Metastatectomy prior to Immunochemotherapy for Metastatic Renal Cell Carcinoma

The effect of metastasectomy on overall survival in metastatic renal cell carcinoma: A systematic review and meta-analysis

PURPOSE

Metastasectomy (MTS) is a treatment option for patients diagnosed with metastatic Renal Cell Carcinoma (mRCC). Nevertheless, the benefits of MTS as they pertain to survival remain controversial. This systematic review aims to compare the survival outcomes of patients who underwent MTS, as well as discover which clinical factors were related to the results.

METHODS

From their inception up to August 2020, a systematic review of the EMBASE, PubMed, Cochrane library, and Web of science databases was performed. Studies which reported outcomes on patients who underwent MTS for the treatment of mRCC were included. The sites, times, amount, histology types of metastasis, and prior nephrectomy were also analyzed. The primary efficacy end point was Overall Survival (OS). A meta-analysis was performed to calculate hazard ratio, 95% confidence intervals, and I² values. Forest plots were constructed for each analysis group.

RESULTS

The systematic review and reference list search identified 294 articles, with 17 meeting studies as inclusion criteria. The MTS group showed a competitive advantage in OS, in that the non-MTS group was negatively associated with an overall survival rate (HR [non-MTS vs. MTS] = 2.15, 95% CI: 1.59-2.92, P< 0.001). Moreover, patients treated with the most recently available target therapy without MTS showed a significantly increased risk compared with the MTS group (HR = 1.82, 95% CI:1.23-2.70, P= 0.003). Additionally, meta-analysis revealed HR elevating in patients with nonlung only metastasis (HR = 1.87, 95% CI: 1.55-2.26, P< 0.001), synchronous metastasis (HR = 1.28, 95% CI: 1.10-1.49, P= 0.001), and multiple metastases (HR = 2.06, 95% CI: 1.64-2.59, P< 0.001). Clear-cell type mRCC (HR = 0.62, 95% CI: 0.48-0.82, P= 0.0006) and prior nephrectomy (HR = 0.37, 95% CI: 0.15-0.91, P= 0.03) were positively associated with a better overall survival rate.

CONCLUSIONS

MTS is a treatment option for mRCC patients with prolonged overall survival time. The operation has additional advantages, particularly in patients with lung only metastasis, asynchronous metastasis, fewer metastasis sites, clear-cell type mRCC, and the patients who had received nephrectomy.

Nine-year survival after iterative metastasectomies for renal cell carcinoma

We report the case of a 24-year-old male, diagnosed with an incidental T3a papillary renal cell carcinoma (RCC), treated with left laparoscopic radical nephrectomy. After 7 months, nodal recurrence was identified and retroperitoneal lymph node dissection (RPLND) was performed. Four months later, due to local recurrence, the patient underwent salvage RPLND, partial psoas resection and left adrenalectomy, and remained without recurrence during the following 15 months, after which treatment with sunitinib was started due to multiple metastases in pelvic lymph nodes, lungs, and bone. After 4 years of stable disease, progression at the quadratus lumborum and psoas muscles led to subsequent metastasectomy. No evidence of progression was identified for 2 years, after which, despite multimodal treatment (axitinib and radiotherapy to bone lesions), widespread disease progression led to patient death. This uncommon case of prolonged survival with metastatic RCC highlights the possible role of iterative metastasectomies in the management of advanced stage disease, as well as its potential to extend the survival substantially, even when progressive on tyrosine kinase inhibitors.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : prise en charge du cancer du reinFrench ccAFU guidelines – Update 2018–2020: Management of kidney cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article.

Therapeutic approaches in clear cell and non-clear cell renal cell carcinoma

Renal cell carcinoma (RCC) accounts for 2.4% of all malignancies worldwide diagnosed with 338,000 estimated new cases globally in 2012. In the last decade, the therapeutic landscape for RCC patients has changed tremendously. In this review, we will summarize the treatment options currently available for clear-cell localized, advanced and metastatic RCC (mRCC); as stated in the ESMO clinical practice guidelines, the EAU guidelines and the NCCN guidelines. Furthermore, we will discuss the recommended therapies in patients diagnosed with non-clear cell tumours.

Local treatments for metastases of renal cell carcinoma: a systematic review

Local treatment of metastases such as metastasectomy or radiotherapy remains controversial in the treatment of metastatic renal cell carcinoma. To investigate the benefits and harms of various local treatments, we did a systematic review of all types of comparative studies on local treatment of metastases from renal cell carcinoma in any organ. Interventions included metastasectomy, radiotherapy modalities, and no local treatment. The results suggest that patients treated with complete metastasectomy have better survival and symptom control (including pain relief in bone metastases) than those treated with either incomplete or no metastasectomy. Nevertheless, the available evidence was marred by high risks of bias and confounding across all studies. Although the findings presented here should be interpreted with caution, they and the identified gaps in knowledge should provide guidance for clinicians and researchers, and directions for further research.

Efficacy of computer-aided detection system and thin-slab maximum intensity projection technique in the detection of pulmonary nodules in patients with resected metastases

OBJECTIVES

To evaluate the efficacy of the computer-aided detection (CAD) system and thin-slab maximum intensity projection (MIP) technique in the detection of pulmonary nodules at multidetector computed tomography (CT) in patients who underwent metastatectomy.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board and patients' informed consent was waived. Forty-nine consecutive patients who underwent pulmonary metastatectomy were enrolled. Four chest radiologists analyzed preoperative 1-mm section CT images and recorded the locus of each nodule candidate. Afterward, they reevaluated the images once using CAD software and once with thin-slab MIP given the results of 1-mm section CT alone. The reference standard for nodule presence was established by a consensus panel and pathologic records for malignant nodules.

RESULTS

A total of 514 nodules were identified by a consensus panel. Of 212 nodules surgically removed, 121 nodules were malignant. The sensitivity of each observer in detecting malignant nodules with thin-section CT scans alone was 91%, 88%, 87%, and 86% for observers A- to D, respectively. With CAD, sensitivity increased significantly to 95%, 95%, 94%, and 95% (P< 0.05 for observer B-D), and using MIP increased to 94%, 96%, 91%, and 92% (P < 0.05 for observer B-D), respectively. There were no significant differences in sensitivity between CAD and MIP for the detection of malignant nodules. The average number of false-positive findings per patient was 0.8 with thin-section CT alone, 1.1 with CAD, and 1.4 with MIP.

CONCLUSIONS

In candidates for metastatectomy, reading with the aid of either CAD or MIP significantly improved the detection of malignant nodules compared with using thin-section CT alone.

Extension of survival by resection of asynchronous renal cell carcinoma metastases to mediastinal lymph nodes

OBJECTIVE

The aim of this study was to determine whether or not resection of isolated mediastinal lymph node renal cell carcinoma metastases confers a survival advantage, as compared with patients with stage IV disease.

PATIENTS AND METHODS

We retrospectively reviewed the charts of all patients with renal cell carcinoma whose histologic specimens were evaluated at our institution from January 1, 2000, through December 31, 2006. Using Kaplan-Meier estimates, we compared the survival of patients who underwent resection of asynchronous mediastinal lymph node metastases with that of patients with stage IV disease.

RESULTS

During the 7-year study period, of the 386 patients with renal cell carcinoma who were evaluated at our institution, 9 underwent resection of asynchronous mediastinal lymph node metastases. After primary tumor resection and before diagnosis of asynchronous mediastinal lymph node metastases, all patients completed chemotherapy, cytokine therapy, or tumor vaccination; 3 underwent radiotherapy. The median age at resection of mediastinal lymph nodes was 57.7 years (range, 39.7-81.2). The median time from primary tumor resection to mediastinal lymph node resection was 2.8 years (range, 0.5-23.3). In all, 4 patients underwent resection of metastases via thoracotomy and 5, via thoracoscopy. The median number of mediastinal lymph nodes pathologically evaluated was 7 (range, 2-28); the median number of positive mediastinal lymph nodes per patient was 1.5 (range, 1-3). We found no surgical complications. The median survival after resection of metastases (3.2 years) was significantly longer (P = .021) than for other patients with stage IV disease at our institution (1.1 years).

CONCLUSIONS

Resection of renal cell carcinoma mediastinal lymph node metastases is safe, appears to extend survival, and should be considered an important component of treating patients with renal cell carcinoma who have asynchronous mediastinal lymph node metastases.