BERKELEY, CA (UroToday.com) - Radical nephrectomy in the setting of metastatic renal cell carcinoma (mRCC), cytoreductive nephrectomy (CRN), is the gold standard of treatment as established through two randomized control trials comparing the outcome of radical nephrectomy, followed by interferon, to interferon alone.[1, 2] However, in the current era of tyrosine kinase and mTOR-inhibitor therapy for mRCC, similar prospective randomized trials evaluating the impact of CRN have not been completed. Urologic surgeons are now pressed to decide whether a CRN operation can be done safely with few postoperative complications so as to not delay effective systemic therapy. We performed a retrospective study to determine which clinical and oncologic characteristics may predict for higher likelihood of developing major complications following CRN. Furthermore we sought to determine if such complications caused a delay in starting of systemic therapy.
We identified 195 patients with known mRCC who underwent CRN. While complications occurred relatively frequently (27% with Clavien grade 2 or greater complications), major complications (grade 3 or greater) occurred only 8% of the time. Older patients (continuous variable) and those with a worse performance status were at greater risk for complications; the most common complications in our study were pulmonary, thromboembolic, and anemia requiring transfusions. Interestingly the surgical approach to nephrectomy (laparoscopy vs. open), location of metastatic disease, or extent of metastatic disease did not correlate with post-operative complications. Patients who did sustain serious complications were less likely to receive systemic therapy in a timely fashion following CRN. Careful surgical planning with attention to medical co-morbidities, age, and performance status is essential prior to proceeding with CRN. For patients with a massive tumor burden with widespread metastatic disease, consideration of tumor biopsy, followed by systemic therapy, is another reasonable alternative. If there is an excellent clinical response to systemic therapy, consideration for an integrated CRN at a later date is reasonable. Ongoing prospective and randomized clinical trials comparing upfront systemic targeted therapies to CRN plus targeted therapies will provide further clarity to this issue upon their completion in the next several years.
References:
- Flanigan, R. C., Salmon, S. E., Blumenstein, B. A. et al.: Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med, 345: 1655, 2001
- Mickisch, G. H., Garin, A., van Poppel, H. et al.: Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial. Lancet, 358: 966, 2001
Written by:
Jonathan L Silberstein, MD and Paul Russo, MD, FACS as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Surgery, Urology Service
Memorial Sloan-Kettering Cancer Center
New York, NY, USA.
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