Improved survival in patients with metastatic renal cell carcinoma undergoing cytoreductive nephrectomy in the era of targeted therapy

Cytoreductive nephrectomy for synchronous metastatic renal cell carcinoma. Is there enough evidence?

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.

Cytoreductive Nephrectomy Promoted Abscopal Effect of Camrelizumab Combined With Radiotherapy for Metastatic Renal Cell Carcinoma: A Case Report and Review of the Literature

There is little evidence around Camrelizumab combined with cytoreductive nephrectomy (CN) and radiotherapy (RT) as a treatment option for metastatic renal cell carcinoma (mRCC). The influence of CN on immune responses and the abscopal effect are not well understood. In this paper, we report a case of anti-programmed cell death-1 (PD-1) treated with combined RT once CN reduced the primary tumor burden (TB). This patient also encountered an increased response to targeted radiotherapy after immune resistance. We also observed a macrophage-to-lymphocyte ratio (MLR) peak, which may be correlated with subsequent pseudoprogression after thoracic radiotherapy. Consequently, even with the disease, this patient has remained stable. This peculiar instance suggests there is a need to investigate the underlying mechanisms of CN in promoting the abscopal effect during immunotherapy when combined with RT. It also suggests that there is a need for further investigation into the role of RT in overcoming immune resistance, and the value of MLR in predicting pseudoprogression. We hypothesize that a heavy tumor burden might suppress the abscopal effect, thereby ensuring that CN promotes it. However, radiotherapy may overcome immune resistance during oligoprogression.

Role of intraoperative ultrasound in robotic-assisted radical nephrectomy with inferior vena cava thrombectomy in renal cell carcinoma

PURPOSE

To determine the impact of intraoperative ultrasound on robotic-assisted radical nephrectomy with inferior vena cava (IVC) tumor thrombectomy in renal cell carcinoma (RCC).

METHODS

We retrospectively analyzed intraoperative records of 27 patients with RCC and invasion of the IVC who underwent robotic-assisted nephrectomy with tumor thrombectomy at our center between December 2017 and July 2018. Diagnostic utility and impact of intraoperative transesophageal echocardiography (TEE), intraoperative robotic-assisted ultrasonography, and intraoperative contrast-enhanced ultrasound (CEUS) on surgical management were extracted from the surgical notes and intraoperative ultrasound reports.

RESULTS

Twenty-seven patients with thrombus had intraoperative ultrasound. Complete tumor removal was achieved in 22 patients, IVC transection in 5 patients, and no residual tumor was observed in all patients. Intraoperative TEE changed the robotic surgical strategy in three patients by monitoring thrombus-level regression. Downstaging of the thrombus level occurred in three patients: Levels IV to III in one and Levels III to II in two. Intraoperative robotic-assisted ultrasonography has facilitated safe VC clamp placement and identification and protection of collateral vessels during IVC transection in five patients. Intraoperative CEUS helped to differentiate the boundary between tumor thrombus (enhancement and small vessel pulsation) and bland thrombus (hypoechoic or no enhancement) in eight (29.6%) patients with bland thrombus.

CONCLUSIONS

Intraoperative ultrasound is a safe, minimally invasive technique that can provide accurate real-time information regarding the presence and extent of IVC involvement and guidance for placement of a vena cava clamp, confirming the character of the thrombus to plan an optimal surgical approach.

The Role of Cytoreductive Nephrectomy for Sarcomatoid Renal Cell Carcinoma: A 29-Year Institutional Experience

OBJECTIVE

To assess which patients respond best following cytoreductive nephrectomy for renal cell carcinoma (RCC) with sarcomatoid dedifferentiation (sRCC) and whether outcomes are improving over time.

METHODS

We identified 562 patients with metastatic RCC treated between 1989 and 2018 with cytoreductive nephrectomy. We reviewed baseline clinical and pathologic characteristics, including the presence of sRCC, and metastatic sites at time of nephrectomy. The primary study endpoint was overall survival (OS). Univariate and multivariate Cox-regression analyses were used to identify significant predictors of OS.

RESULTS

The study cohort had 192 sRCC patients, with a median age of 59 years. Frequently involved metastatic locations were lung (n = 115), retroperitoneal nodes (n = 63), and axial skeleton (n = 43). Lung metastasis were more prevalent in clear cell histology (P = .0017) whereas nodal involvement was associated with nonclear cell subtypes (P = .0064). Median follow-up was 14 months. Estimated 2- and 5-year OS were 34.1% and 14.8%, respectively. On multivariate analysis, metastases to the liver (HR = 1.64; 95% CI 1.02-2.63; P = .04), lung (HR = 1.50; 95% CI 1.05-2.14; P = .03), retroperitoneal nodes (HR = 1.52; 95% CI 1.03-2.25; P = 0.04) and nonclear cell histology (HR = 1.61; 95% CI 1.10-2.35; P = .01) were associated with worse OS in the sRCC cohort.

CONCLUSION

OS after cytoreductive nephrectomy for sRCC and non-sRCC is improving over time. In patients with sRCC, presentations with unifocal metastasis not involving the liver or lung, clear cell histology and node negative disease have better outcomes following cytoreductive nephrectomy and may yield greater benefit from the procedure.

Surgical intervention in renal cell carcinoma patients with lung and bronchus metastasis is associated with longer survival time: a population-based analysis

Background

As the most common metastasis site in renal cell carcinoma (RCC) patients, lung and bronchus metastasis (LBM) represents a late stage and a poor prognosis. The purpose of our study is to determine the impact of surgical intervention on prognosis of RCC patients with LBM by means of analysis the data from the Surveillance, Epidemiology and End Results (SEER) database.

Methods

The population data of RCC patients with LBM was extracted from the SEER database [1973-2015]. For each patient, age, gender, race, region, tumor histology, cause of death to site record, tumor grade, surgical intervention, and overall survival time were extracted from SEER database. Baseline characteristics were compared using the χ² test for the categorical variables. The survival analysis was estimated using the Kaplan-Meier (K-M) method and univariate comparison were performed using the log-rank test and unadjusted Cox proportional hazards regression models. Multivariate Cox proportional hazards regression survival models were adjusted. A second multivariate Cox proportional hazards regression survival model was created using the dataset after propensity score-matching approach (PSM).

Results

A total of 1,190 RCC patients with LBM were included, of whom 1,087 patients underwent surgery and 103 patients unperformed surgery. The median survival time was 56 months (95% CI, 54 to 59) for the surgery group, and 6 months (95% CI, 5 to 7) for non-surgery group. LBM patients underwent surgery had significantly longer survival time (log-rank test, P<0.001). In univariate analysis, the survival of RCC patients was significantly associated with surgery (P<0.001), grade II (P=0.014), grade III (P=0.001) and grade IV (P<0.001). Moreover, multivariate analysis indicated that surgery (P<0.001), grade II (P=0.018), grade III (P<0.001) and grade IV (P<0.001) were independent prognostic indexes for overall survival. Besides, in the subgroup of 1 years survival after diagnosis, longer survival times were seen in the surgery arms rather than non-surgery arms (P<0.001). In addition, longer survival times were observed in surgery arms in the subgroups of grade I, II, III and IV (all P<0.001).

Conclusions

RCC patients with LBM who have surgical intervention might obtain a significantly longer survival time than non-surgical options. In consequence, surgery should be the preferred choice for eligible patients.

The difficulty in selecting patients for cytoreductive nephrectomy: An evaluation of previously described predictive models

PURPOSE

To externally evaluate a preoperative points system and a preoperative nomogram, both created to assess time to death after cytoreductive nephrectomy (CN).

MATERIALS AND METHODS

We identified 298 patients who underwent CN at our institution, a tertiary cancer center, between 1989 and 2015. To validate the points system, we compared reported overall survival (OS) for each criterion to observed OS in our cohort. To evaluate the nomogram, we prognosticated risk of death at 6 months after surgery for 280 patients with sufficient follow-up in our cohort and evaluated discrimination using area under the curve (AUC) and calibration. Decision curve analysis was performed to assess clinical utility of the nomogram.

RESULTS

Significant differences in OS were observed between patients with and without 5 of 7 criteria on univariate analysis: low albumin (P<0.0001), high lactate dehydrogenase (P = 0.002), liver metastasis (P = 0.004), retroperitoneal lymphadenopathy (P = 0.002), and supradiaphragmatic lymphadenopathy (P = 0.019). Discrimination from the preoperative model, predicting death within 6 months of surgery was lower in our cohort (AUC = 0.65, 95% CI: 0.52-0.79) than the original publication (AUC = 0.76). Decision curve analysis demonstrated little benefit for applicability.

CONCLUSIONS

Five previously defined risk factors are predictive of decreased OS after CN in our cohort. We found lower discrimination using the preoperative model and minimal clinical utility according to decision analysis in our study cohort. These findings suggest the need for improved models to aid patient stratification and consequent treatment choice.

Postoperative Changes in Skeletal Muscle Mass Predict Survival of Patients With Metastatic Renal Cell Carcinoma Undergoing Cytoreductive Nephrectomy

BACKGROUND

Sarcopenia, or the degenerative loss of skeletal muscle mass, develops as a consequence of cancer-host interactions, including systemic inflammation and poor nutritional status, and is associated with a poor prognosis in patients with metastatic renal cell carcinoma (mRCC). We explored whether postoperative changes in skeletal muscle mass after cytoreductive nephrectomy (CN) can predict the prognosis of patients with mRCC.

PATIENTS AND METHODS

The present retrospective study included 37 mRCC patients undergoing CN at a single cancer center. The skeletal muscle index (SMI) was calculated by measuring the skeletal muscle areas at the third lumbar vertebra level on computed tomography images taken ≤ 1 month before and 5 to 6 months after CN. The percentage of change in the SMI (ΔSMI) was calculated as [(postoperative SMI - preoperative SMI)/preoperative SMI] × 100, and the association with overall survival (OS) was analyzed.

RESULTS

During the follow-up period (median, 61 months for survivors), 16 patients (43%) died for a 3-year OS rate of 63%. The ΔSMI was significantly associated with OS (hazard ratio, 0.92; P < .001). When the patients were categorized into 3 groups according to the ΔSMI (decreased, 12 patients with ΔSMI ≤ -5; stabilized, 15 patients with ΔSMI < 5; and increased, 10 patients with ΔSMI ≥ 5), the OS curves were distinctly separate, with a 3-year OS rate of 19%, 76%, and 100%, respectively (P < .001).

CONCLUSION

Postoperative changes in the SMI after CN predict OS for patients with mRCC. SMI kinetics is a novel biomarker that can serve as a useful surrogate for the prognosis of patients with mRCC undergoing CN.

The role of cytoreductive surgery in the era of targeted agents

PURPOSE OF REVIEW

Two randomized trials were initiated to define the role and sequence of cytoreductive nephrectomy in combination with VEGF-targeted therapy for metastatic renal cell cancer. While these trials will not report before the end of 2016, recent retrospective population-based studies published real-world data on incidence, treatment, prognosis and outcome that may help to better define the role of cytoreductive nephrectomy for this heterogeneous patient population in the targeted therapy era.

RECENT FINDINGS

Since the introduction of targeted agents, utilization of cytoreductive nephrectomy has declined. Potentially more patients are being treated with their primary tumours in place. Some countries also observed an additional decline in the incidence of primary metastatic disease. Although large population-based studies consistently demonstrate a survival benefit after cytoreductive nephrectomy, confounding factors preclude definite conclusions. However, patients with a life expectancy of less than 1 year or at least four IMDS risk factors may not benefit from cytoreductive nephrectomy.

SUMMARY

Recent retrospective data suggest a more refined use of cytoreductive nephrectomy in the targeted therapy era. With the exception of patients in whom cytoreductive nephrectomy and resection of solitary or oligometastasis may result in cure or delay of systemic therapy, performance, prognostic models and life expectancy estimates help to define the role of cytoreductive nephrectomy in the individual patient.

Prognostic Role of C-Reactive Protein In Urological Cancers: A Meta-Analysis

Growing evidence suggests serum C-reactive protein (CRP) can serve as a prognostic marker in urological cancers. However, some studies yield contradictory results. Our objective was to determine the relationship between baseline serum CRP and survival outcome in urological cancers. We searched PubMed and EMBASE databases until October 2014 without language restrictions. 44 independent studies investigating the association between baseline serum CRP and cancer-specific survival (CSS) or overall survival (OS) were selected. High CRP yielded a worse survival in renal cell carcinoma, prostate cancer, bladder cancer, and upper urinary tract urothelial carcinoma. Combined results of meta-analyses indicated that CRP was a prognostic factor in urological cancers (CSS: p < 0.01; OS: p < 0.01). Subgroup analyses confirmed the significant association between CRP and prognosis, regardless of race and cutoff value of CRP. Specifically, prognostic impact of CRP was also noted in patients with localized RCC treated with nephrectomy (CSS: p < 0.01) and metastatic RCC treated with molecular-targeted therapy (OS: p < 0.01). In conclusion, serum CRP is an independent prognostic factor in urological cancers and risk stratification by serum CRP level could be helpful for prognostic assessment.

Combination with third-generation bisphosphonate (YM529) and interferon-alpha can inhibit the progression of established bone renal cell carcinoma

The aim of this study was to investigate whether the third-generation nitrogen-containing bisphosphonate (YM529) can inhibit the progression of established bone renal cell carcinoma (RCC) and to elucidate its mechanism. Antiproliferative effect and apoptosis induction of RCC cells and mouse osteoclasts by YM529 and/or interferon-alpha (IFN-α) were evaluated in vitro using cell counting and in vivo using soft X-ray, the TUNEL method and tartrate-resistant acid phosphatase stain. For the in vivo study, male athymic BALB/cA Jc1-nu nude mice bearing human RCC cell line RBM1-IT4 cells were treated with YM529 and/or IFN-α. The biological activity of osteoclasts was evaluated using the pit formation assay. The antiangiogenetic effect by YM529 and/or IFN-α was analyzed using micro-vessel density and in situ mRNA hybridization. Osteoclast number in bone tumors was decreased in YM529-treated mouse. YM529 also inhibited osteoclast activity and proliferation in vitro, whereas basic fibroblast growth factor expressions and micro-vessel density within tumors were inhibited by IFN-α. Neither YM529 nor IFN-α alone significantly inhibited the growth of established bone metastatic tumors. Combined treatment with YM529 and IFN-α may be beneficial in patients with human RCC bone metastasis. Their effects are mediated by osteoclast recruitment inhibition and inactivation by YM529 and antiangiogenesis by IFN-α.

The necessity of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma using antiangiogenic targeted therapy after interferon alfa-2b

BACKGROUND

Targeted therapy has improved the survival of patients with metastatic RCC. In the present study, we evaluated whether there was an effect of cytoreductive surgery on prognosis of patients with metastatic RCC using antiangiogenic tyrosine kinase inhibitor (TKI) agents.

PATIENTS AND METHODS

A total of 52 patients with metastatic RCC from Akdeniz University, Afyon Kocatepe University, and Medipol University participated in the study. All the patients had received targeted antiangiogenic therapy after interferon alfa-2b. According to previous CRN, the patients were divided into 2 groups as CRN (+) and CRN (-).

RESULTS

The CRN (+) group was younger than the CRN (-) group (P < .001) and the hemoglobin levels were significantly higher in the CRN (+) group (P = .023). The median progression-free survival time from the date of starting TKIs were 8.5 and 3.0 months for the CRN (+) and CRN (-) groups, respectively (P = .104). The median overall survival was 15.1 and 5.4 months for the CRN (+) and CRN (-) groups, respectively (P = .034).

CONCLUSION

We speculate that CRN is still an important part of treatment modalities in patients with metastatic RCC in modern era targeted therapy, which is currently the best systemic therapy. However, the indications of CRN might be limited to good-risk patients with metastatic RCC. Further randomized studies are warranted to clarify the necessity of CRN in patients with metastatic RCC.