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Dahm P, Ergun O, Uhlig A, Bellut L, Risk MC, Lyon JA, Kunath F. Cytoreductive nephrectomy in metastatic renal cell carcinoma. Cochrane Database Syst Rev 2024; 6:CD013773. [PMID: 38847285 PMCID: PMC11157663 DOI: 10.1002/14651858.cd013773.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
BACKGROUND Nephrectomy is the surgical removal of all or part of a kidney. When the aim of nephrectomy is to reduce tumor burden in people with established metastatic disease, the procedure is called cytoreductive nephrectomy (CN). CN is typically combined with systemic anticancer therapy (SACT). SACT can be initiated before or immediately after the operation or deferred until radiological signs of disease progression. The benefits and harms of CN are controversial. OBJECTIVES To assess the effects of cytoreductive nephrectomy combined with systemic anticancer therapy versus systemic anticancer therapy alone or watchful waiting in newly diagnosed metastatic renal cell carcinoma. SEARCH METHODS We performed a comprehensive search in the Cochrane Library, MEDLINE, Embase, Scopus, two trial registries, and other gray literature sources up to 1 March 2024. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated SACT and CN versus SACT alone or watchful waiting. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. Primary outcomes were time to death from any cause and quality of life. Secondary outcomes were time to disease progression, treatment response, treatment-related mortality, discontinuation due to adverse events, and serious adverse events. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS Our search identified 10 records of four unique RCTs that informed two comparisons. In this abstract, we focus on the results for the two primary outcomes. Cytoreductive nephrectomy plus systemic anticancer therapy versus systemic anticancer therapy alone Three RCTs informed this comparison. Due to the considerable heterogeneity when pooling across these studies, we decided to present the results of the prespecified subgroup analysis by type of systemic agent. Cytoreductive nephrectomy plus interferon immunotherapy versus interferon immunotherapy alone CN plus interferon immunotherapy compared with interferon immunotherapy alone probably increases time to death from any cause (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.51 to 0.89; I²= 0%; 2 studies, 326 participants; moderate-certainty evidence). Assuming 820 all-cause deaths at two years' follow-up per 1000 people who receive interferon immunotherapy alone, the effect estimate corresponds to 132 fewer all-cause deaths (237 fewer to 37 fewer) per 1000 people who receive CN plus interferon immunotherapy. We found no evidence to assess quality of life. Cytoreductive nephrectomy plus tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone We are very uncertain about the effect of CN plus tyrosine kinase inhibitor (TKI) therapy compared with TKI therapy alone on time to death from any cause (HR 1.11, 95% CI 0.90 to 1.37; 1 study, 450 participants; very low-certainty evidence). Assuming 574 all-cause deaths at two years' follow-up per 1000 people who receive TKI therapy alone, the effect estimate corresponds to 38 more all-cause deaths (38 fewer to 115 more) per 1000 people who receive CN plus TKI therapy. We found no evidence to assess quality of life. Immediate cytoreductive nephrectomy versus deferred cytoreductive nephrectomy One study evaluated CN followed by TKI therapy (immediate CN) versus three cycles of TKI therapy followed by CN (deferred CN). Immediate CN compared with deferred CN may decrease time to death from any cause (HR 1.63, 95% CI 1.05 to 2.53; 1 study, 99 participants; low-certainty evidence). Assuming 620 all-cause deaths at two years' follow-up per 1000 people who receive deferred CN, the effect estimate corresponds to 173 more all-cause deaths (18 more to 294 more) per 1000 people who receive immediate CN. We found no evidence to assess quality of life. AUTHORS' CONCLUSIONS CN plus SACT in the form of interferon immunotherapy versus SACT in the form of interferon immunotherapy alone probably increases time to death from any cause. However, we are very uncertain about the effect of CN plus SACT in the form of TKI therapy versus SACT in the form of TKI therapy alone on time to death from any cause. Immediate CN versus deferred CN may decrease time to death from any cause. We found no quality of life data for any of these three comparisons. We also found no evidence to inform any other comparisons, in particular those involving newer immunotherapy agents (programmed death receptor 1 [PD-1]/programmed death ligand 1 [PD-L1] immune checkpoint inhibitors), which have become the backbone of SACT for metastatic renal cell carcinoma. There is an urgent need for RCTs that explore the role of CN in the context of contemporary forms of systemic immunotherapy.
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Affiliation(s)
- Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Onuralp Ergun
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Annemarie Uhlig
- Department of Urology, University Medical Center, Goettingen, Germany
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - Laura Bellut
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael C Risk
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Jennifer A Lyon
- Library Services, Children's Mercy Hospital, Kansas City, Missouri, USA
- Center for Evidence-Based Policy, Portland, Oregon, USA
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Medizinische Fakultät am Medizincampus Oberfranken, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Urology and Pediatric Urology, Klinikum Bayreuth GmbH, Bayreuth, Germany
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Esagian SM, Ziogas IA, Kosmidis D, Hossain MD, Tannir NM, Msaouel P. Long-Term Survival Outcomes of Cytoreductive Nephrectomy Combined with Targeted Therapy for Metastatic Renal Cell Carcinoma: A Systematic Review and Individual Patient Data Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040695. [PMID: 33572149 PMCID: PMC7915816 DOI: 10.3390/cancers13040695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Cytoreductive nephrectomy (CN) refers to the removal of the primary renal tumor in the setting of metastatic renal cell carcinoma. In the past, the combination of CN with cytokine-based immunotherapy was considered the standard of care. However, CN’s role during the targeted treatment era remains controversial. We attempted to address this issue by performing a systematic review and meta-analysis of the literature. We synthesized data from 15 studies comparing CN and targeted therapy to targeted therapy alone. Our results show that CN combined with targeted therapy was associated with increased survival compared to targeted therapy only. Careful patient selection is required to take full advantage of any survival benefit that CN may offer. Future research endeavors should focus on developing appropriate prognostic models to guide appropriate patient selection for CN. Abstract The role of cytoreductive nephrectomy (CN) in the treatment of metastatic renal cell carcinoma (mRCC) remains controversial during the targeted therapy era. To reconcile the current literature, we analyzed the reported survival data at the individual patient level and compared the long-term survival outcomes of CN combined with targeted therapy vs. targeted therapy alone in patients with mRCC. We performed a systematic review of the literature using the MEDLINE, Scopus, and Cochrane Library databases (end-of-search date: 21 July 2020). We recuperated individual patient data from the Kaplan–Meier curves for overall (OS), progression-free (PFS), and cancer-specific survival (CSS) from each study. We subsequently performed one-stage frequentist and Bayesian random-effects meta-analyses using both Cox proportional hazards and restricted mean survival time (RMST) models. Two-stage random-effects meta-analyses were also performed as sensitivity analyses. A subgroup analysis was also performed to determine the effect of CN timing. Fifteen studies fulfilling our inclusion criteria were identified, including fourteen retrospective cohort studies and one randomized controlled trial. In the one-stage frequentist meta-analysis, the CN group had superior OS (hazard ratio [HR]: 0.58, 95% confidence interval [CI]: 0.54–0.62, p < 0.0001) and CSS (HR: 0.63, 95% CI: 0.53–0.75, p < 0.0001). No meaningful clinical difference was observed in PFS (HR: 0.90, 95% CI: 0.80–1.02, p = 0.09). One-stage Bayesian meta-analysis also revealed superior OS (HR: 0.59, 95% credibility interval [CrI]: 0.55–0.63) and CSS (HR: 0.63, 95% CrI: 0.53–0.75) in the CN group, while no meaningful clinical difference was detected in PFS (HR: 0.91, 95% CrI: 0.80–1.02). Similar results were obtained with the RMST models. The OS benefit was also noted in the two-stage meta-analyses models, and in the subgroup of patients who received upfront CN. The combination of CN and targeted therapy for mRCC may lead to superior long-term survival outcomes compared to targeted therapy alone. Careful patient selection based on prognostic factors is required to optimize outcomes.
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Affiliation(s)
- Stepan M. Esagian
- Oncology Working Group, Society of Junior Doctors, 151 23 Athens, Greece; (S.M.E.); (D.K.)
| | - Ioannis A. Ziogas
- Surgery Working Group, Society of Junior Doctors, 151 23 Athens, Greece;
| | - Dimitrios Kosmidis
- Oncology Working Group, Society of Junior Doctors, 151 23 Athens, Greece; (S.M.E.); (D.K.)
- Department of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Mohammad D. Hossain
- Faculty of Medicine, Jalalabad Ragib-Rabeya Medical College, Sylhet 3100, Bangladesh;
| | - Nizar M. Tannir
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence:
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Song XD, Tian YN, Li H, Liu B, Zhang AL, Hong Y. Research progress on advanced renal cell carcinoma. J Int Med Res 2020; 48:300060520924265. [PMID: 32529862 PMCID: PMC7294379 DOI: 10.1177/0300060520924265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/15/2020] [Indexed: 01/29/2023] Open
Abstract
Renal cell carcinoma (RCC) is a malignant tumor and the third most common urinary disease. It was estimated that RCC affected over 350,000 individuals in 2013, and there are nearly 140,000 deaths annually due to this disease. The initial masses in RCC patients are mostly confined to a single organ. However, due to the metastatic spread of cancer cells through the circulatory system, more than 30% of RCC patients relapse after surgery. The appearance of distant metastases often means that patients enter the advanced stage of cancer with low quality of life and a short expected survival time. This review aims to describe the extant research on advanced RCC, including its pathophysiology, heterogeneity, diagnosis, treatment, and prospects. We try to highlight the most suitable means of treating advanced RCC patients, focusing on comprehensive personalized treatments.
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Affiliation(s)
- Xin-da Song
- Department of Urinary Surgery, Graduate School of Peking Union Medical College, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Yi-nong Tian
- Department of Urinary Surgery, Xinle City Hospital, Shijiazhuang, Hebei Province, China
| | - Hao Li
- Department of Oncology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Bin Liu
- Department of Urinary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Ai-li Zhang
- Department of Urinary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Yang Hong
- Department of Clinical Pharmacology Research, Hebei Medical University, Shijiazhuang, P.R. China
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García-Perdomo HA, Zapata-Copete JA, Castillo-Cobaleda DF. Role of cytoreductive nephrectomy in the targeted therapy era: A systematic review and meta-analysis. Investig Clin Urol 2017; 59:2-9. [PMID: 29333508 PMCID: PMC5754578 DOI: 10.4111/icu.2018.59.1.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/20/2017] [Indexed: 01/25/2023] Open
Abstract
Purpose To determine the effectiveness and harm of cytoreductive nephrectomy versus no intervention in patients with metastatic renal carcinoma who undergo targeted therapy to improve overall survival. Materials and Methods A search strategy was conducted in the MEDLINE, CENTRAL, Embase, HTA, DARE, NHS, and LILACS databases. Searches were also conducted for unpublished literature through references from relevant articles identified through the search, conferences, thesis databases, OpenGrey, Google Scholar, and clinicaltrials.gov, among others. Studies were included without language restrictions. The risk of bias assessment was made by using a modified Cochrane Collaboration tool. A meta-analysis of fixed effects was conducted. The expected outcomes were overall survival, quality of life, adverse effects, mortality, and progression- free survival. The measure of the effect was the hazard ratio (HR) with a 95% confidence interval (CI). The planned comparison was cytoreductive nephrectomy versus no intervention. Results A total of 22,507 patients were found among seven studies. Seven studies were included in the qualitative analysis (eight publications) and five in the quantitative analysis for overall survival. One study reported progression-free survival and one reported targeted therapy toxicities. A low risk of bias was shown for most of the study items. The HR for overall survival was 0.58 (95% CI, 0.50 to 0.65) favoring cytoreductive nephrectomy compared with no intervention. Conclusions Cytoreductive nephrectomy is effective for improving overall survival in patients with metastatic renal carcinoma who undergo targeted therapy compared with no intervention.
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Affiliation(s)
- Herney A García-Perdomo
- Department of Urology, School of Medicine, Universidad del Valle, Cali, Colombia.,Department of Epidemiology, Universidad Libre, Cali, Colombia.,Urological Research Group (UROGIV), Universidad del Valle, Cali, Colombia
| | - James A Zapata-Copete
- Department of Epidemiology, Universidad Libre, Cali, Colombia.,Urological Research Group (UROGIV), Universidad del Valle, Cali, Colombia
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Batra U, Parikh PM, Prabhash K, Tongaonkar HB, Chibber P, Dabkara D, Deshmukh C, Ghadyalpatil N, Hingmire S, Joshi A, Raghunath SK, Rajappa S, Rajendranath R, Rawal SK, Singh M, Singh R, Somashekhar SP, Sood R. Oncology Gold Standard™ practical consensus recommendations 2016 for treatment of advanced clear cell renal cell carcinoma. South Asian J Cancer 2016; 5:167-175. [PMID: 28032079 PMCID: PMC5184749 DOI: 10.4103/2278-330x.189933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The Oncology Gold Standard (OGS) Expert Group on renal cell carcinoma (RCC) developed the consensus statement to provide community oncologists practical guidelines on the management of advanced clear cell (cc) RCC using published evidence, practical experience of experts in real life management, and results of a nationwide survey involving 144 health-care professionals. Six broad question categories containing 33 unique questions cover major situations in the routine management of RCC. This document serves as a ready guide for the standard of care to optimize outcome. The table of "Take Home Messages" at the end is a convenient tool for busy practitioners.
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Affiliation(s)
| | | | - PM Parikh
- Correspondence to: Dr Purvish M. Parikh, Department of Precision Oncology, Asian Cancer Institute, Somaiya Hospital, Sion East, Mumbai. E-mail:
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Prognostic value of cytoreductive nephrectomy combined with targeted therapy for metastatic renal cell carcinoma: a meta-analysis. Int Urol Nephrol 2016; 48:967-75. [PMID: 26861063 DOI: 10.1007/s11255-016-1233-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 01/28/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE The role of cytoreductive nephrectomy (CN) has been controversial with the advent of targeted therapy. Our study was to identify the prognostic value of CN combined with targeted therapy for treatment of metastatic renal cell carcinoma (mRCC) by conducting a meta-analysis based on the existing population-based studies. METHODS Research articles published up to September 2015 were searched through PubMed and Embase. A meta-analysis was performed to assess the overall survival (OS) and progression-free survival (PFS) of patients with mRCC undergoing CN combined with targeted therapy compared with targeted therapy alone. Furthermore, analysis was made to evaluate some potential prognostic factors predicting survival. RESULTS Eight studies were included in our analysis with 2688 mRCC patients. A fixed-effect model was performed and found the pooled HR of OS was 0.60 (95 % CI 0.53-0.67, p < 0.0001). Furthermore, the pooled median survival ratio was elevated (HR 2.11, 95 % CI 1.78-2.49, p < 0.0001), indicating that patients who received CN combined with targeted therapy yielded a more than twofold prolonged OS compared with those who received targeted therapy alone. Moreover, no significant difference was observed in PFS in the patients undergoing CN combined with targeted therapy (HR 0.82, 95 % CI 0.57-1.19, p = 0.30). CONCLUSIONS Current evidence suggests that CN combined with targeted therapy has a significant OS advantage in patients with mRCC. However, the results should be evaluated in the context of the potential selection biases of the existing evidence. Large prospective cohort studies are required to confirm these findings.
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