Renal cell carcinoma metastatic to the lung: potential benefit in the combination of biological therapy and surgery

The use of cytoreductive nephrectomy in patients with renal cell carcinoma

INTRODUCTION

The systemic options for managing metastatic renal cell carcinoma (mRCC) have expanded considerably over the past decade. Initially limited to cytokines, clinicians may now choose from several classes of targeted therapies and, most recently, immune checkpoint inhibitors. Areas covered: In this review, we discuss the role and timing of cytoreductive nephrectomy (CN) and its evolution starting with cytokines, and then alongside the emergence of targeted therapy and novel immunotherapy with immune checkpoint inhibitors. Patient selection remains the most critical determinant in offering CN, and the anticipated survival benefits of CN must be weighed against the surgical morbidity and potential delay to receipt of systemic therapies. Expert opinion: Proper patient selection is key for decision-making in mRCC. Prospective data is urgently needed to define the role of CN in the contemporary immunotherapy era, with greater personalization of prognostic models.

Surgery for Metastases of Renal Cell Carcinoma

The role of surgery for RCC in the era of emerging effective systemic therapy (usually immunotherapy) is not yet defined except for solitary metastasis. The retrospective analysis of patients subjected to aggressive surgical management after systemic therapy reinforces the need to find better therapeutic modalities in order to achieve complete eradication of metastatic disease. In the meantime, however, we propose these guidelines. First, we would encourage aggressive surgical resection of the clinically solitary metastasis, whether synchronous or metachronous. Continue to follow those patients indefinitely, because relapse is quite likely, but do not give adjuvant systemic therapy unless on protocol. Second, limited metastases in only one organ may behave similarly to a solitary metastasis, and if the metastases are in a site amenable to surgical resection, e.g., lung, initial surgery might be reasonable. Systemic therapy for these patients is highly recommended and need not necessarily wait for recurrence. Third, for patients with multiple metastases, initial systemic therapy followed then by resection of any residual disease in selected patients seems to be supported by the experience at several medical centers. Apparently prolonged survival times have been observed after systemic therapy followed by surgery in highly selected patients, despite finding viable cancer in the overwhelming majority of specimens. One must be mindful of the morbidity of an attempt to remove all known disease, however, and try to weigh this against potential benefit. Only a prospective, randomized trial could ever confirm the value of an aggressive surgical approach to metastatic RCC. In the meantime, however, metastasectomy offers, at the very least, the opportunity to confirm the histologic response to systemic therapy, render some patients disease-free, and possibly promote long-term survival in selected patients.

The role of metastasectomy in renal cell carcinoma

Despite significant advances in the systemic treatment of metastatic renal cell carcinoma, long-term survival remains low. A potential way to improve outcomes in selected cases is the use of metastasectomy, which is part of the multimodal treatment of this disease. Although the evidence supporting this approach is limited, we believe it is a reasonable option for certain patients. This review summarizes the evidence supporting this approach.

Pulmonary and chest wall metastasectomy in urogenital tumors: a single center experience and review of literature

BACKGROUND

Pulmonary metastases are often found in advanced malignancies. Urogenital malignancies originating from kidney, prostate, testes, and bladder all metastasize preferentially to the lungs.

OBJECTIVES

This retrospective study aimed to evaluate the results of pulmonary and chest wall metastasectomy in patients with primary urogenital Tumors.

PATIENTS AND METHODS

The patients who underwent pulmonary metastasectomy in Ghaem Hospital from 1996 to 2011 were examined. Thirteen out of 79 patients referred for pulmonary metastasectomy to a single thoracic surgeon had metastases from urogenital tumors; two cases with metastasis from urogenital tumors were inoperable. We reviewed their demographic data and also clinicopathological features. Disease free interval (DFI) was defined as the time between the first curative surgery and the appearance of the signs and symptoms of pulmonary metastasis.

RESULTS

Among 11 patients who underwent surgery consisted of eight males and three females. Their metastasis originated from testis tumors (n = 5), renal cell carcinoma (RCC; n = 4), bladder tumor (n = 1), and prostate cancer (n = 1). Their mean age was 41.27 years (range, 21-67). The mean age of the patients with RCC and testis tumor at the time of diagnosing metastasis was 54 and 24.8 years, respectively. There were two other patients (a 62-year-old female and a 54-year-old male) with pleural effusion due to metastatic RCC whose tumor was inoperable because of their poor general condition and hence, were referred for chemotherapy.

CONCLUSIONS

Pulmonary metastasectomy is feasible in selected cases.

Surgical resection of pulmonary metastasis from renal cell carcinoma

Background

Renal cell carcinoma has shown less response to systemic therapies including chemotherapy, radiation, and immunotherapy than other cancers. Surgery has therefore become an important treatment tool. The protocol for treatment is the same for pulmonary metastasis of renal cell carcinoma. We performed surgery for pulmonary metastatic renal cell carcinomas and analyzed the results.

Materials and Methods

We retrospectively analyzed 15 patients who had undergone pulmonary metastasectomy from renal cell carcinoma at our hospital from January 2005 to December 2009.

Results

No patients had extrathoracic metastatsis. The mean age was 60.2 years (range 35~73). There were 12 male and 3 female patients. The number of synchronous and metachronous patients were 8 and 7, respectively. The mean survival times of synchronous and metachronous patients were 32.6 and 42.9 months, respectively. 6 patients had single lesions and 9 patients had multiple (more than 3) lesions. The surgical procedures included wedge resection (10), lobectomy (2), wedge resection with segmentectomy (2), and segmentectomy (1). Median observation and survival time were 54.1 and 34.9 months. The 1-year and 3-year survival rates were 80% and 50%, respectively.

Conclusion

Pulmonary resection for pulmonary metastatic renal cell carcinoma was found to be a safe and effective treatment modality when complete resection was performed.

Metastasectomy after targeted therapy in patients with advanced renal cell carcinoma

PURPOSE

Metastasectomy is often incorporated in overall treatment in patients with metastatic renal cell carcinoma. While this approach was studied in the immunotherapy era, only a few cases have been described in the targeted therapy era. Thus, we evaluated the role of metastasectomy in patients with metastatic renal cell carcinoma who received prior targeted therapy.

MATERIALS AND METHODS

We retrospectively evaluated the records of patients who underwent consolidative metastasectomy after targeted therapy at 3 institutions from 2004 to 2009. All patients received at least 1 cycle of targeted therapy before surgical resection of all visible disease.

RESULTS

We identified 22 patients. Metastasectomy sites included the retroperitoneum in 12 patients, lung in 6, adrenal gland in 2, bowel in 2, and mediastinum, bone, brain and inferior venal caval thrombus in 1 each. A total of 6 postoperative complications were observed in 4 patients within 12 weeks after surgery, which resolved with appropriate management. Postoperatively 9 patients received at least 1 targeted therapy. In 11 patients recurrence developed a median of 42 weeks after metastasectomy and another 11 experienced no recurrence at a median of 43 weeks. At a median followup of 109 weeks 21 patients were alive and 1 died of renal cell carcinoma 105 weeks after metastasectomy.

CONCLUSIONS

In a cohort of select patients with a limited tumor burden after treatment with targeted agents consolidative metastasectomy is feasible with acceptable morbidity. Significant time off targeted therapy and long-term tumor-free status are possible with this approach.

Role of cytoreductive nephrectomy in renal cell carcinoma

Cytoreductive nephrectomy prior to cytokine therapy has a well-established role in the treatment of appropriately selected patients with metastatic renal cell carcinoma (RCC). Recent use of novel molecular targeted agents in the management of metastatic RCC has challenged the current dogma of treatment with regards to the necessity, patient selection for and timing of cytoreductive nephrectomy. Current evidence suggests that cytoreductive nephrectomy still plays an integral part in the multimodal paradigm of management for metastatic RCC. This review highlights the role of cytoreductive nephrectomy, and discusses controversial issues surrounding cytoreductive nephrectomy in the treatment of metastatic RCC, in the context of immunotherapy and also in the new era of targeted therapy. It also gives updates on the changing concepts of surgical approaches to cytoreductive nephrectomy in metastatic RCC.

PET Scans for Decision-Making in Metastatic Renal Cell Carcinoma: A Single-Institution Evaluation

OBJECTIVE

Therapeutic decision-making in metastatic renal cell carcinoma (MRCC) is based on conventional radiological evaluation. Fluorodeoxyglucose positron emission tomography (FDG-PET) scans may modify this strategy.

METHODS

Patients with MRCC for whom a therapeutic decision had been made underwent an FDG-PET scan in order to complete the standard radiological evaluation.

RESULTS

Twenty-four patients and 26 FDG-PET scans were eligible. In 18 patients, metastatic disease was evaluable on the computed tomography (CT) scan; the FDG-PET scan was positive in 16 patients and negative in 10. In 2 patients, the FDG-PET scan was positive while they were considered disease free on radiological evaluation. In 5 patients (20.8%), the previous therapeutic decision was changed. Thirteen patients had a pathological evaluation for 19 sites. One patient out of 13 had a false-positive FDG-PET scan, while 4 sites out of 6 were false-negative. The sensitivity was 75% (95% CI: 47.6-92.7) and the predictive positive value was 92.3% (95% CI: 64-99.8). With a median follow-up of 24 months, 3 patients developed new metastatic sites.

CONCLUSION

Our data suggest that, when positive, an FDG-PET scan may modify the decision made; when negative, it should not modify decision-making especially for surgery, owing to its sensitivity.

Integrating Metastasectomy in the Management of Advanced Urological Malignancies—Where are we in 2005?

PURPOSE

In the past patients with metastatic cancer were considered incurable and they were not candidates for surgical management of metastases. However, experience with testicular cancer has shown that metastasectomy can often be the final, critical step in achieving disease-free status. We summarized the most current data on metastasectomy for advanced urological malignancies.

MATERIALS AND METHODS

We performed an extensive review of the literature from 1990 to the present using MEDLINE. Only original reports were included with an emphasis on specific malignancies and specific sites of metastasis.

RESULTS

There is increasing evidence that patients with metastatic renal cell carcinoma and bladder carcinoma can be cured by surgical resection of metastases, usually combined with systemic therapy. The ideal patient has responded to systemic therapy and has few metastatic sites.

CONCLUSIONS

Metastasectomy should frequently be done in patients with advanced testicular cancer and it should increasingly be considered in patients with metastatic renal cell carcinoma or bladder carcinoma. This technique may be used for cure and palliation. Specific patient factors determine the likelihood and degree of potential benefit.

The Role of Imaging in the Surveillance of Urologic Malignancies

Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.

Interferon alpha for the treatment of advanced renal cancer

This paper is an overview on the place of IFN-alpha in metastatic renal cell carcinoma (MRCC). After a presentation of MRCC and the mode of action of IFN-alpha, the results of studies including IFN-alpha alone or in combination with IL-2, chemotherapy and other biological modifiers are presented. Finally, new trends for new drugs, including antiangiogenic therapies, are discussed.

A Multifactorial Postoperative Surveillance Model for Patients With Surgically Treated Clear Cell Renal Cell Carcinoma

PURPOSE

We designed scoring algorithms for postoperative surveillance based on multivariately significant predictors of site specific disease recurrence.

MATERIALS AND METHODS

We identified 1,864 patients who underwent partial or radical nephrectomy for nonmetastatic clear cell renal cell carcinoma between 1970 and 2000. Clinical features studied included age, sex and symptomatic disease at presentation. Surgical and pathological features studied included nephrectomy type, surgical margin status, 2003 TNM stage, nuclear grade, histological tumor necrosis, sarcomatoid component, cystic architecture and multifocality. Recurrence was classified into locations of abdomen, thoracic region, bone and brain. Recurrence-free survival rates were estimated using the Kaplan-Meier method. Cox proportional hazards models were fit to test associations with recurrence.

RESULTS

Recurrence to abdomen, the thoracic region, bone and brain developed in 185 (10%), 300 (16%), 134 (7%) and 81 (4%) patients, respectively. Positive surgical margins, 2003 TNM stage, size, grade and necrosis were significantly associated with abdominal recurrence in a multivariate setting. These same features, except surgical margins, were significantly associated with thoracic recurrence. The 2003 TNM stage, grade and necrosis were multivariately predictive of recurrence in bone. Scoring algorithms to predict the likelihood of disease recurrence to these sites and to guide the intensity of postoperative surveillance were developed using regression coefficients from the multivariate models. The proposed scoring algorithms resulted in excellent patient stratification.

CONCLUSIONS

We present scoring algorithms based on multivariately significant predictors of site specific recurrence that can be used to tailor postoperative surveillance to the individual patient.

Rapamycin is an effective inhibitor of human renal cancer metastasis

Rapamycin is an effective inhibitor of human renal cancer metastasis.

BACKGROUND

Human renal cell cancer (RCC) is common and is 10 to 100 times more frequent in patients with end-stage renal disease (ESRD) and candidates for renal transplantation. Treatment of metastatic RCC is largely ineffective and is further undermined by immunosuppressive therapy in transplant recipients. A treatment regimen that prevents transplant rejection while constraining RCC progression would be of high value.

METHODS

We developed a human RCC pulmonary metastasis model using human RCC 786-O as the tumor challenge and the severe combined immunodeficient (SCID) beige mouse as the host. We explored the effect of rapamycin, cyclosporine, or rapamycin plus cyclosporine on the development of pulmonary metastases and survival. The effects of the drugs on tumor cell growth, apoptosis, and expression of vascular endothelial growth factor (VEGF-A) and transforming growth factor beta1 (TGF-beta1) were also investigated.

RESULTS

Rapamycin reduced, whereas cyclosporine increased, the number of pulmonary metastases. Rapamycin was effective in cyclosporine-treated mice, and rapamycin or rapamycin plus cyclosporine prolonged survival. Rapamycin growth arrested RCC 786-O at the G1 phase and reduced VEGF-A expression. Immunostaining of lung tissues for von Willebrand factor was minimal and circulating levels of VEGF-A and TGF-beta1 were lower in the rapamycin-treated mice compared to untreated or cyclosporine-treated mice.

CONCLUSION

Our findings support the idea that rapamycin may be of value for patients with RCC and that its antitumor efficacy is realized by cell cycle arrest and targeted reduction of VEGF-A and TGF-beta1. A regimen of rapamycin and cyclosporine, demonstrated to be effective in reducing acute rejection of renal allografts, may prevent RCC progression as well, and has the potential to prevent mortality due to RCC in patients with ESRD who have received renal allografts.

Clinical features of renal cell carcinoma less than 25 millimeters in diameter

BACKGROUND

We retrospectively investigated the clinicopathological features and prognosis of patients who underwent surgical treatment at our department for renal cell carcinoma (RCC) less than 25 mm in diameter.

METHODS

Of the 158 patients who underwent surgical treatment between April 1975 and April 1998, 16 (17 kidney, 10.1%) were included in this study. The study included 11 men and 5 women (ratio: 2.2). The age range was 35-76 years (average: age 53). The right kidney was involved in 9, left kidney in 6 and bilateral kidneys in 1 patient. The follow-up period was 26-157 months (mean: 86 months).

RESULTS

Thirteen tumors (81.2%) were incidental carcinomas. No patients had a tumor of rapid growing type. Radical nephrectomy was performed for 12 kidneys (70.6%), simple nephrectomy for 2 (11.8%) and partial nephrectomy for 3 (17.8%). Seven patients (43.7%) received interferon-alpha as postoperative adjuvant therapy. All tumors were pathologically classified as expansive type; 11 (64.8%) as clear cell carcinoma; 3 (17.6%) cyst-associated, and 3 (17.6%) papillary. Nine (52.9%) tumors were grade 1, and 8 (47.1%) were grade 2. Fourteen patients were pNo and V(-). The 5- and 10-year survival rates were excellent (100%).

CONCLUSION

The features of small RCCs less than 25 mm were as follows: many tumors were incidental to clear cell carcinomas; all tumors were low grade, low stage and expansive type; no tumors showed acute phase reactants; and few tumors were of the solid type. Thus, the prognosis seemed to be excellent.

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

BACKGROUND

The value of nephrectomy in metastatic renal-cell cancer has long been debated. Several nonrandomized studies suggest a higher rate of response to systemic therapy and longer survival in patients who have undergone nephrectomy.

METHODS

We randomly assigned patients with metastatic renal-cell cancer who were acceptable candidates for nephrectomy to undergo radical nephrectomy followed by therapy with interferon alfa-2b or to receive interferon alfa-2b therapy alone. The primary end point was survival, and the secondary end point was a response of the tumor to treatment.

RESULTS

The median survival of 120 eligible patients assigned to surgery followed by interferon was 11.1 months, and among the 121 eligible patients assigned to interferon alone it was 8.1 months (P=0.05). The difference in median survival between the two groups was independent of performance status, metastatic site, and the presence or absence of a measurable metastatic lesion.

CONCLUSIONS

Nephrectomy followed by interferon therapy results in longer survival among patients with metastatic renal-cell cancer than does interferon therapy alone.

Murine renal cell carcinoma: evaluation of a dendritic-cell tumour vaccine

OBJECTIVE

To use a murine model of renal cell carcinoma (RCC), Renca, to aid in developing a dendritic cell (DC)-mediated tumour vaccine for RCC; as conventional therapy has been unsuccessful for RCC and therapy using immune modulators has had limited success, novel therapies enhancing further the immune system must be developed.

MATERIALS AND METHODS

DCs were obtained from mouse bone marrow enriched for the haematopoietic progenitors, and cultured in the presence of interleukin-4 and granulocyte macrophage-colony stimulating factor. In vivo vaccines and in vitro proliferation assays were used to assess ability of the DCs to present tumour antigen.

RESULTS

The presence of DCs was confirmed in the cultures by fluorescent-activated cell sorting analysis. In vivo, tumour-bearing animals receiving tumour extract-pulsed DCs as a vaccine showed a two to threefold reduction in tumour growth at day 12 and day 16 but no significant difference at day 28. In vitro, tumour extract-pulsed DCs stimulated significant proliferation of splenocytes from naive animals but not tumour-bearing animals. In addition, splenocytes from tumour-bearing animals had an attenuated immune response in vitro.

CONCLUSION

These results show that it is possible to use the DC vaccine to modulate the immune response to achieve an antitumour effect, but further manipulation of the DC vaccine may be needed to overcome the tumour-induced immune suppression.

Cytoreductive surgery with liver-involved renal cell carcinoma

The purpose of this study was to demonstrate the benefits of cytoreductive surgery for renal cell carcinomas that also involve the liver. Between 1994 and 1997, four patients with renal cell carcinoma with liver involvement were surgically treated with nephrectomy and hepatectomy. Two of them underwent a simultaneous hepatectomy and nephrectomy (group 1), and the remaining two patients underwent a hepatectomy after a nephrectomy and had a diagnosis of postoperative recurrence (group 2). Two patients, one from each group, died of multiple bone metastasis and lung metastasis 30 months and 12 months after the hepatectomy; the second patient from group 1 died 40 months after the first operation due to gastrointestinal hemorrhaging. The second patient from group 2 displayed no evidence of recurrence 18 months after the second surgical procedure. The survival rates for these patients were 66% and 33% at 1 and 3 years, respectively. Autopsy studies revealed that one patient from group 2 had a local recurrence in the liver while the other two patients from group 1 did not. Our results suggested that a progressive approach may therefore be useful for patients demonstrating renal cell carcinoma where there is liver involvement.

Renal cell carcinoma: should radical nephrectomy be performed in the presence of metastatic disease?

Metastatic renal cell carcinoma is associated with an unfavorable prognosis and the treatment options are limited. Adjunctive radical nephrectomy, performed either before or after the administration of systemic immunotherapy, has been proposed as a means of improving outcome. The role of nephrectomy for patients with metastatic disease remains controversial. This article reviews the role of nephrectomy in metastatic renal cell carcinoma and the optimal timing for surgery relative to immunotherapy.

A stage specific approach to tumor surveillance after radical cystectomy for transitional cell carcinoma of the bladder

PURPOSE

Surveillance protocols after radical surgery for genitourinary tumors typically do not consider that the risk of recurrence is stage dependent. We describe the development of a stage specific protocol for monitoring patients with transitional cell carcinoma for tumor recurrence and conduit complications after radical cystectomy.

MATERIALS AND METHODS

The records of 382 patients with transitional cell carcinoma who underwent cystectomy in 1986 to 1994 were reviewed for the dates and presenting symptoms of local and distant recurrences, and the results of radiological imaging studies and liver function tests. Based on the division of patients into pathological stages of pT1, pT2 and pT3 groups, we developed a new transitional cell carcinoma surveillance protocol.

RESULTS

Of 97 patients with transitional cell carcinoma metastases 72 (74%) were asymptomatic, including 43 with metastases detected by routine chest x-rays (30) or blood tests (13). Surveillance computerized tomography identified isolated asymptomatic intra-abdominal metastases in 10 patients (10%), of whom 90% had pT3 disease. Based on these results we recommend a stage specific surveillance protocol for pT1--annual history, physical examination, chest x-ray and laboratory studies, pT2-same studies at 6, 12, 18, 24, 30, 36, 48 and 60 months after cystectomy, and pT3-same studies at 3, 6, 12, 18, 24, 30, 36, 48 and 60 months plus computerized tomography at 6, 12 and 24 months after cystectomy. A radiographic study of the upper tract should be performed in all patients every 1 to 2 years to evaluate for recurrences and complications of the ileoureteral anastomosis.

CONCLUSIONS

A stage driven surveillance strategy for monitoring patients after radical cystectomy can reduce costly imaging studies while efficiently detecting recurrences and complications.

Pulmonary metastasis

OBJECTIVES

To provide a review of pulmonary-specific pathophysiology and pulmonary metastasis-related information regarding diagnostic tests, differential diagnoses, signs and symptoms, treatment, and nursing implications.

DATA SOURCES

Research studies, review papers, and case reports pertaining to pulmonary metastasis.

CONCLUSIONS

Several site-specific mechanisms of metastasis may begin to explain why the lungs are a common metastatic site. There are circumstances when pulmonary metastases can be either surgically removed or treated with combined modalities, resulting in prolonged survival.

IMPLICATIONS FOR NURSING PRACTICE

Metastatic disease may be treated aggressively; for some patients, this can result in prolonged survival while maintaining reasonable quality of life. A useful basic resource for obtaining a pulmonary history is provided. Key points regarding symptom management and patient education also are discussed.

Efficacy of multimodality therapy in advanced renal cell carcinoma

OBJECTIVES

The integration of systemic biologic response modifier (BRM) therapy and surgery to treat metastatic renal cell carcinoma (RCC) is an evolving approach. The purpose of this study was to evaluate the efficacy of this form of multimodality therapy in patients with metastatic RCC.

METHODS

Between 1988 and 1996, 14 patients at our institution underwent initial BRM therapy followed by surgical resection of primary and metastatic RCC lesions. Patient records were reviewed to determine the response to BRM therapy, progression-free survival rate, and overall survival rate. The mean follow-up for the entire group was 43.5 months.

RESULTS

After BRM therapy, 9 patients manifested an objective response and 5 patients had stable disease. All patients were then rendered disease-free by surgical excision of residual or recurrent metastatic lesions and the primary tumor. The cancer-specific survival rate at 3 years was 81.5%. Currently, 7 patients are alive and disease-free (mean follow-up 41.4 months), 3 patients are alive with recurrent disease (mean survival 48.3 months), 3 patients died of metastatic disease (mean survival 27.9 months), and 1 patient died of an unrelated cause 54.4 months after therapy.

CONCLUSIONS

The results of this study suggest that adjunctive surgery after BRM therapy can extend the survival of selected patients with metastatic RCC. Aggressive surgical resection of stable or responding lesions after BRM therapy should be considered in the management of these patients.

Treatment of renal cell carcinoma with 5-fluorouracil and alfa-interferon

OBJECTIVES

Renal cell carcinoma is relatively resistant to both chemotherapy and immunotherapy. Response, survival, duration of response, and toxicity of treatment were evaluated in patients with advanced renal cell carcinoma receiving a continuous intravenous infusion of 5-fluorouracil (5-FU) and low dose subcutaneous alfa-2b-interferon.

METHODS

Between 1989 and 1994, 21 patients with advanced renal cell carcinoma underwent treatment with continuous intravenous infusion of 5-FU, 200 mg/m2/day, and subcutaneous injections of recombinant interferon alfa-2b (IFN-alpha), 1 x 10(6) U/day.

RESULTS

Objective response was observed in 9 patients (43%). Complete response occurred in 4 patients (19%): 2 with lung, 1 with bone, and 1 with liver metastasis. Partial response occurred in 5 patients (24%). Three of 4 complete responders remain alive without recurrence. Mean survival rate was 195 weeks among complete responders, 184 weeks among partial responders, and 88 weeks among nonresponders. The overall mean duration of response was 101 weeks. Responders developed progression of disease a mean of 62 weeks after the initial response to therapy. Mild dose-dependent toxicity was related to 5-FU infusion. Nearly all toxicities subsided with the temporary cessation of 5-FU infusion and/or decreasing the dose of the infusion. Few if any of the toxicities appear to be directly related to the low dose interferon injections.

CONCLUSIONS

Although this study is based on a small sample size, we believe that the encouraging complete and partial responses, apparent prolongation of survival, and manageable toxicity of this combination therapy warrant further investigation with larger randomized trials.

Nephrectomy and vena caval thrombectomy in patients with metastatic renal cell carcinoma

OBJECTIVES

To report out experience with performing nephrectomy and vena caval thombectomy in patients with metastatic renal cell carcinoma.

METHODS

A retrospective review was performed of 15 patients who underwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites of metastases included lungs (n = 8), bone (n = 3), bulky retroperitoneal or mediastinal lymph nodes (n = 2), liver (n = 1), and contralateral adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score of 0, 11 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months.

RESULTS

Median operative time was 6.5 hours and median hospitalization was 10 days. Two patients required re-exploration for postoperative hemorrhage. There were no perioperative deaths. Four patients underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperatively. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 110). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months (range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Ten of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapid progression at 2 and 5 months after surgery and the other 2 at 17 and 42 months.

CONCLUSIONS

Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furthermore, in patients receiving biologic therapy, nephrectomy may enable a better quality of life and prolonged survival.