The once and future role of cytoreductive nephrectomy

The role of nephrectomy in the setting of metastatic renal cell carcinoma has long been controversial and has continued to evolve over the last two decades. The practice of cytoreductive nephrectomy has only recently been widely accepted following the publication of 2 large multi-center randomized controlled trials that established a survival benefit for those patients undergoing nephrectomy followed by interferon treatment. Half a decade later, the new paradigm looks set to be questioned with the rapid emergence of tyrosine kinase inhibitors (TKIs). This article reviews the evolution of cytoreductive nephrectomy and speculates on its role in the new frontier of molecular targeting for metastatic renal cell carcinoma.     

A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: Morbidity and long-term survival

BACKGROUND: Metastatic renal cell carcinoma (RCC) is an aggressive entity that frequently invades the venous system. We evaluated the morbidity and survival of patients with tumor thrombus who undergo cytoreductive nephrectomy. MATERIALS AND METHODS: We identified 56 patients from our institution's database who had a primary renal tumor in place and documented metastases at the time of surgery. We reviewed demographic and pathologic characteristics from these patients as well as complications and overall survival. RESULTS: Median age was 58 (37-77). There were 33 patients (59%) who had tumor thrombus with 21 (64%) involving the renal vein, 10 (30%) involving the infradiaphragmatic inferior vena cava (IVC), and 2 (6%) involving the supradiaphragmatic IVC. Median tumor size for thrombus patients was 12 cm (5-29). There were 8 (14.2%) who had complications, including 1 death. Thrombus patients were significantly more likely to have a complication (P = 0.008). Median survival for all patients was 10.7 months (0.3-61). There was no significant difference in overall survival between patients with and without thrombus (P = 0.76). CONCLUSIONS: Patients who undergo cytoreductive nephrectomy with a tumor thrombus have a higher rate of complications as compared to patients undergoing cytoreductive nephrectomy without tumor thrombus. The long-term survival, however, was not statistically different and thus aggressive surgery for select metastatic RCC patients is warranted.     

The role of cytoreductive nephrectomy in the era of molecular targeted therapy

While the widespread use of imaging has resulted in an increasing number of incidentally detected renal cancers, up to one third of patients present with metastatic disease and a significant number of those with clinically localized disease subsequently develop metastasis. The prognosis for patients with metastatic disease has traditionally been poor, with a 2-year survival of only 10 to 20%. However, over the past decade a number of developments have enhanced the treatment of these patients. Phase III trials have demonstrated a significant improvement in overall survival for well-selected patients undergoing cytoreductive nephrectomy prior to immunotherapy. Meanwhile, the recent introduction of molecular targeted agents has resulted in improved response rates and tolerability compared with immunotherapy, and has prompted a re-evaluation of the role and timing of surgery in patients with advanced disease. This review examines the role of surgical therapy for patients with metastatic disease in the new era of molecular targeted therapy.     

肿瘤肾脏切除在转移性肾细胞癌治疗中的意义

转移性肾细胞癌的治疗是肾癌治疗的难点。以往认为转移性肾细胞癌切除肿瘤原发灶是没有意义的。但随着肾癌免疫治疗和靶向治疗的发展,越来越多的证据证明肿瘤肾脏切除在转移性肾细胞癌的治疗中有着重要意义。本文通过复习相关文献对肿瘤肾脏切除术在转移性肾细胞癌治疗中的意义作简单介绍。     

The role of cytoreductive nephrectomy in the management of metastatic renal cell carcinoma

Cytoreductive nephrectomy can be an important and effective component of a multidisciplinary treatment approach to metastatic renal cell carcinoma in carefully selected patients. The results of retrospective single institution series and randomized multicenter phase III trials suggest that removal of the primary tumor, even in the setting of metastatic disease, can significantly prolong survival and delay time to progression. It may also enhance the response to systemic therapy in the postoperative period. When employing initial cytoreductive nephrectomy as part of an overall treatment approach, careful patient selection is critical to success. A poor performance status (ECOG performance status less than 1), significant comorbidities that make surgical intervention high risk, or high-volume metastatic disease, and the presence of brain, liver, or bone metastases, or of atypical (sarcomatoid) histology have all been shown to be associated with an extremely poor prognosis. Patients exhibiting these clinical phenotypes should not be considered for initial cytoreductive nephrectomy as part of their treatment paradigm. Instead, they should receive some form of upfront systemic therapy (immunotherapy or novel therapy) and then be considered for delayed nephrectomy as part of a surgical consolidation approach after an interval of treatment if their disease kinetics demonstrate stable or regressing disease in response to systemic therapy. Patients who do not demonstrate these poor prognostic features should be considered for upfront cytoreductive nephrectomy as part of their overall treatment approach because of the potential it offers for palliation from local tumor symptoms, a delay in the time to disease progression, an improved response to systemic therapy, and improved overall survival.     

The difficulty in selecting patients for cytoreductive nephrectomy: An evaluation of previously described predictive models

Purpose

To externally evaluate a preoperative points system and a preoperative nomogram, both created to assess time to death after cytoreductive nephrectomy (CN).

Renal cell carcinoma and brain metastasis: Questioning the dogma of role for cytoreductive nephrectomy

Introduction

Renal cell carcinoma (RCC) brain metastasis is generally viewed as poor prognostic features and often excludes patients from cytoreductive nephrectomy or participation in clinical trials. We aim to evaluate patients presenting with brain metastasis and their outcomes.

Laparoscopic versus open cytoreductive nephrectomy in advanced renal-cell carcinoma

BACKGROUND AND PURPOSE: There is growing evidence of the benefit of cytoreductive nephrectomy prior to immunotherapy in patients with advanced renal-cell carcinoma (RCC). We compared the outcomes of patients with metastatic RCC undergoing laparoscopic and open cytoreductive nephrectomy prior to systemic therapy. PATIENTS AND METHODS: We retrospectively analyzed 27 patients undergoing cytoreductive nephrectomy for metastatic RCC between 2000 and 2004, 16 laparoscopically and 11 by an open approach. Patients with inferior vena-caval tumor thrombus were excluded from analysis. The two groups were comparable with regard to tumor size, clinical stage, and performance status. Surgical, pathologic, and perioperative characteristics and outcomes were compared. RESULTS: The laparoscopic technique was associated with reduced blood loss (149 v 1135 mL; P = 0.03), transfusion rate and quantity (13% v 55%; P = 0.03; 0.13 v 2.0 units of packed red blood cells; P = 0.007), shorter time to oral intake (1.2 v 2.7 days; P < 0.001), and shorter hospitalization (3.6 v 6.8 days; P < 0.001) compared with open nephrectomy. No significant differences were observed with respect to pathologic stage, operative time, complications, fraction receiving subsequent systemic therapy, time to systemic therapy, or survival. CONCLUSIONS: Laparoscopic cytoreductive nephrectomy is associated with reduced morbidity and hospital stay compared with open surgery. There was no increase in complications, and the ability to proceed with subsequent systemic therapy was maintained in the majority of patients. The laparoscopic approach can be considered in patients with metastatic RCC as part of a cytoreductive and systemic-therapy regimen.     

Intentional resection of the diaphragm during cytoreductive laparoscopic radical nephrectomy.

PURPOSE: Laparoscopic radical nephrectomy is being performed more commonly. To our knowledge intentional resection of the diaphragm during laparoscopic radical nephrectomy for large renal tumors has not yet been described. We detail the laparoscopic management of diaphragmatic resection. MATERIALS AND METHODS: From March 1996 to February 2001, 36 patients underwent cytoreductive laparoscopic radical nephrectomy at our institution in preparation for systemic immunotherapy. Charts and operative tapes were reviewed and cases were identified in which diaphragmatic resection was performed for locally invasive tumors. RESULTS: In 3 patients a portion of the diaphragm was dissected via laparoscopy during debulking nephrectomy. All patients had renal cell carcinoma with documented metastatic disease. The diaphragm was repaired laparoscopically using intracorporeal suturing techniques in 2 of the 3 patients and a chest tube was placed in all 3. Transient systolic hypotension and hypercarbia in 1 case resolved with manual ventilation. The chest tube was removed on postoperative days 2 to 4. There were no complications and no ipsilateral pleural metastasis was identified at an average of 6 weeks (range 2 to 23) of followup. CONCLUSIONS: A portion of the diaphragm may be intentionally resected during laparoscopic radical nephrectomy. This maneuver may be successfully managed without conversion to an open procedure. In cases of a large diaphragmatic defect or the potential for coagulopathy postoperatively a chest tube should be inserted. Potential invasion of the diaphragm by large tumors should not be considered a contraindication to cytoreductive laparoscopic radical nephrectomy.     

转移性肾癌减瘤性肾切除术的指征该如何把握

正在过去的20年间我国肾细胞癌(renal cell carcinoma,RCC)的发病率以平均每年6.5%的速度增长,2015年新发与死亡病例数分别为66 800例和23 400例~([1])。据世界卫生组织(WHO)发布的最新数据,2018年全球预计新发RCC 403 262例,死亡175 098例,发患者数占所有恶性肿瘤的2.2%~([2])。在西方发达国家,RCC的发病率则更高,以美国为例,2019年RCC新发患者数位居男性恶性肿瘤第6位,     

The independent oncological role for cytoreductive nephrectomy in metastatic renal cell carcinoma: Prognostic features in the era of targeted therapies

Objectives

To describe the effects of cytoreductive nephrectomy (CN) on the natural course of metastatic renal cell carcinoma (mRCC). CN appears to stabilize metastatic lesions in mRCC in a subgroup of patients and we hypothesize that systemic treatment might be deferred in these patients with stable disease after CN.

Risk prediction models for cancer-specific survival following cytoreductive nephrectomy in the contemporary era

Introduction

To develop a risk-stratification model for cancer-specific survival (CSS) following cytoreductive nephrectomy (CN) in the contemporary era.

Robotic nephrectomy for central renal tumors with intraoperative evaluation of tumor histology

Patients undergoing nephrectomy for central renal tumors suspicious for renal cell carcinoma (RCC) may carry a small risk of having transitional cell carcinoma (TCC) on final pathology, even in the absence of filling defects or abnormal cytology. We describe outcomes in such patients undergoing robotic nephrectomy for suspected RCC, with intraoperative specimen assessment to guide completion ureterectomy if TCC is present. Between September 2010 and August 2015, ten patients had central renal masses suspicious for RCC, which were not amenable to nephron-sparing surgery. Patients underwent a four-arm robotic nephrectomy technique using a GelPOINT^® access port. Following hilar ligation, the ureter was divided between adjacent hem-o-lok clips, placed in an endocatch bag, and extracted through the GelPOINT incision for the frozen section analysis. If intraoperative assessment confirmed TCC, a robotic completion ureterectomy and a bladder cuff excision were performed. Of the ten patients with central tumors who underwent robotic nephrectomy for suspected RCC, four (40 %) had TCC on the frozen section analysis and underwent completion ureterectomy. Five patients had RCC, and one patient had an oncocytoma. Mean age was 63.1 years (49–76) and mean tumor size was 4.0 cm (1.9–7.6). Mean operating time was 246 min (135–328). All patients had negative margins. Mean length of stay was 2.5 days. No recurrences were documented at median 8.5 months follow-up. For patients undergoing robotic nephrectomy for central renal tumors, intraoperative specimen evaluation can help determine the need for minimally invasive completion ureterectomy.