Author:

Keywords:

Science & Technology, Life Sciences & Biomedicine, Urology & Nephrology, 1103 Clinical Sciences, 3202 Clinical sciences

Abstract:

INTRODUCTION AND OBJECTIVES: The impact of surgery in mRCC has been under-studied and may be underestimated.The aim of our study was to identify optimal candidates for surgery as a primary treatment in mRCC METHODS: In a high-volume, single-centre series of metastasis resection, 100 mRCC patients were retrospectively studied. All patients underwent nephrectomy prior to metastasectomy. Metastatic sites were categorized in seven groups: lung 31%, bone 18%, other (uncommon) sites 18%, adrenal 12%, thyroid/parathyroid 7%, liver 6%, and multi-organ metastases 8%. Disease free interval (DFI) was defined as the time between primary tumor and the first site of metastasis. Kaplan-Meier analysis with Log Rank test was used to study overall survival (OS) differences between groups. Cox multivariate models were used to determine independent predictors of survival. RESULTS: Of the primary tumors, 44% were Fuhrman grade 3-4, 39.5% were >=T3 (19.8% T3a, 4.4% T3b and 15.4% T4). Of all patients, 26% had synchronous metastases, 26% had a DFI of 1-24 months and 48% had a DFI of >24 months. The median OS was 64,4 months and the 5-year OS was 52,9%. When comparing metastatic sites in patients with single-organ metastases (92%), following median OS rates were obtained: lung 87.7 months, thyroid/parathyroid 62.6 months, adrenal 34.4 months, bone 31.7 months (p=0.047). Patients with multi-organ metastases (8%) had a median OS of 6.9 month, compared with 87.7 months for those with single-organ metastases (p=0.0001). Patients with synchronous metastases had a 31,7 months median OS compared to 54.7 months for those with DFI of 1-12 months and 87.7 months for those with DFI >24 months (p=0.025). Patients who underwent 2 to 4 metastasectomies (24%) had a 103,8 months median OS compared 54,7 months for those who underwent one single metastasectomy (76%) (p=0.0067). We noticed a statistically significant decrease in OS with increasing stage and grade of the primary tumor, clearly pointing to a major impact of the local aggressiveness of the primary in OS (p=0.0007). The Cox multivariate models confirmed multi-organ metastases and increasing primary T stage and grade to be independent predictors of worse OS, while a DFI > 24 months was an independent predictor of improved OS. CONCLUSIONS: Surgery as primary treatment for single-organ, metachronous mRCC provides excellent overall survival. Patients with low primary T stage and grade and those with a DFI >24 months appear to be the best candidates for a surgical approach. Whenever possible, consecutive resections should be attempted.