li J, Wang P, Cao D, Liu L, Wei Q. The role of cytoreductive nephrectomy in metastatic renal cell carcinoma in the targeted therapy and immunological therapy era: a systematic review and meta-analysis. Int J Surg 2023; 109:982-994. [PMID: 36974696 PMCID: PMC10389335 DOI: 10.1097/js9.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) remains controversial. In addition, several unanswered questions regarding the use of CN remain: Can CN provide survival benefits for patients with mRCC? Where do we place CN in the treatment sequence paradigm among patients with mRCC? How do we best stratify patients with mRCC for CN therapy? MATERIALS AND METHODS A search strategy was conducted in the PubMed, Embase, and Web of Science databases. Studies were included only in the English language. The risk of bias assessment was made by using ROBINS-I (Risk of Bias in Nonrandomized Studies of Interventions) and RoB 2 (Risk of Bias 2) tools. The expected outcomes were analyzed by meta-analyses with the fixed-effects model or random effects model, including overall survival (OS) and progression-free survival (PFS). The measure of effect was the hazard ratio (HR) with a 95% CI, and sensitivity analysis was conducted to assess the reliability of the final results. RESULTS A total of 30 studies were included in the qualitative analysis. The HR for OS was 0.55 (95% CI, 0.50-0.61), and PFS was 0.72 (95% CI, 0.66-0.80), favoring CN compared with no CN. The upfront CN plus targeted therapy (TT) group had superior OS (HR, 0.57; 95% CI, 0.51-0.64) compared with the TT alone group. Furthermore, upfront CN plus systemic therapy (ST) was associated with numerically inferior OS compared with ST plus deferred CN in patients with mRCC (HR, 1.31; 95% CI, 0.98-1.74). Finally, the leave-one-out test of sensitivity analysis indicated that the results of this meta-analysis were stable and reliable in the overall HR estimates for these survival outcomes. CONCLUSIONS First, CN was associated with better survival than no CN in patients with mRCC. Second, the combination of upfront CN and TT may lead to superior survival outcomes compared to TT alone in patients with mRCC. Survival outcomes were similar between the upfront CN+ST group and the ST+deferred CN group in patients with mRCC. Exact patient selection based on baseline prognostic factors is needed to promise maximal survival for patients with mRCC.
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Affiliation(s)
- Bo Chen
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Jinze Li
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yin Huang
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Bo Tang
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Jinjiang Jiang
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Zeyu Chen
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Jin Li
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Puze Wang
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Dehong Cao
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Liangren Liu
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Qiang Wei
- Department of Urology
- Institution of Urology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
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Surgical Approach in Metastatic Renal Cell Carcinoma: A Literature Review. Cancers (Basel) 2023; 15:cancers15061804. [PMID: 36980688 PMCID: PMC10046362 DOI: 10.3390/cancers15061804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/02/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
The treatment of metastatic renal cell carcinoma has undergone considerable advances in the last two decades. Cytoreductive nephrectomy and metastasectomy retains a role in patients with a limited metastatic burden. The choice of optimal treatment regimen remains a matter of debate. The article summarises the current role of surgery in metastatic kidney cancer.
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Britton CJ, Andrews JR, Wallis CJD, Sharma V, Leibovich BC, Thompson RH, Boorjian SA, Bhindi B, Costello BA. Deferred cytoreductive nephrectomy in the management of metastatic renal cell carcinoma: A systematic review and meta-analysis. Urol Oncol 2023; 41:125-136. [PMID: 38832909 DOI: 10.1016/j.urolonc.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/12/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
Deferred cytoreductive nephrectomy (dCN) after upfront systemic therapy has been utilized in the management of select patients with metastatic renal cell carcinoma (mRCC). Herein, we sought to review the current evidence and define oncologic and perioperative outcomes associated with deferred surgical management of newly diagnosed mRCC. Our objective was to critically evaluate the role of dCN in the targeted and immunotherapy eras, comparing oncologic and perioperative outcomes between dCN and upfront CN. Medline, OVID, and Scopus databases were searched for studies evaluating patients undergoing dCN following systemic therapy (ST). PRISMA guidelines were referenced and followed. Outcomes of interest included overall survival (OS), progression free survival (PFS), percent of patients proceeding to dCN, reduction in primary tumor size, complication rates, and perioperative mortality. Random effects meta-analysis was performed comparing overall survival between dCN vs. ST alone and dCN vs. upfront CN. Nineteen studies were included to assess the primary outcomes. The percent of patients proceeding to planned dCN after planned pre-surgical ST ranged from 60.5% to 84%. The most common reason for not undergoing dCN was disease progression on upfront ST. Of patients undergoing dCN, 76% to 96% were able to resume ST postoperatively. OS and PFS ranged from 12.4 to 46 months and 4.5 to 11 months, respectively. Pooled results demonstrated significantly improved OS favoring dCN over upfront CN (hazard ratio, HR = 0.56; 95% CI 0.45-0.69) and ST alone (HR = 0.45; 95% CI 0.38-0.53). Deferred CN represents a potential treatment option in appropriately selected patients with mRCC with a favorable response to upfront systemic therapy. Future randomized trials will be needed to clarify how much this is due to the surgery vs. patient selection.
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Affiliation(s)
| | - Jack R Andrews
- Department of Urology, MD Anderson Cancer Center, Houston, TX; Department of Urology, Mayo Clinic Arizona, Phoenix, AZ
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | | | | | - Bimal Bhindi
- Section of Urology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
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Bakouny Z, El Zarif T, Dudani S, Connor Wells J, Gan CL, Donskov F, Shapiro J, Davis ID, Parnis F, Ravi P, Steinharter JA, Agarwal N, Alva A, Wood L, Kapoor A, Ruiz Morales JM, Kollmannsberger C, Beuselinck B, Xie W, Heng DYC, Choueiri TK. Upfront Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors or Targeted Therapy: An Observational Study from the International Metastatic Renal Cell Carcinoma Database Consortium. Eur Urol 2023; 83:145-151. [PMID: 36272943 DOI: 10.1016/j.eururo.2022.10.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/15/2022] [Accepted: 10/04/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The role of upfront cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) in the era of immune checkpoint inhibitors is unclear. OBJECTIVE To evaluate the relationship between upfront CN and clinical outcomes in the setting of mRCC treated with immune checkpoint inhibitors or targeted therapy. DESIGN, SETTING, AND PARTICIPANTS Using the International Metastatic RCC Database Consortium, we retrospectively identified patients diagnosed with de novo mRCC treated with immune checkpoint inhibitors or targeted therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Overall survival (OS) was compared between the two groups using the Kaplan-Meier method and multivariable Cox regressions adjusting for known prognostic factors. RESULTS AND LIMITATIONS We identified a total of 4639 eligible patients with mRCC. Among the 4202 patients treated with targeted therapy and 437 patients treated with immune checkpoint inhibitors, 2326 (55%) and 234 (54%) patients received upfront CN prior to treatment start. In multivariable analyses, CN was associated with significantly better OS in both the immune checkpoint inhibitor-treated (hazard ratio [HR]: 0.61; 95% confidence interval [CI], 0.41-0.90, p = 0.013) and the targeted therapy treatment (HR: 0.72; 95% CI, 0.67-0.78, p < 0.001) group. There was no difference in OS benefit of CN between the immune checkpoint inhibitor and targeted therapy treatment groups (interaction p = 0.6). Limitations include selection of patients from large academic centers and the retrospective nature of the study. CONCLUSIONS Upfront CN is associated with a significant OS benefit in selected patients treated by either immune checkpoint inhibitors or targeted therapy, and still has a role in selected patients in the era of immune checkpoint inhibitors. PATIENT SUMMARY Before effective systemic therapies were available for metastatic kidney cancer, surgical removal of the primary (kidney) tumor was the mainstay of treatment. The role of removing the primary tumor has recently been called into question given that more effective systemic therapies have become available. In this study, we find that removal of the primary kidney tumor still has a benefit for selected patients treated with highly effective modern systemic therapies, including targeted therapies and immune checkpoint inhibitors.
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Affiliation(s)
- Ziad Bakouny
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Talal El Zarif
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Shaan Dudani
- Department of Oncology, William Osler Health System, Brampton, ON, Canada
| | - J Connor Wells
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | | | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; University Hospital of Southern Denmark, Esbjerg, Denmark
| | | | - Ian D Davis
- Monash University Eastern Health Clinical School, Melbourne, Australia; Cancer Services, Eastern Health, Melbourne, Australia
| | | | - Praful Ravi
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - John A Steinharter
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Neeraj Agarwal
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Ajjai Alva
- University of Michigan, Ann Arbor, MI, USA
| | - Lori Wood
- Dalhousie University, Halifax, NS, Canada
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Benoit Beuselinck
- University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Wanling Xie
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Daniel Y C Heng
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Toni K Choueiri
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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27
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Yang J, Wang K, Yang Z. Treatment strategies for clear cell renal cell carcinoma: Past, present and future. Front Oncol 2023; 13:1133832. [PMID: 37025584 PMCID: PMC10070676 DOI: 10.3389/fonc.2023.1133832] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/09/2023] [Indexed: 04/08/2023] Open
Abstract
Clear cell renal cell carcinoma (ccRCC) is the most prevalent histological subtype of kidney cancer, which is prone to metastasis, recurrence, and resistance to radiotherapy and chemotherapy. The burden it places on human health due to its refractory nature and rising incidence rate is substantial. Researchers have recently determined the ccRCC risk factors and optimized the clinical therapy based on the disease's underlying molecular mechanisms. In this paper, we review the established clinical therapies and novel potential therapeutic approaches for ccRCC, and we support the importance of investigating novel therapeutic options in the context of combining established therapies as a research hotspot, with the goal of providing diversified therapeutic options that promise to address the issue of drug resistance, with a view to the early realization of precision medicine and individualized treatment.
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Affiliation(s)
- Junwei Yang
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, China
| | - Kuansong Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhichun Yang
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, China
- *Correspondence: Zhichun Yang,
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Katsimperis S, Tzelves L, Bellos T, Pikramenos K, Manolitsis I, Tsikopoulos I, Mitsogiannis I. Cytoreductive nephrectomy for synchronous metastatic renal cell carcinoma. Is there enough evidence? Arch Ital Urol Androl 2022; 94:476-485. [PMID: 36576474 DOI: 10.4081/aiua.2022.4.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/02/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To assess the role of Cytoreductive Nephrectomy for synchronous metastatic Renal Cell Carcinoma patients in the Systemic Therapy era and beyond regarding the Overall Survival, the optimal sequence between Systemic Therapy and Cytoreductive Nephrectomy and prognostic factors. METHODS The systematic review was conducted in accordance with the PRISMA guidelines. Bibliographic search was performed in Medline (PubMed), ClinicalTrials.gov, and Cochrane Library-Cochrane Central Register of Controlled Trials (CENTRAL). Studies included were those indexed from 2005 in an attempt to limit those conducted in the cytokine era. Risk of bias assessment was performed by two authors (K.S and T.L) using the Cochrane Collaborative Risk of Bias tool for randomized trials, the Cochrane Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for nonrandomized studies. RESULTS Cytoreductive nephrectomy was associated with improved overall survival in all but one of the observational studies. While in all of these studies the unvariable analysis showed improved overall survival in favor of the cytoreductive nephrectomy group in some studies the subgroup analysis showed no benefit. Regarding the optimal sequence, deferred cytoreductive nephrectomy demonstrated better results in more studies than upfront cytoreductive nephrectomy but a advantage was not clearly certain. In the analysis of possible prognostic factors for overall survival with cytoreductive nephrectomy, most common prognostic factors found were age (in 8 studies), tumor histology (in 7 studies), number of metastasis (in 6 studies), and T stage. CONCLUSIONS Cytoreductive nephrectomy can still play an important role in wisely selected patients, although the role of cytoreductive nephrectomy in the new immunotherapy era needs to be defined.
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29
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Effect of Inferior Vena Cava Tumor Thrombus on Overall Survival in Metastatic Renal Cell Carcinoma Patients Treated with Cytoreductive Nephrectomy. EUR UROL SUPPL 2022; 44:94-101. [PMID: 36185586 PMCID: PMC9520505 DOI: 10.1016/j.euros.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background Survival data regarding cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) patients according to the type and extent of tumor-associated vascular thrombus are scarce. Objective To test for survival differences in mRCC patients treated with CN according to the type and extent of tumor-associated vascular thrombus. Design, setting, and participants Within Surveillance, Epidemiology, and End Results Research Plus (2004–2017), we identified CN mRCC patients with renal vein (pT3a-TT) versus infradiaphragmatic inferior vena cava (IVC; pT3b) versus supradiaphragmatic IVC tumor thrombus/IVC invasion (pT3c). Outcome measurements and statistical analysis Overall survival (OS) was addressed in Kaplan-Meier and Cox regression analyses, in addition to 3-mo landmark analyses. Results and limitations Of 2170 mRCC patients, 1880 (87%), 204 (9%), and 86 (4%) harbored pT3a-TT, pT3b, and pT3c, respectively. The respective median OS periods were 21, 23, and 12 mo (p < 0.001). In multivariable Cox regression models, pT3c stage, but not pT3b stage, was an independent predictor of higher overall mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.09–1.73; p = 0.007), as well as in 6-mo landmark analyses (HR: 1.36; 95% CI: 1.02–1.80; p = 0.04). In the sensitivity analysis, relying on all pT3a patients, the predictor status of pT3c stage remained unchanged (HR: 1.37; 95% CI: 1.09–1.71; p = 0.007). Limitations have to be addressed regarding the sample size and the retrospective design of the current study. Conclusions Although overall mortality is significantly higher in pT3c mRCC patients than in their pT3b and pT3a-TT counterparts, these individuals may still expect 12-mo or better OS after CN versus virtually 2-yr OS in their pT3a and pT3b counterparts. Patient summary In this study, we looked at the survival outcomes of metastatic renal cell carcinoma patients who presented with tumor thrombus at cytoreductive nephrectomy. Even though these patients with most advanced tumor thrombus stage demonstrated lower survival rates, the median overall survival was still 1 yr.
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30
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Rebuzzi SE, Signori A, Banna GL, Gandini A, Fornarini G, Damassi A, Maruzzo M, De Giorgi U, Basso U, Chiellino S, Galli L, Zucali PA, Fantinel E, Naglieri E, Procopio G, Milella M, Boccardo F, Fratino L, Pipitone S, Ricotta R, Panni S, Mollica V, Sorarù M, Santoni M, Cortellini A, Prati V, Soto Parra HJ, Santini D, Atzori F, Di Napoli M, Caffo O, Messina M, Morelli F, Prati G, Nolè F, Vignani F, Cavo A, Roviello G, Rescigno P, Buti S. The prognostic value of the previous nephrectomy in pretreated metastatic renal cell carcinoma receiving immunotherapy: a sub-analysis of the Meet-URO 15 study. Lab Invest 2022; 20:435. [PMID: 36180954 PMCID: PMC9524042 DOI: 10.1186/s12967-022-03601-6] [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: 07/11/2022] [Accepted: 08/18/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Nephrectomy is considered the backbone of managing patients with localized and selected metastatic renal cell carcinoma (mRCC). The prognostic role of nephrectomy has been widely investigated with cytokines and targeted therapy, but it is still unclear in the immunotherapy era. METHODS We investigated the Meet-URO-15 study dataset of 571 pretreated mRCC patients receiving nivolumab as second or further lines about the prognostic role of the previous nephrectomy (received in either the localized or metastatic setting) in the overall population and according to the Meet-URO score groups. RESULTS Patients who underwent nephrectomy showed a significantly reduced risk of death (HR 0.44, 95% CI 0.32-0.60, p < 0.001) with a longer median overall survival (OS) (35.9 months vs 12.1 months), 1-year OS of 71.6% vs 50.5% and 2-years OS of 56.5% vs 22.0% compared to those who did not. No significant interaction between nephrectomy and the overall five Meet-URO score risk groups was observed (p = 0.17). It was statistically significant when merging group 1 with 2 and 3 and group 4 with 5 (p = 0.038) and associated with a longer OS for the first three prognostic groups (p < 0.001), but not for groups 4 and 5 (p = 0.54). CONCLUSIONS Our study suggests an overall positive impact of the previous nephrectomy on the outcome of pretreated mRCC patients receiving immunotherapy. The clinical relevance of cytoreductive nephrectomy, optimal timing and patient selection deserves further investigation, especially for patients with Meet-URO scores of 1 to 3, who are the once deriving benefit in our analyses. However, that benefit is not evident for IMDC poor-risk patients (including the Meet-URO score groups 4 and 5) and a subgroup of IMDC intermediate-risk patients defined as group 4 by the Meet-URO score.
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Affiliation(s)
- Sara Elena Rebuzzi
- Medical Oncology Unit, Ospedale San Paolo, Savona, Italy.,Department of Internal Medicine and Medical Specialties (Di.M.I.), University of Genova, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Giuseppe Luigi Banna
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy.,Department of Oncology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Annalice Gandini
- Medical Oncology Unit 1, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giuseppe Fornarini
- Medical Oncology Unit 1, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Alessandra Damassi
- Medical Oncology Unit 1, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Maruzzo
- Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Umberto Basso
- Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Silvia Chiellino
- Medical Oncology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Galli
- Medical Oncology Unit 2, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Paolo Andrea Zucali
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Oncology, IRCCS, Humanitas Clinical and Research Center, Rozzano, Milano, Italy
| | - Emanuela Fantinel
- Medical Oncology Unit, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy.,Department of Oncology, Azienda Ospedaliera Universitaria Integrata di Verona, University of Verona, Verona, Italy
| | - Emanuele Naglieri
- Division of Medical Oncology, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Giuseppe Procopio
- SS Oncologia Medica Genitourinaria, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Medical Oncology Unit, ASST - Istituti Ospitalieri Cremona Hospital, Cremona, Italy
| | - Michele Milella
- Department of Oncology, Azienda Ospedaliera Universitaria Integrata di Verona, University of Verona, Verona, Italy
| | - Francesco Boccardo
- Department of Internal Medicine and Medical Specialties (Di.M.I.), University of Genova, Genoa, Italy
| | - Lucia Fratino
- Department of Medical Oncology, Centro di Riferimento, Oncologico di Aviano CRO-IRCCS, Aviano, Italy
| | - Stefania Pipitone
- Medical Oncology Unit, Department of Oncology and Hemathology, University Hospital of Modena, Modena, Italy
| | - Riccardo Ricotta
- Oncology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Stefano Panni
- SS Oncologia Medica Genitourinaria, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Mariella Sorarù
- U.O. Oncologia, Ospedale di Camposampiero, Camposampiero, Italy
| | | | - Alessio Cortellini
- Medical Oncology Department, Campus Bio-Medico University of Rome, 00128, Rome, Italy.,Department of Surgery and Cancer, Imperial College London, Faculty of Medicine, Hammersmith Hospital, London, UK
| | - Veronica Prati
- Department of Medical Oncology, Ospedale Michele e Pietro Ferrero, Verduno, (CN) ASL CN2, Italy
| | - Hector Josè Soto Parra
- Department of Oncology, Medical Oncology, University Hospital Policlinico-San Marco, Catania, Italy
| | - Daniele Santini
- UOC Oncologia Medica, "Sapienza University", Polo Pontino, Rome, Italy
| | - Francesco Atzori
- Medical Oncology Department, University Hospital, University of Cagliari, Cagliari, Italy
| | - Marilena Di Napoli
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - Orazio Caffo
- Medical Oncology Department, Santa Chiara Hospital, Trento, Italy
| | - Marco Messina
- UOC Oncologia Medica, Istituto Fondazione G. Giglio, Cefalù, Italy
| | | | - Giuseppe Prati
- Department of Oncology and advanced technologies, AUSL - IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Franco Nolè
- Medical Oncology Division of Urogenital & Head & Neck Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca Vignani
- Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Alessia Cavo
- Oncology Unit, Villa Scassi Hospital, Genoa, Italy
| | - Giandomenico Roviello
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Firenze, Florence, Italy
| | | | - Sebastiano Buti
- Medical Oncology Unit, University Hospital of Parma, Parma, Italy.,Medicine and Surgery Department, University of Parma, Parma, Italy
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Mao Y, Hu M, Yang G, Gao E, Xu W. Cytoreductive prostatectomy improves survival outcomes in patients with oligometastases: a systematic meta-analysis. World J Surg Oncol 2022; 20:255. [PMID: 35945562 PMCID: PMC9361652 DOI: 10.1186/s12957-022-02715-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whether cytoreductive prostatectomy (CRP) should be performed in patients with oligometastatic prostate cancer (OPC) remains controversial. The goal of this systematic meta-analysis was to assess the efficacy of CRP as a treatment for OPC. METHODS This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Data sources included publications in the PubMed, Embase, the Cochrane Library, EBSCO, and Web of Science (SCI) databases as of May 2022. Eligible articles included prospective studies comparing the efficacy of CRP to a lack of CRP in patients with OPC. RESULTS In total, 10 publications incorporating 888 patients were analyzed. Tumor-reducing prostatectomy was found to have no significant effect on long-term or short-term OS [OR = 2.26, 95% CI (0.97, 5.28), P = 0.06] and [OR = 1.73, 95% CI (0.83, 3.58), P = 0.14], but it significantly improved patient long-term or short-term CSS [OR = 1.77, 95% CI (1.01, 310), P = 0.04] and [OR = 2.71, 95% CI (1.72, 4.29), P < 0.0001] and PFS [OR = 1.93, 95% CI (1.25, 2.97), P = 0.003]. CONCLUSION These results suggest that cytoreductive prostatectomy can confer survival benefits to OPC patients. TRIAL REGISTRATION INPLASY protocol 202260017 https://doi.org/10.37766/inplasy2022.6.0017 .
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Affiliation(s)
- Yifeng Mao
- Department of Urology, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China.,Anhui Province Key Laboratory of Translational Cancer Research, Bengbu Medical University, Bengbu, 233030, Anhui, China
| | - Mingqiu Hu
- Department of Urology, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China. .,Anhui Province Key Laboratory of Translational Cancer Research, Bengbu Medical University, Bengbu, 233030, Anhui, China. .,Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China.
| | - Gaowei Yang
- Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China
| | - Erke Gao
- Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China
| | - Wangwang Xu
- Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China
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32
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Rathmell WK, Rumble RB, Van Veldhuizen PJ, Al-Ahmadie H, Emamekhoo H, Hauke RJ, Louie AV, Milowsky MI, Molina AM, Rose TL, Siva S, Zaorsky NG, Zhang T, Qamar R, Kungel TM, Lewis B, Singer EA. Management of Metastatic Clear Cell Renal Cell Carcinoma: ASCO Guideline. J Clin Oncol 2022; 40:2957-2995. [PMID: 35728020 DOI: 10.1200/jco.22.00868] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To provide recommendations for the management of patients with metastatic clear cell renal cell carcinoma (ccRCC). METHODS An Expert Panel conducted a systematic literature review to obtain evidence to guide treatment recommendations. RESULTS The panel considered peer-reviewed reports published in English. RECOMMENDATIONS The diagnosis of metastatic ccRCC should be made using tissue biopsy of the primary tumor or a metastatic site with the inclusion of markers and/or stains to support the diagnosis. The International Metastatic RCC Database Consortium risk criteria should be used to inform treatment. Cytoreductive nephrectomy may be offered to select patients with kidney-in-place and favorable- or intermediate-risk disease. For those who have already had a nephrectomy, an initial period of active surveillance may be offered if they are asymptomatic with a low burden of disease. Patients with favorable-risk disease who need systemic therapy may be offered an immune checkpoint inhibitor (ICI) in combination with a vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitor (TKI); patients with intermediate or poor risk should be offered a doublet regimen (no recommendation was provided between ICIs or an ICI in combination with a VEGFR TKI). For select patients, monotherapy with either an ICI or a VEGFR TKI may be offered on the basis of comorbidities. Interleukin-2 remains an option, although selection criteria could not be identified. Recommendations are also provided for second- and subsequent-line therapy as well as the treatment of bone metastases, brain metastases, or the presence of sarcomatoid features. Participation in clinical trials is highly encouraged for patients with metastatic ccRCC.Additional information is available at www.asco.org/genitourinary-cancer-guidelines.
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Affiliation(s)
| | | | | | | | | | | | - Alexander V Louie
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON.,American Society for Therapeutic Radiology and Oncology Representative, Toronto, ON
| | | | | | - Tracy L Rose
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shankar Siva
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH.,American Society for Therapeutic Radiology and Oncology Representative, Cleveland, OH
| | - Tian Zhang
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | | | | | - Bryan Lewis
- KidneyCan, Philadelphia, PA.,Patient Representative, Philadelphia, PA
| | - Eric A Singer
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Warli SM, Andy A, Mariedina CT, Nasution R, Kadar DD. A Rare Case of Sarcomatoid Renal Cell Carcinoma in a Young Adult Patient. Res Rep Urol 2022; 14:241-245. [PMID: 35734241 PMCID: PMC9208668 DOI: 10.2147/rru.s370975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Sarcomatoid differentiation is a rare condition that could present in different subtypes of renal cell carcinomas (RCCs) and is associated with a significantly poor prognosis. Sarcomatoid renal cell carcinoma (SRCC) patients are typically aged between 54 and 63, with a male-to-female ratio ranging from 1.3:1 to 2:1. Here, we report a case of SRCC in a 29-year-old female patient. Case Presentation A 29-year-old female presented with left flank pain. A large lump was palpated on left flank and there was costovertebral angle tenderness. The lump was enlarged, and the patient also suffered from anemia. Abdominopelvic CT demonstrated solid mass with an internal gliosis in the left part of the renal cortex and the solid component was enhanced with contrast admission. Then, the patient underwent left radical nephrectomy with wide perirenal excision and paraaortic lymph nodes resection. Histopathological examination revealed SRCC with no lymphovascular invasion. Conclusion The scarcity of data on SRCCs emphasizes the need for ongoing research into the biology, diagnostics, and effective treatment options for patients with this disease, as responses to conventional therapies have been disappointing, leaving patients with few options. Cytoreductive nephrectomy for SRCC patients with metastatic disease is debatable, although some research suggests resection at any stage in patients with good performance status. In this case, radical nephrectomy was performed and there was no evidence of metastasis.
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Affiliation(s)
- Syah Mirsya Warli
- Department of Urology, Universitas Sumatera Utara Hospital – Universitas Sumatera Utara, Medan, Indonesia
- Correspondence: Syah Mirsya Warli, Department of Urology, Universitas Sumatera Utara Hospital – Universitas Sumatera Utara, Medan, Indonesia, Tel +6261-8218928, Email
| | - Andy Andy
- Division of Urology, Department of Surgery, Haji Adam Malik General Hospital – Universitas Sumatera Utara, Medan, Indonesia
| | | | - Ramlan Nasution
- Division of Urology, Department of Surgery, Haji Adam Malik General Hospital – Universitas Sumatera Utara, Medan, Indonesia
| | - Dhirajaya Dharma Kadar
- Division of Urology, Department of Surgery, Haji Adam Malik General Hospital – Universitas Sumatera Utara, Medan, Indonesia
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Al-Juhaishi T, Deng X, Bandyopadhyay D, Paul A. The Role of Cytoreductive Nephrectomy and Targeted Therapy on Outcomes of Patients With Metastatic Sarcomatoid Renal Cell Carcinoma: A Population-Based Analysis. Cureus 2022; 14:e25395. [PMID: 35774668 PMCID: PMC9236690 DOI: 10.7759/cureus.25395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/24/2022] Open
Abstract
Sarcomatoid renal cell carcinoma (sRCC) is a rare but aggressive form of kidney cancer with a poor prognosis. Despite recent advances in therapies for kidney cancers, an effective management strategy for sRCC is uncertain. We evaluated the impact of targeted therapy and cytoreductive nephrectomy (CN) on survival outcomes of patients with metastatic sRCC. We identified patients diagnosed with sRCC between January 1, 1973, and December 31, 2014, within the Surveillance, Epidemiology and End Results (SEER) database. Patients with metastatic sRCC were stratified based on the era of diagnosis (before or after the introduction of targeted systemic therapy in 2006) and the status of CN. Cancer-specific survival (CSS) and overall survival (OS) were analyzed. Data of 993 patients with metastatic sRCC were available for analysis. The median age was 62 years. Most patients were male (69%), Caucasian (71%), and were diagnosed in the targeted therapy era (83%); 53% of patients underwent CN. CSS and OS of the whole cohort were 5.0 months and 4.0 months, respectively. While the introduction of targeted therapy did not improve outcomes, CN improved CSS and OS in both pre-targeted therapy and targeted therapy era. On multivariable analysis, CN was a predictor of an improved CSS (hazard ratio [HR] 0.54, p < 0.0001) and OS (HR 0.51, p < 0.0001). Among other factors, older age at diagnosis, higher T stages, and node positivity were associated with worse outcomes. Our results showed that the introduction of targeted therapy did not improve outcomes in patients with metastatic sRCC. CN improved survival in both pre-targeted and targeted therapy eras.
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New Paradigms for Cytoreductive Nephrectomy. Cancers (Basel) 2022; 14:cancers14112660. [PMID: 35681638 PMCID: PMC9179532 DOI: 10.3390/cancers14112660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/15/2022] [Accepted: 05/22/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Cytoreductive surgery (CS) is performed to remove the primary tumor in the setting of metastatic disease. In metastatic renal cell carcinoma (mRCC), the role of cytoreductive nephrectomy (CN) in the treatment paradigm has evolved, adjusting to new changes in systemic therapy agents. In particular, immunotherapeutic agents, which utilize the body’s own immune system to attack cancerous cells, have improved over the past decade. Newer immunotherapy agents offer more effective treatments in mRCC, with the goal of more tolerable side effect profiles. However, now urologic and medical oncologists must reframe the role of CN in the context of these new systemic therapies. This review will discuss the current data on this topic as well as the historical context in which it is being studied. Abstract The role of CN in the treatment of metastatic renal cell carcinoma (mRCC) has been studied over the course of the past few decades. With the advent of immuno-oncologic (IO) agents, there has been a paradigm shift in the treatment of RCC. Within this new era of cancer care, the role of CN is unclear. There are several studies currently underway that aim to assess the role of CN in combination with these therapies. We reviewed articles examining CN, both historically and in the modern immunotherapy era. While immune-oncologic agents are relatively new and large clinical trials have yet to be completed, data thus far is promising that CN may provide clinical benefit. Multiple ongoing trials may clarify the role of CN in this new era of cancer care.
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Chakiryan NH, Gore LR, Reich RR, Dunn RL, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Manley BJ, Sexton WJ, Hollenbeck BK, Gilbert SM. Survival Outcomes Associated With Cytoreductive Nephrectomy in Patients With Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2022; 5:e2212347. [PMID: 35576003 PMCID: PMC9112069 DOI: 10.1001/jamanetworkopen.2022.12347] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Level I evidence has failed to demonstrate an overall survival (OS) advantage for cytoreductive nephrectomy in patients with metastatic clear cell renal cell carcinoma (ccRCC) in the modern era, which is at odds with observational studies reporting a marked OS benefit associated with these operations. These observational studies were not designed to adjust for unmeasured confounding. OBJECTIVE To assess whether cytoreductive nephrectomy is associated with improved OS in patients with metastatic ccRCC. DESIGN, SETTING, AND PARTICIPANTS This cohort study identified patients with metastatic ccRCC in the National Cancer Database from January 1, 2006, to December 31, 2016, who received systemic targeted therapy. The analysis was finalized on July 23, 2021. EXPOSURES Receipt of cytoreductive nephrectomy. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. Distance from the patients' zip code of residence to the treating facility was identified as a valid instrument and was used in a 2-stage residual inclusion instrumental variable analysis. Conventional adjustments for selection bias, multivariable Cox proportional hazards regression, and propensity score matching were performed for comparison. Measured covariates adjusted for in all analyses included age, sex, race, Charlson-Deyo score, facility type, year of diagnosis, clinical T stage, and clinical N stage. RESULTS The final study population included 12 766 patients (median age, 63 years; IQR, 56-70 years; 8744 [68%] male; 11 206 [88%] White). Cytoreductive nephrectomy was performed in 5005 patients (39%). Conventional adjustments for selection bias demonstrated a significant OS benefit associated with cytoreductive nephrectomy (multivariable Cox proportional hazards regression: hazard ratio [HR], 0.49; 95% CI, 0.47-0.51; propensity score matching: HR, 0.48; 95% CI, 0.46-0.50). Instrumental variable estimates did not demonstrate an association between cytoreductive nephrectomy and OS (HR, 0.92; 95% CI, 0.78-1.09). CONCLUSIONS AND RELEVANCE Instrumental variable analysis did not demonstrate a survival advantage associated with cytoreductive nephrectomy for patients with metastatic ccRCC. This discrepancy likely reflects the fact that surgical indication for cytoreductive nephrectomy is primarily driven by factors that are not commonly measured or available in observational data sets.
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Affiliation(s)
| | - L. Robert Gore
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Richard R. Reich
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rodney L. Dunn
- Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J. Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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Numakura K, Nakai Y, Kojima T, Osawa T, Narita S, Nakayama M, Kitamura H, Nishiyama H, Shinohara N. Overview of clinical management for older patients with renal cell carcinoma. Jpn J Clin Oncol 2022; 52:665-681. [PMID: 35397166 DOI: 10.1093/jjco/hyac047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
The rapidly increasing pool of older patients being diagnosed with and surviving their cancer is creating many challenges. Regarding localized renal cell carcinoma, surgery is considered as gold standard treatment options even in older men, whereas active surveillance and ablation therapy are alternative options for a proportion of these patients. With regard to advanced disease, anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) and immune check point inhibitor are standard treatment modalities, although treatment choice from multiple regimens and prevention of adverse events need to be considered. Better assessment techniques, such as comprehensive geriatric assessment to meet the unique needs of older patients, are a central focus in the delivery of high-quality geriatric oncology care. Through this process, shared decision-making should be adopted in clinical care to achieve optimal goals of care that reflect patient and caregiver hopes, needs and preferences. It is necessary to continue investigating oncological outcomes and complications associated with treatment in this population to ensure appropriate cancer care. In this narrative review, we completed a literature review of the various treatments for renal cell carcinoma in older patients that aimed to identify the current evidence related to the full range of the treatments including active surveillance, surgery, ablation therapy and systemic therapy. Prospectively designed studies and studies regarding geriatric assessment were preferentially added as references. Our goals were to summarize the real-world evidence and provide a decision framework that guides better cancer practices for older patients with renal cell carcinoma.
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Affiliation(s)
| | - Yasutomo Nakai
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Takahiro Osawa
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | | | - Masashi Nakayama
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Kitamura
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | | | - Nobuo Shinohara
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
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Chen T, Zhan X, Du J, Liu X, Deng W, Zhao S, Jiang M, Xiong Y, Zhang X, Chen L, Fu B. A Simple-To-Use Nomogram for Predicting Early Death in Metastatic Renal Cell Carcinoma: A Population-Based Study. Front Surg 2022; 9:871577. [PMID: 35392061 PMCID: PMC8980350 DOI: 10.3389/fsurg.2022.871577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/25/2022] [Indexed: 12/24/2022] Open
Abstract
Background Metastatic renal cell carcinoma (mRCC) is usually considered to have a poor prognosis, which has a high risk of early death (≤3 months). Our aim was to developed a predictive nomogram for early death of mRCC. Methods The SEER database was accessed to obtain the related information of 6,005 mRCC patients between 2010 and 2015. They were randomly divided into primary cohort and validation cohort in radio of 7:3. The optimal cut-off point regarding age at diagnosis and tumor size were identified by the X-tile analysis. Univariate and multivariate logistic regression models were applied to determine significant independent risk factors contributed to early death. A practical nomogram was constructed and then verified by using calibration plots, receiver operating characteristics (ROCs) curve, and decision curve analysis (DCA). Results There were 6,005 patients with mRCC included in the predictive model, where 1,816 patients went through early death (death within ≤3 months of diagnosis), and among them 1,687 patients died of mRCC. Based on 11 significant risk factors, including age, grade, N-stage, histologic type, metastatic sites (bone, lung, liver and brain) and treatments (surgery, radiation, and chemotherapy), a practical nomogram was developed. The model's excellent effectiveness, discrimination and clinical practicality were proved by the AUC value, calibration plots and DCA, respectively. Conclusions The nomogram may play a major part in distinguishing the early death of mRCC patients, which can assist clinicians in individualized medicine.
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Affiliation(s)
- Tao Chen
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiangpeng Zhan
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junfu Du
- Department of Urology, Wuning People's Hospital, Jiujiang, China
| | - Xiaoqiang Liu
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wen Deng
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuaishuai Zhao
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ming Jiang
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunqiang Xiong
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaohai Zhang
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Luyao Chen
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Institute of Urology, Nanchang, China
- Luyao Chen
| | - Bin Fu
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Institute of Urology, Nanchang, China
- *Correspondence: Bin Fu
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Significance of upfront cytoreductive nephrectomy stratified by IMDC risk for metastatic renal cell carcinoma in targeted therapy era - a multi-institutional retrospective study. Int J Clin Oncol 2022; 27:563-573. [PMID: 34973106 PMCID: PMC8882566 DOI: 10.1007/s10147-021-02091-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/15/2021] [Indexed: 12/27/2022]
Abstract
Background This retrospective multicenter study aimed to evaluate the survival benefit of upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (RCC) patients stratified by International Metastatic RCC Database Consortium (IMDC) risk criteria. Methods We reviewed the medical records in the Michinoku Database between 2008 and 2019. Patients who received upfront CN, systemic therapy without CN (no CN) and CN after drug therapy (deferred CN) were analyzed. To exclude selection bias due to patient characteristics, baseline clinical data were adjusted by inverse probability of treatment weighting (IPTW). Overall survival (OS) was compared between upfront CN and non-upfront CN (no CN plus deferred CN). Associations between time-varying covariates including systemic therapies and OS stratified by IMDC risk criteria were analyzed by IPTW-adjusted Cox regression method. Results Of 259 patients who fulfilled the selection criteria, 107 were classified in upfront CN and 152 in non-upfront CN group. After IPTW-adjusted analysis, upfront CN showed survival benefit compared to non-upfront CN in patients with IMDC intermediate risk (median OS: 52.5 versus 31.3 months, p < 0.01) and in patients with IMDC poor risk (27.2 versus 11.4 months, p < 0.01). In IPTW-adjusted Cox regression analysis of time-varying covariates, upfront CN was independently associated with OS benefit in patients with IMDC intermediate risk (hazard ratio 0.52, 95% confidence interval 0.29–0.93, p = 0.03) and in patients with IMDC poor risk (0.26, 0.11–0.59, p < 0.01). Conclusions Upfront CN may confer survival benefit in RCC patients with IMDC intermediate and poor risk. Supplementary Information The online version contains supplementary material available at 10.1007/s10147-021-02091-8.
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Surgical Treatment for Metastatic Kidney Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Dursun F, Ramamurthy C, Kaushik D. "Immune-Cell Pawns" Plot Promotion and Corner Kidney Cancer: CheckMate 214. Eur Urol 2021; 81:272-273. [PMID: 34838352 DOI: 10.1016/j.eururo.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/05/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Furkan Dursun
- Department of Urology, University of Texas Health, San Antonio, TX, USA; Mays Cancer Center, University of Texas Health, MD Anderson Cancer Center, San Antonio, TX, USA
| | - Chethan Ramamurthy
- Mays Cancer Center, University of Texas Health, MD Anderson Cancer Center, San Antonio, TX, USA; Department of Internal Medicine, University of Texas Health, San Antonio, TX, USA
| | - Dharam Kaushik
- Department of Urology, University of Texas Health, San Antonio, TX, USA; Mays Cancer Center, University of Texas Health, MD Anderson Cancer Center, San Antonio, TX, USA.
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Gu CY, Wang JJ, Zhang HL, Shi GH, Ye DW. Survival in Metastatic Renal Cell Carcinoma Patients Treated With Sunitinib With or Without Cryoablation. Front Oncol 2021; 11:762547. [PMID: 34746004 PMCID: PMC8565618 DOI: 10.3389/fonc.2021.762547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/04/2021] [Indexed: 01/20/2023] Open
Abstract
Background Percutaneous cryoablation (PCA) has emerged as an alternative to extirpative management of small renal masses in select patients. In recent years, the use of targeted therapies has become mainstream, while the role of PCA in treating primary tumor is not well established among patients with metastatic renal cell carcinoma (mRCC). We sought to evaluate how mRCC patients react to PCA in combination with sunitinib. Methods We retrospectively identified patients with mRCC (primary tumor diameter ≤ 7 cm) treated with sunitinib between 2013 and 2019. These patients were categorized by initial treatment (cryoablation followed by sunitinib versus sunitinib only). Oncological outcomes and rate of adverse events were compared. Results Of the 178 patients analyzed, 65 underwent PCA prior to sunitinib. The median overall survival (OS) in the PCA-sunitinib group was 31.7 months (95% CI; 26.1-37.3), better than the sunitinib-only group, which reported a median OS of 19.8 months (95% CI; 17.1-22.4) (p < 0.001). The median progression-free survival (PFS) in patients treated with PCA-sunitinib versus sunitinib alone was 13.8 months (95% CI; 10.0-17.6) versus 7.2 months (95% CI: 6.1-8.3) (p < 0.005). No significant differences in adverse events were observed (p > 0.05). Conclusions PCA combined with sunitinib is associated with better survival outcomes than sunitinib alone in patients with mRCC. Careful patient selection remains warranted. These results should inform future prospective trials.
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Affiliation(s)
- Cheng-Yuan Gu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jun-Jie Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hai-Liang Zhang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guo-Hai Shi
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ding-Wei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Kamarajah SK, Nathan H. Strengths and Limitations of Registries in Surgical Oncology Research. J Gastrointest Surg 2021; 25:2989-2996. [PMID: 34506025 DOI: 10.1007/s11605-021-05094-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/11/2021] [Indexed: 01/31/2023]
Abstract
Over the past two decades, there has been a dramatic increase in studies based on large multi-institutional tumor registries. Applications of such databases span various research themes including epidemiology, oncology, surgical techniques, perioperative outcomes, and prognosis. Although these databases are acquired relatively easily, offer larger sample sizes and improved generalizability compared with institutional data, acknowledging limitations within analysis and cautious interpretation of data is important. Questionable conclusions can result when insufficient attention is paid to issues such as data quality and depth, potential sources of bias and missing data. This article reviews research themes and important limitations of these databases. The contemporary reporting of these issues in the literature and an increased awareness among surgical oncologists of potential applications and limitations will ensure that studies in the surgical oncology literature achieve high standards of methodological quality and clinical utility.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan, 2210A Taubman Health Care Center, 1500 E Medical Center Dr, SPC 5343, Ann Arbor, MI, 48109-5343, USA.
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Silagy AW, Kotecha RR, Weng S, Holmes A, Singla N, Mano R, Attalla K, Weiss KL, DiNatale RG, Patil S, Coleman JA, Motzer RJ, Russo P, Voss MH, Hakimi AA. Evolving biological associations of upfront cytoreductive nephrectomy in metastatic renal cell carcinoma. Cancer 2021; 127:3946-3956. [PMID: 34286865 PMCID: PMC8516697 DOI: 10.1002/cncr.33790] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/29/2021] [Accepted: 04/30/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Systemic responses to cytoreductive nephrectomy (CN) in the management of metastatic renal cell carcinoma (mRCC) are variable and difficult to anticipate. The authors aimed to determine the association of CN with modifiable International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk factors and oncological outcomes. METHODS Consecutive patients with mRCC referred for potential CN (2009-2019) were reviewed. The primary outcome was overall survival (OS); variables of interest included undergoing CN and the baseline number of modifiable IMDC risk factors (anemia, hypercalcemia, neutrophilia, thrombocytosis, and reduced performance status). For operative cases, the authors evaluated the effects of IMDC risk factor dynamics, measured 6 weeks and 6 months after CN, on OS and postoperative treatment disposition. RESULTS Of 245 treatment-naive patients with mRCC referred for CN, 177 (72%) proceeded to surgery. The CN cases had fewer modifiable IMDC risk factors (P = .003), including none in 71 of 177 patients (40.1%); fewer metastases (P = .011); and higher proportions of clear cell histology (P = .012). In a multivariable analysis, surgical selection, number of IMDC risk factors, metastatic focality, and histology were associated with OS. Total risk factors changed for 53.8% and 57.2% of the patients from the preoperative period to 6 weeks and 6 months after CN, respectively. Adjusted for preoperative IMDC risk scores, an increase in IMDC risk factors at 6 weeks and 6 months was associated with adverse OS (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.13-2.19; P = .007; HR, 2.52; 95% CI, 1.74-3.65; P < .001). CONCLUSIONS IMDC risk factors are dynamic clinical variables that can improve after upfront CN in select patients, and this suggests a systemic benefit of cytoreduction, which may confer clinically meaningful prognostic implications.
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Affiliation(s)
- Andrew W. Silagy
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - Ritesh R. Kotecha
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stanley Weng
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Urology, SUNY Downstate, New York, NY, USA
| | - Arturo Holmes
- Department of Urology, SUNY Downstate, New York, NY, USA
| | - Nirmish Singla
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roy Mano
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kyrollis Attalla
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kate L. Weiss
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renzo G. DiNatale
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Robert J. Motzer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Russo
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin H. Voss
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A. Ari Hakimi
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abu-Ghanem Y, van Thienen JV, Blank C, Aarts MJB, Jewett M, de Jong IJ, Lattouf JB, van Melick HHE, Wood L, Mulders P, Rottey S, Wagstaff J, Zondervan P, Powles T, Neven A, Collette L, Tombal B, Haanen J, Bex A. Cytoreductive nephrectomy and exposure to sunitinib - a post hoc analysis of the Immediate Surgery or Surgery After Sunitinib Malate in Treating Patients With Metastatic Kidney Cancer (SURTIME) trial. BJU Int 2021; 130:68-75. [PMID: 34706141 DOI: 10.1111/bju.15625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To analyse if exposure to sunitinib in the Immediate Surgery or Surgery After Sunitinib Malate in Treating Patients With Metastatic Kidney Cancer (SURTIME) trial, which investigated opposite sequences of cytoreductive nephrectomy (CN) and systemic therapy, is associated with the overall survival (OS) benefit observed in the deferred CN arm. PATIENTS AND METHODS A post hoc analysis of SURTIME trial data. Variables analysed included number of patients receiving sunitinib, time from randomisation to start sunitinib, overall response rate by Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1, and duration of drug exposure and dose in the intention-to-treat population of the immediate and deferred arm. Descriptive methods and 95% confidence-intervals (CI) were used. RESULTS In the deferred arm, 97.7% (95% CI 89.3-99.6%; n = 48) received sunitinib vs 80% (95% CI 66.9-88.7%, n = 40) in the immediate arm. Following immediate CN, 19.6% progressed 4 weeks after CN and the median time to start sunitinib was 39.5 vs 4.5 days in the deferred arm. At week 16, 46.0% had progressed at metastatic sites in the immediate CN arm vs 32.7% in the deferred arm. Sunitinib dose reductions, escalations and interruptions were not statistically significantly different between arms. Among patients who received sunitinib in the immediate or deferred arm the median total sunitinib treatment duration was 172.5 vs 248 days. Reduction of target lesions was more profound in the deferred arm. CONCLUSIONS In comparison to the deferred CN approach, immediate CN impairs administration, onset, and duration of sunitinib. Starting with systemic therapy leads to early and more profound disease control and identification of progression prior to planned CN, which may have contributed to the observed OS benefit.
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Affiliation(s)
- Yasmin Abu-Ghanem
- Royal Free London NHS Foundation Trust and UCL Division of Surgery and Interventional Science, London, UK
| | | | | | | | | | - Igle Jan de Jong
- University of Groningen, University Medical Center Groningen, the Netherlands
| | | | | | - Lori Wood
- QEII Health Sciences Center, Halifax, NS, Canada
| | - Peter Mulders
- Radboud University Hospital, Nijmegen, the Netherlands
| | | | - John Wagstaff
- South West Wales Cancer Centre and Swansea University College of Medicine, Swansea, UK
| | | | - Tom Powles
- Barts and Queen Mary University London, London, UK
| | - Anouk Neven
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Laurence Collette
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Bertrand Tombal
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium.,Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - John Haanen
- Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Axel Bex
- Royal Free London NHS Foundation Trust and UCL Division of Surgery and Interventional Science, London, UK.,Netherlands Cancer Institute, Amsterdam, the Netherlands
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Cytoreductive Nephrectomy in the Management of Metastatic Renal Cell Carcinoma: Is There Still a Debate? Curr Urol Rep 2021; 22:54. [PMID: 34654989 DOI: 10.1007/s11934-021-01073-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this review was to summarize the evidence on the current role of cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC). RECENT FINDINGS Since the advent of systemic targeted therapies for mRCC treatment, the role of CN has been questioned. Several retrospective observational studies demonstrated a therapeutic benefit for CN, while recent prospective randomized trials have challenged this evidence. As such, patient selection has become of paramount importance in this setting. The role of CN on mRCC treatment is still object of debate. In carefully selected patients, CN remains an important option as a component of a multimodal therapeutic approach. As systemic therapies for mRCC continue to evolve, future trials are needed to evaluate the benefits and limits of CN in the immunotherapy era, tailoring the treatment sequence and selecting the patients who are most likely to benefit from surgical interventions.
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Association between cytoreductive nephrectomy and survival among patients with metastatic renal cell carcinoma receiving modern therapies: a systematic review and meta-analysis examining effect modification according to systemic therapy approach. Cancer Causes Control 2021; 32:675-680. [PMID: 33963938 DOI: 10.1007/s10552-021-01435-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cytoreductive nephrectomy (CN) has played a role in treatment of metastatic renal cell carcinoma (mRCC) since trials demonstrated a survival benefit in patients receiving CN with interferon. With the publication of CARMENA, it became clear that the value of CN may depend on the co-therapy administered. We sought to assess the benefit of CN in the era of modern immunotherapy (IO). METHODS We performed a systematic review to identify studies assessing CN in patients receiving TT or IO. We extracted multivariable-adjusted hazard ratios for the association between CN and overall survival (OS) and performed random effects meta-analysis. We tested for effect modification by systemic therapy approach on the association between CN and OS by pooling the difference in logHR associated with CN for patients treated with TT versus IO. RESULTS We identified three comparisons assessing CN in patients receiving TT or IO. Pooled analysis indicated improved survival with CN in both the TT (2 cohorts, pooled HR: 0.52, 95% CI 0.46-0.59; I2 = 80%) and IO era (2 cohorts; pooled HR: 0.28, 95% CI 0.16-0.49; I2 = 21%), with a stronger association in the IO era (p = 0.01; I2 = 0%). CONCLUSION In observational datasets, we observed a larger survival benefit to CN in patients treated with IO-based regimens versus those treated with TT-based regimens. While the role of CN for patients receiving TT has recently been questioned, this suggests that the results of CARMENA do not necessarily preclude a benefit to CN when combined with IO-based regimens.
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48
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Chakiryan NH, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Sexton W, Gilbert SM, Manley BJ. Real-World Survival Outcomes Associated With First-Line Immunotherapy, Targeted Therapy, and Combination Therapy for Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2021; 4:e2111329. [PMID: 34032854 PMCID: PMC8150693 DOI: 10.1001/jamanetworkopen.2021.11329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Clinical trials have shown an overall survival (OS) benefit associated with first-line immunotherapy (IT) and combination targeted therapy (TT) and IT regimens compared with TT among patients with metastatic clear cell renal cell carcinoma (RCC). Generalizability of these findings in a real-world cohort outside of a clinical trial setting is unclear. OBJECTIVE To assess the association of first-line TT, IT, and combination TT and IT regimens with OS in a real-world cohort of patients with metastatic clear cell RCC. DESIGN, SETTING, AND PARTICIPANTS This retrospective propensity-matched cohort study identified 5872 patients with metastatic clear cell RCC in the National Cancer Database from January 1, 2015, to December 31, 2017, who received first-line TT, IT, or combination TT and IT and were not treated on a clinical trial protocol. Patients were stratified by first-line systemic treatment. Statistical analysis was conducted from October 1 to December 1, 2020. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. After 1:1:1 nearest-neighbor caliper matching of propensity scores, survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. RESULTS The final study population included 5872 patients (TT group: n = 4755 [81%]; 3332 men [70%]; median age, 64 years [interquartile range, 57-71 years]; IT group: n = 638 [11%]; 475 men [74%]; median age, 61 years [interquartile range, 54-69 years]; and combination TT and IT group: n = 479 [8%]; 321 men [67%]; median age, 62 years [interquartile range, 55-69 years]), and the matched cohort included 1437 patients (479 per treatment group). Patients in the IT and combination TT and IT groups were younger than those in the TT group, had fewer comorbid conditions (Charlson-Deyo score of 0, 480 of 638 [75%] in the TT group, 356 of 479 [74%] in the IT group, and 3273 of 4755 [69%] in the combination TT and IT group), and were more often treated at academic centers (315 of 638 [49%], 216 of 479 [45%], and 1935 of 4755 [41%], respectively). Both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC (IT group: hazard ratio [HR], 0.60 [95% CI, 0.48-0.75]; P < .001; combination TT and IT group: HR, 0.74 [95% CI, 0.60-0.91]; P = .005). No survival difference was seen between the IT and combination TT and IT groups (combination TT and IT: HR, 1.24 [95% CI, 0.98-1.56]; P = .08). CONCLUSIONS AND RELEVANCE This study suggests that both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC. These findings are similar to those identified in recently reported clinical trials, lending confidence to the broader applicability of these findings outside of a clinical trial setting.
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Affiliation(s)
- Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Wade Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Hsieh PY, Hung SC, Li JR, Wang SS, Yang CK, Chen CS, Lu K, Cheng CL, Chiu KY. The effect of metastasectomy on overall survival in metastatic renal cell carcinoma: A systematic review and meta-analysis. Urol Oncol 2021; 39:422-430. [PMID: 33934963 DOI: 10.1016/j.urolonc.2021.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/09/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Metastasectomy (MTS) is a treatment option for patients diagnosed with metastatic Renal Cell Carcinoma (mRCC). Nevertheless, the benefits of MTS as they pertain to survival remain controversial. This systematic review aims to compare the survival outcomes of patients who underwent MTS, as well as discover which clinical factors were related to the results. METHODS From their inception up to August 2020, a systematic review of the EMBASE, PubMed, Cochrane library, and Web of science databases was performed. Studies which reported outcomes on patients who underwent MTS for the treatment of mRCC were included. The sites, times, amount, histology types of metastasis, and prior nephrectomy were also analyzed. The primary efficacy end point was Overall Survival (OS). A meta-analysis was performed to calculate hazard ratio, 95% confidence intervals, and I2 values. Forest plots were constructed for each analysis group. RESULTS The systematic review and reference list search identified 294 articles, with 17 meeting studies as inclusion criteria. The MTS group showed a competitive advantage in OS, in that the non-MTS group was negatively associated with an overall survival rate (HR [non-MTS vs. MTS] = 2.15, 95% CI: 1.59-2.92, P< 0.001). Moreover, patients treated with the most recently available target therapy without MTS showed a significantly increased risk compared with the MTS group (HR = 1.82, 95% CI:1.23-2.70, P= 0.003). Additionally, meta-analysis revealed HR elevating in patients with nonlung only metastasis (HR = 1.87, 95% CI: 1.55-2.26, P< 0.001), synchronous metastasis (HR = 1.28, 95% CI: 1.10-1.49, P= 0.001), and multiple metastases (HR = 2.06, 95% CI: 1.64-2.59, P< 0.001). Clear-cell type mRCC (HR = 0.62, 95% CI: 0.48-0.82, P= 0.0006) and prior nephrectomy (HR = 0.37, 95% CI: 0.15-0.91, P= 0.03) were positively associated with a better overall survival rate. CONCLUSIONS MTS is a treatment option for mRCC patients with prolonged overall survival time. The operation has additional advantages, particularly in patients with lung only metastasis, asynchronous metastasis, fewer metastasis sites, clear-cell type mRCC, and the patients who had received nephrectomy.
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Affiliation(s)
- Po-Yen Hsieh
- Department of Education, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Sheng-Chun Hung
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jian-Ri Li
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Medicine and Nursing, Hungkuang University, Taichung, Taiwan
| | - Shian-Shiang Wang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan
| | - Cheng-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chuan-Shu Chen
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Kevin Lu
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Cheng-Li Cheng
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Kun-Yuan Chiu
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan.
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50
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Rossi SH, Klatte T, Usher-Smith JA, Fife K, Welsh SJ, Dabestani S, Bex A, Nicol D, Nathan P, Stewart GD, Wilson ECF. A Decision Analysis Evaluating Screening for Kidney Cancer Using Focused Renal Ultrasound. Eur Urol Focus 2021; 7:407-419. [PMID: 31530498 DOI: 10.1016/j.euf.2019.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/19/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Screening for renal cell carcinoma (RCC) has been identified as a key research priority; however, no randomised control trials have been performed. Value of information analysis can determine whether further research on this topic is of value. OBJECTIVE To determine (1) whether current evidence suggests that screening is potentially cost-effective and, if so, (2) in which age/sex groups, (3) identify evidence gaps, and (4) estimate the value of further research to close those gaps. DESIGN, SETTING, AND PARTICIPANTS A decision model was developed evaluating screening in asymptomatic individuals in the UK. A National Health Service perspective was adopted. INTERVENTION A single focused renal ultrasound scan compared with standard of care (no screening). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Expected lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER), discounted at 3.5% per annum. RESULTS AND LIMITATIONS Given a prevalence of RCC of 0.34% (0.18-0.54%), screening 60-yr-old men resulted in an ICER of £18 092/QALY (€22 843/QALY). Given a prevalence of RCC of 0.16% (0.08-0.25%), screening 60-yr-old women resulted in an ICER of £37327/QALY (€47 129/QALY). In the one-way sensitivity analysis, the ICER was <£30000/QALY as long as the prevalence of RCC was ≥0.25% for men and ≥0.2% for women at age 60yr. Given the willingness to pay a threshold of £30000/QALY (€37 878/QALY), the population-expected values of perfect information were £194 million (€244 million) and £97 million (€123 million) for 60-yr-old men and women, respectively. The expected value of perfect parameter information suggests that the prevalence of RCC and stage shift associated with screening are key research priorities. CONCLUSIONS Current evidence suggests that one-off screening of 60-yr-old men is potentially cost-effective and that further research into this topic would be of value to society. PATIENT SUMMARY Economic modelling suggests that screening 60-yr-old men for kidney cancer using ultrasound may be a good use of resources and that further research on this topic should be performed.
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Affiliation(s)
- Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Tobias Klatte
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Department of Urology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kate Fife
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Sarah J Welsh
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Saeed Dabestani
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Lund, Sweden
| | - Axel Bex
- The Royal Free London NHS Foundation Trust, Specialist Centre for Kidney Cancer, UK; Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Amsterdam, The Netherlands
| | - David Nicol
- Department of Urology, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK
| | - Paul Nathan
- Department of Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Cancer Research UK Cambridge Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.
| | - Edward C F Wilson
- Cambridge Centre for Health Services Research, University of Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge, UK; Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK.
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