Introduction:
The CARMENA trial demonstrated that sunitinib alone was non-inferior to cytoreductive nephrectomy (CN) followed by sunitinib with regard to overall survival (OS) for patients with metastatic renal cell carcinoma (mRCC). However, as CARMENA focused on patients requiring systemic therapy; the role of CN for patients not treated with upfront systemic therapy remain unknown. We therefore sought to describe the oncologic outcomes of patients with de-novo synchronous mRCC who underwent CN and initial surveillance, with or without metastasis-directed therapy (MDT), and without planned immediate postoperative systemic therapy.
Methods:
We identified 156 adults in the Mayo Clinic Nephrectomy Registry who underwent upfront CN for unilateral, sporadic, mRCC between 1996 and 2016 without postoperative systemic therapy within 3 months of CN. Patients treated with palliative intent were excluded. Metastases documented at nephrectomy were managed with initial surveillance or MDTs including metastasectomy, radiation, radio-frequency ablation, or cryoablation within 3 months of CN. Complete metastasectomy was defined as resection of all metastatic sites documented at CN. The co-primary outcomes were (i) systemic therapy-free survival (STFS) and (ii) OS, measured from 3-months post-CN. Features associated with STFS and OS were assessed using multivariable Cox regression models with best subsets selection.
Results:
Of the 156 patients studied, 115 (74%) had a single metastatic site. Thirty-seven (24%) patients were managed after CN with surveillance alone and 119 (76%) underwent MDT, of whom 77 (49%) had complete metastasectomy. Seventy-two patients initiated systemic therapy at a median of 0.7 years (IQR 0.3-1.7) following the start date. The median follow-up among survivors was 6.2 years (IQR 4.4-9.5), during which time 133 patients died. STFS rates at 1, 3, and 5 years following the start date were 47%, 21% and 14%, respectively. OS rates at 1, 3, and 5 years were 69%, 37%, and 28%, respectively. On multivariable analysis, having multiple metastatic sites was associated with worse STFS (HR 1.85; 95%CI 1.25-2.73; p=0.002 see Table 1), while complete metastasectomy was associated with improved OS (HR 0.59; 95%CI 0.40-0.87; p=0.008; see Table 2).
Conclusion:
Among appropriately selected patients managed with surveillance or MDT after CN, approximately half are estimated to be alive and not requiring systemic therapy at one year, with a subset achieving long term STFS. Having a single metastatic site and disease amenable to complete metastasectomy are features associated with improved STFS and OS after upfront CN. These data may help select which patients may be well served with upfront CN.
Funding: n/a
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OUTCOMES OF SURVEILLANCE FOLLOWING CYTOREDUCTIVE NEPHRECTOMY IN METASTATIC RENAL CELL CARCINOMA
Category
Kidney Cancer > Advanced
Description
Poster #83
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Presented By: Jack Rogers Andrews
Authors:
Jack Rogers Andrews
Christine Lohse
Stephen A Boorjian
Bradley C Leibovich
R. Houston Thompson
Brian A Costello
Bimal Bhindi