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Abel EJ, Master VA, Spiess PE, Raman JD, Shapiro DD, Sexton WJ, Zemp L, Patil D, Lauer K, Allen GO, Matin SF, Karam JA. The Selection for Cytoreductive Nephrectomy (SCREEN) Score: Improving Surgical Risk Stratification by Integrating Common Radiographic Features. Eur Urol Oncol 2024; 7:266-274. [PMID: 37442673 DOI: 10.1016/j.euo.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/05/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Careful patient selection is critical when considering cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) but few studies have investigated the prognostic value of radiologic features that measure tumor burden. OBJECTIVE To develop a prognostic model to improve CN selection with integration of common radiologic features with known prognostic factors associated with mortality in the first year following surgery. DESIGN, SETTINGS, AND PARTICIPANTS Data were analyzed for consecutive patients with mRCC treated with upfront CN at five institutions from 2006 to 2017. Univariable and multivariable models were used to evaluate radiographic features and known risk factors for associations with overall survival. Relevant factors were used to create the SCREEN model and compared to the International mRCC Database Consortium (IMDC) model for predictive accuracy and clinical usefulness. RESULTS AND LIMITATIONS A total of 914 patients with mRCC were treated with upfront CN during the study period. Seven independently predictive variables were used in the SCREEN score: three or more metastatic sites, total metastatic tumor burden ≥5 cm, bone metastasis, systemic symptoms, low serum hemoglobin, low serum albumin, and neutrophil/lymphocyte ratio ≥4. Predictive accuracy measured as the area under the receiver operating characteristic curves was 0.76 for the SCREEN score and 0.55 for the IMDC model. Decision curve analysis showed that the SCREEN model was useful beyond the IMDC classifier for threshold first-year mortality probabilities between 15% and 70%. CONCLUSIONS The SCREEN score had higher predictive accuracy for first-year mortality compared to the IMDC scheme in a multi-institutional cohort and may be used to improve CN selection. PATIENT SUMMARY This study provides a model to improve selection of patients with metastatic kidney cancer who may benefit from surgical removal of the primary kidney tumor. We found that radiographic measurements of the tumor burden predicted the risk of death in the first year after surgery. The model can be used to improve decision-making by these patients and their physicians.
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Affiliation(s)
- E Jason Abel
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Viraj A Master
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jay D Raman
- Department of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Daniel D Shapiro
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Logan Zemp
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Dattatraya Patil
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kate Lauer
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Glenn O Allen
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Reese SW, Eismann L, White C, Villada JA, Khaleel S, Ostrovnaya I, Vazquez-Rivera K, Carlo MI, Feldman D, Lee CH, Motzer R, Voss MH, Kotecha RR, Matulewicz RS, Goh A, Coleman J, Russo P, Hakimi AA. Surgical outcomes of cytoreductive nephrectomy in patients receiving systemic immunotherapy for advanced renal cell carcinoma. Urol Oncol 2024; 42:32.e9-32.e16. [PMID: 38135627 PMCID: PMC10922785 DOI: 10.1016/j.urolonc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 11/15/2023] [Accepted: 12/02/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE The use of systemic immune checkpoint blockade before surgery is increasing in patients with metastatic renal cell carcinoma, however, the safety and feasibility of performing consolidative cytoreductive nephrectomy after the administration of systemic therapy are not well described. PATIENTS AND METHODS A retrospective review of patients undergoing nephrectomy was performed using our prospectively maintained institutional database. Patients who received preoperative systemic immunotherapy were identified, and the risk of postoperative complications were compared to those who underwent surgery without upfront systemic treatment. Perioperative characteristics and surgical complications within 90 days following surgery were recorded. RESULTS Overall, we identified 220 patients who underwent cytoreductive nephrectomy from April 2015 to December 2022, of which 46 patients (21%) received systemic therapy before undergoing surgery. Unadjusted rates of surgical complications included 20% (n = 35) in patients who did not receive upfront systemic therapy and 20% (n = 9) in those who received upfront systemic immunotherapy. In our propensity score analysis, there was no statistically significant association between receipt of upfront immunotherapy and 90-day surgical complications [odds ratio (OR): 1.82, 95% confidence interval (CI): 0.59-5.14; P = 0.3]. This model, however, demonstrated an association between receipt of upfront immunotherapy and an increased odds of requiring a blood transfusion [OR: 4.53, 95% CI: 1.83-11.7; P = 0.001]. CONCLUSION In our cohort, there was no significant difference in surgical complications among patients who received systemic therapy before surgery compared to those who did not receive upfront systemic therapy. Cytoreductive nephrectomy is safe and with low rates of complications following the use of systemic therapy.
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Affiliation(s)
- Stephen W Reese
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lennert Eismann
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Ludwig-Maximilians University, Geschwister-Scholl-Platz 1, München, Germany
| | - Charlie White
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juan Arroyave Villada
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sari Khaleel
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katiana Vazquez-Rivera
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maria I Carlo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Darren Feldman
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chung-Han Lee
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Motzer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin H Voss
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ritesh R Kotecha
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard S Matulewicz
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alvin Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Ari Hakimi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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3
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Bellouki O, Ibrahimi A, Soufiani I, Boualaoui I, El Sayegh H, Nouini Y. Blepharoptosis revealing a metastatic renal cell carcinoma: A rare case report. Int J Surg Case Rep 2023; 112:108910. [PMID: 37837662 PMCID: PMC10667753 DOI: 10.1016/j.ijscr.2023.108910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/16/2023] Open
Abstract
INTRODUCTION Renal cell carcinoma (RCC) is a relatively rare malignancy often discovered incidentally. Approximately 15 % of cases are metastatic at diagnosis, commonly affecting the lungs, bones, lymph nodes, and liver. We present an exceptional case of RCC metastasizing to the eyelid. CASE PRESENTATION A 67-year-old female with no prior cancer history exhibited rapidly progressing left blepharoptosis. Examination revealed a painless, solid eyelid mass. Immunohistochemistry of the eyelid mass biopsy identified a carcinoma potentially of renal origin. A thorax, abdomen, and pelvis CT scan confirmed the presence of a right renal mass. Following a multidisciplinary discussion, we decided to proceed with an upfront cytoreductive nephrectomy and surgical excision of the eyelid metastasis. DISCUSSION Eyelid metastasis revealing a renal cell carcinoma is exceedingly rare. Immunohistochemistry plays a pivotal role in detecting primary renal tumors. Prognostic models, particularly the IMDC, guide therapeutic decisions. In the era of immune checkpoint inhibitors, cytoreductive nephrectomy remains a safe option for well-selected patients with favorable risk mRCC. CONCLUSION Recognizing unusual metastatic sites of RCC is vital due to its asymptomatic nature and the potential impact of delayed diagnosis on prognosis. Immunohistochemistry plays a critical role in diagnosis. Multidisciplinary tumor board discussions are essential for tailored management of favorable risk mRCC patients.
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Affiliation(s)
- Omar Bellouki
- Urology "A" Department, Ibn Sina University Hospital of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.
| | - Ahmed Ibrahimi
- Urology "A" Department, Ibn Sina University Hospital of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.
| | - Ilyas Soufiani
- Urology "A" Department, Ibn Sina University Hospital of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.
| | - Imad Boualaoui
- Urology "A" Department, Ibn Sina University Hospital of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.
| | - Hachem El Sayegh
- Urology "A" Department, Ibn Sina University Hospital of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.
| | - Yassine Nouini
- Urology "A" Department, Ibn Sina University Hospital of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco.
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Nolazco JI, Chang SL. Role of Surgery in Metastatic Renal Cell Carcinoma. Hematol Oncol Clin North Am 2023; 37:893-905. [PMID: 37330346 DOI: 10.1016/j.hoc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Surgery has historically been the mainstay of treatment for metastatic renal cell carcinoma (mRCC), but recent clinical trials demonstrated that contemporary systemic therapies alone are non-inferior to cytoreductive nephrectomy (CN). Thus, the current role of surgery is not precisely defined. CN remains an appropriate upfront treatment for the palliation of severe symptoms, select cases of metastatic non-clear cell renal cell carcinoma, for consolidation following systemic therapy, and in the setting of oligometastatic disease. Metastasectomy is ideally utilized to achieve a disease-free state when there is minimal morbidity associated with surgery. Given the heterogenous nature of mRCC, the decision for systemic therapy and surgery should be made through a multidisciplinary approach tailored to each individual patient.
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Affiliation(s)
- José Ignacio Nolazco
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA; Servicio de Urología, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina
| | - Steven Lee Chang
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA.
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5
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Hasan, Bramono IA, Hamid ARAH, Santoso RB, Harahap EU, Rayhani F. Renal cell carcinoma not otherwise specified: A case report in Indonesia. Urol Case Rep 2023; 50:102527. [PMID: 37649689 PMCID: PMC10462864 DOI: 10.1016/j.eucr.2023.102527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/07/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023] Open
Abstract
Renal cell carcinoma not otherwise specified (RCC NOS) is a very rare type of kidney cancer which used for renal tumors that do not fit into any of the well-recognized subtypes. We reported a case of RCC NOS of a 64-year-old male presenting an enlarging left flank mass. Abdominal CT showed a left kidney mass infiltrating to the adrenal, with pulmonary metastases. Cytoreductive nephrectomy and lymphadenectomy were performed and diagnosis of RCC NOS was confirmed through histopatological and immunohistochemistry examination.
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Affiliation(s)
- Hasan
- Department of Urology, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No. 71, Salemba, Jakarta Pusat, DKI Jakarta, 10430, Jakarta, Indonesia
| | - Ikhlas Arief Bramono
- Department of Urology, National Cancer Center, Dharmais Hospital, Jl. Letjen S. Parman No.84-86, Palmerah, Kota Jakarta Barat, DKI Jakarta, 11420, Jakarta, Indonesia
| | - Agus Rizal Ardy Hariandy Hamid
- Department of Urology, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No. 71, Salemba, Jakarta Pusat, DKI Jakarta, 10430, Jakarta, Indonesia
| | - Rachmat Budi Santoso
- Department of Urology, National Cancer Center, Dharmais Hospital, Jl. Letjen S. Parman No.84-86, Palmerah, Kota Jakarta Barat, DKI Jakarta, 11420, Jakarta, Indonesia
| | - Edward Usfie Harahap
- Department of Urology, National Cancer Center, Dharmais Hospital, Jl. Letjen S. Parman No.84-86, Palmerah, Kota Jakarta Barat, DKI Jakarta, 11420, Jakarta, Indonesia
| | - Farilaila Rayhani
- Department of Anatomical Pathology, National Cancer Center - Dharmais Hospital, Jl. Letjen S. Parman No.84-86, Palmerah, Kota Jakarta Barat, DKI Jakarta, 11420, Jakarta, Indonesia
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6
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Tappero S, Barletta F, Piccinelli ML, Cano Garcia C, Incesu RB, Morra S, Scheipner L, Tian Z, Parodi S, Dell'Oglio P, Palumbo C, Briganti A, De Cobelli O, Chun FKH, Graefen M, Longo N, Ahyai S, Saad F, Shariat SF, Suardi N, Borghesi M, Terrone C, Karakiewicz PI. The Association Between Cytoreductive Nephrectomy and Overall Survival in Metastatic Renal Cell Carcinoma with Primary Tumor Size ≤4 cm. Eur Urol Focus 2023; 9:742-750. [PMID: 36906483 DOI: 10.1016/j.euf.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/26/2023] [Accepted: 02/21/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND It is unknown whether the survival benefit of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) applies to patients with primary tumor size ≤4 cm. OBJECTIVE To test the association between CN on overall survival (OS) of mRCC patients with primary tumor size ≤4 cm. DESIGN, SETTING, AND PARTICIPANTS Within the Surveillance, Epidemiology, and End Results (SEER) database (2006-2018), all mRCC patients with primary tumor size ≤4 cm were identified. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Propensity score matching (PSM), Kaplan-Meier plots, multivariable Cox regression analyses, and 6-mo landmark analyses addressed OS according to CN status. Sensitivity analyses examined specific populations of special interest: systemic therapy exposed versus naïve, clear-cell (ccmRCC) versus non-clear-cell (non-ccmRCC) mRCC histology, historical (2006-2012) versus contemporary (2013-2018), and young (≤65 yr) versus old (>65 yr) patients. RESULTS AND LIMITATIONS Of 814 patients, 387 (48%) underwent CN. After PSM, the median OS was 44 versus 7 mo (Δ = 37 mo; p < 0.001) in CN versus no-CN patients. CN was associated with higher OS in overall population (multivariable hazard ratio [HR]: 0.30; p < 0.001) as well as in landmark analyses (HR: 0.39; p < 0.001). In all sensitivity analyses, CN was independently associated with higher OS: systemic therapy exposed, HR: 0.38; systemic therapy naïve, HR: 0.31; ccmRCC, HR: 0.29; non-ccmRCC, HR: 0.37; historical, HR: 0.31; contemporary, HR: 0.30; young, HR: 0.23; and old, HR: 0.39 (all p < 0.001). CONCLUSIONS The current study validates the association between CN and higher OS in patients with primary tumor size ≤4 cm. This association is robust, controlled for immortal time bias, and valid across systemic treatment exposure, histologic subtypes, years of surgery, and patient age. PATIENT SUMMARY In the current study, we tested the association between cytoreductive nephrectomy (CN) and overall survival in patients with metastatic renal cell carcinoma and small primary tumor size. We found a strong association between CN and survival, which persists even after several significant variations in patient and tumor characteristics.
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Affiliation(s)
- Stefano Tappero
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy.
| | - Francesco Barletta
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Mattia Luca Piccinelli
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Cristina Cano Garcia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Reha-Baris Incesu
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Morra
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Lukas Scheipner
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, Medical University of Graz, Graz, Austria
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Stefano Parodi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Paolo Dell'Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carlotta Palumbo
- Division of Urology, Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Ottavio De Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nicola Longo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Sascha Ahyai
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Nazareno Suardi
- Department of Urology, Spedali Civili of Brescia, Brescia, Italy
| | - Marco Borghesi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Carlo Terrone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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Luo Z, Jiao B, Xu Q, He W, Zhao H, Liu Y, Chen H, Guan Y, Zhang G, Jiang Z. Do patients with metastatic renal cell carcinoma obtain survival benefits from cytoreductive nephrectomy? A population-based study. J Cancer Res Clin Oncol 2023; 149:9657-9670. [PMID: 37231275 DOI: 10.1007/s00432-023-04885-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/19/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE This study aimed to explore the value of cytoreductive nephrectomy (CN) and develop nomograms to predict the prognosis of metastatic renal cell carcinoma (mRCC) patients with receiving radiology therapy or/and chemotherapy (RT/&CT). METHODS Clinical data of patients with mRCC between 2010 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Prognostic nomograms were constructed to predict the overall survival (OS) and cancer-specific survival (CSS) probability for 1-, 3-, and 5- years in patients with mRCC. A series of validation methods were used to validate the accuracy and reliability of the model, including area under the receiver operating curve (AUC), consistency index (C-index), calibration curve, and decision curve analysis (DCA). RESULTS 1394 patients were enrolled in this study. All patients were randomly divided into the training cohort (n = 976) and the validation cohort (n = 418). In the training cohort, multivariate Cox regression analysis suggested that pathology grade, histology type, T stage, N stage, surgery, and distant metastasis were independent risk factors for OS and CSS. The AUC and C-index were both over 0.65 in both cohorts, indicating that the nomograms for OS and CSS had satisfactory discriminative power. The calibration curves revealed that the predictive nomograms had a good consistency between the observed and the predicted survival. CONCLUSION This study provided evidence that mRCC patients underwent RT/&CT could gain survival benefits from CN. The prognostic nomogram constructed in our study is reliable and practical, may help guide clinical strategies in the treatment of mRCC.
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Affiliation(s)
- Zhenkai Luo
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Binbin Jiao
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 266000, China
| | - Qianwen Xu
- Department of Pediatrics, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266318, China
| | - Weifeng He
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 266000, China
| | - Hang Zhao
- Peking University, China-Japan Friendship School Clinical Medicine, Beijing, 100029, China
- Department of Urology, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yuhao Liu
- Peking University, China-Japan Friendship School Clinical Medicine, Beijing, 100029, China
- Department of Urology, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Haijie Chen
- Peking University, China-Japan Friendship School Clinical Medicine, Beijing, 100029, China
- Department of Urology, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yunfan Guan
- Peking University, China-Japan Friendship School Clinical Medicine, Beijing, 100029, China
- Department of Urology, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Guan Zhang
- Department of Urology, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Zhaoqiang Jiang
- Department of Urology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, China
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8
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Hahn AW, Kotecha RR, Viscuse PV, Pieretti AC, Wiele AJ, Jonasch E, Lee CH, Gao J, Zurita AJ, Shah AY, Campbell MT, Sharma P, Motzer RJ, Russo P, Wood CG, Tannir NM, Voss MH, Karam JA, Hakimi AA, Msaouel P. Cytoreductive Nephrectomy for Patients with Metastatic Sarcomatoid and/or Rhabdoid Renal Cell Carcinoma Treated with Immune Checkpoint Therapy. Eur Urol Focus 2023; 9:734-741. [PMID: 36863962 PMCID: PMC10460829 DOI: 10.1016/j.euf.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 02/16/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Renal cell carcinoma (RCC) with sarcomatoid and/or rhabdoid (S/R) dedifferentiation is a highly aggressive tumor with a poor prognosis. Immune checkpoint therapy (ICT) has shown significant treatment efficacy in this subtype. There remains uncertainly regarding the role of cytoreductive nephrectomy (CN) for patients with metastatic RCC (mRCC) with S/R who received ICT. OBJECTIVE Here, we report the outcomes with ICT for patients with mRCC and S/R dedifferentiation by CN status. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was conducted of 157 patients with sarcomatoid, rhabdoid, or sarcomatoid plus rhabdoid dedifferentiation who received an ICT-based regimen at two cancer centers. INTERVENTION CN performed at any time point; nephrectomy with curative intent was excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS ICT treatment duration (TD) and overall survival (OS) from ICT initiation were recorded. To address the immortal time bias, a time-dependent Cox regression model was generated that accounted for confounders identified by a directed acyclic graph as well as a time-dependent nephrectomy variable. RESULTS AND LIMITATIONS A total of 118 patients underwent CN, and of them, 89 underwent upfront CN. The results did not contradict the supposition that CN does not improve ICT TD (hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.65-1.47, p = 0.94) or OS from ICT initiation (HR 0.79, 95% CI 0.47-1.33, p = 0.37). In patients who underwent upfront CN compared with those who did not undergo CN, there was no association with ICT duration or OS (HR 0.61, 95% CI 0.35-1.06, p = 0.08). A detailed clinical summary of 49 patients with mRCC and rhabdoid dedifferentiation is provided. CONCLUSIONS In this multi-institutional cohort of mRCC with S/R dedifferentiation treated with ICT, CN was not significantly associated with improved TD or superior OS when accounting for the lead time bias. There appears to be a subset of patients who derive meaningful benefit from CN, so improved tools for stratification prior to CN are needed to optimize outcomes. PATIENT SUMMARY Immunotherapy has improved outcomes for patients with metastatic renal cell carcinoma (mRCC) who have sarcomatoid and/or rhabdoid (S/R) dedifferentiation, which is an aggressive and uncommon feature; yet, the utility of a nephrectomy in this setting is unclear. We found that nephrectomy did not significantly improve survival or time on immunotherapy for these patients with mRCC and S/R dedifferentiation; yet, there may be a subset of patients who benefit from this surgical approach.
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Affiliation(s)
- Andrew W Hahn
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ritesh R Kotecha
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul V Viscuse
- University of Virginia Cancer Center, University of Virginia, Charlottesville, VA, USA
| | - Alberto C Pieretti
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eric Jonasch
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chung-Han Lee
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jianjun Gao
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amado J Zurita
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amishi Y Shah
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Padmanee Sharma
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert J Motzer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Russo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Martin H Voss
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Ari Hakimi
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; David H. Koch Center for Applied Research of Genitourinary Cancers, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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9
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Chen K, Liu Z, Li Y, Zhao X, Zhang Y, Bi H, Wang G, Liu C, Tian X, Zhang H, Ma L, Zhang S. Long-term outcomes after cytoreductive nephrectomy and thrombectomy of patients with metastatic renal cell carcinoma with venous tumor thrombus: a retrospective study from a large Chinese center. World J Surg Oncol 2023; 21:170. [PMID: 37280590 DOI: 10.1186/s12957-023-03048-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/26/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Targeted therapy combined with immunotherapy is the current first-line treatment for metastatic renal cell carcinoma (mRCC), but patients with tumor thrombus (TT) may suffer from lower limb edema or even sudden cardiac death, so the purpose of this study is to investigate the efficacy and safety of surgical treatment in patients with mRCC and TT and explore worse factors to affect the prognosis in this series of patients. PATIENTS AND METHODS A total of 85 mRCC patients with TT who received cytoreductive nephrectomy and thrombectomy at our medical center from 2014 to 2023 are included. All patients received postoperative systemic therapy. Overall survival (OS) is defined as the time from surgery to death due to any reason or the last follow-up. Kaplan-Meier analysis was performed to evaluate OS and differences among groups were tested by log-rank. Multivariable Cox proportional hazards analysis was performed to ascertain independent relationships between clinicopathological factors and OS. RESULTS The median age of patients was 58 years old. Eleven patients (12.9%) had no symptoms, 39 patients (45.9%) had local symptoms, 15 patients (17.6%) had systemic symptoms, and 20 patients (23.5%) had both. Mayo grade of TT was 0, 1, 2, 3, and 4 for 12, 27, 31, 7, and 8 patients respectively. Fifty-five patients had lung metastasis, 23 had bone metastasis, 16 had liver metastasis, 13 had adrenal metastasis, and 9 had lymph node metastasis. Of all patients, 17 patients had multiple metastases. The median operation time is 289 min and the median intraoperative hemorrhage is 800 ml. Twenty-eight patients experienced postoperative complications, 8 of which were serious complications of modified Clavien grade III or higher. The median OS of all patients was 33 months and median follow up time was 26 months. In multivariate analysis, systemic symptom (p = 0.00753), pathological type (p = 0.0166), sarcomatous degeneration (p = 0.0334), and perirenal fat infiltration (p = 0.0202) are independent predictors of OS. CONCLUSION Cytoreductive nephrectomy and thrombectomy is relatively safe and effective for patients with mRCC accompanied by TT. In this series of patients, the worse prognosis is associated with systemic symptoms, non-clear cell carcinoma, sarcomatous degeneration and perirenal fat infiltration.
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Affiliation(s)
- Kewei Chen
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Yu Zhang
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Hai Bi
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Guoliang Wang
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China.
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10
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Abstract
The role of surgery for patients with locally advanced and metastatic renal cell carcinoma (RCC) is not precisely defined in our contemporary era of systemic therapies. Research in this field is focused on the role of regional lymphadenectomy, along with indications and timing of cytoreductive nephrectomy and metastasectomy. As our understanding of the molecular and immunological basis of RCC continues to develop along with the advent of novel systemic therapies, prospective clinical trials will be critical in defining how surgery should be integrated into the treatment paradigm of advanced RCC.
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Affiliation(s)
- Shagnik Ray
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA
| | - Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA
| | - Eric A Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA.
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11
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Shapiro DD, Karam JA, Zemp L, Master VA, Sexton WJ, Ghasemzadeh A, Schmeusser BN, Davaro F, Peak T, Patil D, Matin S, Spiess PE, Abel EJ. Cytoreductive Nephrectomy Following Immune Checkpoint Inhibitor Therapy Is Safe and Facilitates Treatment-free Intervals. EUR UROL SUPPL 2023; 50:43-46. [PMID: 36861106 PMCID: PMC9969293 DOI: 10.1016/j.euros.2023.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
Patients with metastatic renal cell cancer (mRCC) who respond to upfront immune checkpoint inhibitor (ICI) combination therapies may be treated with cytoreductive nephrectomy (CN) to remove radiographically viable primary tumors. Early data for post-ICI CN suggested that ICI therapies induce desmoplastic reactions in some patients, increasing the risk of surgical complications and perioperative mortality. We evaluated perioperative outcomes for 75 consecutive patients treated with post-ICI CN at four institutions from 2017 to 2022. Our cohort of 75 patients had minimal or no residual metastatic disease but radiographically enhancing primary tumors after ICI and were treated with CN. Intraoperative complications were identified in 3/75 patients (4%) and 90-d postoperative complications in 19/75 (25%), including two patients (3%) with high-grade (Clavien ≥III) complications. One patient was readmitted within 30 d. No patients died within 90 d after surgery. Viable tumor was present in all but one specimen. Approximately half of the patients (36/75, 48%) remained off systemic therapy at last follow-up. These data suggest that CN following ICI therapy is safe and associated with low rates of major postoperative complications in appropriately selected patients at experienced centers. Post-ICI CN may facilitate observation without additional systemic therapy in patients without significant residual metastatic disease. Patient summary Current first-line treatment for patients with kidney cancer that has spread to other sites (metastatic cancer) is immunotherapy. For cases in which metastatic sites respond to this therapy but primary tumor is still detected in the kidney, surgical treatment of the tumor is feasible and has a low rate of complications, and may delay the need for further chemotherapy.
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Affiliation(s)
- Daniel D. Shapiro
- Department of Urology, The University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Division of Urology, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Jose A. Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Logan Zemp
- Department of Urology, Moffitt Cancer Center, Tampa, FL, USA
| | - Viraj A. Master
- Department of Urology, Emory University Medical Center, Atlanta, GA, USA
| | - Wade J. Sexton
- Department of Urology, Moffitt Cancer Center, Tampa, FL, USA
| | - Ali Ghasemzadeh
- Department of Urology, The University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Facundo Davaro
- Department of Urology, Moffitt Cancer Center, Tampa, FL, USA
| | - Taylor Peak
- Department of Urology, Moffitt Cancer Center, Tampa, FL, USA
| | - Dattatraya Patil
- Department of Urology, Emory University Medical Center, Atlanta, GA, USA
| | - Surena Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - E. Jason Abel
- Department of Urology, The University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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12
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Hao C, Liu J, Ladbury C, Dorff T, Sampath S, Pal S, Dandapani S. Stereotactic body radiation therapy to the kidney for metastatic renal cell carcinoma: A narrative review of an emerging concept. Cancer Treat Res Commun 2023; 35:100692. [PMID: 36842365 DOI: 10.1016/j.ctarc.2023.100692] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
This narrative review provides a historical overview of cytoreductive nephrectomy for metastatic renal cell carcinoma (mRCC) and examines the safety and therapeutic potential of cytoreductive stereotactic body radiation therapy (SBRT) for mRCC in the modern immunotherapy era. In the last five years, the introduction of immune checkpoint inhibitors for the treatment of mRCC has improved outcomes for patients. This has brought forth new exploration of the role of CN in combination with immunotherapy. Early retrospective evidence suggests that there may be a benefit of deferred CN after immunotherapy (IOT) for de novo mRCC patients. However, there has also been concern regarding the feasibility of surgery after IOT due to inflammation. SBRT may be an appropriate alternative in these circumstances. Since 1999, cytoreductive SBRT has been used for inoperable primary RCC. Several prospective and retrospective studies treating the kidney tumor for localized RCC have shown that this technique is safe and produces favorable and durable local control. SBRT has also exhibited similar effectiveness to CN, while providing additional benefits including noninvasiveness and the ability to treat tumors that can't be treated with nephrectomy or ablation due to size or location. Furthermore, SBRT confers immunostimulatory effects, which are hypothesized to work synergistically with immunotherapy. Clinicians should consider SBRT a safe and reliable alternative to CN for RCC patients. Ongoing studies are exploring the utility of SBRT for treatment of the primary tumor in mRCC patients receiving standard of care immunotherapy.
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Affiliation(s)
- Claire Hao
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Tanya Dorff
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Sagus Sampath
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Sumanta Pal
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 91010, USA.
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13
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Yanagisawa T, Schmidinger M, Kawada T, Bekku K, Kimura T, Shariat SF. Radical Nephrectomy After Immune Checkpoint Inhibitors for Metastatic Renal Cell Carcinoma. Eur Urol Focus 2023; 9:275-277. [PMID: 36775716 DOI: 10.1016/j.euf.2023.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/12/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have led to substantial changes in systemic treatment for metastatic renal cell carcinoma (mRCC). For patients whose metastases respond to upfront ICI therapy, deferred cytoreductive nephrectomy (CN) may confer a survival advantage. Further data from ongoing trials are awaited regarding the role of deferred versus immediate CN for mRCC in the ICI era. PATIENT SUMMARY: The first-line treatment currently recommended for kidney cancer that has spread to other sites is immunotherapy. For patients who experience a good response to this treatment, surgical kidney removal to control the primary tumor may have a survival benefit. More evidence from clinical trials is needed to confirm the efficacy of this approach.
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Affiliation(s)
- Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Manuela Schmidinger
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czechia; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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14
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Bakouny Z, El Zarif T, Dudani S, Connor Wells J, Gan CL, Donskov F, Shapiro J, Davis ID, Parnis F, Ravi P, Steinharter JA, Agarwal N, Alva A, Wood L, Kapoor A, Ruiz Morales JM, Kollmannsberger C, Beuselinck B, Xie W, Heng DYC, Choueiri TK. Upfront Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors or Targeted Therapy: An Observational Study from the International Metastatic Renal Cell Carcinoma Database Consortium. Eur Urol 2023; 83:145-151. [PMID: 36272943 DOI: 10.1016/j.eururo.2022.10.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/15/2022] [Accepted: 10/04/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The role of upfront cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) in the era of immune checkpoint inhibitors is unclear. OBJECTIVE To evaluate the relationship between upfront CN and clinical outcomes in the setting of mRCC treated with immune checkpoint inhibitors or targeted therapy. DESIGN, SETTING, AND PARTICIPANTS Using the International Metastatic RCC Database Consortium, we retrospectively identified patients diagnosed with de novo mRCC treated with immune checkpoint inhibitors or targeted therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Overall survival (OS) was compared between the two groups using the Kaplan-Meier method and multivariable Cox regressions adjusting for known prognostic factors. RESULTS AND LIMITATIONS We identified a total of 4639 eligible patients with mRCC. Among the 4202 patients treated with targeted therapy and 437 patients treated with immune checkpoint inhibitors, 2326 (55%) and 234 (54%) patients received upfront CN prior to treatment start. In multivariable analyses, CN was associated with significantly better OS in both the immune checkpoint inhibitor-treated (hazard ratio [HR]: 0.61; 95% confidence interval [CI], 0.41-0.90, p = 0.013) and the targeted therapy treatment (HR: 0.72; 95% CI, 0.67-0.78, p < 0.001) group. There was no difference in OS benefit of CN between the immune checkpoint inhibitor and targeted therapy treatment groups (interaction p = 0.6). Limitations include selection of patients from large academic centers and the retrospective nature of the study. CONCLUSIONS Upfront CN is associated with a significant OS benefit in selected patients treated by either immune checkpoint inhibitors or targeted therapy, and still has a role in selected patients in the era of immune checkpoint inhibitors. PATIENT SUMMARY Before effective systemic therapies were available for metastatic kidney cancer, surgical removal of the primary (kidney) tumor was the mainstay of treatment. The role of removing the primary tumor has recently been called into question given that more effective systemic therapies have become available. In this study, we find that removal of the primary kidney tumor still has a benefit for selected patients treated with highly effective modern systemic therapies, including targeted therapies and immune checkpoint inhibitors.
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Affiliation(s)
- Ziad Bakouny
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Talal El Zarif
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Shaan Dudani
- Department of Oncology, William Osler Health System, Brampton, ON, Canada
| | - J Connor Wells
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | | | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; University Hospital of Southern Denmark, Esbjerg, Denmark
| | | | - Ian D Davis
- Monash University Eastern Health Clinical School, Melbourne, Australia; Cancer Services, Eastern Health, Melbourne, Australia
| | | | - Praful Ravi
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - John A Steinharter
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Neeraj Agarwal
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Ajjai Alva
- University of Michigan, Ann Arbor, MI, USA
| | - Lori Wood
- Dalhousie University, Halifax, NS, Canada
| | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Benoit Beuselinck
- University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Wanling Xie
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Daniel Y C Heng
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Toni K Choueiri
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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15
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Gross EE, Li M, Yin M, Orcutt D, Hussey D, Trott E, Holt SK, Dwyer ER, Kramer J, Oliva K, Gore JL, Schade GR, Lin DW, Tykodi SS, Hall ET, Thompson JA, Parikh A, Yang Y, Collier KA, Miah A, Mori-Vogt S, Hinkley M, Mortazavi A, Monk P, Folefac E, Clinton SK, Psutka SP. A multicenter study assessing survival in patients with metastatic renal cell carcinoma receiving immune checkpoint inhibitor therapy with and without cytoreductive nephrectomy. Urol Oncol 2023; 41:51.e25-51.e31. [PMID: 36441070 PMCID: PMC10938342 DOI: 10.1016/j.urolonc.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/01/2022] [Accepted: 08/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cytoreductive nephrectomy (CN) for the treatment of metastatic renal cell carcinoma (mRCC) was called into question following the publication of the CARMENA trial. While previous retrospective studies have supported CN alongside targeted therapies, there is minimal research establishing its role in conjunction with immune checkpoint inhibitor (ICI) therapy. OBJECTIVE To evaluate the association between CN and oncological outcomes in patients with mRCC treated with immunotherapy. MATERIALS AND METHODS A multicenter retrospective cohort study of patients diagnosed with mRCC between 2000 and 2020 who were treated at the Seattle Cancer Care Alliance and The Ohio State University and who were treated with ICI systemic therapy (ST) at any point in their disease course. Overall survival (OS) was estimated using Kaplan Meier analyses. Multivariable Cox proportional hazards models evaluated associations with mortality. RESULTS The study cohort consisted of 367 patients (CN+ST n = 232, ST alone n = 135). Among patients undergoing CN, 30 were deferred. Median survivor follow-up was 28.4 months. ICI therapy was first-line in 28.1%, second-line in 17.4%, and third or subsequent line (3L+) in 54.5% of patients. Overall, patients who underwent CN+ST had longer median OS (56.3 months IQR 50.2-79.8) compared to the ST alone group (19.1 months IQR 12.8-23.8). Multivariable analyses demonstrated a 67% reduction in risk of all-cause mortality in patients who received CN+ST vs. ST alone (P < 0.0001). Similar results were noted when first-line ICI therapy recipients were examined as a subgroup. Upfront and deferred CN did not demonstrate significant differences in OS. CONCLUSIONS CN was independently associated with longer OS in patients with mRCC treated with ICI in any line of therapy. Our data support consideration of CN in well selected patients with mRCC undergoing treatment with ICI.
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Affiliation(s)
- Evan E Gross
- The University of Washington School of Medicine, Seattle, WA
| | - Mingjia Li
- The Ohio State University Comprehensive Cancer Center, The James Cancer Hospital Columbus, OH
| | - Ming Yin
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Delaney Orcutt
- The University of Washington School of Medicine, Seattle, WA
| | - Duncan Hussey
- The University of Washington School of Medicine, Seattle, WA
| | - Elliot Trott
- The University of Washington School of Medicine, Seattle, WA
| | - Sarah K Holt
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | - Erin R Dwyer
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | - Joel Kramer
- The University of Washington School of Medicine, Seattle, WA
| | - Kaylee Oliva
- The University of Washington School of Medicine, Seattle, WA
| | - John L Gore
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | - George R Schade
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | - Daniel W Lin
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | - Scott S Tykodi
- Department of Medicine, Division of Medical Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Evan T Hall
- Department of Medicine, Division of Medical Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - John A Thompson
- Department of Medicine, Division of Medical Oncology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Anish Parikh
- The Ohio State University Comprehensive Cancer Center, The James Cancer Hospital Columbus, OH
| | - Yuanquan Yang
- The Ohio State University Comprehensive Cancer Center, The James Cancer Hospital Columbus, OH
| | - Katharine A Collier
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Abdul Miah
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Sherry Mori-Vogt
- Department of Pharmacy, The Ohio State University James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH
| | - Megan Hinkley
- Department of Pharmacy, The Ohio State University James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH
| | - Amir Mortazavi
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Paul Monk
- The Ohio State University Comprehensive Cancer Center, The James Cancer Hospital Columbus, OH
| | - Edmund Folefac
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Steven K Clinton
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Sarah P Psutka
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA.
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Choi SY, Ha MS, Lee JW, Kim JH, Kim JH, Chi BH, Kim JW, Chang IH, Kim TH, Myung SC. Shifting role of cytoreductive nephrectomy according to type of systemic therapy: A nationwide cohort study. Asian J Surg 2023; 46:328-336. [PMID: 35450758 DOI: 10.1016/j.asjsur.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/31/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The best protocol of cytoreductive nephrectomy (CN) and systemic therapy (ST) in the treatment of metastatic renal cell carcinoma (mRCC) remains unclear. We sought to evaluate overall survival (OS) in patients with mRCC treated with ST with or without CN. METHODS We collected data from the National Health Insurance Service database. We excluded 2 years of washout period, 2 years of follow-up period, other cancer diagnoses within 2 years, and ≥4 months interval between ST and CN. The patients were divided into two groups according to whether CN was performed. Kaplan-Meier, propensity score matching, Cox regression model, and incremental survival analyses were conducted. Additionally, we performed subgroup analysis according to whether cytokine therapy or targeted therapy was used as first-line ST. RESULTS Of 6478 patients, 1707 (26.4%) underwent CN. The CN group showed significantly better OS than the no CN group (p < 0.001). In the cytokine therapy subgroup, patients who underwent CN had significantly higher OS than those who did not (p < 0.001). In the targeted therapy subgroup, no significant difference was found (p = 0.867). In multivariate analysis, CN was associated with better OS in the total cohort (hazard ratio 0.819, p < 0.001). The incremental OS benefit of CN ranged from +0.98 in patients who survived for <24 months to +2.13 in those who survived during all periods. CONCLUSION About a quarter patients with mRCC from a nationwide database were treated with CN and ST. CN was beneficial in specific patients with mRCC. Patient selection is crucial for obtaining the benefits of CN.
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Affiliation(s)
- Se Young Choi
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea; Biomedical Research Institute, Chung-Ang University Hospital, South Korea.
| | - Moon Soo Ha
- Department of Urology, Hyundae General Hospital, Chung-Ang University College of Medicine, Gyeonggi-do, South Korea.
| | - Jeong Woo Lee
- Data Science Team, Hanmi Pharm. Co.,Ltd, Seoul, South Korea.
| | - Jae Hwan Kim
- Data Science Team, Hanmi Pharm. Co.,Ltd, Seoul, South Korea.
| | - Jung Hoon Kim
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gyeonggi-do, South Korea.
| | - Byung Hoon Chi
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea.
| | - Jin Wook Kim
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gyeonggi-do, South Korea.
| | - In Ho Chang
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea.
| | - Tae-Hyoung Kim
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea.
| | - Soon Chul Myung
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea.
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Beirat AF, Menakuru SR, Khan I, Siddiqui S. Pathological Complete Response of Metastatic Clear Cell Renal Carcinoma with Pembrolizumab and Axitinib: A Case Report and Review of Literature. Case Rep Oncol 2023; 16:30-35. [PMID: 36743880 PMCID: PMC9896169 DOI: 10.1159/000529124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
The role of cytoreductive nephrectomy has become unclear since the introduction of immunotherapy which is now the backbone of the treatment for metastatic renal cell carcinoma. Different combinations are used based on the prognosis. Achieving a complete response would be ideal and includes radiographic disappearance of lesions. However, there have been a few reported cases of pathological complete response with persistent radiographic evidence of cancer. The authors report a case of pathological complete response despite persistent radiographic evidence of residual disease in a patient with metastatic renal cell carcinoma treated with pembrolizumab and axitinib. The patient subsequently underwent cytoreductive nephrectomy after the 13th dose of pembrolizumab. The resected mass consisted of scar tissue with no viable tumor cells seen on pathology but only scar tissue. This case reveals that persistent radiographic evidence of the tumor may be explained by scar tissue, challenging the role of cytoreductive nephrectomy in the era of immunotherapy.
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Affiliation(s)
- Amir F. Beirat
- Internal Medicine, Indiana University School of Medicine, Ball Memorial Hospital, Muncie, IN, USA
| | - Sasmith R. Menakuru
- Internal Medicine, Indiana University School of Medicine, Ball Memorial Hospital, Muncie, IN, USA
| | - Ibrahim Khan
- Internal Medicine, Indiana University School of Medicine, Ball Memorial Hospital, Muncie, IN, USA
| | - Salahuddin Siddiqui
- Hematology-Oncology, Indiana University School of Medicine, Ball Memorial Hospital, Muncie, IN, USA
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18
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Dragomir A, Nazha S, Tanguay S, Breau RH, Bhindi B, Rendon RA, Kapoor A, Hotte SJ, Basappa N, Fairey A, So AI, Kollmannsberger C, Finelli A, Hansen A, Canil C, Heng D, Lattouf JB, Bjarnason G, Power N, Pouliot F, Wood LA. Outcomes of Cytoreductive Nephrectomy for Patients with Metastatic Renal Cell Carcinoma: Real World Data from Canadian Centers. Eur Urol Focus 2022; 8:1703-1710. [PMID: 34736870 DOI: 10.1016/j.euf.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/10/2021] [Accepted: 10/05/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Treatment options for metastatic renal cell carcinoma (mRCC) include cytoreductive nephrectomy (CN) and systemic therapy (ST). Results from the CARMENA and SURTIME trials suggest that CN before ST may not be the optimal treatment strategy for mRCC. OBJECTIVE To use real-world data to evaluate and compare outcomes for patients with mRCC who underwent CN before, after, or without ST to those patients who only received ST. DESIGN, SETTING, AND PARTICIPANTS The Canadian Kidney Cancer information system (CKCis) database was used to identify patients diagnosed with mRCC between January 2011 and April 2020. Only patients with synchronous disease, treated within 12 mo from their initial RCC diagnosis, with International Metastatic Renal Cell Carcinoma Database Consortium intermediate/high risk, and confirmed RCC histology were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Patients were classified into four groups according to the initial treatment received for mRCC. Inverse probability of treatment weighting using propensity scores was used to balance the treatment groups. Cox proportional hazards models were used to assess the impact of CN after adjusting for potential confounding variables in the weighted cohorts. RESULTS AND LIMITATIONS A total of 788 patients were included in the study cohort. Of these 383 patients underwent CN before ST, 73 underwent CN after ST, 80 underwent CN only, and 252 patients received ST only. The median patient age was 63 yr and 73% of the cohort were men. In weighted analysis, the groups undergoing CN before ST (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.52-0.82) and CN after ST (HR 0.41, 95% CI 0.28-0.60) both had better survival compared to the ST only group. No survival benefit was observed for CN only compared to ST only, or for CN before ST compared to CN after ST. CONCLUSIONS We evaluated the association between different sequences of treatment with CN and survival in patients with mRCC using CKCis real world data. The results demonstrate that the selected patients who undergo CN, whether performed before or after ST, have an associated improvement in survival. PATIENT SUMMARY Two of the treatment options for metastatic kidney cancer are surgery and systemic therapy (chemotherapy or immunotherapy). We used data from the Canadian Kidney Cancer information system to determine whether there are differences in survival according to the sequencing of these treatments. Patients who had both surgery and systemic therapy, regardless of which treatment was first, had better survival than patients who only received systemic therapy.
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Affiliation(s)
| | | | | | | | - Bimal Bhindi
- Southern Alberta Institute of Urology, Alberta, Canada
| | | | - Anil Kapoor
- Juravinski Cancer Centre, McMaster University, Hamilton, Canada
| | | | - Naveen Basappa
- Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - Adrian Fairey
- Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - Alan I So
- British Columbia Cancer Agency, Vancouver Cancer Centre, Vancouver, Canada
| | | | - Antonio Finelli
- Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada
| | - Aaron Hansen
- Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada
| | | | - Daniel Heng
- Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
| | - Jean-Baptiste Lattouf
- Centre Hospitalier de l'Université de Montréal, University of Montreal, Montreal, Canada
| | - Georg Bjarnason
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | | | - Frédéric Pouliot
- Centre Hospitalier Universitaire de Québec, University of Laval, Quebec, Canada
| | - Lori A Wood
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
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19
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Andrews JR, Lohse CM, Boorjian SA, Leibovich BC, Thompson H, Costello BA, Bhindi B. Outcomes following cytoreductive nephrectomy without immediate postoperative systemic therapy for patients with synchronous metastatic renal cell carcinoma. Urol Oncol 2022; 40:166.e1-166.e8. [PMID: 35168879 DOI: 10.1016/j.urolonc.2022.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/15/2021] [Accepted: 01/11/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND While the recent CARMENA trial evaluated upfront cytoreductive nephrectomy (CN) among patients treated with immediate subsequent systemic therapy for metastatic renal cell carcinoma (mRCC), the role of CN in patients not immediately requiring systemic therapy remains to be determined. OBJECTIVE To describe the oncologic outcomes of patients with de-novo synchronous mRCC who underwent CN +/- metastasis-directed therapy (MDT) and subsequent surveillance without planned immediate post-CN systemic therapy. DESIGN, SETTING, PARTICIPANTS Adults who underwent CN for unilateral, sporadic mRCC between 1996 and 2016 without immediate postoperative systemic therapy were identified using the prospectively-maintained Mayo Clinic Nephrectomy Registry. Co-primary outcomes were survival free of systemic therapy or death and overall-survival. RESULTS Of 156 patients who met inclusion criteria for study, 37 (24%) patients were managed after CN with surveillance alone and 119 (76%) underwent MDT. Seventy-two patients ultimately initiated systemic therapy at a median of 0.7 years (IQR 0.3-1.7). Median follow-up among survivors was 6.2 years (IQR 4.4-9.5), during which time 133 patients died. At 1, 3, and 5 years, survival free of systemic therapy or death rates were 47%, 21% and 14% and overall-survival rates were 69%, 37%, and 28%. CONCLUSION Among carefully selected patients managed with surveillance after CN +/- MDT, approximately half may avoid systemic therapy for 1 year, with a subset achieving long-term survival free of systemic therapy or death. Having a single metastatic site and disease amenable to complete metastasectomy are features of patients who might be well served with upfront CN +/- MDT.
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Affiliation(s)
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Bimal Bhindi
- Section of Urology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Mori K, Quhal F, Yanagisawa T, Katayama S, Pradere B, Laukhtina E, Rajwa P, Mostafaei H, Sari Motlagh R, Kimura T, Egawa S, Bensalah K, Karakiewicz PI, Schmidinger M, Shariat SF. The effect of immune checkpoint inhibitor combination therapies in metastatic renal cell carcinoma patients with and without previous cytoreductive nephrectomy: A systematic review and meta-analysis. Int Immunopharmacol 2022; 108:108720. [PMID: 35339843 DOI: 10.1016/j.intimp.2022.108720] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/05/2022] [Accepted: 03/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recently, immune checkpoint inhibitor (ICI)-combination therapies have radically altered the treatment landscape in metastatic renal cell carcinoma (mRCC). No phase 3 trials have assessed the impact of cytoreductive nephrectomy (CN) for efficacy in mRCC patients treated with ICI-combination therapy. We aimed to assess the role of ICI-combination therapy based on CN status. METHODS Multiple databases were searched for articles published until June 2021. Studies comparing overall and/or progression-free survival (OS/PFS) in mRCC patients treated with ICI combination-therapy were deemed eligible. RESULTS Six studies met the eligibility criteria. ICI-combination therapy was associated with significantly better OS/PFS than sunitinib in patients who had undergone CN (hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.59-0.77/HR, 0.57; 95% CI, 0.44-0.74, respectively; both P < 0.001), and in those who had not (HR, 0.69; 95% CI, 0.57-0.85/HR, 0.63; 95% CI, 0.52-0.77, respectively; both P < 0.001). Although the OS and PFS benefits of ICI-combination therapy were larger in those undergoing CN, the HR for OS and PFS indicated that ICI-combination therapy's treatment effect did not differ substantially with or without CN. In network meta-analyses, nivolumab plus cabozantinib was the most effective regimen in those undergoing CN, and pembrolizumab plus lenvatinib for those not undergoing CN. CONCLUSION The effect of ICI combination therapy did not differ between mRCC patients undergoing and not undergoing CN. As each ICI combination regimen varied widely in its effect in patients undergoing and not undergoing CN, CN may contribute to better treatment decision-making for ICI-combination therapy recipients.
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Affiliation(s)
- Keiichiro Mori
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fahad Quhal
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Takafumi Yanagisawa
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Satoshi Katayama
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Benjamin Pradere
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Ekaterina Laukhtina
- Department of Urology, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Pawel Rajwa
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Hadi Mostafaei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Sari Motlagh
- Department of Urology, Medical University of Vienna, Vienna, Austria; Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shin Egawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Karim Bensalah
- Department of Urology, University of Rennes, Rennes, France
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada
| | | | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland; Research Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Urology, Weill Cornell Medical College, New York, New York, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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21
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Teishima J, Goto K, Sekino Y, Mita K, Hayashi T, Hasegawa Y, Kato M, Kajiwara M, Shigeta M, Maruyama S, Kadonishi Y, Fujiwara S, Kobayashi K, Asano K, Hinata N. Prognostic model of upfront cytoreductive nephrectomy in patients with metastatic renal cell carcinoma treated with immune checkpoint inhibitors and/or targeted agents. Int Urol Nephrol 2022. [PMID: 35314918 DOI: 10.1007/s11255-022-03157-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/19/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to investigate prognostic factors and to establish a prognostic model using them for upfront cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitor (ICI) and/or tyrosine kinase inhibitor (TKI). MATERIALS AND METHODS Two hundred eleven patients who were diagnosed as mRCC at initial diagnosis and were treated with TKI and/or ICI were classified into 2 groups: those undergoing CN (upfront CN group, 117 cases) and those who initially underwent systemic therapy (non-upfront CN group, 94 cases). In the upfront CN group, the patients' background and overall survival (OS) were compared with those in the other two groups, and prognostic factors were analyzed. A prognostic model of the upfront CN group was established. RESULTS The median of the observation period for the upfront CN group was 25 months. The rates of patients with clear cell histology, with a Karnofsky performance status (KPS) of ≥ 80%, with a single metastatic organ, with a normal pretreated C-reactive protein level, and with an intermediate risk according to the International mRCC Database Consortium (IMDC) model were significantly higher than those in the non-upfront CN group (87.2% and 30.9%, p < 0.0001; 92.3% and 77.7%, p = 0.0025; 41.9% and 24.5%, p = 0.0080; 47.9% and 13.8%, p < 0.0001; 66.7% and 45.7%, p = 0.0023, respectively). The 50% OS in the upfront CN group was 33.1 months, significantly better than that in the non-upfront CN group (11.1 months, p < 0.0001), and these results were consistent regardless of their prognostic risk level. Multivariate analysis showed that multiple metastatic organs and a KPS of < 80% were independent predictive factors for OS (hazard ratio: 1.653 and 2.995, p = 0.0339 and 0.0054, respectively). Using these two parameters to stratify the upfront CN group, the 50% OSs in cases with no risk factors, in those with one factor, and in those with two factors were 43.4 months, 29.1 months, and 7.7 months, respectively (p < 0.0001). CONCLUSION The upfront CN group was able to be stratified by our prognostic model into three subgroups with different prognoses. This model can provide useful information for making decisions in consideration of upfront CN in patients with mRCC.
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22
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Laukhtina E, Schuettfort VM, D'Andrea D, Pradere B, Quhal F, Mori K, Sari Motlagh R, Mostafaei H, Katayama S, Grossmann NC, Rajwa P, Karakiewicz PI, Schmidinger M, Fajkovic H, Enikeev D, Shariat SF. Selection and evaluation of preoperative systemic inflammatory response biomarkers model prior to cytoreductive nephrectomy using a machine-learning approach. World J Urol 2022; 40:747-754. [PMID: 34671856 PMCID: PMC8948147 DOI: 10.1007/s00345-021-03844-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/03/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION This study aimed to determine the prognostic value of a panel of SIR-biomarkers, relative to standard clinicopathological variables, to improve mRCC patient selection for cytoreductive nephrectomy (CN). MATERIAL AND METHODS A panel of preoperative SIR-biomarkers, including the albumin-globulin ratio (AGR), De Ritis ratio (DRR), and systemic immune-inflammation index (SII), was assessed in 613 patients treated with CN for mRCC. Patients were randomly divided into training and testing cohorts (65/35%). A machine learning-based variable selection approach (LASSO regression) was used for the fitting of the most informative, yet parsimonious multivariable models with respect to prognosis of cancer-specific survival (CSS). The discriminatory ability of the model was quantified using the C-index. After validation and calibration of the model, a nomogram was created, and decision curve analysis (DCA) was used to evaluate the clinical net benefit. RESULTS SIR-biomarkers were selected by the machine-learning process to be of high discriminatory power during the fitting of the model. Low AGR remained significantly associated with CSS in both training (HR 1.40, 95% CI 1.07-1.82, p = 0.01) and testing (HR 1.78, 95% CI 1.26-2.51, p = 0.01) cohorts. High levels of SII (HR 1.51, 95% CI 1.10-2.08, p = 0.01) and DRR (HR 1.41, 95% CI 1.01-1.96, p = 0.04) were associated with CSS only in the testing cohort. The exclusion of the SIR-biomarkers for the prognosis of CSS did not result in a significant decrease in C-index (- 0.9%) for the training cohort, while the exclusion of SIR-biomarkers led to a reduction in C-index in the testing cohort (- 5.8%). However, SIR-biomarkers only marginally increased the discriminatory ability of the respective model in comparison to the standard model. CONCLUSION Despite the high discriminatory ability during the fitting of the model with machine-learning approach, the panel of readily available blood-based SIR-biomarkers failed to add a clinical benefit beyond the standard model.
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Affiliation(s)
- Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Victor M Schuettfort
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Satoshi Katayama
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nico C Grossmann
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Manuela Schmidinger
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Harun Fajkovic
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.
- Department of Urology, Weill Cornell Medical College, New York, NY, USA.
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA.
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan.
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Albiges L, Tannir NM, Burotto M, McDermott D, Plimack ER, Barthélémy P, Porta C, Powles T, Donskov F, George S, Kollmannsberger CK, Gurney H, Grimm MO, Tomita Y, Castellano D, Rini BI, Choueiri TK, Leung D, Saggi SS, Lee CW, McHenry MB, Motzer RJ. First-line Nivolumab plus Ipilimumab Versus Sunitinib in Patients Without Nephrectomy and With an Evaluable Primary Renal Tumor in the CheckMate 214 Trial. Eur Urol 2022; 81:266-271. [PMID: 34750035 DOI: 10.1016/j.eururo.2021.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/06/2021] [Indexed: 01/11/2023]
Abstract
We present an exploratory post hoc analysis from the phase 3 CheckMate 214 trial of first-line nivolumab plus ipilimumab (NIVO+IPI) versus sunitinib in a subgroup of 108 patients with advanced renal cell carcinoma (aRCC) without prior nephrectomy and with an evaluable primary tumor, a population under-represented in clinical trials. Patients with clear cell aRCC were randomized to NIVO+IPI every 3 wk for four doses followed by NIVO monotherapy, or sunitinib every day for 4 wk (6-wk cycle). Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and primary tumor shrinkage were assessed. PFS and ORR were assessed per independent radiology review committee using RECIST version 1.1. With minimum study follow-up of 4 yr for intent-to-treat patients, OS favored NIVO+IPI (n = 53) over sunitinib (n = 55; hazard ratio 0.63, 95% confidence interval 0.40-1.0) among patients without prior nephrectomy. ORR was higher (34% vs 15%; p = 0.0041) and median duration of response was longer with NIVO+IPI versus sunitinib (20.5 vs 14.1 mo); the best overall response was partial response in either arm. A ≥30% reduction in the diameter of intact target renal tumors was achieved in 35% of patients with NIVO+IPI versus 20% with sunitinib. Safety was consistent with the global study population. In conclusion, in patients with aRCC without prior nephrectomy and with an evaluable primary tumor, NIVO+IPI showed survival benefits and renal tumor reduction versus sunitinib. This trial is registered at ClinicalTrials.gov as NCT02231749. PATIENT SUMMARY: In an exploratory analysis of a large global trial (CheckMate 214), we observed positive outcomes (both survival and tumor response to treatment) with nivolumab plus ipilimumab over sunitinib in a subgroup of patients with advanced kidney cancer who did not undergo removal of their primary kidney tumor. This subset of patients represents a population that has not been studied in clinical trials and for whom outcomes with new immunotherapy combination regimens are not yet known. We conclude that treatment with nivolumab plus ipilimumab offers these patients a survival benefit versus sunitinib, consistent with that observed in the overall study, as well as a notable kidney tumor reduction.
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Affiliation(s)
- Laurence Albiges
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France.
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David McDermott
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Dana-Farber/Harvard Cancer Center, Boston, MA, USA
| | - Elizabeth R Plimack
- Department of Hematology and Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Philippe Barthélémy
- Medical Oncology, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | | | - Thomas Powles
- Department of Urology, Barts Cancer Institute, Queen Mary University of London, Royal Free NHS Trust, London, UK
| | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Saby George
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | - Howard Gurney
- Department of Medical Oncology, Westmead Hospital and Macquarie University, Sydney, Australia
| | | | - Yoshihiko Tomita
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Daniel Castellano
- Medical Oncology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Brian I Rini
- Division of Hematology Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Toni K Choueiri
- Department of Medical Oncology, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Leung
- Department of Imaging, Bristol Myers Squibb, Princeton, NJ, USA
| | | | - Chung-Wei Lee
- Department of Clinical Trials, Bristol Myers Squibb, Princeton, NJ, USA
| | - M Brent McHenry
- Department of Biostatistics, Bristol Myers Squibb, Princeton, NJ, USA
| | - Robert J Motzer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Maestroni U, Gasparro D, Ziglioli F, Guarino G, Campobasso D. Metastatic Clear Cell Renal Cell Carcinoma: The Great Pretender and the Great Dilemma. World J Oncol 2021; 12:178-182. [PMID: 34804281 PMCID: PMC8577602 DOI: 10.14740/wjon1406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/30/2021] [Indexed: 01/13/2023] Open
Abstract
Metastatic renal cell carcinoma (mRCC) may present with a wide range of clinical pictures. Reportedly, paraneoplastic syndromes are the first sign in 20% of cases and only 15% of cases show the classic triad (flank pain, gross hematuria, and palpable abdominal mass) at presentation. The remaining cases present with signs and symptoms related to the site of distant metastases. These data may explain the reason why about 20-30% of patients are metastatic at presentation. We report the case of a 63-year-old woman who came to our attention for lower back pain. After imaging studies, we detected a left kidney mass of 86 × 61 × 79 mm, multiple right pulmonary nodules and six bone lesions. She underwent left radical nephrectomy. After 1 month, she developed signs of spinal cord compression with neurological deficits and she underwent emergency spinal decompression. In order to allow complete motor recovery, the subsequent stereotactic body radiation therapy was not performed, and she is currently taking combination immunotherapy regimens. Management of mRCC is in a continuous evolution due to availability of new target therapies and the possibility of a multimodal approach with surgical, focal and radiotherapy treatments. However, the ideal treatment algorithm is yet to come. This is why mRCC diagnosis and management are still challenging for the clinicians.
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Affiliation(s)
- Umberto Maestroni
- Department of Urology, University Hospital of Parma/Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, Parma 43126, Italy
| | - Donatello Gasparro
- Medical Oncology Unit, University Hospital of Parma/Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, Parma 43126, Italy
| | - Francesco Ziglioli
- Department of Urology, University Hospital of Parma/Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, Parma 43126, Italy
| | - Giulio Guarino
- Department of Urology, University Hospital of Parma/Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, Parma 43126, Italy
| | - Davide Campobasso
- Department of Urology, University Hospital of Parma/Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, Parma 43126, Italy
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25
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Dilme RV, Rivas JG, Campi R, Puente J, Jerez T, Enikeev D, Esperto F, Sierra JM. Cytoreductive Nephrectomy in the Management of Metastatic Renal Cell Carcinoma: Is There Still a Debate? Curr Urol Rep 2021; 22:54. [PMID: 34654989 DOI: 10.1007/s11934-021-01073-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this review was to summarize the evidence on the current role of cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC). RECENT FINDINGS Since the advent of systemic targeted therapies for mRCC treatment, the role of CN has been questioned. Several retrospective observational studies demonstrated a therapeutic benefit for CN, while recent prospective randomized trials have challenged this evidence. As such, patient selection has become of paramount importance in this setting. The role of CN on mRCC treatment is still object of debate. In carefully selected patients, CN remains an important option as a component of a multimodal therapeutic approach. As systemic therapies for mRCC continue to evolve, future trials are needed to evaluate the benefits and limits of CN in the immunotherapy era, tailoring the treatment sequence and selecting the patients who are most likely to benefit from surgical interventions.
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26
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Steven S, Safriadi F. A rapid progression of new metastatic lesion after cytoreductive nephrectomy: A case report. Urol Case Rep 2021; 39:101848. [PMID: 34557382 PMCID: PMC8445834 DOI: 10.1016/j.eucr.2021.101848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022] Open
Abstract
A 55-years-old man presented with the chief complaint of right flank mass and hematuria. CT scan revealed clinical T4 RCC. Cytoreductive nephrectomy (CN) was performed with histopathology result of Papillary renal cell carcinoma. A month later, the patient was admitted to the emergency room with severe dyspnea suggesting intrapulmonary metastases. Here we present an unusual case with a new pulmonary metastasis lesion rapidly appear a month after cytoreductive nephrectomy.
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Affiliation(s)
- Steven Steven
- Urology Department, Hasan Sadikin Academic Medical Center, Universitas Padjadjaran, Bandung, Indonesia
| | - Ferry Safriadi
- Urology Department, Hasan Sadikin Academic Medical Center, Universitas Padjadjaran, Bandung, Indonesia
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27
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Pieretti AC, Shapiro DD, Westerman ME, Hwang H, Wang X, Segarra LA, Campbell MT, Tannir NM, Jonasch E, Matin SF, Wood CG, Karam JA. Tumor diameter response in patients with metastatic clear cell renal cell carcinoma is associated with overall survival. Urol Oncol 2021; 39:837.e9-837.e17. [PMID: 34551888 DOI: 10.1016/j.urolonc.2021.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/05/2021] [Accepted: 08/22/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Tumor shrinkage of at least 10% after presurgical targeted molecular therapy (TMT) in renal cell carcinoma (RCC) patients has been associated with better overall survival (OS) outcomes. We characterized primary and metastatic tumor diameter response and OS in patients with metastatic clear cell RCC (ccRCC) who received preoperative TMT, immunotherapy, or both followed by deferred cytoreductive nephrectomy (dCN). MATERIALS AND METHODS Patients with metastatic ccRCC (n = 198) who underwent preoperative therapy and dCN from 2005 to 2019 were identified retrospectively. Longest primary and metastatic tumor diameters were calculated using cross-sectional images obtained before systemic therapy and dCN using the Response Evaluation Criteria in Solid Tumors. Patients were stratified by tumor shrinkage of at least 10% in the primary and/or metastatic tumors after systemic therapy. The Kaplan-Meier method was used to estimate OS, and Cox proportional hazards models were used to assess the association of patient characteristics with OS. RESULTS In total, 31.31% of patients had only metastatic tumor shrinkage (MTS) ≥ 10%, 8.08% had only primary tumor shrinkage (PTS) ≥ 10%, 32.32% had PTS and MTS ≥ 10%, and 28.28% had PTS/MTS < 10%. The median OS, number of patients with tumor shrinkage ≥ 10%, and International Metastatic Database Consortium (IMDC) scores were similar among the 3 systemic therapy groups (all P ≥ 0.80). Patients with MTS ≥ 10%, PTS ≥ 10%, and PTS/MTS ≥ 10% had significantly longer median OS compared to patients with PTS/MTS < 10% (P < 0.01). Patients with intermediate-risk IMDC scores had significantly longer median OS compared to patients in the poor-risk group. After adjusting for preoperative therapy and IMDC risk group, MTS ≥ 10%, PTS ≥ 10%, and PTS/MTS ≥ 10% were associated with better OS outcomes (HR 0.48 95% CI 0.32-0.73, P < 0.001; HR 0.48, 95% CI 0.23-0.98, P = 0.04; HR 0.44, 95% CI 0.29-0.67, P < 0.001, respectively). CONCLUSIONS Intermediate risk score and shrinkage of at least 10% in the primary tumor, metastases, or both were associated with better OS outcomes in patients with metastatic ccRCC who underwent dCN independent of the type of preoperative systemic therapy.
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Affiliation(s)
- Alberto C Pieretti
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel D Shapiro
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary E Westerman
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hyunsoo Hwang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Luis A Segarra
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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28
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Okita K, Hatakeyama S, Naito S, Numakura K, Kato R, Koguchi T, Kojima T, Kawasaki Y, Kandori S, Kawamura S, Nishiyama H, Ito A, Kojima Y, Habuchi T, Obara W, Tsuchiya N, Ohyama C. External validation of the REMARCC model for the selection of cytoreductive nephrectomy in patients with primary metastatic renal cell carcinoma: A multicenter retrospective study. Urol Oncol 2021; 39:836.e11-836.e17. [PMID: 34544649 DOI: 10.1016/j.urolonc.2021.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 08/07/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study aims to evaluate the utility of the scoring system of the Registry for Metastatic Renal Cell Carcinoma (REMARCC) model on the overall survival (OS) of patients undergoing cytoreductive nephrectomy (CN). METHODS A total of 278 patients with primary metastatic renal cell carcinoma (mRCC) treated with first-line tyrosine kinase inhibitors (TKIs) between January 2008 and November 2019 were identified. The c-index and net benefit between the REMARCC score were compared with the International mRCC Database Consortium (IMDC) score in patients with CN (CN group, n = 146). The effect of the REMARCC score on OS was compared between the CN group and patients without CN (non-CN group, n = 132) using Cox regression analysis under the propensity score-based inverse probability of treatment weighting (IPTW) method to adjust for group imbalances. RESULTS Of the 146 patients with CN, the c-index of the REMARCC model (0.60) was higher than the IMDC model (0.54). The decision curve analysis showed the advantage of REMARCC model predicting OS compared with the IMDC model. OS was significantly longer in the REMARCC low-score (0-2) than that in the high-score (3-6) among the patients with CN. IPTW-adjusted Cox regression analyses showed that OS was significantly longer in the CN group than that in the non-CN group among the patients with REMARCC low-score but was not significantly different between the groups among the patients with REMARCC high-score. CONCLUSIONS The REMARCC score may be active for selecting the CN candidate in patients treated with TKIs.
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Affiliation(s)
- Kazutaka Okita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingo Hatakeyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Sei Naito
- Department of Urology, Yamagata University School of Medicine, Yamagata, Japan
| | - Kazuyuki Numakura
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Renpei Kato
- Department of Urology, Iwate Medical University School of Medicine, Japan
| | - Tomoyuki Koguchi
- Department of Urology, Fukushima Medical University School of Medicine, Fukushima
| | - Takahiro Kojima
- Department of Urology, University of Tsukuba Graduate School of Medicine, Tsukuba, Japan
| | - Yoshihide Kawasaki
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shuya Kandori
- Department of Urology, University of Tsukuba Graduate School of Medicine, Tsukuba, Japan
| | | | - Hiroyuki Nishiyama
- Department of Urology, University of Tsukuba Graduate School of Medicine, Tsukuba, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshiyuki Kojima
- Department of Urology, Fukushima Medical University School of Medicine, Fukushima
| | - Tomonori Habuchi
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Wataru Obara
- Department of Urology, Iwate Medical University School of Medicine, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University School of Medicine, Yamagata, Japan
| | - Chikara Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Abstract
Cytoreductive nephrectomy makes way for more effective systemic treatments in the current mRCC treatment paradigm, as disease volume and the number of IMDC risk factors increase. Careful patient selection for upfront or deferred cytoreductive nephrectomy based on these criteria remains key.
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Affiliation(s)
- Eduard Roussel
- Department of Urology, University Hospitals Leuven, Leuven, Belgium.
| | - Benoit Beuselinck
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
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Laru L, Ronkainen H, Ohtonen P, Vaarala MH. Nephrectomy improves the survival of metastatic renal cell cancer patients with moderate to good performance status-results from a Finnish nation-wide population-based study from 2005 to 2010. World J Surg Oncol 2021; 19:190. [PMID: 34183025 PMCID: PMC8240260 DOI: 10.1186/s12957-021-02308-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/17/2021] [Indexed: 12/31/2022] Open
Abstract
Background The purpose of this study was to evaluate the effects of cytoreductive nephrectomy (CN) and metastasectomies on the survival of patients with synchronous metastatic renal cell cancer (mRCC) using real-life, population-based national dataset. Methods Nationwide data, including all cases of synchronous mRCC in Finland diagnosed on a 6-year timeframe, based on the Finnish Cancer Registry and complemented with patient records from the treating hospitals, were analyzed. Patients with Eastern Cooperative Oncology Group (ECOG) performance status 3–4 were excluded. Univariate and adjusted multivariable survival analysis were performed, including subgroup analysis for patients with different medical therapies. Nephrectomy complications were also analyzed. Results A total of 732 patients were included in the analysis. CN was performed for 389 (53.1%) patients, whereas 68 (9.3%) patients underwent nephrectomy and metastasectomies of all lesions (surgery with curative intent). Median overall survival (OS) for patients who did not undergo nephrectomy was 5.9 (95% confidence interval [CI] = 4.6–7.2) months. Patients who had a CN had a median OS of 16.6 (95% CI = 14.2–19.1, p < 0.001) months, whereas patients who had surgery with curative intent had a median OS of 51.3 (95% CI = 36.0–66.6, p < 0.001) months. The survival benefit of CN and metastasectomies remained significant in all medical therapy subgroups and in both of the applied multivariable statistical models. Conclusions Surgical treatment of metastatic renal cell cancer is associated with a significant survival benefit in patients with good and moderate performance status, regardless of the chosen medical therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02308-0.
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Affiliation(s)
- Lauri Laru
- Department of Surgery, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. .,Department of Urology, Oulu University Hospital, PO Box 21, FI-90029 OYS, Oulu, Finland.
| | - Hanna Ronkainen
- Department of Surgery, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Division of Operative Care, Oulu University Hospital and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Markku H Vaarala
- Department of Surgery, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Méjean A, Ravaud A, Thezenas S, Chevreau C, Bensalah K, Geoffrois L, Thiery-Vuillemin A, Cormier L, Lang H, Guy L, Gravis G, Rolland F, Linassier C, Lechevallier E, Oudard S, Laguerre B, Gross-Goupil M, Bernhard JC, Colas S, Albiges L, Lebret T, Treluyer JM, Timsit MO, Escudier B. Sunitinib Alone or After Nephrectomy for Patients with Metastatic Renal Cell Carcinoma: Is There Still a Role for Cytoreductive Nephrectomy? Eur Urol 2021; 80:417-424. [PMID: 34187771 DOI: 10.1016/j.eururo.2021.06.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/11/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The CARMENA trial in patients with metastatic renal cell carcinoma (mRCC) demonstrated that treatment with sunitinib alone was noninferior to cytoreductive nephrectomy (CN) followed by sunitinib (nephrectomy-sunitinib). OBJECTIVE The objective of this study was to provide updated overall survival (OS) outcomes of CARMENA and assess whether some subgroups may still benefit from upfront CN. DESIGN, SETTING, AND PARTICIPANTS CARMENA was a phase III trial in 450 patients with mRCC enrolled from 2009 to 2017. INTERVENTION Patients in the intention-to-treat population received nephrectomy-sunitinib (standard of care [SOC]; n = 226) or sunitinib alone (n = 224). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary endpoint was OS, assessed using an updated data cut-off (October 2018; median OS event-free follow-up, 36.6 mo). Patients were reclassified by risk using International Metastatic RCC Database Consortium (IMDC) criteria. RESULTS AND LIMITATIONS Sunitinib alone was noninferior to nephrectomy-sunitinib (hazard ratio [HR], 0.97; 95% confidence interval, 0.79-1.19; p = 0.8) and demonstrated longer median OS (19.8 mo vs 15.6 mo, respectively). For patients with two or more IMDC risk factors, OS was significantly longer with sunitinib alone than with nephrectomy-sunitinib (31.2 mo vs 17.6 mo, respectively; HR, 0.65; p = 0.03). For patients with one IMDC risk factor, OS was longer for nephrectomy-sunitinib versus sunitinib alone although not significantly (31.4 mo vs 25.2 mo; HR, 1.30; p = 0.2). The post hoc nature of the subgroup analyses may limit their interpretation. CONCLUSIONS Sunitinib alone was noninferior compared with nephrectomy-sunitinib, suggesting that CN should not be considered SOC in patients with mRCC requiring systemic treatment. Certain subgroups, including patients with one IMDC risk factor, may still benefit from upfront CN. PATIENT SUMMARY We assessed the survival of patients with metastatic kidney cancer in a clinical trial. Patients treated with sunitinib on its own had the same survival as patients who had surgery before sunitinib treatment. We conclude that surgery may not be necessary for some patients with metastatic kidney cancer.
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Affiliation(s)
- Arnaud Méjean
- Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Alain Ravaud
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Simon Thezenas
- Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | | | - Karim Bensalah
- Centre Hospitalier Universitaire de Rennes, Rennes, France
| | | | | | - Luc Cormier
- Centre Hospitalier Universitaire Dijon Bourgogne, Dijon, France
| | - Hervé Lang
- Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Laurent Guy
- Gabriel Montpied Hospital, Clermont-Ferrand, France; Clermont Auvergne University, Clermont Ferrand, France
| | - Gwenaelle Gravis
- Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France
| | | | | | | | - Stephane Oudard
- Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | | | - Sandra Colas
- Paris Descartes Necker-Cochin Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | - Jean-Marc Treluyer
- Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc-Olivier Timsit
- Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
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32
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Courcier J, Dalban C, Laguerre B, Ladoire S, Barthélémy P, Oudard S, Joly F, Gravis G, Chevreau C, Geoffrois L, Deluche É, Rolland F, Topart D, Culine S, Négrier S, Mahammedi H, Tantot F, Jamet A, Escudier B, Flippot R, Albigès L. Primary Renal Tumour Response in Patients Treated with Nivolumab for Metastatic Renal Cell Carcinoma: Results from the GETUG-AFU 26 NIVOREN Trial. Eur Urol 2021; 80:325-329. [PMID: 34103181 DOI: 10.1016/j.eururo.2021.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
Primary tumour response may impact therapeutic strategies in metastatic renal cell carcinoma (mRCC) but remains unknown in the era of immune checkpoint inhibitors. We aimed to describe the response of the primary tumour in patients who did not undergo upfront cytoreductive nephrectomy (uCN) and were treated with nivolumab in the GETUG-AFU-26 NIVOREN phase 2 trial. Primary tumour response was prospectively assessed, as well as the overall response rate (ORR), progression-free survival (PFS), and overall survival (OS). Among 720 patients, 111 did not undergo uCN, mainly patients with intermediate (45%) and poor (49%) International mRCC Database Consortium (IMDC) risk. In the 111 patients, nivolumab was used in the second line for 63% of patients and the third line or more for 37%, with an ORR of 16% (95% confidence interval [CI] 1025%); with a median follow-up of 24.5 mo (95% CI 21.6-27.1), median PFS was 2.7 mo (95% CI 2.5-4.0) and median OS was 15.9 mo (95% CI 9.5-19.8). A total of 67 patients had an evaluable primary renal lesion, four of whom (6%) experienced shrinkage of more than 30%. Overall, patients who did not undergo uCN had adverse baseline characteristics and nivolumab activity against the primary tumour was limited. PATIENT SUMMARY: In this report, we observed that nivolumab was associated with a limited response of the primary tumour in previously treated patients with metastatic kidney cancer.
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Affiliation(s)
- Jean Courcier
- Department of Urology, UPEC-Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | | | | | | | | | - Stéphane Oudard
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Gwénaëlle Gravis
- Medical Oncology Department, Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France
| | | | - Lionel Geoffrois
- Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | | | | | - Delphine Topart
- Department of Medical Oncology, Montpellier University Hospital, Hôpital Saint Eloi, Montpellier, France
| | - Stéphane Culine
- Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | | | - Antoine Jamet
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Bernard Escudier
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Ronan Flippot
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Laurence Albigès
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France.
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Hall ME, Bhindi B, Luckenbaugh AN, Laviana AA, Moses KA, Satkunasivam R, Rini B, Klaassen Z, Wallis CJD. Association between cytoreductive nephrectomy and survival among patients with metastatic renal cell carcinoma receiving modern therapies: a systematic review and meta-analysis examining effect modification according to systemic therapy approach. Cancer Causes Control 2021; 32:675-80. [PMID: 33963938 DOI: 10.1007/s10552-021-01435-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cytoreductive nephrectomy (CN) has played a role in treatment of metastatic renal cell carcinoma (mRCC) since trials demonstrated a survival benefit in patients receiving CN with interferon. With the publication of CARMENA, it became clear that the value of CN may depend on the co-therapy administered. We sought to assess the benefit of CN in the era of modern immunotherapy (IO). METHODS We performed a systematic review to identify studies assessing CN in patients receiving TT or IO. We extracted multivariable-adjusted hazard ratios for the association between CN and overall survival (OS) and performed random effects meta-analysis. We tested for effect modification by systemic therapy approach on the association between CN and OS by pooling the difference in logHR associated with CN for patients treated with TT versus IO. RESULTS We identified three comparisons assessing CN in patients receiving TT or IO. Pooled analysis indicated improved survival with CN in both the TT (2 cohorts, pooled HR: 0.52, 95% CI 0.46-0.59; I2 = 80%) and IO era (2 cohorts; pooled HR: 0.28, 95% CI 0.16-0.49; I2 = 21%), with a stronger association in the IO era (p = 0.01; I2 = 0%). CONCLUSION In observational datasets, we observed a larger survival benefit to CN in patients treated with IO-based regimens versus those treated with TT-based regimens. While the role of CN for patients receiving TT has recently been questioned, this suggests that the results of CARMENA do not necessarily preclude a benefit to CN when combined with IO-based regimens.
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Silagy AW, Attalla K, Dinatale RG, Weiss KL, Weng S, Mano R, Iosepovici S, Marcon J, Reznik E, Kotecha RR, Motzer RJ, Voss MH, Coleman JA, Hakimi AA, Russo P. A qualitative framework of non-selection factors for cytoreductive nephrectomy. World J Urol 2021. [PMID: 33779820 DOI: 10.1007/s00345-021-03650-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/25/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Cytoreductive nephrectomy (CN) benefits a subset of patients with metastatic renal cell carcinoma (mRCC), however proper patient selection remains complex and controversial. We aim to characterize urologists' reasons for not undertaking a CN at a quaternary cancer center. METHODS Consecutive patients with mRCC referred to MSKCC urologists for consideration of CN between 2009 and 2019 were included. Baseline clinicopathologic characteristics were used to compare patients selected or rejected for CN. The reasons cited for not operating and the alternative management strategies recommended were extrapolated. Using an iterative thematic analysis, a framework of reasons for rejecting CN was designed. Kaplan-Meier estimates tested for associations between the reasons for not undertaking a CN and overall survival (OS). RESULTS Of 297 patients with biopsy-proven mRCC, 217 (73%) underwent CN and 80 (27%) did not. Median follow-up of patients alive at data cut-off was 27.3 months. Non-operative patients were older (p = 0.014), had more sites of metastases (p = 0.008), harbored non-clear cell histology (p = 0.014) and reduced performance status (p < 0.001). The framework comprised seven distinct themes for recommending non-operative management: two patient-fitness considerations and five oncological considerations. These considerations were associated with OS; four of the oncological factors conferred a median OS of less than 12 months (p < 0.001). CONCLUSION We developed a framework of criteria by which patients were deemed unsuitable candidates for CN. These new insights provide a novel perspective on surgical selection, could potentially be applicable to other malignancies and possibly have prognostic implications.
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Mazzaschi G, Quaini F, Bersanelli M, Buti S. Cytoreductive nephrectomy in the era of targeted- And immuno- therapy for metastatic renal cell carcinoma: An elusive issue? A systematic review of the literature. Crit Rev Oncol Hematol 2021; 160:103293. [PMID: 33667661 DOI: 10.1016/j.critrevonc.2021.103293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/18/2021] [Accepted: 02/27/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) in the era of targeted- (TT) and immuno- (IT) therapy remains controversial. DESIGN The primary objective of the present systematic, performed according to PRISMA guidelines review, was to assess the prevalence of nephrectomy in mRCC patients enrolled in TT/IT randomized phase II/III clinical trials (RCTs) or expanded access programs (EAPs). Medline database was searched from 2003 to 2019 for studies with available nephrectomy data. RESULTS We identified 609 studies, subsequently restricted to 57 randomized phase II/III clinical trials and 6 EAPs. Overall, 33,196 patients with mRCC were included, among whom 28,700 (86.4 %) underwent nephrectomy. The trends over time of nephrectomy occurrence remained substantially stable from 2003 to 2019. CONCLUSIONS Our analysis highlighted that data from RCTs and EAPs driving the clinical practice originate from nephrectomized patient populations. This evidence supports the clinical relevance of CN also in mRCC patients candidate to receive TT/IT.
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Affiliation(s)
- Giulia Mazzaschi
- Department of Medicine and Surgery, University of Parma, Medical Oncology Unit, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Federico Quaini
- Department of Medicine and Surgery, Haematology and Bone Marrow Transplantation, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Melissa Bersanelli
- Department of Medicine and Surgery, University of Parma, Medical Oncology Unit, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Sebastiano Buti
- Department of Medicine and Surgery, University of Parma, Medical Oncology Unit, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
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Laukhtina E, Pradere B, D Andrea D, Rosiello G, Luzzago S, Pecoraro A, Palumbo C, Knipper S, Karakiewicz PI, Margulis V, Quhal F, Sari Motlagh R, Mostafaei H, Mori K, Kimura S, Enikeev D, Shariat SF. Association of preoperative serum De Ritis ratio with oncological outcomes in patients treated with cytoreductive nephrectomy for metastatic renal cell carcinoma. Urol Oncol 2020; 38:936.e7-936.e14. [PMID: 32962909 DOI: 10.1016/j.urolonc.2020.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/23/2020] [Accepted: 08/05/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE Identifying which patients are likely to benefit from cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) is important. We tested the association between preoperative serum De Ritis ratio (DRR, Aspartate Aminotransferase/Alanine Aminotransferase) and overall survival (OS) as well as cancer-specific survival (CSS) in mRCC patients treated with CN. MATERIAL AND METHODS mRCC patients treated with CN at different institutions were included. After assessing for the optimal pretreatment DRR cut-off value, we found 1.2 to have the maximum Youden index value. The overall population was therefore divided into 2 DRR groups using this cut-off (low, <1.2 vs. high, ≥1.2). Univariable and multivariable Cox regression analyses tested the association between DRR and OS as well as CSS. The discrimination of the model was evaluated with the Harrel's concordance index (C-index). The clinical value of the DRR was evaluated with decision curve analysis. RESULTS Among 613 mRCC patients, 239 (39%) patients had a DRR ≥1.2. Median follow-up was 31 (IQR 16-58) months. On univariable analysis, high DRR was significantly associated with OS (hazard ratios [HR]: 1.22, 95% confidence interval [CI]: 1.01-1.46, P = 0.04) and CSS (HR: 1.23, 95% CI: 1.02-1.47, P = 0.03). On multivariable analysis, which adjusted for the effect of established clinicopathologic features, high DRR remained significantly associated with both OS (HR: 1.26, 95% CI: 1.04-1.52, P = 0.02) and CSS (HR: 1.26, 95% CI: 1.05-1.53, P = 0.01). The addition of DRR only minimally improved the discrimination of a base model that included established clinicopathologic features (C-index = 0.633 vs. C-index = 0.629). On decision curve analysis, the inclusion of DRR did not improve the net-benefit beyond that obtained by established subgroup analyses stratified by IMDC risk groups, type of systemic therapy, body mass index and sarcomatoid features, did not reveal any prognostic value to DRR. CONCLUSION Despite the statistically significant association between DRR and OS as well as CSS in mRCC patients treated with CN, DRR does not seem to add any further prognostic value beyond that obtained by currently available features.
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Affiliation(s)
- Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Hospital of Tours, Tours, France
| | - David D Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Giuseppe Rosiello
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada; Division of Experimental, OncologyDepartment of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Luzzago
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada; Department of Urology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Angela Pecoraro
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada; Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Carlotta Palumbo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada; Urology Unit, Department of Medical and Surgical Specialties, ASST Spedali Civili of Brescia, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Sophie Knipper
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shoji Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, University of Texas Southwestern, Dallas, TX; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; European Association of Urology Research Foundation, Arnhem, Netherlands.
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Zhang Z, Wu H, Yang T, Wu Y, Yu N, Xu Z. Metastatic renal cell carcinoma patients of T4 stage who are in status of N1 stage or older than 76 years cannot benefit from cytoreductive nephrectomy. BMC Cancer 2020; 20:844. [PMID: 32883242 DOI: 10.1186/s12885-020-07351-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 08/26/2020] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to identify which part of the patients with metastatic renal cell carcinoma (mRCC) is not suitable for cytoreductive nephrectomy (CN). Methods The data of mRCC patients was acquired from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate cox regression analysis and nomogram were performed for selecting factors independently associated with survival. Propensity score matching (PSM) was applied to reduce potential bias when comparing survival of mRCC patients treated by CN or non-surgery (NS). The survival analysis of subgroups was estimated by the Kaplan–Meier method and compared by log-rank testing. The summary of subgroup analysis was showed by forest plots. Results The records of 21,411 patients with mRCC were obtained from the SEER database. After screening, a total of 6532 patients were included for further analysis, of which 6043 underwent CN and 489 underwent NS. Age, T stage, N stage and tumor size were involved in subgroup analysis by PSM according to the result of multivariate cox regression analysis and clinical experience. Survival benefit was not found in T4 stage patients. Further analysis showed that T4&N1 and T4&age ≥ 76 yr subgroups could not obtain survival benefit from CN. Conclusion CN should not be performed in T4 stage mRCC patients who were in status of N1 stage or older than 76 years, because surgery cannot take significant survival benefit for them.
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Petrut B, Bujoreanu CE, Hardo VV, Barbos A, Fetica B. Laparoscopic cytoreductive nephrectomy and adrenalectomy for metachronous RCC metastases-Case report. Int J Surg Case Rep 2020; 74:268-72. [PMID: 32911447 DOI: 10.1016/j.ijscr.2020.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/16/2020] [Accepted: 08/23/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION We report the case of a 69 y.o. man with a left solitary kidney presenting 3 tumoral masses and suspicion of a left adrenal nodular tumor. PRESENTATION OF CASE 48 months previously, the patient underwent laparoscopic right radical nephrectomy and adrenalectomy for a clear cell renal carcinoma, with a tumor free adrenal gland. 3D laparoscopic transperitoneal left cytoreductive nephrectomy and left adrenalectomy were performed within 23 min warm ischemia with no need of post operatory hemodialysis. The pathology exam reported metachronous metastases on left adrenal gland and on a left multifocal tumoral solitary kidney from the contralateral clear cell renal carcinoma prior diagnosed and treated at this patient. DISCUSSION Cytoreductive nephrectomy on a solitary kidney brings technical challenges for the laparoscopic approach, especially when the tumor presents as multifocal lesions. Contralateral metachronous metastases and adrenal involvement in case of renal carcinoma are scarcely presented in the literature. CONCLUSION The "en bloc" excision of the tumoral masses optimized warm ischemia time and improved the technical approach, even if the endophytic presentation imposed difficulty.
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Palumbo C, Mistretta FA, Knipper S, Pecoraro A, Tian Z, Dzyuba-Negrean C, Shariat SF, Saad F, Simeone C, Berruti A, Briganti A, Kapoor A, Antonelli A, Karakiewicz PI. Contemporary Cytoreductive Nephrectomy Provides Survival Benefit in Clear-cell Metastatic Renal Cell Carcinoma. Clin Genitourin Cancer 2020; 18:e730-e738. [PMID: 32800473 DOI: 10.1016/j.clgc.2020.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/04/2020] [Accepted: 05/12/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION A recent randomized trial questioned the role of cytoreductive nephrectomy in clear-cell metastatic renal cell carcinoma (ccmRCC). We reassessed the effect of cytoreductive nephrectomy on survival in a contemporary population-based ccmRCC cohort. PATIENTS AND METHODS Within the Surveillance, Epidemiology, and End Results database (2010-2015), we focused on patients with ccmRCC. The primary endpoint consisted of overall mortality. Univariable and multivariable Cox regression models were applied in the overall cohort and in patients who underwent targeted therapy. Sensitivity analyses included 1:1 propensity score matching, 3- and 6-month landmark analyses, incremental survival benefit analyses, and metastases number and location-based stratifications. RESULTS Of 4062 patients with ccmRCC, 2241 (55.1%) received targeted therapy; cytoreductive nephrectomy was performed in 2226 (54.8%) patients and 1168 (52.1%) patients in the overall and targeted therapy cohorts, respectively. Cytoreductive nephrectomy was associated with lower overall mortality in the overall cohort (median survival, 30 vs. 9 months; hazard ratio [HR], 0.43; P < .001), as well as in the targeted therapy cohort (median survival, 28 vs. 12 months; HR, 0.49; P < .001). In sensitivity analyses, cytoreductive nephrectomy was associated with lower overall mortality after 1:1 propensity score-matching (HR, 0.49; P < .001), in 3- and 6-month landmark analyses (HR, 0.49; P < .001 and HR, 0.51; P < .001, respectively), in metastases number and location-based stratifications, except for exclusive liver metastases, as well as in all incremental benefit analyses. CONCLUSION Cytoreductive nephrectomy is associated with better survival in patients with ccmRCC, including those exposed to targeted therapy, after adjustment for multiple potential confounders.
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Affiliation(s)
- Carlotta Palumbo
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Urology Unit, ASST Spedali Civili of Brescia, Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy.
| | - Francesco A Mistretta
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Department of Urology, European Institute of Oncology, Milan, Italy
| | - Sophie Knipper
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Martini Klinik, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Pecoraro
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - Cristina Dzyuba-Negrean
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | | | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Division of Urology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Claudio Simeone
- Urology Unit, ASST Spedali Civili of Brescia, Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, ASST Spedali Civili of Brescia, Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy
| | - Anil Kapoor
- Division of Urology, Department of Surgery, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Alessandro Antonelli
- Urology Unit, ASST Spedali Civili of Brescia, Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Division of Urology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
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Abstract
Advanced renal cell carcinoma is not uncommon, but necessitates a multidisciplinary approach for optimal treatment. Targeted therapy has increased the likelihood of urologists managing patients in all disease stages. Neoadjuvant therapy is currently experimental. Systemic therapy for metastatic disease demonstrates survival benefits. The role of cytoreductive nephrectomy and adjuvant therapy is dependent on patient selection. Management of advanced renal cell carcinoma involves continued optimization of available agents and biomarker development. This article reviews the role of the urologist in medical and surgical therapies, including prognostication, management of locally advanced and metastatic disease, and provides the most recent clinical trial data.
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Affiliation(s)
- Anil Kapoor
- Division of Urology, Department of Surgery, McMaster University, McMaster Institute of Urology, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Room G334, Hamilton, Ontario L8N 4A6, Canada.
| | - Jaehoon Kim
- Division of Urology, Department of Surgery, McMaster University, McMaster Institute of Urology, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Room G334, Hamilton, Ontario L8N 4A6, Canada
| | - George Goucher
- Division of Urology, Department of Surgery, McMaster University, McMaster Institute of Urology, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Room G334, Hamilton, Ontario L8N 4A6, Canada
| | - Jen Hoogenes
- Division of Urology, Department of Surgery, McMaster University, McMaster Institute of Urology, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Room G334, Hamilton, Ontario L8N 4A6, Canada
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Soares A, Monteiro FSM, Maluf FC, Bastos DA, Jardim DL, Sasse AD, Gonçalves E Silva A, Fay AP, da Rosa DAR, Wierman E, Kater F, Schutz FA, de Oliveira FNG, Morbeck IAP, Rinck JA, da Trindade KM, Maia MC, Souza VC, da Silva Neto DCV, de Almeida E Paula F, Korkes F, Carvalhal GF, Nogueira L, de Carvalho Fernandes R, Dos Reis RB, Matheus WE, Busato WFS, da Costa WH, de Cássio Zequi S. Advanced renal cell carcinoma (RCC) management: an expert panel recommendation from the Latin American Cooperative Oncology Group (LACOG) and the Latin American Renal Cancer Group (LARCG). J Cancer Res Clin Oncol 2020; 146:1829-1845. [PMID: 32410064 PMCID: PMC7256074 DOI: 10.1007/s00432-020-03236-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The outcome of RCC has improved considerably in the last few years, and the treatment options have increased. LACOG-GU and LARCG held a consensus meeting to develop guidelines to support the clinical decisions of physicians and other health professionals involved in the care of RCC patients. METHODS Eighty questions addressing relevant advanced RCC treatments were previously formulated by a panel of experts. The voting panel comprised 26 specialists from the LACOG-GU/LARCG. Consensus was determined as 75% agreement. For questions with less than 75% agreement, a new discussion was held, and consensus was determined by the majority of votes after the second voting session. RESULTS The recommendations were based on the highest level of scientific evidence or by the opinion of the RCC experts when no relevant research data were available. CONCLUSION This manuscript provides guidance for advanced RCC treatment according to the LACOG-GU/LARCG expert recommendations.
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Affiliation(s)
- Andrey Soares
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627-Morumbi, São Paulo, SP, 05652-900, Brazil.
- Centro Paulista de Oncologia/Oncoclínicas, Av. Brigadeiro Faria Lima, 4300-Vila Olímpia, São Paulo, SP, 01452-000, Brazil.
| | - Fernando Sabino Marques Monteiro
- Hospital Santa Lúcia, SHLS 716 Conjunto C, Brasília, DF, 70390-700, Brazil
- Hospital Universitário de Brasília, SGAN 605, Brasília, DF, 70840-901, Brazil
| | - Fernando Cotait Maluf
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627-Morumbi, São Paulo, SP, 05652-900, Brazil
- Hospital Santa Lúcia, SHLS 716 Conjunto C, Brasília, DF, 70390-700, Brazil
- Beneficência Portuguesa de São Paulo, R. Martiniano de Carvalho, 965-Bela Vista, São Paulo, SP, 01323-001, Brazil
| | - Diogo Assed Bastos
- Hospital Sírio-Libanês, R. Dona Adma Jafet, 91-Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Denis Leonardo Jardim
- Hospital Sírio-Libanês, R. Dona Adma Jafet, 91-Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - André Deeke Sasse
- Grupo SOnHE, Av. Dr. Heitor Penteado, 1780-Taquaral, Campinas, SP, 13075-460, Brazil
| | - Adriano Gonçalves E Silva
- Instituto do Câncer e Transplante de Curitiba (ICTR), R. Myltho Anselmo da Silva, 870-Mercês, Curitiba, PR, 80510-130, Brazil
| | - André P Fay
- Escola de Medicina e Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Av. Ipiranga, 6690-Prédio 60-Partenon, Porto Alegre, RS, 90610-000, Brazil
- Grupo Oncoclínicas, R. Tobias da Silva, 126-Moinhos do Vento, Porto Alegre, RS, 90570-020, Brazil
| | | | - Evanius Wierman
- Instituto de Oncologia do Paraná, R. Mateus Leme, 2631/B-Centro Cívico, Curitiba, PR, 80520-174, Brazil
| | - Fabio Kater
- Beneficência Portuguesa de São Paulo, R. Martiniano de Carvalho, 965-Bela Vista, São Paulo, SP, 01323-001, Brazil
| | - Fabio A Schutz
- Beneficência Portuguesa de São Paulo, R. Martiniano de Carvalho, 965-Bela Vista, São Paulo, SP, 01323-001, Brazil
| | | | | | - José Augusto Rinck
- AC Camargo Cancer Center, R. Professor Antônio Prudente, 211-Liberdade, São Paulo, SP, 01509-010, Brazil
| | - Karine Martins da Trindade
- Hospital São Carlos/Oncocentro, Av. Pontes Vieira, 2531-Dionísio Torres, Fortaleza, CE, 60135-237, Brazil
- Santa Casa de Misericórdia de Fortaleza, R. Barão do Rio Branco, s/n-Centro, Fortaleza, CE, 60025-060, Brazil
| | - Manuel Caitano Maia
- Centro de Oncologia do Paraná, Rodovia BR-277, 1437-Ecoville, Curitiba, PR, 82305-100, Brazil
| | - Vinicius Carrera Souza
- Oncologia D'Or., Av. São Rafael, 2152, 6 Andar, Hospital São Rafael, São Marcos, Salvador, BA, 41253-190, Brazil
| | | | - Felipe de Almeida E Paula
- Hospital Regional do Câncer de Presidente Prudente, Av. Coronel José Soares Marcondes, 2380-Vila Euclides, Presidente Prudente, SP, 19013-050, Brazil
| | - Fernando Korkes
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627-Morumbi, São Paulo, SP, 05652-900, Brazil
- ABC Medical School, Av. Príncipe de Gales, 821-Príncipe de Gales, Santo André, SP, 09060-650, Brazil
| | - Gustavo Franco Carvalhal
- Escola de Medicina e Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Av. Ipiranga, 6690-Prédio 60-Partenon, Porto Alegre, RS, 90610-000, Brazil
| | - Lucas Nogueira
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110-Santa Efigência, Belo Horizonte, BH, 30130-100, Brazil
| | - Roni de Carvalho Fernandes
- Hospital Central da Santa Casa de Misericórdia de São Paulo, R. Dr. Cesário Mota Júnior, 112-Vila Buarque, São Paulo, SP, 01221-020, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, R. Dr. Cesário Mota Jr., 61-Vila Buarque, São Paulo, SP, 01221-020, Brazil
| | - Rodolfo Borges Dos Reis
- Faculdade de Medicina de Ribeirão Preto-Universidade de São Paulo, Av. Bandeirantes, 3900-Monte Alegre, Ribeirão Preto, SP, 14049-900, Brazil
| | - Wagner Eduardo Matheus
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas, R. Tessália Vieira de Camargo, 126-Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-887, Brazil
| | | | - Walter Henriques da Costa
- AC Camargo Cancer Center, R. Professor Antônio Prudente, 211-Liberdade, São Paulo, SP, 01509-010, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, R. Dr. Cesário Mota Jr., 61-Vila Buarque, São Paulo, SP, 01221-020, Brazil
- National Institute for Science and Technology in Oncogenomics and Therapeutic Innovation, AC Camargo Cancer Center, R. Professor Antônio Prudente, 211-Liberdade, São Paulo, SP, 01509-010, Brazil
| | - Stênio de Cássio Zequi
- AC Camargo Cancer Center, R. Professor Antônio Prudente, 211-Liberdade, São Paulo, SP, 01509-010, Brazil
- National Institute for Science and Technology in Oncogenomics and Therapeutic Innovation, AC Camargo Cancer Center, R. Professor Antônio Prudente, 211-Liberdade, São Paulo, SP, 01509-010, Brazil
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Janisch F, Hillemacher T, Fuehner C, D'Andrea D, Meyer CP, Klotzbücher T, Kienapfel C, Vetterlein MW, Kimura S, Abufaraj M, Dahlem R, Shariat SF, Fisch M, Rink M. The impact of cytoreductive nephrectomy on survival outcomes in patients treated with tyrosine kinase inhibitors for metastatic renal cell carcinoma in a real-world cohort. Urol Oncol 2020; 38:739.e9-739.e15. [PMID: 32576526 DOI: 10.1016/j.urolonc.2020.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Tyrosine kinase inhibitor therapy (TKI) has changed the treatment paradigm of metastatic renal cell carcinoma (mRCC). The recent CARMENA and SURTIME trials challenged the role of the cytoreductive nephrectomy (CN). OBJECTIVE To assess the impact of CN prior to TKI therapy in patients with mRCC in a real-world setting. METHODS Overall, 262 consecutive patients with mRCC were treated with CN plus TKI or TKI only at our institution between 2000 and 2016. Patients with prior immunotherapy or metastasectomy were excluded. Multiple imputation and inverse probability of treatment weighting (IPTW) were performed to account for missing values and imbalances between the treatment groups, respectively. Unadjusted and adjusted Kaplan-Meier estimates were used to determine differences in progression-free (PFS), overall (OS), and cancer-specific survival (CSS). RESULTS Overall, 104 (40%) patients received CN before TKI treatment. Most frequent first line therapy was Sunitinib (66%), followed by Sorafenib (20%) and Pazopanib (10%). After adjustment with IPTW, there was no difference in PFS, CSS, and OS (all P > 0.05) between the treatment groups. In subgroup analyses, CSS was improved when CN was performed in patients with sarcomatoid features and clear cell histology (P = 0.04 and P = 0.03) and PFS was improved in patients with clear cell histology when CN was performed [0.04]). CN did not improve OS in any subgroup analysis. CONCLUSION The role of CN remains controversial. We found no difference in survival outcomes between patients treated with and without CN before TKI therapy. However, CN was associated with improved survival in specific patient subgroups. Tailored, individualized treatment is key to further improve oncological outcomes for mRCC.
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Affiliation(s)
- Florian Janisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Tobias Hillemacher
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Fuehner
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Christian P Meyer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Klotzbücher
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Kienapfel
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shoji Kimura
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Special Surgery, Jordan University hospital, The University of Jordan, Amman, Jordan
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Department of Urology, Weill Cornell Medical School, New York, NY; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Abstract
The role for cytoreductive nephrectomy (CN) in the treatment of metastatic renal cell carcinoma (mRCC) has evolved with advancements in systemic therapy. During the cytokine-based immunotherapy era, CN provided a clear survival benefit and was considered standard of care in management of mRCC. The development of targeted systemic therapy directed at the vascular endothelial growth factor pathway altered the treatment paradigm and accentuated the importance of risk stratification in treatment selection. This article reviews the literature evaluating the benefit of CN during the evolution of systemic therapy and provides clinical recommendations for current utilization of CN in patients with mRCC.
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Affiliation(s)
- Michael J Biles
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, 600 N. Wolfe Street / Marburg 144, Baltimore, MD 21287, USA.
| | - Hiten D Patel
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, 600 N. Wolfe Street / Marburg 144, Baltimore, MD 21287, USA
| | - Mohamad E Allaf
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, 600 N. Wolfe Street / Marburg 144, Baltimore, MD 21287, USA
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Larcher A, Fallara G, Rosiello G, Re C, Baiamonte G, Agnesi S, Cignoli D, Colandrea G, Basile G, Briganti A, Salonia A, Bertini R, Montorsi F, Capitanio U. Cytoreductive Nephrectomy in Metastatic Patients with Signs or Symptoms: Implications for Renal Cell Carcinoma Guidelines. Eur Urol 2020; 78:321-326. [PMID: 32507335 DOI: 10.1016/j.eururo.2020.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/12/2020] [Indexed: 11/18/2022]
Abstract
The role of cytoreductive nephrectomy (CN) patients with metastatic renal cell carcinoma (mRCC) is unclear. To define the proportion of symptomatic mRCC, to investigate the impact of CN on symptomatic improvement and perioperative morbidity, and to elucidate the trade-off between such benefit and harm, an observational study of 317 mRCC patients treated with CN was performed. Symptomatic mRCC was defined as the presence of any sign or symptom causally related to the disease. Sign or symptom resolution and improvement were defined as the absence of all the signs and symptoms recorded at baseline, and the absence of at least one sign or symptom recorded at baseline, respectively. Perioperative morbidity was assessed using the Clavien-Dindo classification. Response to CN was classified as beneficial, mixed, or harmful according to the trade-off between symptomatic improvement and perioperative morbidity. The proportions of local, metastasis-specific, and general signs or symptoms were 37%, 23%, and 27%, respectively. The proportions of any sign or symptom resolution and improvement after CN were 43% and 71%, respectively. The proportions of local sign or symptom resolution and improvement after CN were 91% and 95%, respectively. The risks of any complication and major complication were 37% and 10%, respectively. At regression analysis, symptomatic status was not associated with perioperative morbidity. The proportion of beneficial response was invariably higher than the proportion of harmful response. At mRCC diagnosis, two out of three patients suffer from any sign or symptom, and one out of three suffers from local signs or symptoms. CN has a positive impact on symptomatic status. PATIENT SUMMARY: Most metastatic renal cell carcinoma patients are symptomatic, and they should be aware that cytoreductive nephrectomy has a positive impact on symptomatic status.
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Affiliation(s)
- Alessandro Larcher
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Giuseppe Fallara
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Rosiello
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiara Re
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianfranco Baiamonte
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Agnesi
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Daniele Cignoli
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianmarco Colandrea
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Basile
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Bertini
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, URI - Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Singla N, Hutchinson RC, Ghandour RA, Freifeld Y, Fang D, Sagalowsky AI, Lotan Y, Bagrodia A, Margulis V, Hammers HJ, Woldu SL. Improved survival after cytoreductive nephrectomy for metastatic renal cell carcinoma in the contemporary immunotherapy era: An analysis of the National Cancer Database. Urol Oncol 2020; 38:604.e9-604.e17. [PMID: 32253116 PMCID: PMC7269798 DOI: 10.1016/j.urolonc.2020.02.029] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/23/2020] [Accepted: 02/29/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Despite immune checkpoint inhibitor (ICI) approval for metastatic renal cell carcinoma (mRCC) in 2015, cytoreductive nephrectomy (CN) is guided by extrapolation from earlier classes of therapy. We evaluated survival outcomes, timing, and safety of combining CN with modern immunotherapy (IO) for mRCC. METHODS From 96,329 renal cancer cases reported to the NCDB between 2015 and 2016, we analyzed 391 surgical candidates diagnosed with clear cell mRCC treated with IO ± CN and no other systemic therapies. Primary outcome was overall survival (OS) stratified by the performance of CN (CN + IO vs. IO alone). Secondary outcomes included OS stratified by the timing of CN, pathologic findings, and perioperative outcomes. RESULTS Of 391 patients, 221 (56.5%) received CN + IO and 170 (43.5%) received IO only. Across a median follow-up of 14.7 months, patients who underwent CN + IO had superior OS (median NR vs. 11.6 months; hazard ratio 0.23, P < 0.001), which was upheld on multivariable analyses. IO before CN resulted in lower pT stage, grade, tumor size, and lymphovascular invasion rates compared to upfront CN. Two of 20 patients (10%) undergoing CN post-IO achieved complete pathologic response in the primary tumor (pT0). There were no positive surgical margins, 30-day readmissions, or prolonged length of stay in patients undergoing delayed CN. CONCLUSION Using a large, national, registry-based cohort, we provide the first report of survival outcomes in mRCC patients treated with CN combined with modern IO. Our findings support an oncologic role for CN in the ICI era and provide preliminary evidence regarding the timing and safety of CN relative to IO administration.
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Affiliation(s)
- Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ryan C Hutchinson
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rashed A Ghandour
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Yuval Freifeld
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dong Fang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Arthur I Sagalowsky
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, I.M. Sechenov First Moscow State University, Moscow, Russia
| | - Hans J Hammers
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
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Luzzago S, Palumbo C, Rosiello G, Knipper S, Pecoraro A, Mistretta FA, Tian Z, Musi G, Montanari E, Soulières D, Shariat SF, Saad F, Briganti A, de Cobelli O, Karakiewicz PI. Association Between Systemic Therapy and/or Cytoreductive Nephrectomy and Survival in Contemporary Metastatic Non-clear Cell Renal Cell Carcinoma Patients. Eur Urol Focus 2021; 7:598-607. [PMID: 32444303 DOI: 10.1016/j.euf.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/22/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Optimal management of metastatic non-clear cell renal cell carcinoma (non-ccmRCC) remains largely unknown. OBJECTIVE To test the effect of systemic therapy (ST) and/or cytoreductive nephrectomy (CNT) on overall mortality (OM) in patients with non-ccmRCC. DESIGN, SETTING, AND PARTICIPANTS Within the Surveillance, Epidemiology and End Results (SEER) registry (2006-2015), we identified patients with papillary, chromophobe, sarcomatoid, and collecting duct metastatic renal cell carcinoma (mRCC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Temporal trends (estimated annual percentage change [EAPC]), Kaplan-Meier plots, and multivariable Cox regression models were used. RESULTS AND LIMITATIONS Of 1573 patients with non-ccmRCC, 22%, 25%, 25%, and 28% underwent no treatment, ST, CNT, and CNT with ST, respectively. Between 2006 and 2015, rates of CNT and the combination of CNT and ST decreased (EAPC: -6.3% and -3.2%, respectively). Conversely, rates of no treatment and ST increased over time (EAPC: 4.6% and 7.5%, respectively). In multivariable Cox regression models, relative to no treatment, ST (hazard ratio [HR]: 0.5; p < 0.001), CNT (HR: 0.4; p < 0.001), and CNT with ST (HR: 0.3; p < 0.001) were associated with lower OM. Histological subtypes were associated with OM, relative to papillary renal cell carcinoma (RCC): chromophobe (HR: 0.7; p < 0.01), sarcomatoid (HR: 2.1; p < 0.001), and collecting duct RCC (HR: 1.9; p < 0.001). Limitations include the impossibility to stratify patients according to mRCC risk groups. CONCLUSIONS Most non-ccmRCC patients are treated with a combination of CNT and ST or CNT alone or ST alone. The rates of ST alone are increasing. Conversely, the rates of combined CNT and ST and CNT alone are decreasing. These observed temporal patterns of treatment rates are counterintuitive with respect to associated OM benefits, where combination of CNT and ST, as well as CNT alone, resulted in the lowest absolute OM, relative to ST alone, or, even worse, no treatment. PATIENT SUMMARY We investigated the effect of treatment modalities on survival of patients with metastatic non-clear cell renal cell carcinoma. The combination of cytoreductive nephrectomy and systemic therapy confers greater benefit with respect to single treatments alone.
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Roussel E, Campi R, Larcher A, Verbiest A, Antonelli A, Palumbo C, Derweesh I, Ghali F, Bradshaw A, Meagher MF, Heck M, Amiel T, Kriegmair MC, Rubio J, Musquera M, D'Anna M, Autorino R, Guruli G, Veccia A, Linares-Espinos E, Van Bruwaene S, Hevia V, Porpiglia F, Checcucci E, Minervini A, Mari A, Pavan N, Claps F, Marchioni M, Capitanio U, Beuselinck B, Mir MC, Albersen M. Rates and Predictors of Perioperative Complications in Cytoreductive Nephrectomy: Analysis of the Registry for Metastatic Renal Cell Carcinoma. Eur Urol Oncol 2020; 3:523-529. [PMID: 32414697 DOI: 10.1016/j.euo.2020.04.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/13/2020] [Accepted: 04/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients. OBJECTIVE We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes. DESIGN, SETTING, AND PARTICIPANTS Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates. RESULTS AND LIMITATIONS Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era. CONCLUSIONS Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients. PATIENT SUMMARY We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.
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Affiliation(s)
- Eduard Roussel
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Riccardo Campi
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Annelies Verbiest
- Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Alessandro Antonelli
- Department of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Carlotta Palumbo
- Department of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Ithaar Derweesh
- Department of Urology, University of California San Diego Cancer Center, Lousiana Jolla, CA, USA
| | - Fady Ghali
- Department of Urology, University of California San Diego Cancer Center, Lousiana Jolla, CA, USA
| | - Aaron Bradshaw
- Department of Urology, University of California San Diego Cancer Center, Lousiana Jolla, CA, USA
| | - Margaret F Meagher
- Department of Urology, University of California San Diego Cancer Center, Lousiana Jolla, CA, USA
| | - Matthias Heck
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Thomas Amiel
- Department of Urology, Technical University of Munich, Munich, Germany
| | | | - Jose Rubio
- Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain
| | | | | | | | - Georgi Guruli
- Department of Urology, VCU Medical Center, Richmond, VA, USA
| | | | | | | | - Vital Hevia
- Department of Urology, Hospital Ramon y Cajal, Madrid, Spain
| | - Francesco Porpiglia
- Department of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Enrico Checcucci
- Department of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Andrea Minervini
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Mari
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Nicola Pavan
- Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Francesco Claps
- Department of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Michele Marchioni
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, "G. d'Annunzio" University of Chieti, Chieti, Italy; Department of Urology, SS Annunziata Hospital, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Umberto Capitanio
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | - Benoit Beuselinck
- Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Maria C Mir
- Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain.
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
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Muraoka K, Nishikawa Y, Isoyama T. Spontaneous regression of metastatic renal cell carcinoma after cytoreductive nephrectomy: A case report. Urol Case Rep 2020; 31:101179. [PMID: 32300531 DOI: 10.1016/j.eucr.2020.101179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
We herein report a case involving a 59-year-old man with right lung and mediastinal lymph node metastases from renal cell carcinoma. After cytoreductive nephrectomy without neoadjuvant therapy, he achieved spontaneous regression. The regression was maintained 3 years after the operation. We immunohistochemically examined the surgical specimens and considered the possible mechanism underlying this phenomenon.
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Rosiello G, Palumbo C, Knipper S, Pecoraro A, Luzzago S, St-Hilaire PA, Tian Z, Capitanio U, Montorsi F, Shariat SF, Saad F, Briganti A, Karakiewicz PI. Comparison of survival outcomes in patients with metastatic papillary vs. clear-cell renal cell carcinoma: a propensity-score analysis. World J Urol 2020; 39:461-472. [PMID: 32253579 DOI: 10.1007/s00345-020-03187-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 03/27/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND To compare survival outcomes of metastatic patients harbouring either papillary (pRCC) or clear-cell (ccRCC) renal cell carcinoma in overall population and according to treatment modality. METHODS Within the Surveillance, Epidemiology and End Results database (2006-2015), we identified 6800 patients (585 papillary and 6215 clear-cell) with metastatic RCC. Propensity-score (PS) matching, Kaplan-Meier plots and multivariable Cox-regression models (CRMs) were used. RESULTS Overall, 585 (8.6%) patients harboured pRCC. Rates of nodal metastases were higher in patients with pRCC (49.7 vs. 23.3%; p < 0.001). Median overall survival (OS) was 13 vs. 18 months for pRCC vs. ccRCC patients. After multivariable adjustments, no difference in OS was recorded. Furthermore, after propensity-score matching, virtually the same results were recorded. Median OS of pRCC vs. ccRCC was 8 vs. 4 months for no treatment (NT), 11 vs. 12 months for targeted therapy alone (TT), 17 vs. 35 months for cytoreductive nephrectomy alone (CN) and 18 vs. 25 months for combination of CN with TT. CONCLUSIONS Metastatic pRCC patients exhibit poor survival, regardless of treatment received. Moreover, pRCC patients are more likely to present nodal metastases, compared to ccRCC patients, as demonstrated by twofold higher rates of lymph node invasion at diagnosis. These observations indicate that papillary variant represents more prognostically unfavorable tumor histology, in the context of metastatic RCC.
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Affiliation(s)
- Giuseppe Rosiello
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
| | - Carlotta Palumbo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
- Urology Unit, ASST Spedali Civili of Brescia, Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Sophie Knipper
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Pecoraro
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Stefano Luzzago
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
- Department of Urology, European Institute of Oncology, Milan, Italy
| | - Pierre-Antoine St-Hilaire
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Umberto Capitanio
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Francesco Montorsi
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Institute of Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Alberto Briganti
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
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Abstract
PURPOSE OF REVIEW The treatment landscape for metastatic renal cell carcinoma (mRCC) continues to evolve with ongoing advancements in systemic therapy, raising further questions about the optimal role of surgery in the management of mRCC. Herein, we provide a context and review of the recent evidence concerning the role of surgical therapy for patients with mRCC including cytoreductive nephrectomy and distant metastatectomy. RECENT FINDINGS One randomized trial has been published in the targeted therapy era suggesting that initial systemic therapy is non-inferior to cytoreductive nephrectomy among patients with intermediate and poor-risk mRCC. Delaying cytoreductive nephrectomy until after systemic therapy may be a viable treatment approach, although a high level of evidence is lacking. Additional questions remain regarding the sequence of surgery with systemic therapy, utility of distant metastatectomy, as well as the application of these findings to the current generation of immunotherapy. Recent evidence challenges the need of upfront cytoreductive nephrectomy for unselected patients with mRCC. However, surgical therapy continues to play an important role in the management of the disease.
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Affiliation(s)
| | - Patrick A Kenney
- Yale University School of Medicine, New Haven, USA
- Department of Urology, Yale University School of Medicine, New Haven, USA
| | - Michael S Leapman
- Yale University School of Medicine, New Haven, USA.
- Department of Urology, Yale University School of Medicine, New Haven, USA.
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