Complications and Outcomes Associated With Surgical Management of Renal Cell Carcinoma Involving the Liver: A Matched Cohort Study

Focal therapy for oligometastatic and oligoprogressive renal cell carcinoma: a narrative review

Metastatic renal cell carcinoma (RCC) can present with oligometastatic disease and/or develop oligoprogression following systemic therapy. Cytoreductive and focal metastasis-directed therapy options include resection, stereotactic ablative radiation and thermal ablation. Aggressive focal therapy may allow delay in initiation of or modification to systemic therapy and improve clinical outcomes. In this narrative review we synthesize current practice guidelines and prospective data on focal therapy management options and highlight future research. Patient selection and the choice of focal treatment techniques are controversial due to limited and heterogeneous data and patients may benefit from multidisciplinary evaluation. Prospective comparative trials with clearly defined inclusion criteria and relevant end points are needed to clarify the risks and benefits of different approaches.

A case report of liver infiltration from a large renal cell carcinoma: Diagnostic and management enigma

INTRODUCTION AND IMPORTANCE

Renal cell carcinoma is the most lethal malignancy of urinary tract. Invasion of right lobe of liver by Renal cell carcinoma is rare and possess a treatment challenge. Simultaneous nephrectomy with right hepatectomy has been proposed as a part of multi-modality treatment approach. But its safety and feasibility is not well established.

CASE PRESENTATION

We herein discuss a case of 30-year old female patient who underwent simultaneous nephrectomy with right hepatectomy along with single peritoneal metastasectomy for a huge Renal cell carcinoma of right kidney and infiltrating the right lobe of liver. Intra-operatively a single peritoneal nodule was present which came positive for malignancy on frozen section. Considering young age, good performance status and oligometastatic disease definitive procedure in the form of combined right nephrectomy and right hepatectomy was performed. She was discharged from the hospital on 6th post-operative day with an uneventful post-operative course.

CLINICAL DISCUSSION

The patients with locally advanced Renal cell carcinoma with involvement of adjacent organs require en block surgical resection in combination with targeted therapy and immunotherapy. The surgical management of patients with direct liver infiltration requires a right nephrectomy with some form of liver resection based on the extent of liver involvement to achieve a margin negative resection. In our case a plan of formal right hepatectomy was made as the tumor was infiltrating into segment VI, VII, and VIII.

CONCLUSION

The combined nephrectomy and right hepatectomy is safe and feasible for this type of huge RCC invading right hepatic lobe.

Morbidity and mortality of multivisceral resection with radical nephrectomy for locally advanced renal cell carcinoma: An analysis of the National Surgical Quality Improvement Program (NSQIP) database

INTRODUCTION

Locally advanced renal cell carcinoma (RCC) can rarely invade into adjacent abdominal viscera without clinical evidence of distant metastases. The role of multivisceral resection (MVR) of involved adjacent organs at the time of radical nephrectomy (RN) remains poorly described and quantified. Using a national database, we aimed to evaluate the association between RN+MVR and 30-day postoperative complications.

METHODS AND MATERIALS

We conducted a retrospective cohort study of adult patients undergoing RN for RCC with and without MVR between 2005 and 2020 using the ACS-NSQIP database. The primary outcome was a composite of any of the following 30-day major postoperative complications: mortality, reoperation, cardiac event, and neurologic event. Secondary outcomes included individual components of the composite primary outcome, as well as infectious and venous thromboembolic complications, unplanned intubation and ventilation, transfusion, readmission, and prolonged length of stay (LOS). Groups were balanced using propensity score matching. Likelihood of complications was assessed by conditional logistic regression adjusted for unbalanced total operation time. Postoperative complications were compared by Fisher's exact test among subtypes of resection.

RESULTS

A total of 12,417 patients were identified: 12,193 (98.2%) undergoing RN alone and 224 (1.8%) undergoing RN+MVR. Patients undergoing RN+MVR were more likely to experience major complications (odds ratio [OR] 2.46; 95% confidence interval [CI] 1.28-4.74). However, there was no significant association between RN+MVR and postoperative mortality (OR 2.49; 95% CI 0.89-7.01). RN+MVR was associated with higher rates of reoperation (OR 7.85; 95% CI 2.38-25.8), sepsis (OR 5.45; 95% CI 1.83-16.2), surgical site infection (OR 4.41; 95% CI 2.14-9.07), blood transfusion (OR 2.24; 95% CI 1.55-3.22), readmission (OR 1.78; 95% CI 1.11-2.84), infectious complications (OR 2.62; 95% CI 1.62-4.24), and longer hospital stay (5 days [IQR 3-8] vs. 4 days [IQR 3-7]; OR 2.31 [95% CI 2.13-3.03]).  There was no heterogeneity in the association between subtype of MVR and major complication rate.

CONCLUSION

Undergoing RN+MVR is associated with an increased risk of 30-day postoperative morbidity, including infectious complications, reoperation, blood transfusion, prolonged LOS, and readmission.

The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis

The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short- and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.

The role of cytoreductive nephrectomy in renal cell carcinoma patients with liver metastasis

It is widely accepted that renal cell carcinoma (RCC) with liver metastasis (LM) carries a dismal prognosis. We aimed to explore the value of cytoreductive nephrectomy among these patients. Patients were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. The univariate and multivariate Cox proportional hazards models were conducted to select the prognostic predictors of survival. Patients were divided into nephrectomy and non-nephrectomy groups. Propensity score-matching (PSM) analyses were applied to reduce the above factors' differences between the groups. Overall survival (OS) was compared by Kaplan-Meier analyses. Data from 683 patients were extracted from the database. The univariate Cox regression and multivariate Cox regression revealed that factors including age, histologic type, T and N stages, lung metastasis, brain metastasis, and nephrectomy were significant predictors of survival in the patients. After the PSM analyses, we found that nephrectomy prolonged OS. Nephrectomy can prolong OS in eligible RCC patients with LM.

Metastasectomy in patients with renal cell carcinoma: when and how?

PURPOSE OF REVIEW

The role of metastasectomy in the management of metastatic renal cell carcinoma (mRCC) remains controversial. The aim of this review is to summarize and evaluate the recent findings about the surgical treatment of patients with mRCC focusing on the literature published in the last 2 years.

RECENT FINDINGS

Despite the lack of randomized controlled trials, the benefit of metastasectomy in term of cancer-specific and overall survival have been demonstrated in large observational studies. Results of ongoing clinical trials evaluating the impact of combination of surgical and systemic therapies are eagerly awaited and may shed the light on a new treatment armamentarium in this subset of patients.

SUMMARY

Several novel systemic agents have emerged and is continuously changing the treatment paradigm in patients with advanced RCC. However, surgical resection of the primary tumor and metastatic deposits represents a definitive cure option in well selected patients.

Combined liver and multivisceral resections: A comparative analysis of short and long-term outcomes

BACKGROUND

En bloc liver and adjacent organs resections are technically demanding procedures. Few case series and nonmatched comparative studies reported the outcomes of multivisceral liver resections (MLRs).

OBJECTIVES

To compare the short and long-term outcomes of patients submitted MLRs with those submitted to isolated hepatectomies.

METHODS

From a prospective database, a case-matched 1:2 study was performed comparing MLRs and isolated hepatectomy. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity, mortality, and long-term survival.

RESULTS

Fifty-three MLRs were compared with 106 matched controls. Patients undergoing MLRs had longer operative time (430 [320-525] vs 360 [270-440] minutes, P = .005); higher estimated blood loss (600 [400-800] vs 400 [100-600] mL; P = .011); longer hospital stay (8 [6-14] vs 7 [5-9] days; P = .003); and higher postoperative mortality (9.4% vs 1.9%, P = .042). Number of resected organs was not an independent prognostic factor for perioperative major complications (odds ratio [OR], 1 organ = 1.8 [0.54-6.05]; OR ≥ 2, organs = 4.0 [0.35-13.84]) or perioperative mortality (OR, 1, organ = 5.2 [0.91-29.51]; OR ≥ 2, organs = 6.5 [0.52-79.60]). No differences in overall (P = .771) and disease-free survival (P = .28) were observed.

CONCLUSION

MLRs are feasible with acceptable morbidity but relatively high perioperative mortality. MLRs did not negatively affect long-term outcomes.

3D reconstruction of CT scans aid in preoperative planning for sarcomatoid renal cancer: A case report and mini-review

Contrast-enhanced multi-slice computed tomography (MSCT) is commonly used in the diagnosis of complex malignant tumours. This technology provides comprehensive and accurate information about tumour size and shape in relation to solid tumours and the affected adjacent organs and tissues. This case report demonstrates the benefit of using MSCT 3D imaging for preoperative planning in a patient with late-stage (T4) sarcomatoid renal cell carcinoma, a rare renal malignant tumour. The surgical margin on the liver was negative, and no metastases to veins, lungs or other organs were detected by abdominal and chest contrast-enhanced CT. Although sarcomatoid histology is considered to be a poor prognostic factor, the patient is alive and well 17 months after surgery. The MSCT imaging modality enables 3D rendering of an area of interest, which assists surgical decision-making in cases of advanced renal tumours. In this case, as a result of MSCT 3D reconstruction, the patient received justified surgical treatment without compromising oncological principles.

Surgical Metastasectomy in Renal Cell Carcinoma: A Systematic Review

CONTEXT

The benefit of surgical metastasectomy (SM) for patients with metastatic renal cell carcinoma (mRCC) remains controversial because of the lack of high-level evidence on the role of SM in terms of survival benefit in the era of systemic therapy.

OBJECTIVE

To perform a systematic review of the literature on the role of SM in the treatment of mRCC and discuss key issues in the SM decision-making process.

EVIDENCE ACQUISITION

A systematic search of the Embase and Medline databases was carried out and a systematic review of the role of SM in mRCC was performed. A total of 56 studies were finally included in the evidence synthesis.

EVIDENCE SYNTHESIS

All the studies included were retrospective and mostly noncomparative. Median overall survival (OS) ranged from 36 to 142mo for those undergoing SM, compared to 8-27mo for no SM. SM was associated with a lower risk of all-cause mortality compared to no SM (pooled adjusted hazard ratio 2.37, 95% confidence interval 2.03-2.87; p<0.001). Morbidity and mortality were similar for SM and primary tumor surgery. The most important prognostic factor for OS was complete resection of metastases. Other prognostic factors included disease free-survival from nephrectomy, primary tumor features (T stage ≥3, high grade, sarcomatoid features, and pathological nodal status), the number of metastases, and performance status. Lung metastasectomy seemed to show the best survival benefit.

CONCLUSIONS

Although no randomized clinical data are available, published studies support the role of SM in selected patients in the modern era. Complete SM allows sustained survival free of systemic treatment. Integration of SM and systemic therapy in a multimodal approach remains a valid option for some patients.

PATIENT SUMMARY

Surgical resection of metastases originating from renal cell carcinoma may play a role in prolonging survival and avoiding systemic therapy when complete resection is achievable. This strategy is an option for selected patients with a limited number of metastases who still have good general health status.

Role of metastasis-directed treatment in kidney cancer

Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.

Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma

INTRODUCTION

Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.

Accompanying role of hepato-biliary-pancreas surgeon in urological surgery

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Accompanying support by full use of procedure of general or cardiovascular surgeons for urological surgery in malignancies provide curability.

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Cardiovascular intervention should be necessary to remove long extension of tumor thrombus into the vena cava or right atrium.

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Hepatic or pancreatic mobilization or combined resection is required for invasive or metastatic urological malignancies.

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Operative safety is also required by precise preoperative planning and arrangement of procedure during operation by the good combination in each.

Introduction

The present case reports demonstrated the accompanying surgical support from hepato-biliary-pancreas (HBP) surgeons for urological surgery to secure operative safety because HBP surgeons are well experienced in dissecting techniques for mobilization of the liver or pancreas. We experienced 9 consecutive patients who underwent nephrectomy, adrenectomy or resection of retroperitoneal tumors by urological surgeons. Cardiovascular intervention was also required in cases of long tumor thrombus into the vena cava.

Cases

All patients had no severe co-existing diseases except the main tumor. Reverse T-shape incision was performed in 7 cases and thoracolaparotomy in two. Dissection and mobilization at the site of severe compression by the urinary tumors were performed in three cases. Partial liver resection was performed for testicular liver metastases in two, and right hepatectomy for right renal cancer was performed in one. Encircling the vena cava and preparation of transection for tumor thrombi were performed in three, and among these, cardiovascular intervention was necessary in two because of extension into the right atrium. During admission, all patient outcomes were uneventful without severe complications. We herein showed the representative two cases of combined surgery.

Discussion

and conclusion The point of this case report is the coordination between each surgeon and anesthesiologist under precise perioperative planning or management. The role of HBP surgeons is to provide information as a specialist on the operative field for urological or cardiovascular surgery to achieve operative safety.

Complications After Metastasectomy for Renal Cell Carcinoma-A Population-based Assessment

Metastasectomy has long been considered a valid treatment option for patients with oligometastatic renal cell carcinoma (oligo-mRCC). However, the literature on complications in this setting is scarce. Our objective was to describe in-hospital complications after metastasectomy in a contemporary cohort of patients with mRCC. Using the National Inpatient Sample database (2000-2011), 45 279 mRCC patients were identified. Of those, 1102 underwent metastasectomies. The metastatic sites were the lungs, bone, liver, lymph nodes, adrenal glands, and brain in, respectively, 52%, 29%, 19%, 14%, 11%, and 3.4% of patients. The overall complication rate was 45.7%. Major complications (Clavien III-V) constituted 27.5%. Resections of hepatic lesions were significantly associated with higher odds of overall complications compared with any other site (odds ratio 2.59, 95% confidence interval 1.84-3.62, p<0.001). While metastasectomy remains a potential treatment option in RCC with oligometastatic disease, the associated complication rates are non-negligible; therefore, careful patient selection is warranted.

PATIENT SUMMARY

We studied outcomes of patients with metastatic kidney cancer treated with metastasectomy. While metastasectomy is a treatment option for metastatic renal cell carcinoma, complications are not insignificant and our results may guide preoperative counseling.