Surgical Palliation of Renal Cell Carcinoma Metastatic to Bone
Surgical Palliation of Renal Cell Carcinoma Metastatic to Bone
ABSTRACT & COMMENTARY
Synopsis: Management of boney metastasis from renal cell carcinoma is often problematic. These lesions may be extremely painful and may exhibit only in marginal response to radiation therapy. The natural history of metastatic RCC can be highly variable with some patients living more than five years with metastatic disease. Successful palliation of these boney lesions can often result in a markedly improved quality of life. Kollender and colleagues report on the outcomes of surgical management of boney metastasis in 45 highly selected patients with metastatic RCC. Pain relief and a good to excellent functional outcome was achieved in approximately 90% of the patients. Reflecting the selection process, approximately half of the patients lived more than two years and 38% lived more than three years.
Source: Kollender Y, et al. J Urol 2000;164:1505-1508.
Management of renal cell carcinoma (rcc) to the bone is frequently problematic due to the relative radio-resistance of these lesions. Between 1980 and 1997, 45 patients with a total of 56 lesions underwent surgery for metastatic RCC of the bone. Indications for surgery were a solitary bone metastasis (11 cases), interactable pain (24 cases), or impending/pathological fracture (21 cases). A wide excision (29 cases) consisting of en-block removal of the tumor with margins of normal bone and soft tissue was performed when bone destruction was extensive or when there was a solitary bone metastasis. Marginal excision with cryosurgery (25 cases) was performed when the circumferential realm of cortex remaining after tumor removal was sufficient to ensure a stable reconstruction. This technique involved curettage with adjuvant freezing of the tumor cavity with liquid nitrogen. Amputation was done when there was massive tumor extension to the soft tissue with invasion of a major neurovascular bundle of the extremity (2 cases). In those patients for whom amputation was not planned, preoperative embolization of the lesion was typically performed to decrease interoperative blood loss. Three patients who underwent marginal resection with cryotherapy also received postoperative adjuvant radiation therapy. No patient had more than 600 cc of blood loss from an extremity lesion or 1200 cc from a pelvic lesion. There were no incidences of flap necrosis, deep wound infection, nerve palsy, or thromboembolic complications. Mean hospital stay was 9.8 days (range, 6-21 days). Of 34 patients with disease in the pelvic girdle or lower extremities, 34 (94%) were ambulatory postoperatively. The remaining two patients were wheelchair bound. Forty-one patients (91%) had significant pain relief and function was estimated to be good or excellent in 89%. Four lesions recurred, including three after marginal excision. Radiation therapy was administered for two of the recurrent lesions, but the remaining two were asymptomatic and occurred preterminally. Of the 11 patients with a solitary metastasis, 73% lived more than three years. However, only 25% of those patients who underwent surgery for intractable pain or for an impending or pathological fracture lived more than three years.
COMMENT BY MICHAEL J. HAWKINS, MD
Patients with metastatic RCC to bone often present difficult management decisions for a medical oncologist. While a systemic, usually immunologically induced, complete remission is the most desirable outcome, most patients do not respond to interleukin-2 administered either alone or in combination with interferon-alpha and/or chemotherapy. It is well recognized that metastatic RCC can have a highly variable course. It is not uncommon for patients to be completely or relatively asymptomatic despite the presence of slow growing metastatic disease. In the face of widespread but slow growing disease, the development of a painful boney metastasis is often treated with radiation. The relative radioresistance of RCC is well recognized, and it is not uncommon for patients to continue to have pain and/or progressive bone destruction despite radiation therapy. In highly selected patients, an aggressive surgical approach is indicated. Patients whose only site of metastatic disease is in the bone can typically be treated surgically with a local control rate that exceeds 90%. When patients have developed extremely painful or mechanically unstable bone metastasis, selection for surgery needs to be weighed with their length of anticipated length of survival. Even though only approximately 25% of the patients in this series lived for more than two years, when they were operated on for these indications significant palliation of symptoms was consistently achieved. The use of adjuvant cryotherapy has resulted in good local tumor control despite less extensive surgical procedures and permits a greater incidence of limb sparing.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.