Complete resection of multiple metastases

Kidney cancer. Principles and practice. Second edition. Primo N. Lara, Jr. Eric Jonasch (Editors). Springer International Publishing (2015)

Complete resection of multiple metastases can be defined as either a resection performed simultaneously at one or more sites or as repeat metastasectomy of asynchronous recurrences after first resection.

The latter reflects a more benign course of the disease. It is therefore not surprising that repeat metastasectomy can result in exceptionally long survival lasting more than 10 years in selected individuals [135, 153]. In a series of 141 patients with complete resection of solitary metastases, 5-year survival rates after complete resection of second and third metastases were not different compared with initial metastasectomy (46 and 44%, respectively, vs 43% 5-year OS rates; p = nonsignificant) [64]. This is in line with an early retrospective study in which repeat metastasectomy led to longer survival when compared to nonsurgical treatment of recurrence after first metastasectomy [40].

Table 11.2. Five-year survival rates after complete resection of solitary or oligometastasis for various sites

__Kidney Cancer_ Principles and Practice-Springer International Publishing (2015) T 11.2

Survival of patients who underwent complete metastasectomy for multiple synchronous RCC metastases at one or more sites has recently been analyzed for a larger series [2]. Of 887 patients with metastatic RCC, 125 patients were identified who underwent complete surgical resection of multiple metastases (2–>3 metastases). Multiple metastases in the lungs as single site were removed in 39.2%, but 52% had resection at two or more sites including the lungs, bone, visceral organs, and other locations. Patients with complete metastasectomy restricted to the lungs had a 5-year survival rate of 73% versus 19% for those who did not undergo complete resection. Likewise, patients with multiple non-lung-only metastases had a 5-year survival rate of 32.5% with complete resection versus 12.4% without. Controlling for ECOG performance status and disease burden those without complete resection had a nearly threefold increased risk of death from RCC. A previous study from the same institution reported on a scoring algorithm to predict cancer-specific survival for patients with clear cell metastatic RCC [73]. Complete resection of multiple metastases was associated with a 50% decrease in the risk of death on multivariate analysis. Conversely, others reported that patients with metastatic RCC to only one organ site fared significantly better than patients who had evidence of disease in multiple organs (Han et al. [41]). Because of the retrospective, nonrandomized setting of these studies, it cannot be ruled out that multiple metastasectomy benefited patients who would have had a favorable course of disease regardless of surgical intervention. Careful selection of patients with multiple RCC metastases should be made according to general prognostic factors (Tables 11.1 and 11.2).

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