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Metastic renal cancer and the role of surgery
British Journal of Medical and Surgical Urology (2008) 1, 41—42
CASE REPORT
Metastic renal cancer and the role of surgery P. Whelan Department of Urology, St. James’ University Hospital, Leeds, UK
History A 48-year-old maintenance electrician was referred by a chest physician colleague to whom he presented 3 weeks previously with continual chest symptoms that were thought to be pneumonic recurrent pneumonia. A chest X-ray on the 24th February 1986 had shown pulmonary and pleural metastases in both lung fields. An ultrasound scan taken on the same day demonstrated a 17 cm × 13 cm × 10 cm tumour occupying the whole of the left kidney with a 4 cm visible lymph node mass around the left hilum. This gentleman was entered into a Phase II study of high dose medroxyprogesterone (Farlutal) weekly injections × 6 to be commenced immediately following radical nephrectomy, which he underwent on the 26th February 1986. The patient was discharged without problems on the 6th March 1986. On his first review chest X-ray on the 21st April 1986 there was apparent progression of chest metastases in both size and number. The chest X-ray on the 4th June, 12 weeks after his nephrectomy and 6 weeks after the end of the high dose progesterone, reported that there had been a partial response with considerable shrinkage of all known lesions. At that stage his only medication was a maintenance dose of 400 g progesterone per day. A chest X-ray on the 11th July 1986 showed complete disappearance of all chest lesions and on E-mail address: [email protected].
the 2nd September 1986 the chest X-ray remained clear. An ultrasound of the abdomen at the same time, while showing the presence of gallstones, showed no other intra-abdominal abnormality. The patient continued to have a clear chest X-ray and ultrasound of the abdomen during 1987 and, when ready access to CT scanning became available and for the purposes of defining a complete response, a CT scan of the abdomen and chest on the same day showed no evidence of any disease anywhere. A bone scan on the 18th April 1988 was also normal. He was the only patient to show a complete response of the 26 patients in this Phase II study. The patient continued his follow up on an annual basis — mostly from clinical interest and possibly patient dependence — until it was finally agreed in May 2006 when he was 69 years old that he would be discharged from the clinic with no evidence of disease. This was 20 years since diagnosis. To show that life is never fair, however, in November 2007 he was admitted acutely with severe upper left quadrant pain and an urgent CT showed evidence of small bowel obstruction. He underwent a laparotomy and division of adhesions and made a good recovery. A follow-up CT carried out at the beginning of 2008 shows that he continues to have no evidence of disease in his chest or abdomen.
Discussion Adjuvant therapy for patients presenting with a large primary and simultaneous metastases from
1875-9742/$ — see front matter © 2008 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2008.05.001
42
P. Whelan
renal cancer has been tried for many years in many settings. There have always been anecdotal tales of complete responses following the removal of the primary, although the best literature suggests that this happens within the order of 0.6%. We know from later experience in the MRC trial, when Interferon as a new agent was compared with progesterone, that progesterone showed no specific benefit to patients. Why this case is important in my own practice is that this spectacular response, which may or may not have been due to the combination of surgery and medroxyprogesterone or may have just been a once in a lifetime spontaneous remission, made me more determined to put these sporadic responses into some sense and therefore to remain a constant contributor to Phase II trials of adjuvant therapy of patients with metastasis from renal cancer. Such trials have borne fruit in that we now know from a combined analysis of two carefully constructed studies of Interferon plus nephrectomy versus Interferon alone, one from the EORTC and one from the South West Oncology Group, that a definite and persistent survival benefit was obtained in undertaking radical surgery in the presence of metastases [1]. This confirmed my overt prejudice that surgery can be delivered to a standard fashion, it can therefore be assessed in a trial and especially as part of multi-modality therapy for cancer, and such trials can produce valid re-producible and sustainable outcomes that are of benefit to our patients. All
the single institution, personal surgical series in the world have not contributed one wit, the sense and science that this particular paper has given.
Conclusion This particular case was a surgical challenge which any self respecting thirty something would undertake. The lesson I believe I learnt was to realise that the favourable outcome was not due to my spectacular and unique ability in renal tumour ablation but, having carried out competent cytoreductive surgery, the biology of the metastases which fortunately proved sensitive and favourable to involution. It was essential that a continuing research for effective systemic treatment combined with primary surgery was undertaken and although the responses unfortunately still remain modest overall, the two prospective trials, in my view, confirm the need for well conducted prospective randomized trials with surgery. The necessary part of the multi-modality treatment for a cancer.
Reference [1] Flanigan RC, Mickisch G, Sylvester R, et al. Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis. J Urol 2004;171:1071—6.
Available online at www.sciencedirect.com
CASE REPORT
Metastic renal cancer and the role of surgery P. Whelan Department of Urology, St. James’ University Hospital, Leeds, UK
History A 48-year-old maintenance electrician was referred by a chest physician colleague to whom he presented 3 weeks previously with continual chest symptoms that were thought to be pneumonic recurrent pneumonia. A chest X-ray on the 24th February 1986 had shown pulmonary and pleural metastases in both lung fields. An ultrasound scan taken on the same day demonstrated a 17 cm × 13 cm × 10 cm tumour occupying the whole of the left kidney with a 4 cm visible lymph node mass around the left hilum. This gentleman was entered into a Phase II study of high dose medroxyprogesterone (Farlutal) weekly injections × 6 to be commenced immediately following radical nephrectomy, which he underwent on the 26th February 1986. The patient was discharged without problems on the 6th March 1986. On his first review chest X-ray on the 21st April 1986 there was apparent progression of chest metastases in both size and number. The chest X-ray on the 4th June, 12 weeks after his nephrectomy and 6 weeks after the end of the high dose progesterone, reported that there had been a partial response with considerable shrinkage of all known lesions. At that stage his only medication was a maintenance dose of 400 g progesterone per day. A chest X-ray on the 11th July 1986 showed complete disappearance of all chest lesions and on E-mail address: [email protected].
the 2nd September 1986 the chest X-ray remained clear. An ultrasound of the abdomen at the same time, while showing the presence of gallstones, showed no other intra-abdominal abnormality. The patient continued to have a clear chest X-ray and ultrasound of the abdomen during 1987 and, when ready access to CT scanning became available and for the purposes of defining a complete response, a CT scan of the abdomen and chest on the same day showed no evidence of any disease anywhere. A bone scan on the 18th April 1988 was also normal. He was the only patient to show a complete response of the 26 patients in this Phase II study. The patient continued his follow up on an annual basis — mostly from clinical interest and possibly patient dependence — until it was finally agreed in May 2006 when he was 69 years old that he would be discharged from the clinic with no evidence of disease. This was 20 years since diagnosis. To show that life is never fair, however, in November 2007 he was admitted acutely with severe upper left quadrant pain and an urgent CT showed evidence of small bowel obstruction. He underwent a laparotomy and division of adhesions and made a good recovery. A follow-up CT carried out at the beginning of 2008 shows that he continues to have no evidence of disease in his chest or abdomen.
Discussion Adjuvant therapy for patients presenting with a large primary and simultaneous metastases from
1875-9742/$ — see front matter © 2008 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2008.05.001
42
P. Whelan
renal cancer has been tried for many years in many settings. There have always been anecdotal tales of complete responses following the removal of the primary, although the best literature suggests that this happens within the order of 0.6%. We know from later experience in the MRC trial, when Interferon as a new agent was compared with progesterone, that progesterone showed no specific benefit to patients. Why this case is important in my own practice is that this spectacular response, which may or may not have been due to the combination of surgery and medroxyprogesterone or may have just been a once in a lifetime spontaneous remission, made me more determined to put these sporadic responses into some sense and therefore to remain a constant contributor to Phase II trials of adjuvant therapy of patients with metastasis from renal cancer. Such trials have borne fruit in that we now know from a combined analysis of two carefully constructed studies of Interferon plus nephrectomy versus Interferon alone, one from the EORTC and one from the South West Oncology Group, that a definite and persistent survival benefit was obtained in undertaking radical surgery in the presence of metastases [1]. This confirmed my overt prejudice that surgery can be delivered to a standard fashion, it can therefore be assessed in a trial and especially as part of multi-modality therapy for cancer, and such trials can produce valid re-producible and sustainable outcomes that are of benefit to our patients. All
the single institution, personal surgical series in the world have not contributed one wit, the sense and science that this particular paper has given.
Conclusion This particular case was a surgical challenge which any self respecting thirty something would undertake. The lesson I believe I learnt was to realise that the favourable outcome was not due to my spectacular and unique ability in renal tumour ablation but, having carried out competent cytoreductive surgery, the biology of the metastases which fortunately proved sensitive and favourable to involution. It was essential that a continuing research for effective systemic treatment combined with primary surgery was undertaken and although the responses unfortunately still remain modest overall, the two prospective trials, in my view, confirm the need for well conducted prospective randomized trials with surgery. The necessary part of the multi-modality treatment for a cancer.
Reference [1] Flanigan RC, Mickisch G, Sylvester R, et al. Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis. J Urol 2004;171:1071—6.
Available online at www.sciencedirect.com