Benefit from cytoreductive nephrectomy and the prognostic role of neutrophil-to-lymphocyte ratio in patients with metastatic renal cell carcinoma

Characteristics of patients with metastatic renal cell carcinoma who do not respond to axitinib treatment

BACKGROUND

Axitinib is a widely used tyrosine kinase inhibitor (TKI) in metastatic renal cell carcinoma (mRCC) treatment. Here, we analyzed the characteristics of patients who did not respond to axitinib and evaluated alternative options for their treatment.

METHODS

We retrospectively analyzed data for 449 patients with mRCC who were administered axitinib following another TKI as initial therapy. Patients with progressive disease (PD) at their first assessment were defined as showing early-PD. We analyzed the characteristics of patients at risk of early-PD and evaluated the relationship between the treatment following axitinib and their prognosis.

RESULTS

Early-PD was diagnosed in 102 patients, and was more common in those who had not undergone nephrectomy (p < 0.001), those treated with a TKI for a short period (p < 0.001), and those in the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) poor risk category for mRCC (p < 0.001). Multivariate analysis showed that these were independent risk factors for early-PD (all p < 0.001). Of those with early-PD, 52 changed to next-line treatment. The progression-free survival periods were 5.5 (95% confidence interval (CI) 2.4-8.6) months for patients administered TKIs, 4.2 (95% CI 0.3-8.1) months for those on nivolumab, and 2.2 (1.8-2.6) months for those on mammalian target of rapamycin inhibitors (p = 0.030).

CONCLUSION

Patients who have not undergone nephrectomy, those previously treated with another TKI for a short period, and those in the IMDC poor risk category are more likely to experience early-PD when taking axitinib. Furthermore, TKIs are the best treatment for patients with early-PD who have previously been administered axitinib.

NLR as prognostic biomarker for metastatic renal cell carcinoma patients treated with cytoreductive nephrectomy

PURPOSE

This study aimed to determine the prognostic value of preoperative Neutrophil-to-lymphocyte ratio (NLR) in patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN).

METHODS

We retrospectively investigated the clinicopathological data of patients with mRCC from two Chinese hospitals (2008-2018). Patients were stratified and analyzed for survival prognosis using X-tile software, Kaplan-Meier curves, log-rank test, and univariate/multivariate Cox regression analyses.

RESULTS

The patients were divided into low NLR group (≤2.7) and high NLR group (>2.7) based on the optimal cutoff value of 2.7 obtained using the X-tile software, containing 137 and 93 patients, respectively. Kaplan - Meier analysis indicated that high NLR group had significantly inferior median progression-free survival (PFS) and overall survival (OS) than low NLR group (median PFS of 8.3 months vs. 17.9 months, p = 0.003 and median OS of 21.6 months vs. 45.1 months, p = 0.009). Multivariate Cox regression analysis showed that NLR was an independent prognostic factor for PFS (hazard ratio [HR], 1.4; 95% CI, 1.1-1.9; p = 0.022) and OS (HR, 1.5; 95% CI, 1.1-2.1; p = 0.015).

CONCLUSIONS

Elevated preoperative NLR demonstrates significant association with poor survival in post-CN mRCC patients and may facilitate clinical decision-making.

Real-World Impact of Upfront Cytoreductive Nephrectomy in Metastatic Non-Clear Cell Renal Cell Carcinoma Treated with First-Line Immunotherapy Combinations or Tyrosine Kinase Inhibitors (A Sub-Analysis from the ARON-1 Retrospective Study)

BACKGROUND

About 20% of patients with renal cell carcinoma present with non-clear cell histology (nccRCC), encompassing various histological types. While surgery remains pivotal for localized-stage nccRCC, the role of cytoreductive nephrectomy (CN) in metastatic nccRCC is contentious. Limited data exist on the role of CN in metastatic nccRCC under current standard of care.

OBJECTIVE

This retrospective study focused on the impact of upfront CN on metastatic nccRCC outcomes with first-line immune checkpoint inhibitor (IO) combinations or tyrosine kinase inhibitor (TKI) monotherapy.

METHODS

The study included 221 patients with nccRCC and synchronous metastatic disease, treated with IO combinations or TKI monotherapy in the first line. Baseline clinical characteristics, systemic therapy, and treatment outcomes were analyzed. The primary objective was to assess clinical outcomes, including progression-free survival (PFS) and overall survival (OS). Statistical analysis involved the Fisher exact test, Pearson's correlation coefficient, analysis of variance, Kaplan-Meier method, log-rank test, and univariate/multivariate Cox proportional hazard regression models.

RESULTS

Median OS for patients undergoing upfront CN was 36.8 (95% confidence interval [CI] 24.9-71.3) versus 20.8 (95% CI 12.6-24.8) months for those without CN (p = 0.005). Upfront CN was significantly associated with OS in the multivariate Cox regression analysis (hazard ratio 0.47 [95% CI 0.31-0.72], p < 0.001). In patients without CN, the median OS and PFS was 24.5 (95% CI 18.1-40.5) and 13.0 months (95% CI 6.6-23.5) for patients treated with IO+TKI versus 7.5 (95% CI 4.3-22.4) and 4.9 months (95% CI 3.0-8.1) for those receiving the IO+IO combination (p = 0.059 and p = 0.032, respectively).

CONCLUSIONS

Our study demonstrates the survival benefits of upfront CN compared with systemic therapy without CN. The study suggests that the use of IO+TKI combination or, eventually, TKI monotherapy might be a better choice than IO+IO combination for patients who are not candidates for CN regardless of IO eligibility. Prospective trials are needed to validate these findings and refine the role of CN in current mRCC management.

Understanding and integrating cytoreductive nephrectomy with immune checkpoint inhibitors in the management of metastatic RCC

Cytoreductive nephrectomy became accepted as standard of care for selected patients with metastatic renal cell carcinoma (mRCC) because of improved survival observed in patients treated with cytoreductive nephrectomy in combination with interferon-α in two randomized clinical trials published in 2001. Over the past two decades, novel systemic therapies have shown higher treatment response rates and improved survival outcomes compared with interferon-α. During this rapid evolution of mRCC treatments, systemic therapies have been the primary focus of clinical trials. Results from multiple retrospective studies continue to suggest an overall survival benefit for selected patients treated with nephrectomy in combination with systemic mRCC treatments, with the notable exception of one debated clinical trial. The optimal timing for surgery is unknown, and proper patient selection remains crucial to improving surgical outcomes. As systemic therapies continue to evolve, clinicians have an increasing need to understand how to incorporate cytoreductive nephrectomy into the management of mRCC.

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.

Surgical and focal treatment for metastatic renal cell carcinoma: A literature review

Accompanied by the development of systemic therapy for metastatic renal cell carcinoma, the concept of focal treatment, including surgical treatment, has been changing. Although immediate cytoreductive nephrectomy was essentially considered for synchronous metastatic renal cell carcinoma patients, the CARMENA trial and SURTIME trial revealed the negative impact of immediate cytoreductive nephrectomy. Therefore, immediate cytoreductive nephrectomy is currently considered only for a limited number of patients. Besides, deferred cytoreductive nephrectomy seems to have efficacy for overall survival in prior retrospective studies. Two randomized controlled trials, the PROBE trial (NCT04510597) and the NORDIC-SUN trial (NCT03977571), are underway to elucidate deferred cytoreductive nephrectomy. Metastasectomy is also considered in metastatic renal cell carcinoma patients because previous studies demonstrated the overall survival benefit of metastasectomy. However, since all reports were retrospective studies, physicians could exclude the patients who were not expected to show the efficacy of metastasectomy. Therefore, an adequate patient selection for metastasectomy is important. A common factor predicting better overall survival was complete resection. Radiotherapies for metastatic lesions during systemic therapy showed approximately 90% local disease control rate at 1 year. However, no report has demonstrated that radiotherapy improves survival so far. Since surgical and focal treatments for metastatic renal cell carcinoma patients generally have minimal evidence, further investigations are needed.

Cytoreductive Nephrectomy in Patients Presenting With Advanced Disease: Have We Finally Answered the Question?

Determining the appropriate patients for cytoreductive nephrectomy (CN) has evolved with the integration of more effective systemic therapies for patients with metastatic renal cell carcinoma (mRCC). While previously considered to be first-line therapy for mRCC, CN has not demonstrated a significant survival advantage over systemic therapy in more recent randomized trials when compared with targeted therapy. Conversely, multiple observational studies demonstrate a therapeutic benefit for CN. This review synthesizes the current literature regarding patient selection for CN and further evaluates the role of CN in the current era of immune checkpoint inhibitor therapy. With careful patient selection, CN maintains an important role in the management of mRCC patients.

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.

Position of cytoreductive nephrectomy in the setting of metastatic renal cell carcinoma patients: does the CARMENA trial lead to a paradigm shift?

Introduction > The role of cytoreductive nephrectomy (CN) in combination with targeted therapy has been debated after the results of the CARMENA trial. We decided to reassess the available evidence on the setting of CN in metastatic renal cell carcinoma (mRCC) patients. Methods > Critical review of the literature focusing on CN in mRCC patients. Results > Previous trials demonstrated a survival benefit of CN during the cytokine-era. In the targeted therapies-era, retrospective studies has confirmed the survival benefit of CN but presented inherent selection biases. Recently, the CARMENA trial showed that sunitinib alone was not inferior to CN plus sunitinib, and could be followed by subsequent CN in good-responders patients. CN is found to be a morbid surgery (perioperative mortality rate of 0-13% and major postoperative complications rate of 3-36%) and should be avoided in patients with primary refractory disease, using targeted therapy as a selection tool. Some parameters have been associated with shorter overall survival, leading to propose up-front CN only to patients with good performance status, a high-volume renal tumor and a low metastatic burden. Conclusions > While previous studies demonstrated a survival benefit of CN, the CARMENA trial showed that immediate CN was not necessary in some patients with mRCC, leading to a paradigm shift. Targeted therapy should be proposed as first line treatment, and the response to pre-surgical therapy could be used as a selection tool for subsequent decision of CN in good-responders patients.

The Value of Neutrophil to Lymphocyte Ratio in Patients Undergoing Cytoreductive Nephrectomy with Thrombectomy

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) is an established signature of inflammation used for evaluating renal cell carcinoma (RCC).

OBJECTIVE

To determine the utility of NLR and its relationship with known risk factors associated with poor survival in patients with metastatic RCC and tumor thrombus undergoing cytoreductive nephrectomy (CN).

DESIGN, SETTING, AND PARTICIPANTS

Prognostic variables were reviewed for patients undergoing CN with thrombectomy between 2000 and 2014 from six different institutions. Patients were stratified for NLR >4.0 based on cut point analysis.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Kaplan-Meier curves compared overall survival of the total cohort and established risk models (Memorial Sloan Kettering Cancer Center [MSKCC], International Metastatic Renal-Cell Carcinoma Database Consortium [IMDC], and M.D. Anderson Cancer Center [MDACC]) stratified by NLR. Multivariable Cox regression determined predictors of overall survival. Receiver operator characteristic curves tested the predictive accuracy of survival ≥12 mo, and area under the curve (AUC) was compared between models.

RESULTS AND LIMITATIONS

In total, 332 patients were identified. Patients with NLR ≤4.0 had longer median survival (24.7 vs 15.2 mo, p=0.004). NLR >4.0 distinguished patients with significantly shorter survival for non-poor-risk groups defined by MSKCC, IMDC, and MDACC criteria. Systemic symptoms, low hemoglobin, elevated lactate dehydrogenase, retroperitoneal adenopathy, level IV thrombus, elevated absolute neutrophil count, and NLR >4 were independent predictors of decreased survival (p<0.05). These factors had higher predictive accuracy for survival at 12 mo (AUC=0.755) than MKSCC, IMDC, and MSKCC models.

CONCLUSIONS

NLR >4.0 independently predicts poor survival and further distinguishes established risk model survival curves. We identified seven preoperative risk factors related to poor survival for patients with metastatic RCC with tumor thrombus undergoing CN.

PATIENT SUMMARY

The neutrophil-lymphocyte ratio and six additional preoperative variables can be used to better council patients regarding survival after surgery for metastatic renal cell carcinoma with tumor thrombus.

Role of cytoreductive nephrectomy in the targeted therapy era: A systematic review and meta-analysis

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.