Renal cell carcinoma (RCC) represents 90% of all kidney cancers, with most patients being diagnosed with clear cell histology.1 Metastatic renal cell carcinoma (mRCC) is not uncommon; 35% of patients eventually developing metastases and more than 25% of patients are diagnosed with metastatic disease upon initial diagnosis.2 Although treatments vary on a patient-to-patient basis, options include systemic and hormonal therapy, radiation, and surgery.3
Systemic treatments include immune checkpoint inhibitors (ICIs): programmed cell death 1 (PD-1) inhibitors and programmed cell death ligand 1 (PD-L1) inhibitors, and anticytotoxic T lymphocyte protein 4 (CTLA-4) antibodies.3 In addition to ICIs, there are also vascular endothelial growth factor (VEGF) inhibitors, tyrosine kinase inhibitors (TKIs), and mammalian target of rapamycin (mTOR) inhibitors.3 Despite the array of medications available, these treatment options typically do not result in a complete response in patients with mRCC.3 Therefore, these patients are frequently evaluated for surgery, both of the primary tumor and metastases.
The decision to pursue metastasectomy can be challenging, especially in the setting of increasingly available and innovative systemic options. However, there is evidence to support the role of metastasectomy in providing patients with mRCC an improvement in certain clinical outcomes such as median cancer-specific survival (CSS) and overall survival (OS).4,5 Prior studies have indicated that if metastasectomy is pursued, there are certain clinical features that appear to make metastasectomy more favorable: younger age at presentation, solitary metastasis, lung metastasis, and metachronous presentation with disease-free survival (DFS) greater than 12 months.6,7
Much of the data from previous studies evaluating metastasectomy in mRCC occurred prior to the significant expansion of systemic treatment options such as TKIs and ICIs. Therefore, a group led by Dragomir et al recently aimed to update the outcomes associated with metastasectomy in the current treatment environment of mRCC, and published their findings in Urologic Oncology.1
Between January 2011 and April 2019, the authors evaluated patients with mRCC who underwent complete metastasectomy (CM) and compared them to control patients who did not using the Canadian Kidney Cancer information system (CKCis) database.
The cohort included a total of 1471 patients with mRCC who had undergone a prior nephrectomy, of which 250 (17%) underwent CM compared with 1221 (83%) without a metastasectomy. The CM group had a significantly longer median time between primary RCC tumor and diagnosis of metastasis compared with the control group (17.9 months vs 4.8 months, P <.001). This corresponded to 55.6% of CM and 33.3% of control patients having had an interval of longer than 1 year from primary RCC diagnosis to their first metastasis. The most common sites of CM included the lung (29.4%), adrenals (15.2%), and lymph nodes (12.4%).
Locations of the actual metastases varied between the groups, with the CM group having more patients with adrenal metastases compared with the control group (16% vs 10.1%, respectively, P =.0065) and more patients in the CM group with brain metastases compared with the control group (8.8% vs 1.5%, respectively, P <.0001).