Abstract
Renal cell carcinoma (RCC) often presents in its metastatic form, or progresses after curative treatment. While the management of metastatic RCC has historically been mainly surgical, contemporary approaches often incorporate systemic immunotherapy. This review examines the current indications and scope of surgical treatment of patients with metastatic RCC. Surgery is sometimes indicated for symptom palliation at either the primary or secondary sites. However, other less invasive therapies may be equally effective, and should be considered carefully. Cytoreductive surgery prior to immunotherapy appears to confer a survival advantage, but only selected patients are suitable for this treatment regimen. Primary immunotherapy followed by surgical removal of the tumour in partial responders is an alternative treatment strategy, which has not yet been evaluated as in randomized trials. As immunotherapy develops further, the precise timing and role of surgery in multimodality treatment will need to be carefully evaluated. Occasionally, the complete surgical excision of metastases, and the primary tumour, if present, is feasible and this may prolong survival. Empirically, it would seem that such patients should also be treated with adjuvant immunotherapy, as eventual relapse is frequent. Surgery with the aim of inducing spontaneous tumour regression is not justifiable, given the rarity of this phenomenon.
Similar content being viewed by others
References
Novick AC, Campbell SC (2002) Renal tumours. In: Walsh PC, Retik AB, Vaughan EDJ, Wein AJ (eds) Campbell’s urology. WB Saunders, Philadelphia, pp 2672–2772
Wood CG (2003) The role of cytoreductive nephrectomy in the management of metastatic renal cell carcinoma. Urol Clin North Am 30:581–588
Motzer RJ, Bander NH, Nanus DM (1996) Renal-cell carcinoma. N Engl J Med 335:865–875
Neves RJ, Zincke H, Taylor WF (1988) Metastatic renal cell cancer and radical nephrectomy: identification of prognostic factors and patient survival. J Urol 139:1173–1176
Kirkali Z, Tuzel E, Mungan MU (2001) Recent advances in kidney cancer and metastatic disease. BJU Int 88:818–824
Fishman M, Seigne J (2002) Immunotherapy of metastatic renal cell cancer. Cancer Control 9:293–304
Flanigan RC (1996) Role of surgery in patients with metastatic renal cell carcinoma. Semin Urol Oncol 14:227–229
Yonover PM, Sharma SK, Flanigan RC (2003) Role of nephrectomy in metastatic kidney cancer. Cancer Treat Res 116:119–135
Munro NP, Woodhams S, Nawrocki JD, Fletcher MS, Thomas PJ (2003) The role of transarterial embolization in the treatment of renal cell carcinoma. BJU Int 92:240–244
Volkmer BG, Gschwend JE (2002) Value of metastases surgery in metastatic renal cell carcinoma, in German. Urologe A 41:225–230
Olerud C, Jonsson B (1996) Surgical palliation of symptomatic spinal metastases. Acta Orthop Scand 67:513–522
Wedin R (2001) Surgical treatment for pathologic fracture. Acta Orthop Scand [Suppl] 72: 1–29
Stepanek E, Josph S, Campbell P, Porte M (1999) Embolization of a limb metastasis in renal cell carcinoma as a palliative treatment of bone pain. Clin Radiol 54:855–857
Swanson DA, Johnson DE, Von Eschenbach AC, Chuang VP, Wallace S (1983) Angioinfarction plus nephrectomy for metastatic renal cell carcinoma—an update. J Urol 130:449–452
Kurth KH, Debruyne FM, Hall RR, Denis L, Verbaes A, Bollack C, De Voogt HJ, De Pauw M, Silvester R (1987) Embolization and postinfarction nephrectomy in patients with primary metastatic renal adenocarcinoma. Eur Urol 13:251–255
Mebust WK, Weigel JW, Lee KR, Cox GG, Jewell WR, Krishnan EC (1984) Renal cell carcinoma—angioinfarction. J Urol 131:231–235
Gottesman JE, Crawford ED, Grossman HB, Scardino P, McCracken JD (1985) Infarction-nephrectomy for metastatic renal carcinoma. Southwest oncology group study. Urology 25:248–250
Minasian LM, Motzer RJ, Gluck L, Mazumdar M, Vlamis V, Krown SE (1993) Interferon alfa-2a in advanced renal cell carcinoma: treatment results and survival in 159 patients with long-term follow-up. J Clin Oncol 11:1368–1375.
Joffe JK, Banks RE, Forbes MA, Hallam S, Jenkins A, Patel PM, Hall GD, Velikova G, Adams J, Crossley A et al. (1996) A phase II study of interferon-alpha, interleukin-2 and 5-fluorouracil in advanced renal carcinoma: clinical data and laboratory evidence of protease activation. Br J Urol 77:638–649
Quesada JR, Rios A, Swanson D, Trown P, Gutterman JU (1985) Antitumor activity of recombinant-derived interferon alpha in metastatic renal cell carcinoma. J Clin Oncol 3:1522–1528
Ljungberg B, Landberg G, Alamdari FI (2000) Factors of importance for prediction of survival in patients with metastatic renal cell carcinoma, treated with or without nephrectomy. Scand J Urol Nephrol 34:246–251
Mosharafa A, Koch M, Shalhav A, Gardner T, Logan T, Bihrle R, Foster R (2003) Nephrectomy for metastatic renal cell carcinoma: Indiana University experience. Urology 62:636–640
Fujikawa K, Matsui Y, Miura K, Kobayashi T, Oka H, Fukuzawa S, Takeuchi H (2000) Serum immunosuppressive acidic protein and natural killer cell activity in patients with metastatic renal cell carcinoma before and after nephrectomy. J Urol 164:673–675
Dadian G, Riches PG, Henderson DC, Taylor A, Moore J, Atkinson H, Gore ME (1994) Immunological parameters in peripheral blood of patients with renal cell carcinoma before and after nephrectomy. Br J Urol 74:15–22
Montie JE, Straffon RA, Deodhar SD, Barna B (1976) In vitro assessment of cell-mediated immunity in patients with renal cell carcinoma. J Urol 115:239–242
Flanigan RC, Salmon SE, Blumenstein BA, Bearman SI, Roy V, McGrath PC, Caton JRJr, Munshi N, Crawford ED (2001) Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 345:1655–1659
Jocham D, Richter A, Hoffmann L, Iwig K, Fahlenkamp D, Zakrzewski G, Schmitt E, Dannenberg T, Lehmacher W, Von Wietersheim J et al. (2004) Adjuvant autologous renal tumour cell vaccine and risk of tumour progression in patients with renal-cell carcinoma after radical nephrectomy: phase III, randomised controlled trial. Lancet 363:594–599
Figlin RA, Thompson JA, Bukowski RM, Vogelzang NJ, Novick AC, Lange P, Steinberg GD, Belldegrun AS (1999) Multicenter, randomized, phase III trial of CD8(+) tumor-infiltrating lymphocytes in combination with recombinant interleukin-2 in metastatic renal cell carcinoma. J Clin Oncol 17:2521–2529
Rackley R, Novick A, Klein E, Bukowski R, McLain D, Goldfarb D (1994) The impact of adjuvant nephrectomy on multimodality treatment of metastatic renal cell carcinoma. J Urol 152:1399–1403
Bennett RT, Lerner SE, Taub HC, Dutcher JP, Fleischmann J (1995) Cytoreductive surgery for stage IV renal cell carcinoma. J Urol 154:32–34
Mani S, Todd MB, Katz K, Poo WJ (1995) Prognostic factors for survival in patients with metastatic renal cancer treated with biological response modifiers. J Urol 154:35–40
Figlin RA, Pierce WC, Kaboo R, Tso CL, Moldawer N, Gitlitz B, DeKernion J, Belldegrun A (1997) Treatment of metastatic renal cell carcinoma with nephrectomy, interleukin-2 and cytokine-primed or CD8(+) selected tumor infiltrating lymphocytes from primary tumor. J Urol 158:740–745
Fallick ML, McDermott DF, LaRock D, Long JP, Atkins MB (1997) Nephrectomy before interleukin-2 therapy for patients with metastatic renal cell carcinoma. J Urol 158:1691–1695
Wagner JR, Walther MM, Linehan WM, White DE, Rosenberg SA, Yang JC (1999) Interleukin-2 based immunotherapy for metastatic renal cell carcinoma with the kidney in place. J Urol 162:43–45
Walther MM, Yang JC, Pass HI, Linehan WM, Rosenberg SA (1997) Cytoreductive surgery before high dose interleukin-2 based therapy in patients with metastatic renal cell carcinoma. J Urol 158:1675–1678
Levy DA, Swanson DA, Slaton JW, Ellerhorst J, Dinney CP (1998) Timely delivery of biological therapy after cytoreductive nephrectomy in carefully selected patients with metastatic renal cell carcinoma. J Urol 159:1168–1173
Tigrani VS, Reese DM, Small EJ, Presti JCJr, Carroll PR (2000) Potential role of nephrectomy in the treatment of metastatic renal cell carcinoma: a retrospective analysis. Urology 55:36–40
Pantuck AJ, Belldegrun AS, Figlin RA (2001) Nephrectomy and interleukin-2 for metastatic renal-cell carcinoma. N Engl J Med 345:1711–1712
Mickisch GH, Garin A, Van Poppel H, De Prijck L, Sylvester R (2001) Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial. Lancet 358:966–970
Flanigan RC, Mickisch G, Sylvester R, Tangen C, Van Poppel H, Crawford ED (2004) Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis. J Urol 171:1071–1076
Eggermont AM, Steller EP, Sugarbaker PH (1987) Laparotomy enhances intraperitoneal tumor growth and abrogates the antitumor effects of interleukin-2 and lymphokine-activated killer cells. Surgery 102:71–78
Sella A, Swanson DA, Ro JY, Putnam JBJr, Amato RJ, Markowitz AB, Logothetis CJ (1993) Surgery following response to interferon-alpha-based therapy for residual renal cell carcinoma. J Urol 149:19–22
Bex A, Horenblas S, Meinhardt W, Verra N, De Gast GC (2002) The role of initial immunotherapy as selection for nephrectomy in patients with metastatic renal cell carcinoma and the primary tumor in situ. Eur Urol 42:570–576
Kim B, Louie AC (1992) Surgical resection following interleukin 2 therapy for metastatic renal cell carcinoma prolongs remission. Arch Surg 127:1343–1349
Krishnamurthi V, Novick AC, Bukowski RM (1998) Efficacy of multimodality therapy in advanced renal cell carcinoma. Urology 51:933–937
Zisman A, Pantuck AJ, Chao DH, Wieder JA, Dorey F, Said JW, Kernion JB, Figlin R, Belldegrun AS (2002) Renal cell carcinoma with tumor thrombus: is cytoreductive nephrectomy for advanced disease associated with an increased complication rate? J Urol 168:962–967
Slaton JW, Balbay MD, Levy DA, Pisters LL, Nesbitt JC, Swanson DA, Dinney CP (1997) Nephrectomy and vena caval thrombectomy in patients with metastatic renal cell carcinoma. Urology 50:673–677
Walther MM, Lyne JC, Libutti SK, Linehan WM (1999) Laparoscopic cytoreductive nephrectomy as preparation for administration of systemic interleukin-2 in the treatment of metastatic renal cell carcinoma: a pilot study. Urology 53:496–501
Bromwich E, Hendry D, Aitchison M (2002) Cytoreductive nephrectomy: is it a realistic option in patients with renal cancer? BJU Int 89:523–525
Mejean A, Roupret M, Larousserie F, Hopirtean V, Thiounn N, Dufour B (2003) Is there a place for radical nephrectomy in the presence of metastatic collecting duct (Bellini) carcinoma? J Urol 169:1287–1290
Calvo FA, Zincke H, Gunderson LL, Aristu J, Gerard JP, Berian JM (1999) Genitourinary IORT. In: Gunderson LL, Willett CG, Harrison LB, Calvo FA (eds) Intraoperative irradiation: techniques and results. Humana, Totowa, pp 421–436
Frydenberg M, Gunderson L, Hahn G, Fieck J, Zincke H (1994) Preoperative external beam radiotherapy followed by cytoreductive surgery and intraoperative radiotherapy for locally advanced primary or recurrent renal malignancies. J Urol 152:15–21
Santos M, Ucar A, Ramos H, Escude L, Berian JM, Zudaire J, Calvo FA (1989) Intraoperative radiotherapy in locally advanced carcinoma of the kidney: initial experience, in Spanish. Actas Urol Esp 13:36–40
Eble MJ, Stahler G, Wannenmacher M (1997) IORT for locally advanced or recurrent renal cell carcinoma. Front Radiat Ther Oncol 31:253–255
De Riese W, Goldenberg K, Allhoff E, Stief C, Schlick R, Liedke S, Jonas U (1991) Metastatic renal cell carcinoma (RCC): spontaneous regression, long-term survival and late recurrence. Int Urol Nephrol 23:13–25
Aref I, Bociek RG, Salhani D (1997) Is post-operative radiation for renal cell carcinoma justified? Radiother Oncol 43:155–157
Buskirk SJ, Smalley SR, Zincke H (2000) Kidney and Ureteral Carcinoma. In: Gunderson L, Tepper JE (eds) Clinical radiation oncology. Churchill Livingstone, New York, pp 863–878
Kavolius JP, Mastorakos DP, Pavlovich C, Russo P, Burt ME, Brady MS (1998) Resection of metastatic renal cell carcinoma. J Clin Oncol 16:2261–2266
Kierney PC, Van Heerden JA, Segura JW, Weaver AL (1994) Surgeon’s role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: an institutional review. Ann Surg Oncol 1:345–352
O’Dea M J, Zincke H, Utz DC, Bernatz PE (1978) The treatment of renal cell carcinoma with solitary metastasis. J Urol 120:540–542
Piltz S, Meimarakis G, Wichmann MW, Hatz R, Schildberg FW, Fuerst H (2002) Long-term results after pulmonary resection of renal cell carcinoma metastases. Ann Thorac Surg 73:1082–1087
Pfannschmidt J, Hoffmann H, Muley T, Krysa S, Trainer C, Dienemann H (2002) Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma. Ann Thorac Surg 74:1653–1657
Alves A, Adam R, Majno P, Delvart V, Azoulay D, Castaing D, Bismuth H (2003) Hepatic resection for metastatic renal tumors: is it worthwhile? Ann Surg Oncol 10:705–710
Lau WK, Zincke H, Lohse CM, Cheville JC, Weaver AL, Blute ML (2003) Contralateral adrenal metastasis of renal cell carcinoma: treatment, outcome and a review. BJU Int 91:775–779
Harada Y, Nonomura N, Kondo M, Nishimura K, Takahara S, Miki T, Okuyama A (1999) Clinical study of brain metastasis of renal cell carcinoma. Eur Urol 36:230–235
Badalament RA, Gluck RW, Wong GY, Gnecco C, Kreutzer E, Herr HW, Fair WR, Galicich JH (1990) Surgical treatment of brain metastases from renal cell carcinoma. Urology 36:112–117
Ghavamian R, Klein KA, Stephens DH, Welch TJ, LeRoy AJ, Richardson RL, Burch PA, Zincke H (2000) Renal cell carcinoma metastatic to the pancreas: clinical and radiological features. Mayo Clin Proc 75:581–585
Sohn TA, Yeo CJ, Cameron JL, Nakeeb A, Lillemoe KD (2001) Renal cell carcinoma metastatic to the pancreas: results of surgical management. J Gastrointest Surg 5:346–351
Law CH, Wei AC, Hanna SS, Al-Zahrani M, Taylor BR, Greig PD, Langer B, Gallinger S (2003) Pancreatic resection for metastatic renal cell carcinoma: presentation, treatment, and outcome. Ann Surg Oncol 10:922–926
Itano NB, Blute ML, Spotts B, Zincke H (2000) Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. J Urol 164:322–325
Schrodter S, Hakenberg OW, Manseck A, Leike S, Wirth MP (2002) Outcome of surgical treatment of isolated local recurrence after radical nephrectomy for renal cell carcinoma. J Urol 167:1630–1633
Wiesner C, Jakse G, Rohde D (2002) Therapy of local recurrence of renal cell carcinoma. Oncol Rep 9:189–192
Blom JH, Van Poppel H, Marechal JM, Jacqmin D, Sylvester R, Schroder FH, De Prijck L (1999) Radical nephrectomy with and without lymph node dissection: preliminary results of the EORTC randomized phase III protocol 30881. EORTC Genitourinary Group. Eur Urol 36:570–575
Blute ML, Leibovich BC, Cheville JC, Lohse CM, Zincke H (2004) A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma. J Urol 172:465–469
Pantuck AJ, Zisman A, Dorey F, Chao DH, Han KR, Said J, Gitlitz BJ, Figlin RA, Belldegrun AS (2003) Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection. J Urol 169:2076–2083
Tatsuta M, Shiozaki K, Masutani S, Hashimoto K, Imamura H, Ikeda M, Miya A, Ishida H, Kawasaki T, Furukawa H et al. (2001) Splenic and pulmonary metastases from renal cell carcinoma: report of a case. Surg Today 31:463–465
Lokich J (1997) Spontaneous regression of metastatic renal cancer. Case report and literature review. Am J Clin Oncol 20:416–418
Thoroddsen A, Gudbjartsson T, Geirsson G, Agnarsson BA, Magnusson K (2002) Spontaneous regression of pleural metastases after nephrectomy for renal cell carcinoma—a histologically verified case with nine-year follow-up. Scand J Urol Nephrol 36:396–398
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sengupta, S., Leibovich, B.C., Blute, M.L. et al. Surgery for metastatic renal cell cancer. World J Urol 23, 155–160 (2005). https://doi.org/10.1007/s00345-005-0504-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00345-005-0504-6