Systemic therapy following metastasectomy for renal cell carcinoma: Using insights from other clinical settings to address unanswered questions

Surgical resection for metastatic renal cell carcinoma (RCC) was first described several decades ago, but the appropriate role for surgery in coordinated multidisciplinary care has not been well-defined. The explosive development of new therapies for advanced RCC over the past 10 years has improved the outlook for patients, and there is now renewed interest in surgical metastasectomy for selected patients with metastatic RCC, moving away from the conventional dichotomy between surgery for local disease and systemic therapy for metastatic disease. Patients rendered disease-free after metastasectomy are at high risk of recurrence, but to date no postoperative medical treatment has been shown to be beneficial. Ongoing studies and relevant data will be reviewed to frame the multidisciplinary approach to patients with oligometastatic RCC and to outline future challenges and opportunities for advancing their care.     

Efficacy of Multimodality Therapy in Advanced Renal Cell Carcinoma

Objectives. The integration of systemic biologic response modifier (BRM) therapy and surgery to treat metastatic renal cell carcinoma (RCC) is an evolving approach. The purpose of this study was to evaluate the efficacy of this form of multimodality therapy in patients with metastatic RCC.Methods. Between 1988 and 1996, 14 patients at our institution underwent initial BRM therapy followed by surgical resection of primary and metastatic RCC lesions. Patient records were reviewed to determine the response to BRM therapy, progression-free survival rate, and overall survival rate. The mean follow-up for the entire group was 43.5 months.Results. After BRM therapy, 9 patients manifested an objective response and 5 patients had stable disease. All patients were then rendered disease-free by surgical excision of residual or recurrent metastatic lesions and the primary tumor. The cancer-specific survival rate at 3 years was 81.5%. Currently, 7 patients are alive and disease-free (mean follow-up 41.4 months), 3 patients are alive with recurrent disease (mean survival 48.3 months), 3 patients died of metastatic disease (mean survival 27.9 months), and 1 patient died of an unrelated cause 54.4 months after therapy.Conclusions. The results of this study suggest that adjunctive surgery after BRM therapy can extend the survival of selected patients with metastatic RCC. Aggressive surgical resection of stable or responding lesions after BRM therapy should be considered in the management of these patients.     

Integrating metastasectomy in the management of advanced urological malignancies-where are we in 2005?

PURPOSE: In the past patients with metastatic cancer were considered incurable and they were not candidates for surgical management of metastases. However, experience with testicular cancer has shown that metastasectomy can often be the final, critical step in achieving disease-free status. We summarized the most current data on metastasectomy for advanced urological malignancies. MATERIALS AND METHODS: We performed an extensive review of the literature from 1990 to the present using MEDLINE. Only original reports were included with an emphasis on specific malignancies and specific sites of metastasis. RESULTS: There is increasing evidence that patients with metastatic renal cell carcinoma and bladder carcinoma can be cured by surgical resection of metastases, usually combined with systemic therapy. The ideal patient has responded to systemic therapy and has few metastatic sites. CONCLUSIONS: Metastasectomy should frequently be done in patients with advanced testicular cancer and it should increasingly be considered in patients with metastatic renal cell carcinoma or bladder carcinoma. This technique may be used for cure and palliation. Specific patient factors determine the likelihood and degree of potential benefit.     

Surgery for metastases of renal cell carcinoma.

The role of surgery for RCC in the era of emerging effective systemic therapy (usually immunotherapy) is not yet defined except for solitary metastasis. The retrospective analysis of patients subjected to aggressive surgical management after systemic therapy reinforces the need to find better therapeutic modalities in order to achieve complete eradication of metastatic disease. In the meantime, however, we propose these guidelines. First, we would encourage aggressive surgical resection of the clinically solitary metastasis, whether synchronous or metachronous. Continue to follow those patients indefinitely, because relapse is quite likely, but do not give adjuvant systemic therapy unless on protocol. Second, limited metastases in only one organ may behave similarly to a solitary metastasis, and if the metastases are in a site amenable to surgical resection, e.g., lung, initial surgery might be reasonable. Systemic therapy for these patients is highly recommended and need not necessarily wait for recurrence. Third, for patients with multiple metastases, initial systemic therapy followed then by resection of any residual disease in selected patients seems to be supported by the experience at several medical centers. Apparently prolonged survival times have been observed after systemic therapy followed by surgery in highly selected patients, despite finding viable cancer in the overwhelming majority of specimens. One must be mindful of the morbidity of an attempt to remove all known disease, however, and try to weigh this against potential benefit. Only a prospective, randomized trial could ever confirm the value of an aggressive surgical approach to metastatic RCC. In the meantime, however, metastasectomy offers, at the very least, the opportunity to confirm the histologic response to systemic therapy, render some patients disease-free, and possibly promote long-term survival in selected patients.     

Recurrent metastatic renal cell carcinoma presenting as a bleeding gastric ulcer after a complete response to high-dose interleukin-2 treatment

Immunotherapy with high-dose recombinant interleukin-2 is an effective therapy for selected patients with metastatic renal cell carcinoma (RCC). Objective responses (complete or partial) are observed in about 15% of treated patients. The overall and disease-free survival of patients with a complete response are significantly prolonged. Although RCC is known to spread hematogenously, isolated RCC metastasis to the stomach is a rare event. Recurrent RCC, after a complete response to interleukin-2, presenting clinically as an isolated gastric metastasis, has not been reported to date. In this report, we describe the clinical course of a patient with metastatic RCC who had a complete response to high-dose interleukin-2 and was disease free for 4 years before presenting with massive upper gastrointestinal hemorrhage due to an isolated gastric metastasis. The patient remained disease free for 3 years after resection of the metastasis. Metastatic RCC to the stomach, although rare, should be suspected in any patient with a history of RCC who presents with gastrointestinal symptoms. In the absence of diffuse disease, aggressive therapy, including surgical resection, is appropriate for isolated gastric metastasis, because prolonged survival is possible.     

Prognostic factors and survival after pulmonary resection of metastatic renal cell carcinoma

OBJECTIVE: Pulmonary metastasectomy as well as immunotherapy have reproducible, albeit limited efficacy in advanced renal cell carcinoma (RCC). We examined whether metastasectomy improved overall survival compared with results of immunotherapy. METHODS: Between 1975 and 2003, 64 patients (41 men, 23 women) underwent pulmonary resection of metastatic RCC. Only patients who met the criteria for potentially curative operation, that means, control of primary tumor, ability to resect metastatic disease and no other extrapulmonary metastases, were included. RESULTS: The overall 5-year survival was 33.4% (median survival: 39.2 months). A significant longer survival was observed using multivariate analysis in patients with complete pulmonary resection (R0), with a 5-year survival of 39.9% and a median survival of 46.6 months in correlation to patients with incomplete resection (5-year survival 0%, median survival 13.3 months). In multivariate analysis patients with synchronous metastases had a significant worse prognosis in correlation to patients with metachronous metastases. The 5-year survival of curative resected patients with metachronous metastases was 43.7% versus 0% for synchronous metastases, respectively. In patients with solitary metastasis and R0 resection, we observed a 5-year survival of 49%, whereas the rate was 23% in patients with more than a single metastasis. When establishing prognostic groups as suggested by the International Registry based on the risk factors disease-free interval, number of metastasis and complete resection the group with the best prognosis showed a 5-year survival of 52% (median survival 75.2 months). CONCLUSION: Metastasectomy nowadays is the best treatment option in cases with technical resectable metastases with as much as possible good prognostic factors (metachronous metastases with long DFI, number up to 6 metastases).     

Clinicopathological features and treatment outcomes of metastatic tumors in the stomach

The metastasis of tumors to the stomach is rare, which underlies the clinical problems regarding their diagnosis and treatment. The present review summarizes the current knowledge regarding the clinicopathological characteristics, therapeutic strategies and outcomes for metastatic tumors in the stomach. The primary malignancies of the metastatic tumors in the stomach were most often breast cancers (27.9 %), followed by lung cancer (23.8 %), esophageal cancer (19.1 %), renal cell carcinoma (RCC; 7.6 %) and malignant melanoma (7.0 %). In cases of breast cancer and RCC as the primary malignancy, the median interval between the treatment of the primary tumor and diagnosis of the metastatic tumor in the stomach (IPM) was 50–78 and 75.6 months, respectively, highlighting the fact that the metastatic spread to the stomach may occur many years after the initial treatment of the cancer. In nine patients with metastatic gastric tumors arising from ovarian cancer, an endoscopic examination revealed submucosal tumors in six patients (66.7 %), with a median IPM of 30 months. Appropriate systemic treatment for these tumors is the preferred therapeutic strategy. Although solitary metachronous gastric metastasis several years after treatment of the primary tumor is an exceptionally rare event, surgical resection of metastatic gastric tumors may be recommended to control hemorrhaging or for selected tumors.     

Clinical study of brain metastasis of renal cell carcinoma.

OBJECTIVES: To evaluate the natural history and the efficacy of treatments for renal cell carcinoma (RCC) with brain metastasis, we reviewed 18 patients with this disease. METHODS: Out of 325 cases with RCC treated at Osaka University Hospital from 1957 to 1993, 18 (5.5%, male:female ratio 16:2) cases developed brain metastases. Median follow-up was 44 months after the initial treatment of the primary lesion. Twelve patients had surgical resection of brain metastases (surgical group), and 7 of them received adjuvant radiotherapy. Six patients with poor performance status were treated with supportive therapy alone (nonsurgical group). RESULTS: Of 18 RCC patients with brain metastasis, 16 were male and 2 female. All brain metastases except for 1 case were symptomatic. Median interval between the initial treatment of the primary lesion and the diagnosis of brain metastasis was 19 months. The most frequent metastatic site prior to brain was the lung, which was detected in 7 cases (38.9%). Median survival of the entire group, measured from the onset of brain metastasis, was 9.5 months. One-year survival rate after the diagnosis of brain metastasis was 43.2% (64.8% in surgical group, 0% in nonsurgical group), 3-year 18.5% and 5-year 0%. Among 109 metastatic RCC, 14 patients were treated by lymphokine-activated killer (LAK) therapy. Out of 14 metastatic RCC patients treated by LAK therapy, 3 (21.4%) developed brain metastases. On the other hand, out of 95 metastatic RCC patients without LAK therapy, 15 (15.8%) had brain metastases. There was no significant difference in the rate of brain metastases between these two groups. CONCLUSION: There was a trend for prognosis of the surgical group to be better compared to that of the nonsurgical group, although it is not statistically significant. The optimum treatment for brain metastasis of RCC remains undefined, but our data suggested surgical resection in selected patients might contribute to prolonged survival of patients with brain metastasis. LAK therapy was not necessarily the risk factor of the brain metastasis.     

Pancreatic Secondary Lesions from Renal Cell Carcinoma

Background

Metastatic lesions to the pancreas are uncommon. The most frequent metastases are from renal cell carcinoma (RCC). We analyzed the clinical features and survival of patients with pancreatic metastasis from renal cell carcinoma.

Methods

We retrospectively reviewed the clinical records of patients with pancreatic metastases from RCC, observed in our department from January 2004 to March 2010. Follow-up continued to September 2013.

Results

In the study period 13 patients with a diagnosis of metastasis from RCC were observed in our clinic, and among them 9 pancreatic resections were performed (2 pancreaticoduodenectomy, 1 duodenum-preserving pancreatic head resection, 1 central pancreatectomy, and 5 distal pancreatectomy). Four patients did not undergo a pancreatic resection: two refused surgery, one had an endoscopic biliary stent for jaundice placed and then underwent a surgical biliary bypass, and the fourth patient was too advanced and had only an endoscopic biliary stent. The mean follow-up was 56 months (range  5–115, median  53), with one nonresected patient lost in follow-up after 38 months. Among the other 12 patients, 4 died: two for progression of disease 5 and 20 months respectively after our observation. The mean (±SEM) disease-free survival of seven resected patients with curative intent was 40 ± 11 months (median  34).

Conclusions

Pancreatic metastases from RCC are often asymptomatic. They generally present slow growth and an indolent behavior. Surgery is the treatment of choice in those patients with only pancreatic involvement, achieving long-term survival and disease-free survival.     

Histology is a Prognostic Indicator After Pulmonary Metastasectomy from Renal Cell Carcinoma

Objectives

There are only a few detailed reports concerning the prognosticators following surgical resection of pulmonary metastases (PMs) from renal cell carcinoma (RCC). We investigated the prognosis of patients with RCC PMs undergoing pulmonary metastasectomy and identified prognostic factors in a multi-institutional retrospective study.

Methods

We retrospectively evaluated 84 patients who underwent resection of PMs from RCC between 1993 and 2014. We assessed the clinicopathological characteristics, focusing on the histological findings of PMs. We classified the histology into three types: pure clear cell carcinoma (N = 68), clear cell carcinoma combined with other histology type (N = 8), and non-clear cell carcinoma (N = 8). We examined the relationship between these histological types and the prognosis of patients with PMs from RCC.

Results

Complete resection was achieved in 78 patients (93%). The 5-year overall survival rate after metastasectomy was 59.7%. In multivariate analysis, three factors were found to be independent favorable prognostic factors of overall survival after lung metastasectomy [tumor size <2 cm, hazard ratio (HR) = 0.31, 95% confidence interval (CI) 0.13–0.78, P = 0.012; clear cell type, HR = 0.37, 95% CI 0.16–0.83, P = 0.025; and complete resection, HR = 0.27, 95% CI 0.10–0.78, P = 0.015].

Conclusions

This study indicates that a histological finding of the clear cell type is a significant favorable prognostic factor in addition to complete resection and a tumor size <2 cm. Histological evaluation of PM lesions is important for predicting survival after metastasectomy.

     

Repeated Resection of Colorectal Cancer Pulmonary Oligometastases: Pooled Analysis and Prognostic Assessment

Background

Repeated resection of colorectal cancer pulmonary metastasis is associated with long-term survival. Nevertheless, very limited data addressing the best candidates for repeated pulmonary resection is available.

Patients and Methods

We searched the PubMed database for retrospective studies evaluating lung metastasectomy for metastatic colorectal cancer (CRC). We included studies with available data about repeated pulmonary metastasectomy. Potential prognostic factors were analyzed for possible impact on survival following the second metastasectomy through univariate and multivariate analysis.

Results

Between 1983 and 2008, 944 lung metastasectomies were carried out on 759 patients. Of those, 148 patients had a second metastasectomy. The 5-year survival rate was 52 % for patients who had 1 metastasectomy and 57.9 % from the second metastasectomy for patients who had repeated resection. More than 2 metastatic pulmonary nodules and maximum diameter of largest pulmonary nodule ≥3 cm were the only independent factors associated with inferior survival following repeated pulmonary resection.

Conclusions

In selected patients with metastatic CRC, repeated pulmonary metastasectomy offers an excellent chance for long-term survival and is associated with a quite low operative mortality. Patients with more than 2 metastatic nodules and a maximum diameter of the largest metastatic lung nodule of ≥3 cm have a significantly inferior survival.     

Cytokine therapy in renal cell cancer

Despite extensive investigations with many different treatment modalities, metastatic renal cell carcinoma (RCC) remains a disease highly resistant to systemic therapy. The outlook for patients with metastatic RCC is poor, with a 5-year survival rate of less than 10%. Late relapses after nephrectomy, prolonged stable disease in the absence of systemic therapy, and rare spontaneous regression are clinical observations that suggest host immune mechanisms could be important in regulating tumor growth. Interleukin-2 (IL-2) and interferon- (IFN-) have been extensively studied in advanced RCC with responses in the 10 to 20% range. Two randomized trials suggest that treatment with IFN- compared with vinblastine or medroxyprogesterone results in a small improvement in survival. Prolonged responses with high-dose IL-2 is significant but is accompanied by formidable toxicity. Although the combination of IFN- and IL-2 compared with monotherapy with IFN- or IL-2 increases the response proportion, no improvement in survival could be demonstrated in a recent randomized trial. In addition, three randomized trials showed no survival benefit associated with IFN- therapy given as adjuvant therapy following complete resection of locally advanced RCC. Small numbers of patients exhibit complete or partial responses to IFN- and/or IL-2, but most patients do not respond and there are few long-term survivors. Clinical investigation of new agents and treatment programs to identify improved antitumor activity against metastases remain the highest priorities in this refractory disease.     

Impact of multimodal treatment on survival in patients with metastatic urothelial cancer

OBJECTIVES: Systemic combination chemotherapy remains the mainstay of treatment for metastatic urothelial cancer. Although initial response rates are 50-70%, these responses are usually transient. The present study investigated the impact of multimodal treatment including metastasectomy on survival in patients with metastatic urothelial cancer. METHODS: Between 1989 and 2005, 48 patients with metastatic urothelial cancer underwent systemic chemotherapy at our institution. The majority received conventional cisplatin-based chemotherapy, whereas some patients underwent novel chemotherapeutic regimens mainly as salvage therapy with or without resection of metastases, aiming to improve the outcome. The relationship between clinical characteristics and survival was analyzed using the Cox proportional hazards model. The characteristics analyzed were sex, age, primary site, prior systemic chemotherapy, histology of primary lesion, white blood cell counts, hemoglobin levels, metastatic sites, total number of chemotherapy courses, and resection of the primary lesion and metastasis. RESULTS: Median survival-time was 17 mo (95% confidence interval, 9-27 mo) for all 48 patients. Using a multivariate model, five or more chemotherapy cycles (p=0.0022), absence of liver, bone, and local recurrence (p=0.0146), and resection of metastasis (p=0.0006) were independent significant predictors of prolonged survival. Median survival time in the 12 patients with metastasectomy was 42 mo, which was significantly longer than that of patients who did not undergo metastasectomy (10 mo). CONCLUSIONS: The number of chemotherapy cycles, sites of metastasis, and metastasectomy had an impact on survival. In selected patients, a multimodal approach including metastasectomy may contribute to long-term disease control.     

Role of metastasectomy for metastatic renal cell carcinoma in the era of targeted therapy

Numerous biological pathways are affected in renal cell carcinoma and the introduction of targeted agents has improved the survival of patients with advanced and metastatic disease. Durable and long-lasting cure is rarely achieved, and in select cases, the excision of metastatic deposits has shown to increase survival. Clinical trials of targeted agents are being explored as neoadjuvant and adjuvant therapies with the role of metastasectomy evolving in the treatment paradigm. This review examines published reports of metastasectomy and its developing role in the era of targeted therapy. A Medline search was conducted using keywords “metastasectomy,” “renal cell carcinoma,” and “targeted therapy,” and selected articles are discussed by examining prognostic stratification and metastasectomy in major anatomic regions. Most published reports span earlier periods of immunotherapy and chemotherapy, and henceforth, discussions are in historical context in this review. Although there is lack of Level 1 evidence, reports have suggested the prognostic value and survival benefit for metastasectomy in lesions that are amenable to complete resection after longer disease-free intervals in carefully selected patients with adequate performance status. Therefore, the role of metastasectomy must be further elucidated in the era of targeted therapy.     

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: An institutional review

Background: Solitary metastases from a primary renal cell carcinoma (RCC) occur in <10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented. Materials and Methods: Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970–1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded. Results: Mevtastases were intrathoracic (n=20), intracranial (n=7), and intraabdominal or in the extrapleural chest wall soft tissue (n=10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival. Conclusion: A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Rare presentation of renal cell carcinoma: Solitary sternal metastasis

Renal cell carcinoma (RCC) may present as metastatic disease. However, RCC with solitary sternal metastasis is rare. We report a rare case of RCC with synchronous solitary sternal metastasis. The patient underwent radical nephrectomy, sternal tumour resection and reconstruction as a one‐stage procedure. The role of open sternal biopsy is also described. Review of the literature was carried out and a reasonably lengthy survival was observed. We concluded that radical surgical resection and reconstruction may offer the best chance of survival in managing RCC with solitary sternal metastasis in renal cell carcinoma.     

Predictors for a further local in-brain progression after re-craniotomy of locally recurrent cerebral metastases

Treatment of recurrent cerebral metastases is an emerging challenge due to the high local failure rate after surgery or radiosurgery and the improved prognosis of patients with malignancies. A total of 36 patients with 37 metastases who underwent surgery for a local in-brain progression of a cerebral metastasis after previous metastasectomy were retrospectively analyzed. Degree of surgical resection on an early postoperative MRI within 72 h after surgery was correlated with the local in-brain progression rate and overall survival. Complete surgical resection of locally recurrent cerebral metastases as confirmed by early postoperative MRI could only be achieved in 37.8%. Detection of residual tumor tissue on an early MRI following recurrent metastasis surgery correlated with further local in-brain progression when defining a significance level of p?=?0.05 but not after ?idák or Bonferroni significance level correction for multiple testing: However, definite local tumor control could finally be achieved in 91.9% after adjuvant therapy. Overall survival after recurrent metastasectomy was significantly higher as predicted by diagnosis-specific graded prognostic assessment (12.9?±?2.3 vs. 8.4?±?0.7 months; p?<?0.0001). However, our series involved a limited number of heterogeneous patients. A larger, prospective, and controlled study is required. Considering the adequate local tumor control achieved in the vast majority of patients, surgery of recurrent metastases may represent one option in a multi-modal treatment approach of patients suffering from locally recurrent cerebral metastases.     

Role of targeted therapy in combination with surgery in renal cell carcinoma

Surgical complete resection is the only curative treatment of renal cell carcinoma including patients with locally advanced disease and those with limited metastatic disease. Patients at high risk of recurrence after complete resection might theoretically benefit from adjuvant and neoadjuvant systemic treatment strategies to prolong disease‐free survival and ultimately overall survival. Another rationale for using targeted therapy includes downsizing/downstaging of surgically complex locally advanced renal cell carcinoma to facilitate complete resection or primary tumors to allow for nephron‐sparing strategies. Unfortunately, a considerable percentage of patients are diagnosed with metastatic disease at first presentation. Although large population‐based studies consistently show a survival benefit after cytoreductive nephrectomy in the targeted therapy era, confounding factors preclude definite conclusions for this heterogeneous patient group until ongoing phase III trials are published. Presurgical targeted therapy has been proposed to identify patients with clinical benefit and potentially long‐term survival after cytoreductive nephrectomy. Recently, the use of targeted therapy before or after local treatment of metastases has been reported in small retrospective series. The present review revisits the current evidence base of targeted therapy in combination with surgery for the various disease stages in renal cell carcinoma.     

Synchronous pulmonary metastases from renal cell carcinoma - a whole nation study on prevalence and potential resectability

Background: At the time of diagnosis, almost one third of patients with renal cell carcinoma (RCC) have metastasis. We studied the prevalence, survival, and potential resectability of syn-chronous pulmonary metastases (SPMs) in a well-defined cohort of RCC patients.Material and Methods: A retrospective whole nation study including RCC patients with SPM diagnosed 1970-2005 in Iceland. Imaging studies and histology were reviewed, the TNM sys-tem used for staging the primary tumors, and disease-specific survival estimated. Eligibility for SPM removal was evaluated using different criteria from the literature on surgical management of SPM, including solitary SPM and SPMs confined to one lung.Results: Altogether, 154 patients (16.9%) had SPMs. In 55 of these patients (35.7%) the lungs were the only site, with detailed information available in 46 cases. Of these 46 patients with SPMs, 15 were unilateral, and of those 11 were solitary. All of these 11 patients were in good physical condition and were deemed eligible for surgical resection; however, only one of them was operated with metastasectomy. Disease-specific survival at five years for patients with so-litary SPM was 27.2%, as compared to 12.7%, 7.1%, and 12.0% for patients with unilateral SPMs, all patients with SPMs, and patients with extrapulmonal metastases, respectively (p?=?0.33).Conclusion: At the time of diagnosis, 16.9% of RCC patients had SPM. In one in three of these SPM patients metastases were confined to the lungs, while one in five had solitary pulmonary metastases. Although the benefit of pulmonary metastasectomy in RCC is still debated and criteria for resection are not well defined, it appears that many RCC patients with SPM are potentially eligible for pulmonary metastasectomy.     

Outcome and survival with nonsurgical management of renal cell carcinoma

OBJECTIVE: To document long-term survival in patients with renal cell carcinoma (RCC) in whom the primary tumour was left in situ and treatment limited to palliative and symptomatic measures. PATIENTS AND METHODS: All patients with a diagnosis of RCC from January 1994 to January 1999 and in whom the primary tumour was left in situ were identified from hospital records (nine women and 16 men, mean age 69 years). The tumour stage was T1-T4. RESULTS: The mean survival overall was 19.3 months; patients with locally advanced disease, i.e. stage >or= T3a, had a mean survival of 16.9 months. CONCLUSIONS: There is renewed interest in the management of advanced RCC, with data supporting cytoreductive nephrectomy with systemic biological therapy. These results confirm that such patients with or without metastatic disease can survive for a considerable period with no aggressive surgical or systemic measures, and such intervention may offer no significant advantage in outcome and survival over supportive treatment alone.