Department of Urology, Mayo Clinic, Rochester, MN.
Department of Urology, MD Anderson Cancer Center, Houston, TX; Department of Urology, Mayo Clinic Arizona, Phoenix, AZ.
Urol Oncol. 2023 Mar;41(3):125-136. doi: 10.1016/j.urolonc.2022.09.021. Epub 2022 Oct 28.
Deferred cytoreductive nephrectomy (dCN) after upfront systemic therapy has been utilized in the management of select patients with metastatic renal cell carcinoma (mRCC). Herein, we sought to review the current evidence and define oncologic and perioperative outcomes associated with deferred surgical management of newly diagnosed mRCC. Our objective was to critically evaluate the role of dCN in the targeted and immunotherapy eras, comparing oncologic and perioperative outcomes between dCN and upfront CN. Medline, OVID, and Scopus databases were searched for studies evaluating patients undergoing dCN following systemic therapy (ST). PRISMA guidelines were referenced and followed. Outcomes of interest included overall survival (OS), progression free survival (PFS), percent of patients proceeding to dCN, reduction in primary tumor size, complication rates, and perioperative mortality. Random effects meta-analysis was performed comparing overall survival between dCN vs. ST alone and dCN vs. upfront CN. Nineteen studies were included to assess the primary outcomes. The percent of patients proceeding to planned dCN after planned pre-surgical ST ranged from 60.5% to 84%. The most common reason for not undergoing dCN was disease progression on upfront ST. Of patients undergoing dCN, 76% to 96% were able to resume ST postoperatively. OS and PFS ranged from 12.4 to 46 months and 4.5 to 11 months, respectively. Pooled results demonstrated significantly improved OS favoring dCN over upfront CN (hazard ratio, HR = 0.56; 95% CI 0.45-0.69) and ST alone (HR = 0.45; 95% CI 0.38-0.53). Deferred CN represents a potential treatment option in appropriately selected patients with mRCC with a favorable response to upfront systemic therapy. Future randomized trials will be needed to clarify how much this is due to the surgery vs. patient selection.
在转移性肾细胞癌（mRCC）患者中，采用初始全身治疗后延期细胞减灭性肾切除术（dCN）已被用于治疗选择患者。在此，我们旨在回顾现有证据并定义新诊断的 mRCC 患者接受延期手术治疗相关的肿瘤学和围手术期结局。我们的目标是在靶向和免疫治疗时代批判性评估 dCN 的作用，比较 dCN 和初始 CN 的肿瘤学和围手术期结局。我们检索了评估接受全身治疗（ST）后行 dCN 的患者的 Medline、OVID 和 Scopus 数据库。参考并遵循 PRISMA 指南。感兴趣的结局包括总生存（OS）、无进展生存（PFS）、行 dCN 的患者比例、原发肿瘤大小的缩小、并发症发生率和围手术期死亡率。比较 dCN 与单独 ST 及 dCN 与初始 CN 的 OS 进行了随机效应荟萃分析。纳入了 19 项研究来评估主要结局。计划术前 ST 后计划行 dCN 的患者比例从 60.5%到 84%不等。不行 dCN 的最常见原因是初始 ST 时疾病进展。行 dCN 的患者中，76%至 96%术后能恢复 ST。OS 和 PFS 分别为 12.4 至 46 个月和 4.5 至 11 个月。汇总结果显示，与初始 CN（危险比，HR = 0.56；95%CI 0.45-0.69）和单独 ST（HR = 0.45；95%CI 0.38-0.53）相比，dCN 显著改善 OS。dCN 是对初始全身治疗有良好反应的 mRCC 患者的潜在治疗选择。需要未来的随机试验来阐明这在多大程度上归因于手术和患者选择。
