SUO 2017: Management of Recurrent Disease in the Current Era of Kidney Cancer Management

Washington, DC (UroToday.com) Dr. Paul Russo from Memorial Sloan Kettering Cancer Center presented the management of recurrent disease in the current era of kidney cancer management. Dr. Russo notes that in the era of minimally invasive surgery, there can be unusual patterns of recurrence with different GU cancers. For instance, he has seen cases of robotic cystectomy for low grade Ta urothelial carcinoma in which the patient developed and ultimately died of carcinomatosis, a laparoscopic RPLND for NSGCT in which the patient developed carcinomatosis, as well as similar cases for patients with adrenal cortical carcinoma and seminal vesicle sarcoma treated with minimally invasive modalities. As Dr. Russo mentions, this is not a new phenomenon, considering there are reports going back to the early days of laparoscopy, as well as contemporary studies documenting port site metastatic disease1.

In the pre-MIS era at MSKCC (1989-2014), 1,618 patients underwent localized kidney cancer surgery, of which 179 patients (11%) had disease progression including 16 patients (1%) that had isolated local recurrence and 163 patients (10%) had distant metastases over a median follow-up of 50.4 months2 In the MIS kidney surgery era, Dr. Russo notes several changes in the natural history of RCC recurrence, including (i) time to recurrence from initial tumor resection by partial or radical nephrectomy to recurrence, (ii) location of recurrences (port site, multiple perinephric tumor deposits), (iii) survival and treatment implications of these unusual patterns of behavior.

In the post-MIS era at MSKCC (2006-2017), there were 22 local recurrences, the majority (55%) of which were robotic, male (59%), with ccRCC (50%) histology. Among 15/22 patients with recurrence in <12 months, 12 recurrent with distant metastasis over a median follow-up time to recurrence of 8.5 months. Four of 22 patients are currently NED.

The true mechanism of port site and intraperitoneal metastatic disease is unknown (i) faulty surgical technique with tumor spillage into CO2 filled peritoneal cavity, (ii) aggressive tumor biology, (iii) tumor cells spread locally under the abdominal pressure outside of lymphatic and vascular spaces, and (iv) immune suppression by pneumoperitonem.

Certainly, there is a degree of referral bias considering that MSKCC is a tertiary referral center and the denominator is unknown. In conclusion, median time to recurrence was less than 1 year and can happen in ccRCC and non-ccRCC histologies. The precise incidence is unknown but is likely higher considering that cases are underreported.

References:
  1. Song J, Kim E, Mobley J, et al. Port site metastasis after surgery for renal cell carcinoma: Harbinger of future metastasis. J Urol 2014;192:364-368.
  2. Russo P, Jang TL, Pettus JA, et al. Survival rates after resection for localized cancer: 1989 to 2004. Cancer 2008;113(1):84-96.
Presented by: Paul Russo, Memorial Sloan Kettering Cancer Center, New York, NY

Written by: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC
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