Lost in time pulmonary metastases of renal cell carcinoma: complete surgical resection of metachronous metastases, 18 and 15 years after nephrectomy

Prognostic Factors Affecting Survival after Pulmonary Resection of Metastatic Renal Cell Carcinoma: A Multicenter Experience

Simple Summary

This multicentric paper aimed at evaluating the role of pulmonary metastasectomy in patients affected by metastatic renal cell carcinoma. The impact of pulmonary metastasectomy was analysed with respect to long-term survival and disease-free survival in a wide population of patients affected by pulmonary metastases from renal cell carcinoma. The prognostic value of factors affecting survival, disease-free interval and disease-free survival was evaluated. Our results aid clinicians in identifying those patients affected by pulmonary metastases from renal cell carcinoma who are more likely to benefit from pulmonary metastasectomy.

Abstract

In this paper we aimed to address the role of pulmonary metastasectomy (PM) in patients affected by Lung Metastases (LM) from Renal Cell Carcinoma (RCC) and to analyse prognostic factors affecting overall survival (OS), disease-free interval (DFI) between primary RCC and first LM, and disease-free survival (DFS) after PM and before lung recurrence. Medical records of 210 patients who underwent PM from RCC in 4 Italian Thoracic Centres, from January 2000 to September 2019, were collected and analysed. All patients underwent RCC resection before lung surgery. The main RCC histology was clear cells (188, 89.5%). The 5- and 10-year OS from the first lung operation were 60% and 34%, respectively. LM synchronous with RCC (p = 0.01) and (Karnofsky Performance Status Scale) KPSS < 80% (p < 0.001) negatively influenced OS. Five- and 10-year DFI were 54% and 28%, respectively. The main factors negatively influencing DFI were: male gender (p = 0.039), KPSS < 80% (p = 0.009) and lactate dehydrogenase > 1.5 times 140 U/L (p = 0.001). Five- and 10-year disease-free survival were 54% and 28%, respectively; multiple LM (p = 0.036), KPSS < 80% (p = 0.001) and histology of RCC other than clear cells negatively influenced disease-free survival. Conclusions: patients with KPSS > 80%, single metachronous LM with a long DFI from RCC diagnosis, and clear cell histology, benefit from pulmonary metastasectomy.

Spontaneous Regression of Delayed Pulmonary and Mediastinal Metastases from Clear Cell Renal Cell Carcinoma

Renal cell carcinoma (RCC) is often metastatic at diagnosis. Conventional therapies such as chemotherapy, radiotherapy, and hormonal therapy have generally proven ineffective in the treatment of RCC. The abscopal effect, specifically, the ability of localized radiation to trigger systemic antitumor effects, has been reported to lead to regression of non-irradiated distant tumor lesions. Herein, we report 3 patients with non-metastatic clear cell RCC (CCRCC) who underwent a nephrectomy and experienced metachronous pulmonary/mediastinal metastases confirmed as CCRCC. No patients underwent radiation post-nephrectomy or pulmonary metastasectomy. The mean duration was 7.24 weeks from the last negative chest CT prior to the nephrectomy and 96.2 weeks post-nephrectomy. All patients achieved durable complete response by RECIST criteria, with a mean follow-up duration of 115 months. Our case series represents the largest in the literature of patients who underwent a nephrectomy for CCRCC with no pre-existing pulmonary/mediastinal metastatic disease confirmed by chest CT, did not undergo radiotherapy, and developed significantly delayed CCRCC pulmonary/mediastinal metastases. We highlight the spontaneous regression of delayed metastatic disease and the role of immune responses in curtailing the growth of pulmonary metastasis in CCRCC.

Surgical intervention in renal cell carcinoma patients with lung and bronchus metastasis is associated with longer survival time: a population-based analysis

Background

As the most common metastasis site in renal cell carcinoma (RCC) patients, lung and bronchus metastasis (LBM) represents a late stage and a poor prognosis. The purpose of our study is to determine the impact of surgical intervention on prognosis of RCC patients with LBM by means of analysis the data from the Surveillance, Epidemiology and End Results (SEER) database.

Methods

The population data of RCC patients with LBM was extracted from the SEER database [1973-2015]. For each patient, age, gender, race, region, tumor histology, cause of death to site record, tumor grade, surgical intervention, and overall survival time were extracted from SEER database. Baseline characteristics were compared using the χ² test for the categorical variables. The survival analysis was estimated using the Kaplan-Meier (K-M) method and univariate comparison were performed using the log-rank test and unadjusted Cox proportional hazards regression models. Multivariate Cox proportional hazards regression survival models were adjusted. A second multivariate Cox proportional hazards regression survival model was created using the dataset after propensity score-matching approach (PSM).

Results

A total of 1,190 RCC patients with LBM were included, of whom 1,087 patients underwent surgery and 103 patients unperformed surgery. The median survival time was 56 months (95% CI, 54 to 59) for the surgery group, and 6 months (95% CI, 5 to 7) for non-surgery group. LBM patients underwent surgery had significantly longer survival time (log-rank test, P<0.001). In univariate analysis, the survival of RCC patients was significantly associated with surgery (P<0.001), grade II (P=0.014), grade III (P=0.001) and grade IV (P<0.001). Moreover, multivariate analysis indicated that surgery (P<0.001), grade II (P=0.018), grade III (P<0.001) and grade IV (P<0.001) were independent prognostic indexes for overall survival. Besides, in the subgroup of 1 years survival after diagnosis, longer survival times were seen in the surgery arms rather than non-surgery arms (P<0.001). In addition, longer survival times were observed in surgery arms in the subgroups of grade I, II, III and IV (all P<0.001).

Conclusions

RCC patients with LBM who have surgical intervention might obtain a significantly longer survival time than non-surgical options. In consequence, surgery should be the preferred choice for eligible patients.

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 approaches of endobronchial neoplasms

Endobronchial tumors are a rare entity that presents with different pathological findings. The interventional pulmonologist, but also the thoracic surgeon have at their disposal the same techniques for diagnosis, however; the two modalities differentiate in the treatment approach. Diagnosis evaluation should include lymph node evaluation. Minimal invasive techniques under local or general anesthesia are usually preferred by the interventional pulmonologists, whereas in the surgical approach of the thoracic surgeons the general anesthesia is necessary. A more extensive surgical approach either lobotomy or pneumonectomy should be performed in cases with positive intrapulmonary lymph nodes. Carinal reconstruction should be performed skillfully to get a negative proximal margin whenever needed. In the current manuscript we will present the methods of patient evaluation and surgical techniques for the management of these lesions.

Pulmonary hamartoma resembling multiple metastases: A case report

The current study presents the case of a patient with multiple pulmonary nodules as observed by computed tomography. Furthermore, a marginal increase in fluorodeoxyglucose uptake was identified by positron emission tomography. Due to the appearance of multiple small nodules and a history of radical nephrectomy, a hypothetical diagnosis of pulmonary metastasis of a previously excised renal carcinoma was determined, which was confirmed by biopsy. Video-assisted thoracoscopic surgical resection of the nodules was proposed and pathological examination exhibited an unforeseen and rare observation.