Journal of Surgical Oncology 49:4548 (1992)

Solitary Metastases From Renal Cell Carcinoma: A Review HEMANT 6 . TONGAONKAR, MS, JAGDEESH N. KULKARNI, MS, MCh, MNAMS, FCPL, ANii MURALIDHAR R. KAMAT, MS, FICS, FCPS From the Department of Uro-Oncology, Tata Memorial Hospital, Parel, Bombay, h d i a

Nineteen patients with solitary metastatic lesions from renal cell carcinoma, 5 synchronous and 14 metachronous, were seen at the Tata Memorial Hospital over a 7 year period between 1981 and 1987. The mean metastatic interval for the metachronous lesions was 31.2 months. The commonest sites of metastases were bone, lung, and liver. The solitary nature of the metastasis was confirmed by appropriate investigations. All patients underwent nephrectomy for the primary kidney lesion. The metastatic lesions were treated with intent of cure. Only l patient with synchronous metastasis survived for 2 years and none survived 5 years while in the metachronous metastasis group, the estimated overall survival was 50% at 2 years and 25% at 5 years. The patients with a long metastasis-free interval were found to have a better survival. The patients with liver metastasis did poorly as compared to those with metastases at other sites. The stage of the disease also had a bearing on the survival. KEYWORDS:kidney neoplasms, surgery, disease-free period, prognosis

INTRODUCTION Survival in patients with metastatic renal cell carcinoma is poor, the majority of patients dying of the disease within 12-24 months. The presently available nonoperative modalities of treatment have failed to significantly improve the survival. However, there is a small subset of patients with solitary metastasis who may have a better survival than patients with multiple metastases. Reports from various centers of the successful surgical treatment of solitary metastatic lesions against the lack of any alternative adjuvant treatment modalities have prompted many to approach the solitary metastatic lesions surgically with intent of cure. We herein report our experience of 19 patients with solitary metastasis from renal cell carcinoma. MATERIALS AND METHODS A total of 250 patients with renal cell carcinoma were seen at the Tata Memorial Hospital over a seven year period between 1981 and 1987, 19 of whom developed a solitary metastatic lesion (7.6%). There were 12 men and 7 women, ranging in age from 21-72 years (mean 55.3 years). There were five patients who presented with renal cell carcinoma and a synchronous solitary metastatic le0 1992 Wiley-Liss, Inc.

sion (26.3%). In the other 14 patients, the metastatic lesion appeared after the completion of the primary treatment of renal cell carcinoma (73.7%), the metastasis-free interval in these patients ranging from 1-84 (mean 3 1.2) months. The sites of synchronous metastases were bone in four and lung in one patient while the sites of metachronous metastases were bone in four, lung and liver in three each, and the spine, testis, breast, and parotid in one each. The extent of metastatic disease was determined by various diagnostic modalities available at the evaluation of each patient. The evaluation included a radiograph of the chest in all patients, lung tomograms in patients with lung metastasis, isotope bone scan and radiographs of the specific skeletal sites to rule out multiple bony metastases, and an ultrasound or a liver scan to detect liver metastasis. An attempt was made to obtain histological proof of the metastatic lesions, either by fine needle aspiration cytology or computed tomography (CT) guided biopsy. Ultrasonography or CT scan of the abdomen was done in all cases with metachronous solitary metastasis, to rule out a recurrence in renal fossa. All Accepted for publication September 28, 1991. Address reprint requests to Dr. M.R. Kamat, Chief, Department of Uro-Oncology, Tata Memorial Hospital, Dr. E. Borges Marg, Parel, Bombay 400012, India.

46

Tongaonkar et al.

after the excision of metastasis. The third patient received a combination of radiation therapy and chemotherapy, but was lost to follow up within 1 year. Three patients developed solitary liver metastasis, with an interval of 6 2 7 months (mean 14 months). All these patients had pathological stage 111 disease at the time of RESULTS nephrectomy . One patient underwent a segmental resecThe patients were separated into two groups: Group 1 tion of the liver metastasis and is alive with disseminated consisted of five patients with the solitary metastatic le- disease 10 months later. The other two patients were sion existing synchronously with the primary kidney le- given hormonal therapy and chemotherapy, respectively, sion and Group I1 consisted of 14 patients with the soli- but succumbed to the disease within 1 year. One patient developed a solitary metastatic lesion in tary metastatic lesion appearing sometime after the the breast 18 months after nephrectomy, which was treatment of primary kidney lesion. pathologically a stage I disease. After excision of the Group I metastatic lesion, the patient is alive 7 years later. One patient developed metastasis in the parotid gland There were four patients with skeletal metastasis. All these patients underwent nephrectomy followed by surgi- after an interval of 72 months after nephrectomy for cal excision of the metastatic lesion in 1 and local radia- pathologically stage I tumour. She underwent a superfition therapy to the metastatic site in the other 3 . The cial parotidectomy and is alive at the end of 3 years after patient who underwent surgical excision of the metastasis excision of the metastasis. One patient developed vertebral metastasis 12 months is alive at the end of one year. Of the 3 patients who received local radiation therapy to the metastatic site, one after nephrectomy for a pathologically stage I11 kidney died of disseminated metastatic disease after two and one tumour. He underwent laminectomy decompression of half years, one died of an unrelated cause after eight the spine followed by local radiation therapy. He was lost to follow up without any evidence of active disease 18 months while the third patient is alive at one year. One patient had a synchronous solitary metastatic le- months after decompressive surgery. Testicular metastasis developed in one patient one sion in the lung. He had a large right kidney tumour with tumour thrombus extension into the inferior vena cava. month after nephrectomy for a pathologically stage 111 He underwent radical nephrectomy with extraction of the disease. He was treated with orchidectomy but developed vena caval tumour thrombus but died of pulmonary em- multiple lung metastases soon thereafter and was alive bolism in the early postoperative period. Thus, only one with disease at 6 months. The estimated overall survival in this group was 50%at patient in this group survived for more than two years and 2 years, 33.3% at 3 years, and 25% at 5 years. This is none survived five years. much better than that encountered with Group I patients Group I1 with synchronous solitary metastasis. The disease-free interval appeared to have a marked All 14 patients underwent radical nephrectomy for the primary kidney lesion and developed solitary metastasis influence on subsequent survival in patients without meduring their follow up period, with a mean metastatic tastasis at the time of diagnosis. The patients with liver interval of 31.2 months. There were four patients with metastasis did very poorly as compared to skeletal or lung skeletal metastasis, occurring 13-72 months (mean 32.5 metastases or metastases to other sites. The stage of the months) after radical nephrectomy . One patient had primary tumour also was found to have a definite bearing pathological stage I, two had pathological stage I1 (capsu- on survival. However, the number of patients in each lar infiltration), and one had stage 111 disease (retroperito- group is small, making statistically significant conclusions difficult. neal node metastases) at nephrectomy. Three patients underwent radical surgery for the metaDISCUSSION static lesions and are alive more than 4, 3 , and 2 years, About 25-35% of patients with renal cell carcinoma respectively, after excision of metastasis, while the fourth patient was given local radiation therapy and was have metastases at the time of presentation [ M I . In addition, of the patients who undergo surgery for an lost to follow up at 8 months. Three patients developed solitary lung metastasis, the apparently localised discase, nearly 50% will have local metastatic interval being 18-75 months (mean 50 recurrence or metastatic disease [7]. However, once memonths). Two of these patients had pathological stage I tastases have occurred, prognosis is grim because nonopand the third stage 111 disease at nephrectomy. Two pa- erative modalities for advanced renal carcinoma have tients underwent surgical resection in the form of lobec- failed to significantly improve survival [S]. Only a small tomy and are alive more than 3 and 2 years, respectively, subgroup of patients may be candidates for excision of

patients underwent either radical or simple nephrectomy. Metastatic renal carcinoma was confirmed at operation in all the patients who underwent surgery for the metastatic lesions. Survivals were calculated from the time of institution of the treatment for the metastatic lesions.

Solitary Metastasis From Renal Carcinoma

metastatic lesions by virtue of their number, site, and slow biological behaviour meriting an aggressive treatment, since it has been suggested that excision of a solitary metastasis, in particular, may result in 5 year survival rates equivalent to those with localised disease [4,61. Our finding of 7.6% incidence of solitary metastasis from renal carcinoma is slightly more than 2 4 % reported in various series [4-6,9]. Barney and Churchill [ 101 excised an apparently solitary pulmonary metastasis in a patient who had undergone nephrectomy for renal cell carcinoma, with 23 years postmetastatectomy survival, This, coupled with the lack of effective nonsurgical modalities in the treatment of this disease has prompted many workers to assume an aggressive surgical approach towards the management of this small group of patients. Middleton [4] reported on eight cases and added 51 additional cases from the literature and concluded that the survival after surgical excision of solitary metastatic lesions was 45% at 3 years and 34% at 5 years. Skinner et al. [9] reported a 29% 5 year survival in a series of 41 patients in whom one or two metastases were excised surgically in addition to nephrectomy. Tolia and Whitmore [ 5 ] , Dekernion et al. [ l I], Temple and Ketcham [ 121, Morrow et al . [ 131, and Jett et al. [ 141 also reported similar 5 year survivals in the range of 25-35%. We report a 25% 5 year survival after the treatment of solitary metastatic lesions. However, not all our patients were amenable to surgery and that could have probably lowered the survival. Middleton [4] in his own series did not find a significant difference in survival after treatment of synchronous and metachronous solitary metastasis. However, after a review of several series, he concluded that concurrent excision of metastasis at nephrectomy had a poorer prognosis than excision of metastatic lesion occurring some time later during the follow up period. Tolia and Whitmore [5], O’Dea et al. [6], and Rafla [ 151 also agreed that the patients with a solitary metastasis synchronous with a primary lesion have a decreased survival as compared to patients who develop metastasis after removal of the primary lesion. Also in our series patients whose metastasis developed sometime after nephrectomy (25% 5 year survival) had a much better survival than those with synchronous metastasis, no patient in the latter group surviving more than two and one half years. Although many reports indicate that the site of metastasis does not have a bearing on survival, we have noticed that skeletal or lung metastasis fared much better than liver metastasis. Skinner et al. [9] noted the importance of metastatic interval in the ultimate survival. Of the 12 long term survivors in their series, nine underwent excision of metastasis more than 4 years after nephrectomy. Jett et al. [14] considered 18 months and Talley et al. [16] 24

47

months as the critical metastatic interval. Patients with metastasis-free intervals longer than this proved to have a much better prognosis. We have also found a strong correlation between the disease-free interval and the survival after metastatectomy in our series, with a critical metastasis-free interval of 24 months. Thus, the critical aspect of the survival of patients after the removal of solitary metastasis seems to be the disease-free interval, i.e., the time between the initial nephrectomy and the subsequent appearance of metastatic lesion. Patients who experience the greatest survival in the presence of a metastatic lesion are those whose lesions appear some years after nephrectomy .

CONCLUSIONS Nephrectomy and excision of solitary metastatic lesion seem to be justified in good surgical risk candidates. However, it may be understood that concurrent excision of metastasis at nephrectomy has a poorer prognosis than later excision for a metachronous metastasis. In the absence of any proven treatment alternatives, surgical excision of metastasis may be justified in selected patients with limited tumour burden and long term survivals may be obtained in a few patients. Whether good results from aggressive management of solitary metastasis represent other than the natural history of the disease, remains to be determined. However, most of the series are retrospective in nature and are limited by the small number of patients and the intrinsic limitations of the available diagnostic modalities to detect small volume disease. REFERENCES 1. Pontes JE: Adjuvant treatment of renal cell carcinoma. Int Adv

Surg Oncol 6:309-322, 1983. 2. Patel NP, Lavengood RW: Renal cell carcinoma: natural history and results of treatment. J Urol 119:722-726, 1978. 3. Ritchie AWS, deKernion JB: The natural history and clinical features of renal carcinoma. Semin Nephrol 7: I3 1- 139, 1987. 4. Middleton RG: Surgery for metastatic renal cell carcinoma. J Urol 97:973-977, 1967. 5 . Tolia BM, Whitmore WF Jr: Solitary metastasis from renal cell carcinoma, J Urol 114:83&838, 1975. 6. O’Dea MJ, Zincke H, Utz DC, Bematz PE: The treatment of renal cell carcinoma with solitary metastasis. J Urol 120540-542, 1978. 7. Swanson DA, Johnson DE: The management of renal cell carcinoma. Weekly Urol Update Series 1.2, lesson 36, 1978. 8. Dineen MK, Pastore RD, Emrich LJ, Huben RP: Results of surgical treatment of renal cell carcinoma with solitary metastasis. J Urol 140:277-279, 1988. 9. Skinner DG, Colvin RB, Vermillion CD, Pfister RC, Leadbetter WF: Diagnosis and management of renal cell carcinoma: a clinical and pathological study of 309 cases. Cancer 28: I 1.55-1 177, 1971, 10. Barney JD, Churchill EJ: Adenocarcinoma of the kidney with metastasis to the lung cured by nephrectomy and lobectomy. J Urol42:298, 1961. 11. deKernion JB, Ramming KP, Smith RB: The natural history of metastatic renal cell carcinoma: a computer analysis. J Urol 120:148-152, 1978. 12. Temple WJ, Ketcham AS: Surgical management of isolated systemic metastases. Semin Oncol7:468-480, 1980.

48

Tongaonkar et al.

13. Morrow CE. Vassilopoulos P, Grage TB: Surgical resection for nietastatic neoplasms of the lung. Cancer 45:298 1-2985, 1980. 14. Jett JR, Hollinger CG, Zinsmeister AR, Pairolero PC: Pulmonary resection of metastatic renal cell carcinoma. Chest 84:442445, 1983.

15. Rafla S: Renal cell carcinoma: natural history and results of treatment. Cancer 25:26, 1970. 16. Talley RW, Moorhead EL, Tucker WC, San Diego EL, Brennan MJ: Treatment of metastatic hypernephroma. JAMA 207:322328, 1969.

Solitary metastases from renal cell carcinoma: a review.

Nineteen patients with solitary metastatic lesions from renal cell carcinoma, 5 synchronous and 14 metachronous, were seen at the Tata Memorial Hospit...
348KB Sizes 0 Downloads 0 Views