Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer

Pre-surgical targeted molecular therapy in renal cell carcinoma

Pre-surgical systemic therapy with targeted molecular agents is an attractive option as an approach to the treatment of patients with renal cell carcinoma. This treatment strategy offers a rational approach for selecting patients with metastatic disease who are most likely to benefit from cytoreductive nephrectomy, but also allows access to treated tumour tissue to study the molecular mechanisms of response and resistance. In patients with locally advanced disease, this strategy offers the potential for improved resectability and timely delivery of systemic therapy to treat subclinical metastatic disease. Preliminary evidence indicates that the use of targeted therapies before nephrectomy is safe. Reliable therapy-specific prognostic biomarkers are needed for the optimal integration of aggressive surgical intervention and systemic therapy to maximize the oncological benefits for the patient.

Cytoreductive nephrectomy in metastatic renal cell carcinoma

PURPOSE OF REVIEW

Cytoreductive nephrectomy has an established role in management of metastatic renal cell carcinoma when performed in properly selected patients prior to administration of systemic cytokine therapy. Within the past several years, novel molecular targeted agents have not only revolutionized management of metastatic renal cell carcinoma but also created controversy regarding the necessity, patient selection for and timing of cytoreductive nephrectomy.

RECENT FINDINGS

Benefits of targeted molecular therapeutics have largely been observed in the context of prior cytoreductive nephrectomy, and limited available evidence supports cytoreductive nephrectomy in appropriately selected patients with metastatic renal cell carcinoma who are candidates for targeted systemic therapy. Presurgical systemic therapy with targeted molecular agents is an attractive paradigm, which not only offers a rational approach to select patients who are most likely to benefit from cytoreductive nephrectomy but also allows access to treated tumor tissue to study molecular mechanisms of response and resistance. Surgical approaches increasingly utilized in patients with localized kidney cancer, such as nephron-sparing and minimally invasive techniques are similarly relevant and should be utilized, when appropriate, in patients with metastatic renal cell carcinoma.

SUMMARY

Cytoreductive nephrectomy should be considered to provide a survival benefit for patients with metastatic renal cell carcinoma and should be used in patients who are candidates for systemic therapy before or after surgery.

Performance status and cytoreductive nephrectomy: redefining management in patients with poor performance

BACKGROUND

An Eastern Cooperative Oncology Group performance status (ECOG PS) of 2/3 can quantify cancer patients' well being and may be used to select patients for treatment. The objective of the current study was to investigate the outcomes of cytoreductive nephrectomy (CN) for patients who have an impaired performance status (ECOG PS 2/3).

METHODS

Patients who underwent CN for renal cell carcinoma (RCC) between 1989 and 2006 were identified. Patient records were reviewed for age, symptoms, ECOG PS, tumor size, stage, grade, histology, sarcomatoid features, lymph node metastasis, site of metastasis, and the presence of bone metastases (BM) in weight-bearing structures. The relation of ECOG PS to outcome variables was evaluated.

RESULTS

Four hundred eighteen patients underwent CN, including 117 patients who had an ECOG PS of 0, 274 patients who had an ECOG PS of 1, and 27 patients who had an ECOG PS of 2/3. Patients who had a worse ECOG PS were younger, had higher tumor classification and grade, and more frequently demonstrated anemia and BM. Only 37.5% of patients who had an ECOG PS of 2/3 experienced an improvement in performance in the postoperative period, and only 57.5% went on to receive systemic therapy, of whom none attained an objective responses. The median disease-specific survival for patients who had an ECOG PS of 0, 1, and 2/3 was 27 months, 13.8 months, and 6.6 months, respectively (P<.001). Patients who had an ECOG PS of 2/3 could be stratified further by the presence or absence of BM into 2 groups (median disease-specific survival: 17.7 months and 2.1 months, respectively; P = .006).

CONCLUSIONS

Surgery in patients who have a poor performance may serve a palliative function but should be performed with caution because of the poor outcome of such patients. ECOG PS is influenced strongly by BM. A subset of patients with an ECOG PS of 2/3 that are symptomatic specifically from BM may derive greater benefit from CN than patients who hare symptomatic because of visceral metastases.

Conclusion and future directions

Twenty-five years ago treatment for metastatic renal cancer was generally ineffective. Over the intervening period, cytokines such as interferon-alpha and interleukin-2 gained prominence in the treatment of metastatic renal cancer. These agents produced clinical responses in a minority of patients with metastatic renal cancer, albeit with substantial toxicity. Over the last 3 years, there has been a substantial increase in our understanding of kidney cancer at the molecular level. This has led to major breakthroughs in the management of this once untreatable disease. Substantial gains in progression free and overall survival have occurred as a consequence. This issue of The Cancer Journal has been devoted to reviewing clinical progress in the treatment of metastatic renal cancer, with an eye toward current needs and the likely future directions of the field.

Oral cavity metastasis of renal cell carcinoma: a case report

Introduction

Despite being reported rarely, renal cell carcinoma is the third most frequent neoplasm to metastasize to the head and neck region preceded only by breast and lung cancer. Little information exists regarding the presentation and work-up of metastatic renal cell carcinoma in the oral cavity.

Case presentation

We report the case of a 63-year-old Caucasian man presenting with an oral cavity lesion that was painful and that had grown substantially over several months. Biopsy resulted in persistent bleeding requiring cautery and manual pressure. Immunoperoxidase testing was necessary to make the diagnosis of metastatic renal cell carcinoma and rule out other clear cell carcinomas of salivary gland origin.

Conclusion

Metastatic renal cell carcinoma is part of the differential diagnosis for patients presenting with a new head or neck lesion in the setting of a history of kidney cancer. The physician needs to be prepared for the increased risk of bleeding and understand the importance of immunohistochemical staining to differentiate between metastatic renal cell carcinoma and malignancies of salivary origin. Unfortunately, the prognosis is invariably poor in these patients.

Cytoreductive partial nephrectomy does not undermine cancer control in metastatic renal cell carcinoma: a population-based study

OBJECTIVES

We examined the population-based rates of cancer-specific survival in patients with metastatic renal cell carcinoma (MRCC) treated with either partial (PN) or radical cytoreductive nephrectomy (RN).

METHODS

Patients diagnosed with MRCC and treated with either PN or RN were identified within nine SEER cancer registries. Matched and unmatched Kaplan-Meier survival analyses, as well as multivariable Cox regression models compared the effect of RN (n = 1997, 97.8%) vs. PN (n = 46, 2.2%) on cancer-specific survival (CSS). Covariates consisted of age, gender, community type (rural vs urban), race, Surveillance, Epidemiology, and End Results (SEER) registry, tumor size and year of diagnosis.

RESULTS

In multivariable unmatched Cox regression analyses, no statistically significantly difference was found in CSS between the two groups (hazard ratio [HR] 1.40, P = .16). Similarly, no difference in CSS was found in the matched analyses (HR 1.35, log rank P = .34).

CONCLUSION

Cytoreductive PN does not appear to undermine survival in patients with MRCC.

Interferon-alpha in combination with either imatinib (Gleevec) or gefitinib (Iressa) in metastatic renal cell carcinoma: a phase II trial

Treatments for metastatic renal cell carcinoma (MRCC) are limited. RCCs frequently overexpress epithelial growth factor receptor and express c-Kit and platelet-derived growth factor receptor-beta. Combination of interferon with tyrosine kinase inhibitors of epithelial growth factor receptor [gefitinib (Iressa)] or c-Kit and platelet-derived growth factor receptor-beta [imatinib (Gleevec)] was evaluated for efficacy and safety. Patients with MRCC received 12-week cycles of interferon [3 million units (MU) subcutaneously thrice in week 1 and 6 MU thrice weekly thereafter] and either gefitinib (500 mg daily) or imatinib (600 mg daily). The gefitinib/imatinib dose was reduced as needed owing to toxicity. The primary endpoint was objective tumor response. Secondary endpoints were time to tumor progression, overall survival, and safety. Seventeen patients were enrolled. Most had clear cell [36% (6/17)] or papillary [36% (6/17)] tumors. Most (n=14) were treated on the gefitinib arm, including two patients who crossed over from the imatinib arm after experiencing disease progression. Objective tumor responses were evaluable in 14 patients (82%). Of these 14, partial responses occurred in three (21%), stable disease in seven (50%), and progressive disease in four (29%). The most frequent treatment-related adverse events were skin rash, flu-like symptoms, and fatigue (both treatment arms); diarrhea (gefitinib arm only); and thrombocytopenia and leukopenia (imatinib arm only). Median time to tumor progression (range) for patients on the gefitinib arm only was 4.27 (1.13-15.97) months and median overall survival (range) was 11.42+ (1.13-29.07+) months. Combination of gefitinib with interferon safely delays progression of refractory MRCC. Further studies in this setting are warranted.

Advanced-stage renal cell carcinoma treated by radical nephrectomy and adjacent organ or structure resection

OBJECTIVE

To examine the effect of radical nephrectomy (RN) with adjacent organ and structure resection on survival, as invasion of adjacent organs in patients with renal cell carcinoma (RCC) is rare.

PATIENTS AND METHODS

After institutional review board approval, we reviewed our database and statistically analysed of patients with pathological stage T3 or T4 RCC who had RN and resection of a contiguous organ or structure.

RESULTS

We identified 38 patients of 2464 (1.5%) who had RN with adjacent organ or structure resection. The median (interquartile range) size of the mass was 11 (8-14) cm, and the follow-up 13 (5-33) months. Most patients (68%) were pT4 stage and had conventional clear cell carcinoma (95%). Fourteen patients (37%) had positive surgical margins. The liver (10) was the most commonly resected adjacent organ or structure. Only one patient remains alive with no evidence of disease at 5 years, while three are currently alive with disease. Overall, 34 of 38 patients (90%) ultimately died from disease at a median (range) of 11.7 (5.4-29.2) months after surgical resection. The surgical margin status was the only statistically significant factor for recurrence and death (P = 0.006).

CONCLUSIONS

The prognosis for patients with advanced RCC and adjacent organ or structure involvement is extremely poor and similar to that of patients with metastatic disease. These patients should be thoroughly counselled about the impact of surgical management and considered for entry into neoadjuvant or adjuvant clinical trials with new targeted systemic agents.

Preoperative tyrosine kinase inhibition as an adjunct to debulking nephrectomy

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A preoperative prognostic model for patients treated with nephrectomy for renal cell carcinoma

BACKGROUND

Currently two pretreatment prognostic models with limited accuracy (65-67%) can be used to predict survival in patients with localized renal cell carcinoma (RCC).

OBJECTIVE

We set out to develop a more accurate pretreatment model for predicting RCC-specific mortality after nephrectomy for all stages of RCC.

DESIGN, SETTING, AND PARTICIPANTS

The data originated from a series of prospectively recorded contemporary cases of patients treated with radical or partial nephrectomy between 1984 and 2006. Model development was performed using data from 2474 patients from five centers and external validation was performed using data from 1972 patients from seven centers.

MEASUREMENTS

The probability of RCC-specific mortality was modeled using Cox regression. The significance of the predictors was confirmed using competing risks analyses, which account for mortality from other causes.

RESULTS AND LIMITATIONS

Median follow-up in patients who did not die of RCC-specific causes was 4.2 yr and 3.5 yr in the development and validation cohorts, respectively. The freedom from cancer-specific mortality rates in the nomogram development cohort were 75.4% at 5 yr after nephrectomy and 68.3% at 10 yr after nephrectomy. All variables except gender achieved independent predictor status. In the external validation cohort the nomogram predictions were 88.1% accurate at 1 yr, 86.8% accurate at 2 yr, 86.8% accurate at 5 yr, and 84.2% accurate at 10 yr.

CONCLUSIONS

Our model substantially exceeds the accuracy of the existing pretreatment models. Consequently, the proposed nomogram-based predictions may be used as benchmark data for pretreatment decision making in patients with various stages of RCC.

Prospective study of combined treatment with interferon-alpha and active vitamin D3 for Japanese patients with metastatic renal cell carcinoma

OBJECTIVES

To assess the safety and efficacy of combined therapy with interferon-alpha (INF-alpha) and active vitamin D(3) for metastatic renal cell carcinoma (RCC).

METHODS

Sixteen patients with metastatic RCC were enrolled in this prospective study. All received oral alfacalcidol (1 microg once daily) and INF-alpha (Sumiferon; 3 million units, three times a week). The primary endpoint was the response rate (defined as complete + partial remission). Secondary endpoints were cancer-specific survival and toxicity. The median follow-up period was 17 months (range: 5-49 months).

RESULTS

The median age of the patients was 68 years (range: 41-73 years). The sites of metastases were: lung in 13 patients, bone in one, lung and bone in one, and lung, bone, and lymph nodes in one. Four patients (25%) had a partial response (PR), 10 patients (62.5%) showed no change (NC), and two patients (12.5%) had progressive disease (PD). The median cancer-specific survival time was 45 months. One patient had to discontinue vitamin D(3) because of hypercalcemia. Kaplan-Meier survival analysis revealed that metastasis at the time of initial diagnosis and older than average age were significant predictors of poor survival (P < 0.05).

CONCLUSIONS

Combined treatment with INF-alpha and active vitamin D(3) has shown to be safe and effective for metastatic RCC patients.

Pre-treatment global quality of health predicts progression free survival in metastatic kidney cancer patients treated with sorafenib or sunitinib

PURPOSE

Our goal was to prospectively evaluate self-reported quality-of-life (QoL) during second-line therapy in 51 consecutive patients with cytokine-refractory kidney cancer treated with sorafenib or sunitinib.

METHODS

QoL was assessed by the EORTC QoL questionnaire QLQ-C30 at baseline and at weeks 4, 6, 10, 12 and 16.

RESULTS

Global QoL deteriorated significantly during the first 4 weeks of treatment (P < 0.0001). Patients experienced a reduction of their role, cognitive, and social function (all P < 0.0001). In addition, fatigue (P < 0.0001), nausea/vomiting (P = 0.003), and pain (P < 0.0001) as well as dyspnoea (P < 0.0001), insomnia (P = 0.026), appetite loss (P = 0.013), and diarrhoea (P < 0.0001) increased significantly. After 16 weeks, fatigue (P < 0.0001), pain (P = 0.015), appetite loss (P = 0.002) and diarrhoea (P = 0.038) were still influenced by the therapy, while all functional scales recovered. Global QoL at baseline was predictive of overall response (P = 0.006) and progression free survival (PFS) (P < 0.0001). A better physical function at baseline, a better ECOG performance status, and a low risk profile according to MSKCC risk groups correlated with a longer PFS (all P < 0.0001). No significant differences regarding QoL were found between sorafenib and sunitinib during the study period.

CONCLUSIONS

Second-line therapy with sorafenib or sunitinib does not adversely affect patients global QoL after 16 weeks of treatment. Evaluation of baseline QoL can help to further stratify patients into risk groups predicting overall response and PFS.

A comprehensive prognostic stratification for patients with metastatic renal clear cell carcinoma

PURPOSE

To develop a reliable prognostic model for patients with metastatic renal cell carcinoma (RCC) based on features readily available in common clinical settings.

PATIENTS AND METHODS

A total of 197 patients with RCC who underwent nephrectomy and immunotherapy from 1995 to 2004 were retrospectively reviewed. Their mean age was 55.1+/-11.8 yrs (24-83 yrs) and mean survival time from metastasis was 22.6+/-20.2 mos (3-120 mos). The impact of 24 clinicopathological features on disease specific survival was investigated.

RESULTS

On univariate analysis, constitutional symptoms, sarcomatoid differentiation, tumor necrosis, multiple primary lesions, liver metastasis, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), thrombocytosis, alkaline phosphatase, hematocrit, T stage, N stage, and nuclear grade had significant influence on survival (p<0.05). Multivariate analysis revealed the following features associated with survival: sarcomatoid differentiation [hazard ratio (HR)=2.99, p<0.001], liver metastasis (HR=2.09, p=0.002), ECOG-PS (HR=1.95, p=0.005), N stage (HR=1.94, p=0.002), and number of metastatic sites (HR=1.76, p=0.003). An individual prognostic score was defined as the sum of the weight of these features. According to prognostic scores, patients could be subdivided into 3 groups: low risk (score 0), intermediate risk (score 1 or 2), and high risk (score >or= 3).

CONCLUSION

A comprehensive prognostic stratification model was developed to predict survival and stratify patients for prospective clinical trials.

Improving outcomes in patients with advanced renal cell carcinoma

The emergence of targeted therapies for advanced renal cell carcinoma has been a dramatic turning point in improving outcomes for the majority of patients with this disease. In study populations comprising primarily good- and intermediate-risk patients with clear cell renal cell carcinoma and prior nephrectomy, prolonged progression-free survival was demonstrated for three angiogenesis-targeted agents: sunitinib (compared with interferon [IFN]), bevacizumab plus IFN (vs IFN alone) and sorafenib (vs placebo in cytokine-refractory patients). As a first-line treatment for patients with multiple poor-risk factors, temsirolimus, which inhibits mTOR, has improved not only progression-free survival compared with IFN but, more importantly, overall survival. Further studies are needed to determine whether combinations and/or sequencing of these targeted agents can further improve outcomes.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Association of surgery with improved survival in stage IV breast cancer patients

OBJECTIVE

This study aims to examine the role of surgery in patients with stage IV breast cancer.

BACKGROUND

Historically, women who present with metastatic breast cancer are not offered surgical treatment. However, recent reports indicate that surgery may improve outcome. Using a large database of women whom presented with stage IV breast cancer, we compared outcome of patients who had resection of their primary cancer to those who did not.

METHODS

Of 16,401 patients, 807 had stage IV disease at presentation, and 395 survived >90 days and were included in this analysis. Clinical and tumor characteristics, surgical treatment, and survival were compared for the surgically versus nonsurgically treated patients.

RESULTS

Two hundred and forty-two patients (61.3%) had definitive surgery for their primary tumor and 153 (38.7%) did not. Patients who underwent surgery were significantly older, were more likely to be white, more often had hormone receptor positive disease, had small primary tumors, and had fewer metastatic sites and less visceral involvement. The median survival of surgically treated patients was 27.1 months versus 16.8 months for patients without surgical resection (P < 0.0001). In multivariate analysis, which included surgical treatment, age, race, estrogen and progesterone receptor status, number of metastatic sites, and presence of visceral metastases, surgery remained an independent factor associated with improved survival (P = 0.006).

CONCLUSION

Patients with stage IV breast cancer who had definitive surgical treatment of their primary tumors had more favorable disease characteristics. However, after adjustment for these characteristics, surgical treatment remained an independent factor associated with improved survival.

No improvement in renal cell carcinoma survival: a population-based study in the Netherlands

BACKGROUND

The increased finding of kidney 'incidentalomas' and more frequent surgery in patients with renal cell cancer (RCC) metastases may have improved survival from the disease. However, recent data on survival of unselected population-based series of patients with RCC are sparse.

METHODS

We collected the follow-up data for all the patients registered with RCC in the population-based cancer registry held by the Comprehensive Cancer Centre East, the Netherlands.

RESULTS

Patients (1504) diagnosed with RCC between 1989 and 2002 were included. Eighty-three percent of all tumours were histologically confirmed; 17% of all diagnoses were based on clinical examination only. The latter group was older, had a worse stage distribution, often did not receive any kind of therapy and showed a 5-year relative survival of 8%. Five-year relative survival for patients with a histologically confirmed RCC was 60% and did not improve over the last 15 years. A low resection rate in patients with metastasis was observed, most pronounced in elderly, without a tendency of increase in more recent years.

CONCLUSION

The relative survival of RCC did not improve over the years. The resection rate in patients with metastasised disease did not increase over time, despite current knowledge concerning its benefit on tumour complications, time to progression and response to immunotherapy.

Sunitinib for treatment of advanced renal cell cancer: primary tumor response

PURPOSE

Nephrectomy before immunotherapy in patients with metastatic renal cell cancer (RCC) will improve patient outcome. In addition, the primary tumor is known to be refractory to cytokines. Sunitinib is now approved for treatment of advanced RCC, but its effect on the primary tumor has yet to be reported.

EXPERIMENTAL DESIGN

All patients treated with sunitinib for advanced RCC without prior nephrectomy were reviewed and sequential computed tomography scans were evaluated for response in the primary tumor as well as metastases according to Response Evaluation Criteria in Solid Tumors. Volumes of primary tumors and central necrotic areas were measured with the perimeter method.

RESULTS

Computed tomography scans were available for evaluation of response in 17 of 22 patients with a primary tumor in situ (1 patient with two primaries). According to Response Evaluation Criteria in Solid Tumors, 4 patients had a partial response, 12 had stable disease, and 1 had progressive disease. The one-dimensional longest diameter of the primary tumor correlated with the volumetric measurements both at baseline and at the time of evaluation of response. Excluding the patient with progressive disease, the median volume reduction was 31% associated with a median increase in the volume of necrosis of 39%. Three patients underwent nephrectomy and tumors showed extensive necrotic areas next to small fields of vital tumor cells.

CONCLUSIONS

Sunitinib can induce a significant reduction in volume of primary renal cell tumors. Further trials need to address the role of nephrectomy in advanced RCC patients on sunitinib treatment.

Surgical morbidity associated with administration of targeted molecular therapies before cytoreductive nephrectomy or resection of locally recurrent renal cell carcinoma

PURPOSE

Targeted molecular therapies such as bevacizumab, sunitinib and sorafenib before surgical resection hold promise as rational treatment paradigms for patients with metastatic or locally recurrent renal cell carcinoma. To analyze the safety of this approach we evaluated surgical parameters and perioperative complications in patients treated with targeted molecular therapies before cytoreductive nephrectomy or resection of retroperitoneal renal cell carcinoma recurrence, and compared them to a matched patient cohort who underwent up-front surgical resection.

MATERIALS AND METHODS

We evaluated surgical parameters and perioperative complications in 44 patients treated with targeted molecular therapies before cytoreductive nephrectomy or resection of local renal cell carcinoma recurrence, and in a matched cohort of 58 patients who underwent up-front surgery.

RESULTS

Cohorts of patients treated with preoperative targeted molecular therapy and initial surgical resection were matched in terms of clinical characteristics, burden of metastatic disease and number of adverse prognostic factors. A total of 39 complications occurred in 17 (39%) patients treated with preoperative targeted molecular therapy and in 16 (28%) who underwent up-front resection (p = 0.287). There were no statistically significant differences in surgical parameters, incidence of perioperative mortality, re-exploration, readmission, thromboembolic, cardiovascular, pulmonary, gastrointestinal, infectious or incision related complications between patients treated with preoperative targeted molecular therapy and those who underwent up-front surgery. Duration, type and interval from targeted molecular therapy to surgical intervention were not associated with the risk of perioperative morbidity.

CONCLUSIONS

Preoperative administration of targeted molecular therapies is safe, and does not increase surgical morbidity or perioperative complications in patients treated with cytoreductive nephrectomy or resection of recurrent retroperitoneal renal cell carcinoma.

Surgery insight: management of renal cell carcinoma with associated inferior vena cava thrombus

Renal cell carcinoma with inferior vena cava thrombus can be a diagnostic and therapeutic challenge; however, the surgical resection of these tumors can be facilitated by appropriate preoperative imaging and planning. First and foremost, we believe that this procedure should be considered an operation on the inferior vena cava rather than on the kidney. The level and extent of the tumor thrombus dictates the surgical approach used. Although the patient should be given an appropriate explanation of the procedure and its risks, the surgeon needs to be adequately prepared and have intraoperative versatility in order to maintain the safety of this operation. In this Review, we describe our approach to surgical resection in patients who have renal cell carcinoma with inferior vena cava thrombus, and outcomes for the management of patients with this disorder.

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

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

Neoadjuvant targeted therapy and advanced kidney cancer: observations and implications for a new treatment paradigm

OBJECTIVE

To evaluate our early experience with neoadjuvant therapy (sunitinib or sorafenib) in advanced renal cell carcinoma (RCC), to explore the effect on both tumour biology and potential for downstaging advanced tumours, as systemic therapy for RCC has historically resulted in little if any primary tumour response, but recent experience with targeted therapy suggests otherwise.

PATIENTS AND METHODS

The preliminary experience with neoadjuvant therapy for the surgical management of RCC was reviewed at two large referral centres. Several unique patients were identified who had a novel response to systemic therapy that altered the surgical strategy.

RESULTS

Four patients who had targeted therapy before surgery are described and in whom there were effects on tumour biology not seen previously with chemotherapy and cytokine therapy. The selected patients who had neoadjuvant targeted therapy had shrinkage of a tumour thrombus in the inferior vena cava, nodal involvement, renal fossa recurrence and tumour within a solitary kidney.

CONCLUSIONS

The introduction of new molecular agents has revolutionized the treatment of patients with metastatic RCC. Responses to targeted therapy within the primary tumour, tumour thrombus, renal fossa recurrence, and lymph node metastases are novel findings not seen during treatment with immunotherapeutic-based strategies. This might be a signal for urological surgeons to re-evaluate the paradigm for the surgical management of advanced RCC. Potential applications are presented to encourage further investigations with targeted therapy in the neoadjuvant setting.

Tyrosine kinase inhibitors and anti-angiogenic therapies in kidney cancer

Renal cell carcinoma (RCC) is a heterogeneous disease as reflected in its presentation and clinical course, pathological subtypes, nuclear grades and molecular biology. Emerging data indicate that renal tumors express a variety of molecular tumor markers and unique patterns of gene expression. Clinically the disease behaves quite heterogeneously, with courses ranging from indolent to highly aggressive. Surgical monotherapy or as part of a multimodal approach remains the standard of care for most cases of RCC. Radical or partial nephrectomy is associated with a 5-year cancer specific survival (CSS) of 85-97% for pT1 tumors. Unfortunately, 20% of patients have either locally advanced or node positive (N+) RCC while another 22% have metastatic RCC (mRCC) at presentation. Unlike the outcomes in early localized disease, survival rates for N+ patients are poor and patients with mRCC are rarely cured despite aggressive multimodal therapy. Classic cytotoxic chemotherapy has repeatedly been shown to have little effect and only 5-20% of patients with mRCC respond to immunologic agents such as interferon and/or interleukin. Cytoreductive nephrectomy with systemic immunotherapy is associated with few cures with median survivals of 12-24 months. Recent advances in our understanding of the molecular origins and pathways of RCC have led to the development of more effective targeted therapies. Here we review the molecular pathways that define the pertinent therapeutic targets in RCC and the clinical data for these new and promising agents.

Changing concepts in the surgery of renal cell carcinoma

INTRODUCTION

Herein, current developments in open and minimally invasive renal surgery are presented.

MATERIALS AND METHODS

This also includes considerations on the appropriate indication for the two surgical procedures in small renal tumours, locally advanced disease (>pT2), complicated renal tumours as well as cytoreductive surgical situations. In small renal tumours, similar survival rates have been described for laparoscopic radical and partial nephrectomy. However, even experienced high volume laparoscopic centres report a high learning curve, increased complications and initial technical problems to achieve parenchymal haemostasis and renal ischaemia during nephron-sparing surgery. Surgical management of large (>T2) or complicated tumours is feasible, but long-term oncological outcome is not yet available.

CONCLUSION

Promising new developments such as natural orifice translumenal endoscopic surgery (NOTES) might add to our surgical armamentarium for minimally invasive surgery.

Cytoreductive nephron-sparing surgery does not appear to undermine disease-specific survival in patients with metastatic renal cell carcinoma

BACKGROUND

The role of nephron-sparing surgery (NSS) showed promise in patients with metastatic renal cell carcinoma (MRCC). The disease-specific survival of patients with MRCC was compared according to the type of surgery, NSS (N=45) versus radical nephrectomy (RN) (N=732), in unmatched and matched analyses.

METHODS

Kaplan-Meier, life tables, log-rank test, and univariate as well as multivariate Cox regression analyses addressed disease-specific survival of NSS versus RN patients. Subsequently, up to 4 RN cases were matched with each NSS case for TNM stage, Fuhrman grade, and histology. Then, disease-specific survival differences were tested with the log-rank statistic. Finally, the sample size necessary to achieve 80% power in survival analyses between the 2 groups (NSS vs RN) was calculated.

RESULTS

Of 45 NSS cases, 38 were matched with 99 of 732 RN cases. First, in multivariate unmatched analyses RN predisposes to 1.7-fold higher RCC-specific mortality rate; second, in matched analyses RN predisposes to 1.5-fold higher RCC-specific mortality rate; and third, both analyses failed to demonstrate statistically significant differences. Based on these findings it could be postulated that until further data become available, NSS does not appear to undermine RCC-specific survival in carefully selected patients with MRCC. The power analyses demonstrated that at least 146, 48, and 76 observations per arm are necessary at 1, 2, and 3 years, respectively, to confirm survival equivalence.

CONCLUSIONS

Although the data were limited in size and completeness, they may indicate that RCC-specific survival may not be undermined if NSS is performed in properly selected cases.