Cytoreductive Nephrectomy and Nephrectomy/Complete Metastasectomy for Metastatic Renal Cancer

Abstract

The objective of this study was to determine our institutional experience with cytoreductive nephrectomy alone or in conjunction with nephrectomy complete metastasectomy. Between July 1989 and September 2003, we queried our department's renal tumor database for patients undergoing cytoreductive nephrectomy alone or in conjunction with complete metastasectomy. Clinical and pathological factors analyzed included primary tumor size, stage and histological subtype, age, gender, Karnofsky Performance Status (KPS) prior to nephrectomy, number and location of metastatic sites, and the presence or absence of any systemic therapy. Preoperative laboratory values analyzed included hemoglobin (HGB), calcium (CA), albumin (ALB), lactose dehydrogenase (LDH), alkaline phosphatase (ALP), and corrected calcium. Corrected calcium was defined as follows: corrected calcium = total calcium - 0.707*(albumin - 3.4). During this time frame, 1628 patients underwent nephrectomy (partial or radical) for renal masses, 91 (5.6%) of whom had metastatic disease. In this group, 71% of patients were male, 88% of patients had a KPS of 80% or greater, and 92% had conventional clear cell histology. Sixty-four percent of patients had a single site of metastatic disease, with lung the most common, followed by bone, adrenal, brain, and liver. Sixty-one patients (67%) had nephrectomy with removal of all metastatic sites (nephrectomy/complete metastasectomy) and 30 (33%) had cytoreductive nephrectomy alone. Median survival for patients undergoing nephrectomy/complete metastasectomy was 30 months. Median survival for patients undergoing cytoreductive nephrectomy alone was 12 months. Perioperative complications occurred in 13% of patients and four patients died within 30 days of their operation. For patients with metastatic renal cell carcinoma, surgical resection of the primary tumor alone (cytoreductive nephrectomy) or in conjunction with metastasectomy can be accomplished with acceptable perioperative morbidity and mortality. This surgical experience provides a contemporary foundation as new targeted therapeutic agents are integrated into the neoadjuvant or adjuvant treatment of locally advanced and metastatic renal cancer.

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

“…Of the two remaining studies, in one 29 there was no signifi cant diff erence in cancer-specifi c survival between complete metastasectomy and no metastasectomy (58 vs 50 months; p=0·223); however, only 18 and 16 patients were assessed in the respective study groups. In the other study 31 there was a numerically longer median overall survival for the metastasectomy group (30 vs 12 months), but the p value was not provided. A forest plot of hazard ratios for overall survival or cancer-specifi c survival in studies in which incomplete or no metastasectomy was compared with complete metastasectomy for metastatic renal cell carcinoma to various organs shows improved overall survival and cancer-specifi c survival for complete metastasectomy (fi gure 2).…”

“…We have described the best available contemporary evidence base, from which 12 Amiraliev et al (2012) 23 Brinkmann et al (2007) 29 Eggener et al (2008) 27 Fokas et al (2010) 36 Fuchs et al (2005) 35 Hunter et al (2012) 34 Ikushima et al (2000) 37 Kwak et al (2007) 30 Lee et al (2006) 32 Pretalia et al (2010) 24 Russo et al (2007) 31 Staehler et al (2009) 26 Staehler et al (2010) 25 Zelefsky et al (2012) 33 Zerbi et al (2008) Review some conclusions can be made, and identifi ed knowledge gaps that can only be addressed through well-designed, prospective comparative studies. However, there are several limitations.…”

“…No randomised controlled trials or prospective non-randomised comparative studies were identifi ed. Eight studies assessed local treatments of metastases from renal cell carcinoma in various organs, 12,24,26,27,[29][30][31][32] of which the most common sites were lung, bone, liver, and brain, and less common sites were pancreas, adrenal gland, lymph nodes, thyroid gland, spleen, ethmoid sinus, and skin (table 1). Other studies also assessed local treatments for metastases from renal cell carcinoma in bone (including the vertebrae), 33 29 used treatment beforehand.…”

“…All of the eight studies 12,24,26,27,[29][30][31][32] that assessed metastases from renal cell carcinoma in various organs reported on complete metastasectomy versus no metastasectomy, incomplete metastasectomy, or both (table 2). However, in one study, 32 complete resection was achieved in only 45% of the metastasectomy group, which was compared with patients with no metastasectomy.…”

“…There was a moderate-to-high risk of confounding regarding previous treatment, tumour histology, grade, and size or volume of metastases, especially in studies on local treatments of bone and brain metastases. [33][34][35][36][37] Regarding diff erent sites treated in the same study, there was generally a moderate-to-high risk of confounding, especially for studies pertaining to treatment of metastases at various sites, 12,27,[30][31][32] because it was often unclear if these confounders were adjusted. Evidence quality was not assessed by GRADE because of the nature of the included studies (ie, retrospective comparative studies), and the high risk of bias across the studies.…”