Surgical Metastasectomy in Renal Cell Carcinoma: A Systematic Review

Context: The benefit of surgical metastasectomy (SM) for patients with metastatic renal cell carcinoma (mRCC) remains controversial because of the lack of high-level evidence on the role of SM in terms of survival benefit in the era of systemic therapy. Objective: To perform a systematic review of the literature on the role of SM in the treatment of mRCC and discuss key issues in the SM decision-making process. Evidence acquisition: A systematic search of the Embase and Medline databases was carried out and a systematic review of the role of SM in mRCC was performed. A total of 56 studies were finally included in the evidence synthesis. Evidence synthesis: All the studies included were retrospective and mostly noncomparative. Median overall survival (OS) ranged from 36 to 142 mo for those undergoing SM, compared to 8–27 mo for no SM. SM was associated with a lower risk of all-cause mortality compared to no SM (pooled adjusted hazard ratio 2.37, 95% confidence interval 2.03–2.87; p < 0.001). Morbidity and mortality were similar for SM and primary tumor surgery. The most important prognostic factor for OS was complete resection of metastases. Other prognostic factors included disease free-survival from nephrectomy, primary tumor features (T stage ≥3, high grade, sarcomatoid features, and pathological nodal status), the number of metastases, and performance status. Lung metastasectomy seemed to show the best survival benefit. Conclusions: Although no randomized clinical data are available, published studies support the role of SM in selected patients in the modern era. Complete SM allows sustained survival free of systemic treatment. Integration of SM and systemic therapy in a multimodal approach remains a valid option for some patients. Patient summary: Surgical resection of metastases originating from renal cell carcinoma may play a role in prolonging survival and avoiding systemic therapy when complete resection is achievable. This strategy is an option for selected patients with a limited number of metastases who still have good general health status. Surgical metastasectomy in renal cell carcinoma has potential benefits. It offers prolonged survival in a subgroup of patients with slowly growing disease and allows survival free from medical treatment, thus avoiding treatment-related toxicities. Complete resection is the primary goal in all patients. However, relief of metastases-related symptoms is also an indication for the procedure. Features identifying the best candidates for metastasectomy include achievable complete resection, good performance status, a long disease-free interval (from nephrectomy), and limited metastatic sites, ideally in the lungs. In all cases, the decision should be individualized and closely discussed within dedicated multidisciplinary cancer centers.