Treatment of kidney cancer with lung metastases

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

The 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 by primary treatment (Ml);
• patients who underwent radical nephrectomy, and metastases to the lungs appeared later (MO).

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

The use of targeted therapy has shown sufficient effectiveness, which led some experts to question the advisability of performing surgical interventions for this group of patients. However, most researchers still believe that the 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, which also performed surgical removal of pulmonary metastases. In 6 of them, lung metastases were detected at the time of diagnosis (Ml), and in 10 (MO) metastases to the lungs appeared some time after radical treatment.

Surgical treatment of metastases in the lung with M1

Of 6 patients with Ml 5, palliative nephrectomy with lung resection (lobectomy, tumor removal, atypical resection) and 1 patient only lung resection (lobectomy) without pallial nephrectomy was performed. 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 on the background of the progression of the tumor process, having lived an average of 19.9 months. Two patients who underwent nephrectomy and lung resection, are alive to the present day and lived, respectively, 2.0 and 44.5 months.

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

Patient A., born in 1946, was diagnosed with calcification of the right kidney T3N0M1 (pulmonum) in 2003. A palliative nephrectomy was performed. Histological conclusion: low-grade renal cell carcinoma, in lymph nodes - hyperplasia of lymphoid tissue. Then the patient underwent 2 courses of immunotherapy with reaferon for 6 million units. However, against the backdrop of immunotherapy, negative dynamics were noted and during 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 without signs of continuation of the disease.

It should be noted that with metastases in both lungs, several operations (cytoreductive nephrectomy and successive thoracotomy from different sides with the removal of metastases to the lungs) are not without reason a long and painful process. With the advent and development of thoracoscopic operations, one-stage two-way thoracoscopic metastasectomies were widely used. At the same time, our experience shows that with a careful visual and palpatory intraoperative revision, it is sometimes possible to detect a much larger number of small metastases than with CT. The detection of such metastases seems difficult even with videotorakoscopy.

Surgical treatment of metastases in the lung with M0

Ten patients with kidney cancer (MO) underwent lung resection (tumor enucleation, atypical resection, lobectomy, pleuropulmonectomy) at the clinic for metastases that appeared some time after radical treatment at 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, 2 died of the progression of the tumor process. The average life expectancy of 2 deaths is from the moment of diagnosis of 34.2 months and 11 months after resection of the lung.

At 8 people living now after a resection of the lungs has passed from 12 days to 993 days (32.7 months), an average of 17.7 months.

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

The average life expectancy of patients with cancer of the kidney (MO) who received radical treatment, who subsequently developed lung metastases but did not undergo lung resection, was 18.4 months after nephrectomy (9 patients died due to tumor progression).

Particular mention should be made of the case of the treatment of the patient K., who suffered a radical nephrectomy for the right kidney carcinoma T3N0M0. After 3 years, the patient showed metastases in both lungs. The removal of multiple metastases from both lungs was performed alternately. After 1 year, metastasis was removed into the maxillary sinus. Currently receives 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. A day, a course dose of 30 to 60 million units. The number of courses was from 3 to 5. Three patients received Nexavar targeted therapy. Severe complications associated with the use of immunotherapy and targeted therapy, we have not observed. 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 remote observation, the following conclusions can be drawn.

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

When there are metastases of kidney cancer in the lungs, multiple operations are justified.

In the presence of metastases in both lungs, simultaneous two-way thoracoscopic operations can reduce the number of operations and improve the quality of life of patients.

The use of targeted therapy, and if it is not possible - immunotherapy can improve the results of surgical treatment.

Assoc. A. G. Kudryashov, prof. A. Yu. Popovich, Cand. Honey. Nauk Yu. V. Ostapenko, r. S. Chistyakov. Treatment of kidney cancer with metastases in the lungs // International Medical Journal - №4 - 2012