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.