AB 46. Lost in time pulmonary metastases of renal cell carcinoma: complete surgical resection of metachronous metastases, 18 and 15 years after nephrectomy

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.