Original article
Surgical resection of locally recurrent renal cell carcinoma after nephrectomy: Oncological outcome and predictors of survival☆

https://doi.org/10.1016/j.urolonc.2017.08.021Get rights and content

Highlights

  • •

    Surgical treatment of isolated locally recurrent renal cell carcinoma offers local tumor control.

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    In patients with a disease-free interval of more than 2 years after surgery for the primary tumor, surgical removal of locally recurrent renal cell carcinoma may achieve long-term survival in the majority of patients.

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    The overall surgical complication rate is moderate.

Abstract

Objective

To describe the course of disease of patients surgically treated for locally recurrent renal cell carcinoma (LRRCC) after nephrectomy and to identify potential predictive factors for long-term survival.

Patients and methods

We, retrospectively, identified 54 patients who underwent surgical resection of LRRCC after open nephrectomy for localized kidney cancer. The median age at time of surgery for LRRCC was 65 years. Survival rates were determined with the Kaplan-Meier method. Mantel-Haenszel hazard ratios were calculated. Comparisons were made with the log-rank test. Cox proportional hazard models were used to analyze combined effects of variables.

Results

Median time to local recurrence after nephrectomy was 36 months (5–242 months). Median follow-up after surgery for LRRCC was 39 months. At time of analysis 18 patients (33%) were alive without any evidence of disease, 8 patients (15%) were alive with disease, 20 patients (37%) died of renal cell carcinoma, and 8 patients (15%) died of other causes. A 5-year overall survival (OS) was 60% (95% CI: 0.44–0.73) and 10-year OS was 32% (95% CI: 0.15–0.51). The median survival after surgery for LRRCC was 79 months. In univariate analysis OS differed significantly by the time period between primary surgery and occurrence of LRRCC (<2 years vs. ≥2 years: 10-year OS rate 31% (95% CI: 10.2–55.0) vs. 45% (95% CI: 21.5–65.8; hazard ratio = 0.26; P = 0.0034). In multivariate analysis sarcomatoid features in the primary nephrectomy specimen, positive surgical margins of the LRRCC specimen and a Charlson score of ≥2 were associated with a significantly worse prognosis in this cohort.

Conclusion

In patients with a disease-free interval of more than 2 years after surgery for the primary tumor, surgical removal of LRRCC may achieve long-term survival in most patients. In those with a shorter disease-free interval, long-term survival is unlikely.

Introduction

Up to 30% of patients who undergo surgical therapy of renal cell carcinoma (RCC) with curative intent will develop metastasis and about one-third of all patients with RCC have systemic disease at presentation [1]. The aim of postoperative surveillance after surgery for localized RCC is to detect local recurrence or metastatic disease while the patient is still surgically curable [2]. Isolated local recurrence of RCC is rare and occurs in about 3% after radical nephrectomy [3], [4]. Most patients with local recurrence of RCC are diagnosed by either computed tomography (CT) or magnetic resonance imaging scans as part of the postoperative surveillance regimen after nephrectomy for RCC. However, some patients with LRRCC have single or multiple distant metastases at time of diagnosis of LRRCC. Targeted therapy is effective in stabilizing metastatic disease in approximately 70% to 80% of patients in the first-line setting and prolonging overall survival (OS) in a significant proportion of patients with metastatic RCC. Nevertheless, complete responses are reported in only 1% to 3% of these patients [5], [6]. Therefore, the primary curative option for oligometastatic patients remains the surgical removal of all evident metastasis if feasible.

Disease data from retrospective series suggest that with a surgical approach to local recurrence long-term tumor control and longer OS can be achieved in a significant proportion of patients without evidence of systemic disease [3], [4], [7], [8], [9], [10], [11], [12]. In this study we, retrospectively, examined the natural history of locally recurrent RCC in patients with isolated local recurrence. We also analyzed our data for factors that may potentially predict long-term survival after surgery for LRRCC.

Section snippets

Patients and methods

We, retrospectively, identified 54 consecutive patients who underwent surgical resection for suspected locally recurrent RCC between 1992 and 2014 at 2 academic institutions. The study was approved by the institution's ethics committee. All patients had undergone radical nephrectomy for localized RCC. Postoperative follow-up after nephrectomy was done by the outpatient office urologists according to their discretion, usually consisting of physical examination, blood chemistry and imaging

Patient and tumor baseline characteristics

A total of 62 patients underwent surgery for contrast-enhancing lesions suspicious of LRRCC according to the definition of Margulis et al. [9] at our 2 academic centers. In all, 8 patients had to be excluded from the analysis with 4 patients having concomitant lung metastasis and 4 patients having a benign histology. All of the remaining 54 patients included in the final analysis had histologically proven RCC recurrence. The median age was 59 years at time of nephrectomy (range: 30–75 years).

Discussion

We present data analyzing the oncological outcome of a relatively large cohort of patients who underwent surgery for locally recurrent RCC and this represents an update and extension of our first report of surgery for LRRCC in 2002 [12].

Historical data for local RCC recurrence had reported a dismal prognosis when LRRCC was left untreated. There have been no prospective, randomized trials of surgery for LRRCC and systemic treatment because isolated LRRCC is relatively rare and because the

Conclusion

Surgery for local recurrence of RCC after radical nephrectomy offers good tumor control if the time interval between radial nephrectomy and local recurrence is two years or more. The complication rate of the surgical procedure is moderate hence excision of LRRCC should be offered to appropriately selected patients as a potentially curative treatment option.

Cited by (9)

  • Renal cell carcinoma: The role of radical surgery on different patterns of local or distant recurrence

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    Partial nephrectomy (PN) is considered the standard of care for clinical T1a tumors, providing excellent cancer control with optimal preservation of renal function, while radical nephrectomy (RN) is instead preferred for patients with clinical T1b–T4 tumors or for some patients with localized RCC when PN is unsuitable mainly due to tumor-related and patient-related factors (locally advanced tumor growth, unfavorable tumor location, significant medical comorbidities, etc.) [1,6]. Following curative treatment for localized RCC, up to 30% of patients develop tumor recurrence after being considered disease-free [6–9]. Isolated local recurrence after nephrectomy for kidney cancer is fairly uncommon and the prevalence has been reported to range between 1 and 2% in different series [7,10,11].

  • Capturing Renal Cell Carcinoma Recurrences When Asymptomatic Improves Patient Survival

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    Capturing RCC recurrences early, potentially when tumor burden is theoretically lower, affords more therapeutic options to be available, such as surgical excision. In fact, previous retrospective analyses have found that surgical removal of locally recurrent RCC offers improved tumor control and longer overall survival.13-16 Interestingly, some of these studies found that size of tumor recurrence acted as an adverse risk factor associated with an increased risk of disease-specific death.15,16

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Study type: Therapy (case series), Level of Evidence 4.

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