Extended hepatic metastasectomy for renal cell carcinoma—new aspects in times of targeted therapy: a single-center experience over three decades

Abstract

Purpose Despite the introduction of novel targeted therapies on patients with renal cell carcinoma, syn-and metachronous metastases (including hepatic lesions) are observed frequently and significantly influence patient survival. With introduction of targeted therapies as an effective alternative to surgery, therapeutical strategies in stage IV disease must be reevaluated. Methods This is a retrospective analysis of 40 patients undergoing hepatic resection of histologically confirmed RCC metastases at our institution between April 1993 and April 2017. Results The interval between nephrectomy for renal cell carcinoma and hepatic metastasectomy was 44.0 months (3.3-278.5). Liver resections of different extents were performed, including multivisceral resections. The median follow-up was 37.8 months (0.5-286.5). Tumor recurrence after resection of hepatic metastases occurred in 19 patients resulting in a median disease-free survival of 16.2 months (0.7-265.1) and a median overall survival of 37.8 months (0.5-286.5). Multivariable analysis identified multivisceral resection as an independent risk factor for disease-free and overall survival (p = 0.043 and p = 0.001, respectively). A longer interval between nephrectomy and hepatic metastasectomy was identified as an independent significant protective factor for overall survival (p < 0.001). Patients undergoing metastasectomy after introduction of sunitinib in Europe in 2006 (n = 15) showed a significantly longer overall survival (45.2 (9.1-111.0) versus 27.5 (0.5-286.52) months in the preceding era; p = 0.038). Conclusion Hepatic metastasectomy, including major and extended resections, on patients with metastasized renal cell carcinoma can be performed safely and may facilitate long-term survival. Due to significant morbidity and increased mortality, multivisceral resections must be weighed against other options, such as targeted therapy.

Chirurgische Therapie von Leber- und Pankreasmetastasen von Nierenzellkarzinomen

“…In der Literatur beeinflussten die R-Klassifikation des Lebereingriffs [10,16,23], das Grading [20], das Intervall zwischen Nephrektomie und Diagnose der Metastase [3,5,10,11,16,20,23], andere Tumormanifestationen vor der Lebermetastase [9], der Nachweis eines extrahepatischen Tumors zum Zeitpunkt der Leberresektion [5,9], die Metastasengröße [10], der Performance-Status des Patienten sowie eine Systemtherapie [10] die Prognose nach Leberteilresektion.…”

Simultaneous Kidney and Liver Resection in Renal Cell Carcinoma Liver Metastases: A Tale of Two Cases

“…The prognosis of RCCLM is especially poor and significantly worse than metastases to other organs [1,4]. Despite the advancement of targeted therapy, an R0 surgical resection is still regarded as the most favorable approach for the long-term survival of metastatic RCC [4,5,6]. While curative intent of surgical intervention for pulmonary metastases of RCC has shown significant OS improvement, liver resection, or radiofrequency ablation (RFA) of RCCLM has been controversial [3,6].…”

Role of metastasectomy in the management of renal cell carcinoma

“…Kim et al observed that mRCC patients with liver metastases have a poor prognosis, with a median OS of 7.4 months (32). In 2020, Beetz et al reported on 40 mRCC patients with liver metastases who underwent MTX, 14 (35%) of whom had concomitant extrahepatic metastases, and found a significant difference in median OS between the two groups (70). Patients without extrahepatic metastases had a median OS of 47.2 months compared to a median OS of 23.4 months in those with extrahepatic metastases (p = 0.017).…”

“…In 2010, Staehler et al published a study of 88 mRCC patients, 68 (77.3%) of whom underwent MTX, and 20 (22.7%) who were offered MTX but declined (non-MTX) (26). They observed that, with baseline characteristics not 35.737; p = 0.001) was a poor prognosticator of OS, while a longer interval from nephrectomy to hepatic MTX (HR 0.971, 95% CI, 0.956-0.987; p < 0.001) was favorable (70). Similarly, Kim et al reported that patients with concomitant liver and lung metastasis had poorer OS (HR 2.62, 95% CI, 1.23-5.58; p = 0.0126) and PFS (HR 2.62, 95% CI, 1.07-4.58; p = 0.0320) (32).…”

“…Multiple prognostic factors identified through retrospective studies demonstrate common variables that should be considered in the patient selection process. These favorable factors include if complete resection of metastatic disease is feasible (46,49,(56)(57)(58)(59)68), solitary or oligometastatic disease (36,38,46,55,57), metastatic disease isolated to a single organ and those lacking lymph node involvement of the primary tumor (32,36,46,49,50,52,56,58,60,61,(68)(69)(70), younger patients, especially under 60 years old (53, 54, 60, 69), clear-cell histology (21, 25,41,65,93), and lung metastases (22).…”