Treatment of kidney cancer with metastases to the lungs

Kidney cancer ranks 8th in the structure of oncological morbidity in men and 12th in women in Ukraine. The situation is aggravated by the fact that at the time of initial treatment, 32-34% of patients have distant metastases (Ml), and in 30-40% of radically operated patients they occur at a later date. Thus, more than half of patients who have kidney cancer face the problem of distant metastases.

Most often, distant metastases of kidney cancer occur in the lungs. Patients with this pathology can be divided into 2 groups:

• patients with lung metastases detected during initial consultation (Ml);
• patients who underwent radical nephrectomy and whose lung metastases developed later (MO).

Historically, the treatment of metastatic kidney cancer has gone through several stages: the first stage involved only surgical removal of metastases; the second, starting in the mid-1970s, involved combined treatment, including surgery and subsequent immunotherapy; the third stage, since 2006, has involved combined treatment, which often involves surgery and targeted therapy (TT).

The use of targeted therapy has shown sufficient effectiveness, which has prompted some specialists to question the advisability of performing surgical interventions for this group of patients. However, most researchers still believe that a combination of surgical treatment and targeted therapy gives the best results.

In the clinic of the Donetsk Regional Antitumor Center, 16 patients were operated on for kidney cancer, who also underwent surgical removal of pulmonary metastases. In 6 of them, metastases in the lungs were detected at the time of diagnosis (Ml), and in 10 (MO) metastases in the lungs appeared some time after radical treatment.

Surgical treatment of lung metastases in M1

Of the 6 patients with Ml 5, palliative nephrectomy with lung resection (lobectomy, tumor removal, atypical resection) was performed, and 1 patient only lung resection (lobectomy) without palliative nephrectomy. One patient from this group, who underwent palliative nephrectomy, died in the postoperative period after lobectomy due to pulmonary embolism. Two patients died much later due to tumor progression, having lived an average of 19.9 months. Two patients who underwent nephrectomy and lung resection are alive to the present time and lived, respectively, 2.0 and 44.5 months.

Special mention should be made of the treatment of 2 patients with primary metastatic kidney cancer (Ml).

Patient A., born in 1946, was diagnosed with calcinoma of the right kidney T3N0M1 (pulmonum) in 2003. Palliative nephrectomy was performed. Histological conclusion: poorly differentiated renal cell carcinoma, lymphoid tissue hyperplasia in the lymph nodes. Then the patient underwent 2 courses of immunotherapy with reaferon at 6 million units. However, negative dynamics were noted against the background of immunotherapy and over the next 5 years he underwent 5 operations to remove metastases in both lungs (4 atypical resections and 1 lobectomy). Currently, the patient is alive with no signs of continued disease.

It should be noted that in case of metastases in both lungs, performing several operations (cytoreductive nephrectomy and successive thoracotomies from different sides with removal of metastases in the lungs) is not without reason considered a long and painful process. With the advent and development of thoracoscopic operations, one-stage bilateral thoracoscopic metastasectomies have become widely used. At the same time, our experience shows that with careful visual and palpatory intraoperative revision, it is sometimes possible to detect a significantly larger number of small metastases than with CT. Detection of such metastases also seems difficult with videothoracoscopy.

Surgical treatment of lung metastases in M0

Ten patients with kidney cancer (RC) underwent lung resections (tumor enucleation, atypical resection, lobectomy, pleuropulmonectomy) in the clinic for metastases that appeared some time after radical treatment, ranging from 6 to 242 months (20.2 years). On average, metastases were detected after 88.8 months (7.4 years).

Of the 10 patients in this group, 8 are alive and 2 died from tumor progression. The average life expectancy of the 2 deceased is 34.2 months from the time of diagnosis and 11 months after lung resection.

In 8 currently living patients, the time after lung resection ranged from 12 days to 993 days (32.7 months), with an average of 17.7 months.

Five patients underwent lung resections 2 and 3 times with an interval of 1-5 months. Of these, three are alive and lived an average of 24.3 months (2.0 years) after the first lung resection.

The average survival time of patients diagnosed with kidney cancer (RC), who received radical treatment and who subsequently developed lung metastases but did not undergo lung resection, was 18.4 months after nephrectomy (9 patients died due to tumor progression).

Of particular note is the case of patient K., who underwent radical nephrectomy for right kidney carcinoma T3N0M0. Three years later, metastases were found in both lungs. Multiple metastases were removed from both lungs one by one. One year later, the metastasis in the maxillary sinus was removed. He is currently receiving targeted therapy; there is no data on the continuation of the disease.

In addition to surgical treatment, all patients received immunotherapy, mainly intron-A in doses of 6-9 million units every other day, the course dose from 30 to 60 million units. The number of courses was from 3 to 5. Three patients received targeted therapy with Nexavar. We did not observe any severe complications associated with the use of immunotherapy and targeted therapy. At the same time, a significant drawback of conservative therapy is the lack of prognostic factors for its effectiveness.

As a result of the treatment and long-term observation, the following conclusions can be drawn.

In the presence of metastases of kidney cancer to the lungs (Ml), palliative nephrectomy and surgical removal of pulmonary metastases can not only prolong the life of patients, but also cure some of them.

If kidney cancer metastasizes to the lungs, multiple surgeries are justified.

In the presence of metastases in both lungs, performing one-stage bilateral thoracoscopic operations reduces the number of operations and improves the quality of life of patients.

The use of targeted therapy, and when this is not possible, immunotherapy, can improve the results of surgical treatment.

Assoc. Prof. A. G. Kudryashov, Prof. A. Yu. Popovich, PhD in Medicine Yu. V. Ostapenko, R. S. Chistyakov. Treatment of kidney cancer with metastases to the lungs // International Medical Journal - No. 4 - 2012