Background: Renal Cell Carcinoma (RCC) is resistant to most
systemic treatments (chemotherapy, radiotherapy, hormonal therapy)
having limited response to immunotherapy. Better results have been
achieved with anti-angiogenic treatment, indicated in metastatic disease.
Nevertheless, surgery remains the only potentially curative treatment. In
metastatic disease, complete metastasectomy improves the prognosis,
and surgery should be evaluated despite improved results of newer
systemic treatments. One of the commonest sites of synchronous or
metachronous RCC metastases is the lung. In the majority of patients
with pulmonary metastatic disease, metastases occur within 5 years after
initial nephrectomy. We present 2 very rare cases of surgical treatment of
late multiple unilateral pulmonary metastases of clear cell RCC (ccRCC).
Patients and methods: A 77 year old woman with history of
nephrectomy for ccRCC (15 years ago) and mastectomy for breast cancer
(13 years ago), underwent complete metastasectomy (wedged resections)
through a video-assisted right mini-thoracotomy. A 66 year old man with
history of nephrectomy for ccRCC (18 years ago) underwent complete
metastasectomy (right upper and middle bilobectomy and right lower
lobe nodule wedged resection) through a right anterolateral thoracotomy.
In both patients pulmonary nodules were revealed on thoracic
imaging during investigation of other diseases. Both patients had good
performance status, absence of enlarged mediastinal lymph-nodes, pleural
infiltration and extrapulmonary disease. Histology revealed ccRCC
metastases in 2 and 6 pulmonary nodules (respectively).
Results: The resection was deemed complete in both patients, who had
uneventful postoperative courses, were discharged home on the 3rd, and
4th postoperative day and remain alive and well 1-year, and 5-months
after metastasectomy (respectively).
Conclusions: The 5-year survival after RCC pulmonary metastasectomy
varied between 21-83%. Good prognostic factors identified were:
complete resection, absence of: mediastinal lymph-nodes, pleural
infiltration, and extrapulmonary disease at metastasectomy, absence of
positive lymph-nodes at initial nephrectomy, lower number and size,
solitary (vs. multiple), metachronous (vs. synchronous) metastases,
higher disease free interval. There are very few reports of very late lung
metastasectomy and the long-term results are lacking. Nevertheless, complete metastasectomy performed in selected patients with resectable
disease and good clinical status appears associated with low postoperative
morbidity and mortality, and satisfactory short/medium-term results.