lung mets from kidney cancer

Between 1980 and 1995, 77 patients underwent complete resection of pulmonary metastases from a renal cell carcinoma after exclusion of a primary tumor recurrence and other metastatic localizations. 30-day mortality was 3%. The Median follow-up was 34 months (M). Cumulative 5-year survival (5-YS) was 39%. Prognostic criteria are the duration of the disease-free interval (DFI) and the number of metastases. Patients with a DFI > or = 48 M had a 5-YS of 46% compared to 26% for a DFI of < 48 M. Patients with a solitary metastasis had a 5-YS of 49% compared to 19% for multiple metastases. There was no significant difference in terms of sex, kind of access, kind of operation, and unilateral or bilateral affection. Since metastases from renal cell carcinomas are almost resistant to chemotherapy and radiotherapy and immunotherapy at present does not considerably improve long-term survival, surgical resection currently is the only effective therapeutic access in renal cell cancer metastasized to the lung.

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

Hofmann HS, Eur Urol. 2005 Jul;48(1):77-81;

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).

Lung metastases of renal cell carcinoma: results of surgical resection.

Fourquier P, R Eur J Cardiothorac Surg. 1997 Jan;11(1):17-21.

Marie Lannelongue Hospital, Le Plessis Robinson, France.

OBJECTIVE: The research was designed to evaluate the results of surgical resection of renal lung metastases. METHODS: Between 1960 and 1994, 50 consecutive patients underwent resection for pulmonary metastases from renal cell carcinoma. Mean age was 59 years (range: 40-78 years). Mean time between nephrectomy and pulmonary resection was 3 years (range: 0-18 years). Nineteen patients had solitary metastase, 13 multiple unilateral, and 18 bilateral. Wedge excision was performed in 28 patients, segmentectomy in 3, lobectomy in 17, sleeve lobectomy in 1, pneumonectomy in 5 and biopsy in 3. Twelve patients had repeat resection for recurrent metastases. RESULTS: The resection was complete in 45 patients. Three patients also had a complete resection of limited extra-pulmonary disease. There was one postoperative death and 3 complications. Mean follow-up was 42 months without loss of follow-up. The cause of death was always metastatic recurrent disease. Five-year survival in complete resection was 44%. Only one long survivor was observed in the case of incomplete resection in a patient who had a complete response after adjuvant immunotherapy. Five-year survival for the 12 patients with repeat resections was similar to the overall survival rate (42%). CONCLUSIONS: Resection of renal lung metastases is a safe and effective treatment. No factor influenced the 5-year survival in this series except the complete resection. Extra-pulmonary metastases does not contra-indicate pulmonary resection. In selected patients, repeat resection for recurrent disease is warranted.

Long-term results after pulmonary resection of renal cell carcinoma metastases.

Piltz S, Ann Thorac Surg. 2002 Apr;73(4):1082-7.

Department of Surgery and Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University Munich, Germany. spiltz@gch.med.uni-muenchen.de

BACKGROUND: Until now no conclusive data exist regarding the factors influencing long-term survival after pulmonary resection of renal cell carcinoma metastases. The aim of the present study, therefore, was to discover definitive prognostic factors for survival using a large and homogeneous single center patient cohort. METHODS: Between 1980 and 2000, 105 patients, after curative resection of lung metastases from renal cell carcinoma, were followed in this long-term study. These patients underwent a total of 150 surgical procedures. Survival analysis was done using the Kaplan-Meier method and the log-rank test. Multivariate analysis of prognostic factors was performed using the Cox multivariate proportional hazard model. RESULTS: Median survival after curative resection reached 43 months (range, 1 to 218 months). Survival at 3, 5, and 10 years was 54%, 40%, and 33%, respectively. Univariate analysis revealed that a complete resection, a less than 4-cm diameter of the metastases and tumor-free lymph nodes at the time of primary operation, were highly significant dependent prognostic factors (p < 0.001). These factors were also shown to be independent prognostic factors as suggested by multivariate analysis (p < 0.05). CONCLUSIONS: The size of the metastatic nodule, the completeness of pulmonary resection, and the lymph node status at the time of nephrectomy are the most important prognostic factors that influence survival after resection of pulmonary metastases. Recurrence of resectable pulmonary metastases does not impair survival, thus favoring repeated resection in patients with recurrent disease.

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

Kierney PC, Ann Surg Oncol. 1994 Jul;1(4):345-52.

Section of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905.

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: Metastases 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.

Can we predict long-term survival after pulmonary metastasectomy for renal cell carcinoma?

Murthy SC, Ann Thorac Surg. 2005 Mar;79(3):996-1003.

Department of Thoracic and Cardiovascular Surgery, Hematology and Medical Oncology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

BACKGROUND: The purpose of this study is to identify factors associated with time-related survival after pulmonary metastasectomy for renal cell carcinoma and to confirm the safety of metastasectomy. METHODS: From January 1986 to July 2001, 417 patients were diagnosed with pulmonary metastases from renal cell carcinoma; 92 underwent pulmonary metastasectomy. Median disease-free interval after nephrectomy was 3.0 years. Half the patients had 1 or 2 pulmonary nodules; 37% had 5 or more. Median size of the largest nodule (pulmonary metastasis) was 15 mm. Complete resection was obtained in 63 patients (68%). Twenty-nine patients received preoperative immunotherapy. Multivariable hazard function analysis was used to identify continuous, ordinal, and true dichotomous risk factors. RESULTS: Predictors: The strongest risk factor for time-related mortality was incomplete resection. Five-year survival was 8% for incomplete and 45% for complete resection. Other risk factors included the following continuous and ordinal variables: larger nodule size (p = 0.0001), increasing number of involved lymph nodes (p = 0.01), and decreased preoperative 1-second forced expiratory volume (p = 0.02). Immunotherapy did not improve survival. For completely resected patients, shorter disease-free interval was a risk factor (p = 0.01). Fewer pulmonary nodules predicted higher probability of complete resection (p < 0.0001). Safety: No operative deaths occurred. Nine patients (10%) experienced a total of 12 complications, with persistent air leak and atrial arrhythmia accounting for 5 (42%). CONCLUSIONS: Because pulmonary metastasectomy for renal cell carcinoma is safe, survival depends on complete resection of pulmonary disease and adequate pulmonary reserve. Preoperative determination of resectability is thus critical, and computed chest tomography and mediastinoscopy are valuable tools for optimizing patient selection

Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma.

Vasselli JR, J Urol. 2001 Jul;166(1):68-72.

Surgery Branch, Clinical Oncology Program, Division of Cancer Treatment, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA.

PURPOSE: Patients with metastatic renal cell carcinoma have a reported 5-year survival of 0% to 20%. The ability to predict which patients would benefit from nephrectomy and interleukin-2 (IL-2) therapy before any treatment is initiated would be useful for maximizing the advantage of therapy and improving the quality of life. MATERIALS AND METHODS: A retrospective analysis of the x-rays and charts of patients treated at the National Institutes of Health Surgery Branch between 1985 and 1996, who presented with metastatic renal cancer beyond the locoregional area and the primary tumor in place, was performed. Preoperative computerized tomography or magnetic resonance imaging, or radiological reports if no scans were available, were used to obtain an estimate of the volume of retroperitoneal lymphadenopathy. Operative notes were used to evaluate whether all lymphadenopathy was resected or disease left in situ, or if any extrarenal resection, including venacavotomy, was performed. Mean survival rate was calculated from the time of nephrectomy to the time of death or last clinical followup. If patients received IL-2 therapy, the response to treatment was recorded. Mean survival and response rate for IL-2 were compared among patients in 3 separate analyses. Patients without preoperatively detected lymphadenopathy were compared with those with at least 1 cm.3 retroperitoneal lymphadenopathy. Also, the patients who had detectable lymphadenopathy were divided into subgroups consisting of all resected, incompletely resected, unresectable and unknown if all disease was resected. Each subgroup was compared with patients without detectable preoperative lymphadenopathy. Patients with less than were compared to those with greater than 50 cm.3 retroperitoneal lymphadenopathy. Patients undergoing extrarenal resection at nephrectomy (complex surgery) due to direct invasion of the tumor into another intra-abdominal organ were compared with those undergoing radical nephrectomy alone, regardless of lymph node status. Statistical analysis was done with the Mantel-Cox test for comparison of survival on Kaplan-Meier curves and with Fisher's exact test for response rates for IL-2. RESULTS: A total of 154 patients with metastatic renal cell carcinoma underwent cytoreductive nephrectomy as preparation for IL-2 based regimens. There were 82 patients with metastatic renal cell carcinoma and no preoperative retroperitoneal lymphadenopathy who survived longer (median 14.7 months) than the 72 with lymphadenopathy (median 8.5, p = 0.0004). Patients with incompletely resected, unresectable or an unknown volume resected had decreased survival compared to those with no retroperitoneal lymphadenopathy. A multivariate analysis of survival was performed evaluating the known prognostic indicators, performance status and tumor burden, as represented by the number of organs involved with metastases, and the new prognostic factor, lymphadenopathy. Lymphadenopathy was more closely associated with survival than performance status, and appeared to be a new prognostic variable. Patients with and without retroperitoneal lymphadenopathy at initial presentation had similar rates for treatment with IL-2 (54% for both groups). Of the 82 patients with no lymphadenopathy 11 (13%) had long-term survival greater than 5 years. Of the 6 complete responses to IL-2, 5 occurred in this group. Only 1 other patient with incompletely resected retroperitoneal lymphadenopathy survived longer than 5 years. No significant difference in survival was seen between patients who did or did not undergo complex surgery. CONCLUSIONS: Patients who presented with metastatic renal cancer and retroperitoneal lymphadenopathy had a shorter survival than those with no detectable retroperitoneal lymphadenopathy. It is warranted to continue to perform complex extrarenal resection during nephrectomy since no significant difference in the response rate for IL-2 or mean survival compared with those of patients undergoing nephrectomy alone is currently detectable.

Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases.

J Thorac Cardiovasc Surg. 1997 Jan;113(1):37-49

OBJECTIVES: The International Registry of Lung Metastases was established in 1991 to assess the long-term results of pulmonary metastasectomy. METHODS: The Registry has accrued 5206 cases of lung metastasectomy, from 18 departments of thoracic surgery in Europe (n = 13), the United States (n = 4) and Canada (n = 1). Of these patients, 4572 (88%) underwent complete surgical resection. The primary tumor was epithelial in 2260 cases, sarcoma in 2173, germ cell in 363, and melanoma in 328. The disease-free interval was 0 to 11 months in 2199 cases, 12 to 35 months in 1857, and more than 36 months in 1620. Single metastases accounted for 2383 cases and multiple lesions for 2726. Mean follow-up was 46 months. Analysis was performed by Kaplan-Meier estimates of survival, relative risks of death, and multivariate Cox model. RESULTS: The actuarial survival after complete metastasectomy was 36% at 5 years, 26% at 10 years, and 22% at 15 years (median 35 months); the corresponding values for incomplete resection were 13% at 5 years and 7% at 10 years (median 15 months). Among complete resections, the 5-year survival was 33% for patients with a disease-free interval of 0 to 11 months and 45% for those with a disease-free interval of more than 36 months; 43% for single lesions and 27% for four or more lesions. Multivariate analysis showed a better prognosis for patients with germ cell tumors, disease-free intervals of 36 months or more, and single metastases. CONCLUSIONS: These results confirm that lung metastasectomy is a safe and potentially curative procedure. Resectability, disease-free interval, and number of metastases enabled us to design a simple system of classification valid for different tumor types.