Cytoreductive nephrectomy for metastatic renal cell carcinoma with nonclear cell histology.

PURPOSE: To our knowledge the benefit of cytoreductive surgery for patients with metastatic renal cell carcinoma with nonclear cell histology is unknown. In this retrospective study we report our experience with cytoreductive nephrectomy for nonclear cell metastatic renal cell carcinoma at M. D. Anderson Cancer Center. We compared the outcomes with those in patients with clear cell metastatic renal cell carcinoma. MATERIALS AND METHODS: From 1991 to 2006, 606 patients with metastatic renal cell carcinoma underwent cytoreductive nephrectomy and they formed the basis of this report. Of these patients 92 had nonclear cell metastatic renal cell carcinoma. The remaining 514 patients had clear cell metastatic renal cell carcinoma and they formed a comparative group. Multivariate Cox regression analysis was performed to evaluate the relationship between clinical variables and histology (clear cell vs nonclear cell) on disease specific survival. RESULTS: Compared with patients with clear cell histology those with nonclear cell metastatic renal cell carcinoma were younger (p = 0.0001), and more likely to have nodal metastases (p <0.0001) and sarcomatoid features (23% vs 13%, p = 0.026). On multivariate analysis median disease specific survival in patients with nonclear cell histology was significantly worse than that in patients with clear cell metastatic renal cell carcinoma (9.7 vs 20.3 months, p = 0.0003) even after adjusting for T stage, grade, performance status, age and sarcomatoid features. Sarcomatoid features were a predictor of poor outcome in cases of clear and nonclear cell histology, although even in the absence of sarcomatoid features nonclear cell histology was associated with worse disease specific survival (p = 0.017). Interestingly although there was a significantly higher incidence of positive nodes in patients with nonclear histology (p <0.0001), this phenotype was not associated with a worse disease specific survival, as it was in those with clear cell histology (p = 0.0001). In fact, patients with node negative disease with nonclear cell histology had the worst prognosis overall in the entire group. CONCLUSIONS: Patients with nonclear cell metastatic renal cell carcinoma were younger and had a higher incidence of nodal metastases, a higher incidence of sarcomatoid features and a worse prognosis than those with clear cell histology who underwent cytoreductive surgery.

Cytoreductive nephrectomy for T4NxM1 renal cell carcinoma: the M.D. Anderson Cancer Center experience.

OBJECTIVES: Although cytoreductive nephrectomy may provide a survival benefit in metastatic renal cell carcinoma, patients with locally advanced lesions may be denied cytoreduction because of a perceived worse outcome and increased morbidity. We reviewed our experience with cytoreductive nephrectomy in patients with contiguous organ involvement (Stage T4NxM1) to evaluate the outcome and morbidity. METHODS: From 1993 to 2004, 498 patients underwent cytoreductive nephrectomy for renal cell carcinoma. Of those, 23 patients had Stage T4NxM1 disease. The analyzed variables included surgical complications, palliation of symptoms, and survival. RESULTS: The median patient age was 55 years (range 35 to 73), with a median tumor size of 15 cm (range 7 to 30). The median overall and disease-specific survival was 6.8 months (range 1.4 to 25.7). The distribution of the histologic type was conventional in 16, papillary in 2, and unclassified in 5. Sarcomatoid features were present in 9 patients. In 2 patients, surgery was aborted because of unresectable disease. Three patients developed postoperative complications (one wound dehiscence, one pancreatic collection, and one seizure). The median length of stay was 7 days (range 5 to 19). Of the 7 patients with local symptoms, 5 experienced postoperative palliation. Most patients (79%) received postoperative systemic therapy after a median of 39 days (range 24 to 114). Five patients did not receive systemic therapy because of disease progression. The median disease-specific survival for the patients who received systemic therapy was 7.1 months (range 1.4 to 25.7), but only 2.5 months (range 0 to 5.2) for those who had not (P = 0.003). CONCLUSIONS: Cytoreductive nephrectomy in Stage T4NxM1 renal cell carcinoma is feasible and provides significant palliation in symptomatic patients; however, the survival benefit is unclear. Our retrospective series has demonstrated that the prognosis in these patients is poor.