Impact of metastasectomy on prognosis in patients treated with targeted therapy for metastatic renal cell carcinoma

Pulmonary Metastasectomy in Renal Cell Carcinoma

Recent advances in immunotherapy and targeted therapy have resulted in survival rates as high as 90% at 1 year in metastatic renal cell carcinoma patients; however, sustained response and ultimate cure is rarely achieved with systemic therapy alone (complete response rates remain <5%), and progression of disease at distant sites is common. Pulmonary metastasectomy is recommended as a component of multimodal management in patients with favorable-risk or intermediate-risk classification and can be associated with excellent survival if complete resection is obtained.

Development and validation of a prediction model for the prognosis of renal cell carcinoma with liver metastases: a population-based cohort study

Background

Current studies on the establishment of prognostic model for renal cell carcinoma (RCC) with liver metastases (LM) were scarce. This study aimed to develop nomograms to predict the prognosis of RCC with LM.

Methods

Patients diagnosed with RCC between 2010 and 2021 from the Surveillance, Epidemiology, and End Results (SEER) database were selected. The eXtreme Gradient Boosting (XGBoost) and Random Forest (RF) machine learning algorithms were used to screen for the most influential factors affecting prognosis, and the Venn diagram method was employed for further refinement. Subsequently, a nomogram related to brain metastases was constructed. The performance of the nomograms was evaluated through receiver operating characteristics (ROC) curves, calibration plots, C-index, time-dependent C-index, and decision curve analysis (DCA). Kaplan-Meier (K-M) survival curves were used to provide additional verification of the clinical efficacy of the nomogram.

Results

This research comprised 2,395 RCC patients with LM. The Venn diagram demonstrated that age, histological type, grade, AJCC T stage, AJCC N stage, surgery, chemotherapy, marital status, and lung metastasis were highly relevant variables to patients with LM. The AUC, C-index, calibration curves, and DCA curves showed excellent performance of the nomogram. Additionally, the prognostic nomogram accurately classified RCC with LM patients into low- and high-risk groups for mortality.

Conclusion

This study developed a novel nomogram to predict the prognostic factors of RCC with LM, providing a valuable reference for making accurate clinical decisions.

A pooled analysis of pancreatic resection for metastatic renal cell carcinoma

BACKGROUND

Pancreatic metastasis from renal cell carcinoma (PMRCC) is unusual and there is no consensus on its treatment. The present study aims to evaluate the clinical outcomes of surgical resection for PMRCC.

METHODS

PubMed and Web of Science were searched for Eligible studies from January 1980 to January 2024. Individual-patient data were pooled.

RESULTS

A total of 436 participants were identified. The morbidity and 90-day mortality were 38.1% and 3.4%, respectively. Post-pancreatectomy recurrence occurred in 44.1% of the patients. The overall median survival was 116 months, with a 3-, 5- and 10-year survival rate of 85.3%, 76.6%, and 46.5% respectively. On univariate analysis, repeat metastasectomy was associated with a significantly better prognosis (P =0.003).

CONCLUSION

These data suggest that surgical resection is a safe and effective therapeutic option for PMRCC. Repeat metastasectomy is positively suggested for recurrent disease provided all metastases can be removed curatively.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42024525218.

The impact of metastasectomy on survival of patients with synchronous metastatic renal cell cancer in Finland: A nationwide study

BACKGROUND AND OBJECTIVE

Most of the studies on metastasectomy in renal cell cancer are based on metachronous, often oligometastatic disease. Prior data on the impact of metastasectomy in synchronous metastatic renal cell cancer (mRCC) is, however, very scarce. We aimed to investigate the role of complete and incomplete metastasectomy in a large, nationwide patient population.

METHODS

We analyzed nationwide data, including all synchronous mRCC cases in Finland diagnosed during a 6-year period identified from the Finnish Cancer Registry, and complemented with patient records from the treating hospitals. We only included the patients who underwent removal of the primary tumor by nephrectomy. We performed univariate and multivariable adjusted analysis to identify the effect of metastasectomy on overall survival (OS) and cancer-specific survival (CSS).

RESULTS

We included 483 patients with synchronous mRCC. Overall, 57 patients underwent complete and 96 incomplete metastasectomy, while 330 patients had no metastasectomy. The median OS was 17.9 and CSS 17.2 months for all patients. The median OS and the median CSS were 59.3 and 60.8 months for the complete, 21.9 and 25.1 for the incomplete, and 14.5 and 14.8 months for the no metastasectomy groups (p < 0.001 for differences). In both applied multivariable statistical models, the OS and CSS benefit from complete metastasectomy remained significant (hazard ratios (HRs) varied between 0.42 and 0.54, p < 0.001) compared with the no metastasectomy group. However, there was no improvement in survival estimates in the incomplete metastasectomy group compared with the no metastasectomy group (HRs varied between 1.04 and 1.10, p > 0.40).

CONCLUSIONS

Complete metastasectomy, when possible, can be considered as a treatment option for selected patients with synchronous mRCC who are fit for surgery. By contrast, we found no survival benefit from an incomplete metastasectomy suggesting that such procedures should not be performed for these patients.

Long-term outcomes after surgical resection of pancreatic metastases from renal Clear-cell carcinoma

BACKGROUND

Clear-cell renal cell carcinoma frequently metastasizes to the pancreas (PMRCC). The management of such metastases remains controversial due to their frequent multifocality and indolent evolution.

METHODS

This study describes the surgical management of these lesions and their long-term oncological outcomes. The study included patients who underwent pancreatic resection of PMRCC at Bordeaux University Hospital between June 2005 and March 2022. Morbidity and mortality were assessed at 90 days. Overall survival (OS) and disease-free (DFS) survival were assessed at 5 years.

RESULTS

Forty-two patients underwent pancreatic resection for PMRCC, including 18 (42.8 %) total pancreatectomies. The median time from nephrectomy to the diagnosis of PMRCC was 121 (range: 6-400) months. Lesions were multiple in 19/42 (45.2 %) patients. Ten (23.8 %) patients suffered a severe complication (Dindo-Clavien classification ≥ IIIA by D90), including one patient who died postoperatively. The median follow-up was 76 months. The R0 rate was 100 %. The OS and DFS rates were 92.8 % and 29.6 %, respectively, at 5 years.

CONCLUSION

Pancreatic resection for PMRCC provides long-term oncological control despite a high recurrence rate.

Surgical metastasectomy for metastatic renal cell carcinoma in the era of targeted and immune therapy: a narrative review

PURPOSE

Metastatic renal cell carcinoma (mRCC) still harbours a big propensity for future metastasis. Combinations of immune and targeted therapies are currently the cornerstone of management with a less clear role for surgical metastasectomy (SM).

METHODS

We performed a narrative review of literature searching for the available evidence on the yield of surgical metastasectomy in the era of targeted and immune therapies. The review consisted of a PubMed search of relevant articles using the Mesh terms:" renal cell carcinoma", "surgery», «resection", "metastasectomy", "molecular targeted therapies", "immune checkpoint inhibitors" alone or in combination.

RESULTS

In this review, we exposed the place of surgical metastasectomy within a multimodal treatment algorithm for mRCC Also, we detailed the patient selection criteria that yielded the best results when SM was performed. Finally, we discussed the feasibility and advantages of SM per organ site.

CONCLUSION

Our work was able to show that SM could be proposed as a consolidation treatment to excise residual lesions that were deemed unresectable prior to a combination of systemic therapies. Contrastingly, it can be proposed as an upfront treatment, leaving systemic therapies as an alternative in case of future relapse. However, patient selection regarding their performance status, metastatic sites, number of lesions and tumorous characteristics is of paramount importance.

Surgical treatment for pelvic bone metastatic disease from renal cell carcinoma

INTRODUCTION

Pelvic bone metastases from renal cell carcinoma (RCC) are challenging due to their destructive pattern, poor response to radiotherapy and hypervascularity. The purpose of our study was to review a series of patients undergoing surgical treatment with the aim to investigate: 1) survival; 2) local disease control; and 3) complications.

METHODS

A series of 16 patients was reviewed. A curettage procedure was performed on 12 patients. In eight the lesion involved the acetabulum; a cemented hip arthroplasty with cage was performed in seven; a flail hip in one. Four patients received a resection; in two cases with acetabular involvement, reconstruction was performed with a custom-made prosthesis and with an allograft and prosthesis.

RESULTS

Disease-specific survival accounted for 70% at 3 years and 41% at 5 years. Only one local tumor progression after curettage occurred. Revision surgery (flail hip) was necessary for deep infection of the custom-made prosthesis.

CONCLUSION

A prolonged survival in patients affected by bone metastatic disease from RCC can justify also major surgical procedures. Due to a low local progression rate after intralesional procedures, curettage, cement and a total hip arthroplasty with cage, when feasible, should be considered as an alternative to more demanding surgeries like resections and reconstructions.

LEVEL OF EVIDENCE (OXFORD)

Level 4.

Beyond the Knife in Renal Cell Carcinoma: A Systematic Review-To Ablate or Not to Ablate?

Intensified systemic therapy in metastatic renal cell carcinoma (mRCC) has led to improved patient outcomes. Patients commonly require local control of one or a few metastases. The aim was to evaluate metastasis-directed ablative therapies in extracranial mRCC. Two databases and one registry were searched, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, for all prospective and matched-pair case-control mRCC studies of radiofrequency ablation (RFA), cryotherapy, microwave ablation (MWA), and stereotactic body radiotherapy (SBRT). Eighteen studies were identified. Fourteen investigated SBRT in 424 patients. Four thermal ablation studies were identified: two cryotherapy (56 patients) and two RFA studies (90 patients). The median participant number was 30 (range 12-69). The combined median follow-up was 17.3 months (range 8-52). Four SBRT studies reported local control (LC) at 12 months, median 84.4% (range 82.5-93). Seven studies (six SBRT and one cryotherapy) reported an LC rate of median 87% (79-100%). Median overall survival (OS) was reported in eight studies (five SBRT, two cryotherapy, and one RFA) with a median of 22.7 months (range 6.7-not reached). Median progression-free survival was reported in seven studies (five SBRT, one cryotherapy, and one RFA); the median was 9.3 months (range 3.0-22.7 months). Grade ≥ 3 toxicity ranged from 1.7% to 10%. SBRT has excellent local control outcomes and acceptable toxicity. Only four eligible thermal ablative studies were identified and could not be compared with SBRT. Translationally rich definitive studies are warranted.

Surgical Approach in Metastatic Renal Cell Carcinoma: A Literature Review

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.

A clinical prediction model for predicting the risk of liver metastasis from renal cell carcinoma based on machine learning

BACKGROUND

Renal cell carcinoma (RCC) is a highly metastatic urological cancer. RCC with liver metastasis (LM) carries a dismal prognosis. The objective of this study is to develop a machine learning (ML) model that predicts the risk of RCC with LM, which is used to assist clinical treatment.

METHODS

The retrospective study data of 42,547 patients with RCC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. ML includes algorithmic methods and is a fast-rising field that has been widely used in the biomedical field. Logistic regression (LR), Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGB), random forest (RF), decision tree (DT), and naive Bayesian model [Naive Bayes Classifier (NBC)] were applied to develop prediction models to predict the risk of RCC with LM. The six models were 10-fold cross-validated, and the best-performing model was selected based on the area under the curve (AUC) value. A web online calculator was constructed based on the best ML model.

RESULTS

Bone metastasis, lung metastasis, grade, T stage, N stage, and tumor size were independent risk factors for the development of RCC with LM by multivariate regression analysis. In addition, the correlation of the relative proportions of the six clinical variables was shown by a heat map. In the prediction models of RCC with LM, the mean AUC of the XGB model among the six ML algorithms was 0.947. Based on the XGB model, the web calculator (https://share.streamlit.io/liuwencai4/renal_liver/main/renal_liver.py) was developed to evaluate the risk of RCC with LM.

CONCLUSIONS

This XGB model has the best predictive effect on RCC with LM. The web calculator constructed based on the XGB model has great potential for clinicians to make clinical decisions and improve the prognosis of RCC patients with LM.

Role of metastasectomy in the management of renal cell carcinoma

Treatment of metastatic renal cell carcinoma (mRCC) has evolved with the development of a variety of systemic agents; however, these therapies alone rarely lead to a complete response. Complete consolidative surgery with surgical metastasectomy has been associated with improved survival outcomes in well-selected patients in previous reports. No randomized control trial exists to determine the effectiveness of metastasectomy. Therefore, reviewing observational studies is important to best determine which patients are most appropriate for metastasectomy for mRCC and if such treatment continues to be effective with the development of new systemic therapies such as immunotherapy. In this narrative review, we discuss the indications for metastasectomies, outcomes, factors associated with improved survival, and special considerations such as location of metastasis, number of metastases, synchronous metastases, and use of systemic therapy. Additionally, alternative treatment options and trials involving metastasectomy will be reviewed.

Prognostic Significance of Pancreatic Metastases in Patients With Advanced Renal Cell Carcinoma Treated With Systemic Therapy

BACKGROUND

Pancreatic metastases (PM) are rare in renal cell carcinoma. It has been suggested that patients with metastases to the pancreas have a more favorable prognosis, but little is known about the long-term outcomes with systemic therapy. We sought to understand the outcomes of patients with metastatic renal cell carcinoma with PM treated with systemic therapy.

PATIENTS AND METHODS

We conducted a pooled analysis of 4736 patients with metastatic renal cell carcinoma treated on phase II/III clinical trials. Systemic therapies included anti-vascular endothelial growth factor targeted therapy, mammalian target of rapamycin-targeted therapy, and cytokine therapy.

RESULTS

The primary end point was overall survival (OS) in patients with versus without PM. Statistical analyses were performed using Kaplan-Meier analysis and Cox regression. Among 4736 patients, 235 (5.0%) were identified to have baseline PM at therapy initiation. The median OS in patients with PM was significantly prolonged with OS of 41.7 months versus 19.0 months (adjusted hazard ratio, 0.52; P < .0001). Similarly, progression-free survival was significantly prolonged in patients with PM (10.9 vs. 6.9 months; adjusted hazard ratio, 0.72; P = .004). The effect of PM on OS and progression-free survival was independent of other sites of metastasis or International mRCC Database Consortium risk group.

CONCLUSION

The presence of PM in RCC is an independent positive predictor for survival and improved response to systemic therapy. These findings suggest RCC with PM is associated with favorable outcomes and further work to understand the underlying disease biology of these patients is warranted.

Biologic Reconstruction With a Motorized Intramedullary Bone Transport Nail After Tumor Resection

Distraction osteogenesis is an option for reconstruction of intercalary defects. The use of bone transport after tumor surgery has been limited because of concerns of pin tract infections with external fixation and the theoretical risk of causing tumor growth. The effects of chemotherapy and radiation on the regenerate and healing of the docking site are also not well studied, but the current literature has mostly favorable outcomes with no evidence of causing tumor proliferation. The Precice bone transport nail offers a noninvasive method of distraction osteogenesis, which eliminates the need for prolonged external fixation and the risk of pin tract infections. This report discusses the technique for using the Precice bone transport nail after tumor resection. Bone transport may be considered for intercalary defects after en bloc resection of sarcoma, metastatic disease, and benign aggressive bone tumors. The use of distraction osteogenesis after tumor resection is a promising technique for the biologic reconstruction of intercalary defects.

Clinical outcomes and prognostic factors following the surgical resection of renal cell carcinoma spinal metastases

The efficacy of surgical resection in metastatic renal cell carcinoma is an active and important research field in the postcytokine era. Bone metastases, especially in the spine, compromise patient performance status. Metastasectomy is indicated, if feasible, because it helps to achieve the best clinical outcomes possible compared with other treatments. This study examined the postoperative survival and prognostic factors in patients who underwent metastasectomy of spinal lesions. The retrospective study included 65 consecutive patients with metastatic renal cell carcinomas who were operated on by spinal metastasectomy between 1995 and 2017 at our institution. The cancer‐specific survival times from the first spinal metastasectomy to death or the last follow‐up (≥3 years) were determined using Kaplan‐Meier analysis. Potential factors influencing survival were analyzed using Cox proportional hazard models. Planned surgical resection of all the spine tumors was achieved in all patients. Of these, 38 had complete metastasectomy of all visible metastases, including extraspinal lesions. In all patients, the estimated median cancer‐specific survival time was 100 months. The 3‐, 5‐, and 10‐year cancer‐specific survival rates were 77%, 62%, and 48%, respectively. The survival times after spinal metastasectomy were similar in both cytokine and postcytokine groups. In multivariate analyses, postoperative disability, the coexistence of liver metastases, multiple spinal metastases, and incomplete metastasectomy were significant risk factors associated with short‐term survival. Complete metastasectomy, including extraspinal metastases, was associated with improved cancer‐specific survival. Proper patient selection and complete metastasectomy provide a better prognosis in metastatic renal cell carcinoma patients.

The effect of metastasectomy on overall survival in metastatic renal cell carcinoma: A systematic review and meta-analysis

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.

Update on First-Line Combination Treatment Approaches in Metastatic Clear-Cell Renal Cell Carcinoma

OPINION STATEMENT

The treatment for metastatic renal cell carcinoma (mRCC) has significantly evolved in recent years with a deeper understanding of the molecular make-up of the disease and the clinical development of therapies with novel mechanisms of action. While some patients with more indolent disease may benefit from local therapy such as metastasectomy or cytoreductive nephrectomy, others may safely embark on an active surveillance program or be offered targeted therapy. Yet, a combination regimen including an ICI is the most effective regimen and should be considered in most mRCC cases. Ongoing studies will help determine which factors can be further used to optimize treatment selection and personalize disease management.

Stereotactic radiotherapy combined with immunotherapy or targeted therapy for metastatic renal cell carcinoma

OBJECTIVES

To evaluate the safety and efficacy of stereotactic radiotherapy (SRT) in patients with metastatic renal cell carcinoma (mRCC) concurrently receiving targeted therapy (TT) or immunotherapy.

PATIENTS AND METHODS

Data on patients with mRCC were extracted from a retrospective international multicentre register study (TOaSTT), investigating SRT concurrent (≤30 days) with TT/immune checkpoint inhibitor (ICI) therapy. Overall survival (OS), progression-free survival (PFS), local metastasis control (LC) and time to systemic therapy switch were analysed using Kaplan-Meier curves and log-rank testing. Clinical and treatment factors influencing survival were analysed using multivariate Cox regression. Acute and late SRT-induced toxicity were defined according to the Common Terminology Criteria for Adverse Events v.4.03.

RESULTS

Fifty-three patients who underwent 128 sessions of SRT were included, of whom 58% presented with oligometastatic disease (OMD). ICIs and TT were received by 32% and 68% of patients, respectively. Twenty patients (37%) paused TT for a median (range) of 14 (2-21) days. ICI therapy was not paused in any patient. A median (range) of 1 (1-5) metastatic tumour was treated per patient, with a median (range) SRT dose of 65 (40-129.4) Gy (biologically effective dose). The OS, LC and PFS rates at 1 year were 71%, 75% and 25%, respectively. The median OS and PFS were not significantly different among patients receiving TT vs those receiving ICIs (P = 0.329). New lesions were treated with a repeat radiotherapy course in 46% of patients. After 1 year, 62% of patients remained on the same systemic therapy as at the time of SRT; this was more frequent for ICI therapy compared to TT (83% vs 36%; P = 0.035). OMD was an independent prognostic factor for OS (P = 0.004, 95% confidence interval [CI] 0.035-0.528) and PFS (P = 0.004; 95% CI 0.165-0.717) in multivariate analysis. Eastern Cooperative Oncology Group performance status (ECOG-PS) was the other independent prognostic factor for OS (P = 0.001, 95% CI 0.001-0.351). Acute grade 3 toxicity was observed in two patients, and late grade 3 toxicity in one patient. No grade 4 or 5 toxicity was observed.

CONCLUSION

Combined treatment with TT or immunotherapy and concurrent SRT was safe, without signals of increased severe toxicity. As we observed no signal of excess toxicity, full-dose SRT should be considered to achieve optimal metastasis control in patients receiving TT or immunotherapy. Favourable PFS and OS were observed for patients with oligometastatic RCC with a good ECOG-PS, which should form the basis for prospective testing of this treatment strategy in properly designed clinical trials.

Prognostic impact of metastasectomy in renal cell carcinoma in the postcytokine therapy era

OBJECTIVES

To explore the real-world data regarding survival following metastasectomy (MS) for renal cell carcinoma (RCC) in the postcytokine therapy era.

PATIENTS AND METHODS

Patients diagnosed with metastatic renal cell carcinoma (mRCC) between January 2008 and December 2018 at our institutions were retrospectively evaluated. The patients were classified into three groups according to their MS status: (1) complete MS (cMS), (2) incomplete MS (icMS), and (3) without MS (nonMS). Factors for overall survival (OS) after diagnosis were analyzed.

RESULTS

Overall, 314 patients were evaluated. During the follow-up period (median: 25.3 months), a total of 98 patients (31.2%) underwent at least one MS. The cMS group (n = 45, 14.3%) had a significantly longer OS (median: not reached [N.R.]) than the icMS (n = 53, 16.9%) (81.5 months, P= 0.0042) and nonMS groups (28.1 months, P< 0.0001). The icMS group had a significantly longer OS than the nonMS group did (P= 0.0010). Multivariate analysis showed that the MS status was an independent factor for OS (cMS vs. nonMS: P= 0.0004; icMS vs. nonMS: P= 0.0176), together with histopathological type, International Metastatic Renal Cell Carcinoma Database Consortium risk, liver metastasis status, and prior nephrectomy status (all, P< 0.05). In addition, the OS was comparable throughout the eras of systemic therapy (early molecular-targeted therapy, late molecular-targeted therapy, and immune checkpoint inhibitor eras) in the MS group (median: 121.9 vs. N.R. vs. N.R. months, P= 0.948).

CONCLUSIONS

MS, especially cMS improved survival in selected patients with mRCC in the postcytokine therapy era. In addition, MS still plays a significant role in the current systemic therapy.

Outcomes of complete metastasectomy in metastatic renal cell carcinoma patients: The Canadian Kidney Cancer information system experience

BACKGROUND

Surgical resection of metastasis can be integrated in the management of metastatic renal cell carcinoma (mRCC) as it can contribute to delay disease progression and improve survival.

OBJECTIVE

This study assessed the impact of complete metastasectomy in mRCC patients using real-world pan-Canadian data.

DESIGN, SETTING AND PARTICIPANTS

The Canadian Kidney Cancer information system (CKCis) database was used to select patients who were diagnosed with mRCC between January 2011 and April 2019. To minimize selection bias, each patient having received a complete metastasectomy was matched with up to 4 patients not treated with metastasectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Overall survival (OS) was calculated from the date of metastasectomy or selection, to death from any cause. A Cox proportional hazards model was used to assess the impact of the metastasectomy while adjusting for potential confounding variables.

RESULTS

A total of 229 patients undergoing complete metastasectomy were matched with 803 patients not treated with metastasectomy. After matching, baseline characteristics were well balanced between groups. After 12 months, the proportion of patients that were still alive was 96.0% and 89.8% in the complete metastasectomy and its matched group, respectively; the 5-year OS were 63.2% and 51.4%, respectively. Multivariate analysis performed in the matched cohort revealed that patients who underwent complete metastasectomy had a lower risk of mortality compared to patients who did not undergo metastasectomy (hazard ratio: 0.41, 95% confidence interval:0.27-0.63).

CONCLUSION

Our study found that patients who underwent complete metastasectomy have a longer overall survival and a longer time to initiation of targeted therapy compared to patients not receiving metastasectomy. These findings should support aggressive resection of metastasis in selected patients.

Exploration of IMDC model in patients with metastatic renal cell carcinoma using targeted agents: a meta-analysis

Purpose:

To explore the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model application for predicting outcome of patients with metastatic renal cell carcinoma using targeted agents.

Materials and Methods:

We performed a literature review of 989 articles. The selecting process used preferred reporting items for systematic reviews and meta-analyses (PRISMA). All included studies were assessed by Newcastle-Ottawa scale. Results of individual studies were pooled using Stata 14.0 software.

Results:

A total of 17 articles were included. Most articles provided univariate and multivariate analysis of IMDC model prognosis. Combined HRs were 1.58 (95% CI 1.34-1.82) and 3.74 (95% CI 2.67-4.81) for univariate PFS of intermediate to favorable and poor to favorable respectively. In the category of multivariate PFS, combined HRs were 1.27 (95% CI 0.99-1.56) and 2.29 (95% CI 1.65-2.93) with intermediate to favorable and poor to favorable respectively. Regarding univariate OS, combined HRs were 1.93 (95% CI 1.62-2.24) and 6.25 (95% CI 4.18-8.31) with intermediate to favorable and poor to favorable respectively. With multivariate OS, combined HRs were 1.32 (95%CI 1.04-1.59) and 2.35 (95%CI 1.69-3.01) with intermediate to favorable and poor to favorable respectively.

Conclusion:

In summary, analysis of currently available clinical evidence indicated that IMDC model could be applied to classify patients with metastatic renal cell carcinoma using targeted agents. However, different types of targeted agents and various areas could affect the accuracy of the model. There was also a difference in predicting patients' PFS and OS.

Extended hepatic metastasectomy for renal cell carcinoma-new aspects in times of targeted therapy: a single-center experience over three decades

Purpose

Despite the introduction of novel targeted therapies on patients with renal cell carcinoma, syn- and metachronous metastases (including hepatic lesions) are observed frequently and significantly influence patient survival. With introduction of targeted therapies as an effective alternative to surgery, therapeutical strategies in stage IV disease must be reevaluated.

Methods

This is a retrospective analysis of 40 patients undergoing hepatic resection of histologically confirmed RCC metastases at our institution between April 1993 and April 2017.

Results

The interval between nephrectomy for renal cell carcinoma and hepatic metastasectomy was 44.0 months (3.3–278.5). Liver resections of different extents were performed, including multivisceral resections. The median follow-up was 37.8 months (0.5–286.5). Tumor recurrence after resection of hepatic metastases occurred in 19 patients resulting in a median disease-free survival of 16.2 months (0.7–265.1) and a median overall survival of 37.8 months (0.5–286.5). Multivariable analysis identified multivisceral resection as an independent risk factor for disease-free and overall survival (p = 0.043 and p = 0.001, respectively). A longer interval between nephrectomy and hepatic metastasectomy was identified as an independent significant protective factor for overall survival (p < 0.001). Patients undergoing metastasectomy after introduction of sunitinib in Europe in 2006 (n = 15) showed a significantly longer overall survival (45.2 (9.1–111.0) versus 27.5 (0.5–286.52) months in the preceding era; p = 0.038).

Conclusion

Hepatic metastasectomy, including major and extended resections, on patients with metastasized renal cell carcinoma can be performed safely and may facilitate long-term survival. Due to significant morbidity and increased mortality, multivisceral resections must be weighed against other options, such as targeted therapy.

Electronic supplementary material

The online version of this article (10.1007/s00423-019-01852-4) contains supplementary material, which is available to authorized users.

A Retrospective Analysis of the Impact of Metastasectomy on Prognostic Survival According to Metastatic Organs in Patients With Metastatic Renal Cell Carcinoma

This study evaluated the effects of metastasectomy on overall survival (OS) and progression-free survival (PFS) in metastatic renal cell carcinoma (mRCC) according to metastatic organs. The medical records (2005–2017) of 273 patients with mRCC were analyzed retrospectively to evaluate OS and PFS according to metastatic organs and their metastasectomy states. The Cox proportional hazard model was used to determine the prognostic significance of metastasectomy. The Kaplan-Meier curve and log-rank test were used to compare groups with different modalities and metastatic organs at a statistical significance of p < 0.05. The overall median age was 57 years; 175 (64.3%) and 83 (30.4%) patients received cytoreductive nephrectomy and metastasectomy, respectively. The metastasectomy group was significantly younger and had a lower clinical T stage with significantly better PFS/OS (20.2/32.0 vs. 9.7/12.8 months) than that in the non-metastasectomy group (N = 190, p < 0.05). Liver with lung metastases were the worst metastatic combination for survivals in which liver metastasis was the only significant unfavorable risk factor for both PFS (HR 1.67) and OS (HR 1.74) (p < 0.05). Multivariable analysis confirmed that metastasectomy was a significant favorable risk factor for PFS (HR 0.70) and OS (HR 0.56) (p < 0.05) along with non-clear cell type (HR 0.61 for PFS), whereas the nuclear grade and poor Heng risk group were unfavorable risk factors (HR > 2.0) for both PFS and OS (p < 0.05). Metastasectomy and the affected metastatic organs significantly influenced prognostic survival in mRCC.

Traitement focal et traitement systémique dans la prise en charge du cancer du rein métastatique : une question de complémentarité

FOCAL TREATMENT AND SYSTEMIC THERAPY IN METASTATIC KIDNEY CANCER

COMPLEMENTARY APPROACHES: To treat metastatic renal cell carcinoma, therapies used are with an oral intake, for the vast majority, and have many side effects that may compromise observance. Strategies of drug holiday have been studied and, in case of an indolent and oligometastatic tumor, studies have shown that active surveillance is possible to delay the introduction of systemic treatment, without compromising the patient survival. A multimodal approach combining systemic and focal treatments can be done with several objectives: to delay even more introduction of systemic treatment by focally treating metastases, to allow drug holiday after partial response to medical treatment by local control of persistent metastases, and to permit drug continuation even in case of dissociated response to systemic therapy, by focal treatment of metastasis(es) in progression. Technics that can be used for focal treatment are metastasectomy, radiofrequency ablation or cryotherapy, and stereotactic radiotherapy. In literature, studies that evaluated this approach are for almost retrospective studies, but they have reported interesting results in terms of local control and low morbidity. In the era of checkpoint's inhibitors, it seems important to make prospective collections of data to validate these practices. In any case, and because international recommendations about multimodal approach are poor, discussions between the different actors of the patient care are essential to find the most beneficial treatment for him.

[Is surgical treatment ever indicated in metastatic renal cell carcinoma and if so, based on which scientific rationale?]

BACKGROUND

Metastasis is a common event in renal cell carcinoma. Surgical resection of metastases may be feasible in two scenarios: aiming at palliation, which may be feasible due to reduced radiosensitivity of renal cell cancer, and aiming at prolonging survival, which may be feasible given the rather good prognosis of some patterns of metastasis.

OBJECTIVE

This review intends to reflect on current evidence for surgical resection of metastases in both scenarios. The literature was searched in PubMed and respective guidelines were reviewed.

RESULTS AND CONCLUSIONS

Palliative resection is mainly feasible to control symptoms like spinal compression; adjuvant radiation is advisable. Resection is markedly feasible, however, for improvement of cancer-specific survival in probably all resectable patterns of metastasis-solitary, multiple, syn- and metachronous, and in all organs-provided complete resection can be achieved. A fairly good prognosis is seen in solitary pulmonary metastasis without concomitant hilar or mediastinal lymph node metastasis and a metachronous appearance following long recurrence-free survival after tumor nephrectomy; complete resection may be considered curative in certain cases. Neo- or adjuvant medical therapy or radiation is not established. In cases lacking complete resectability, stereotactic radiation may be considered as an alternative.