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5 mei 2017: Bron: The Journal of Urology Jan. 2017 Volume 197

Wanneer bij patienten met uitgezaaide nierkanker (meestal uitgezaaid in omringende lymfklieren) de uitzaaiingen operatief worden verwijderd dan stijgen de kansen om te overleven met enkele jaren in vergelijking met als de uitzaaiingen niet worden verwijderd. Uit een meta analyse van 8 studies met totaal 2,267 patiënten met nierkanker kwam als resultaat dat de levensverwachting van gemiddeld 8 maanden tot 2 jaar bij de patiënten uit de groep die geen operatie kreeg, steeg naar 3 tot 12 jaar bij de patiënten waarbij de uitzaaiingen wel operatief waren verwijderd. En in die laatste groep bleken mensen ook echt genezen te zijn van uitgezaaide nierkanker.

nierkanker uitgezaaid

Source: http://www.cancer.net/cancer-types/kidney-cancer/stages

Hoofdonderzoeker Bradley Leibovich, MD, een uroloog werkzaam in de Mayo Clinic zegt dat minder dan de helft van de patiënten, waarvan de uitzaaiingen werden verwijderd uiteindelijk toch kwamen te overlijden. Dit is een enorme verbetering, ook omdat met een operatie patienten dus bljkbaar genezen terwijl met medicijnen / chemokuren zelden een patiënt met uitgezaaide nierkanker ook echt geneest.

Leibovich: “Eerdere onderzoeken konden geen uitsluitsel geven over de effectiviteit van operatie, ondanks dat het bewijs ervoor wel aanwezig was. Door onze analyse van voorgaande onderzoeken zijn wij in staat gebleken het bewijs te leveren.”

Nierkanker kan op zich wel goed behandeld worden met medicijnen / chemotherapie. Maar dit onderzoek toont aan volgens dr. Leibovich dat de effectiviteit van behandelingen met medicijnen alleen geldt voor die patiënten die geen volledige verwijdering van de uitzaaiingen hebben gehad.
Bovendien verbetert de levensduur wel met medicijnen maar geneest het de patiënten niet.

Dr. Leibovich stelt: “Als medicijnen maar voor een beperkte tijd effectief werken terwijl operatie de overlevingskans aanzienlijk vergroot, dan zouden meer patiënten moeten overwegen om voor een operatie te kiezen.”

In een vervolgstudie wordt onderzocht of een combinatie van operatie en behandeling met medicijnen de kans op overleving en genezing nog meer kan verhogen.

Hier de 8 studies die in deze meta analyse zijn betrokken: (tekst gaat verder onder grafiek)

Characteristics of the 8 included studies

ReferencesStudy IntervalMedian Pt AgeMedian Mos FollowupHistology (% clear cell)Study SizeMedian Mos OSNo. Organ Sites with Metastases (%)% Systemic Therapy Received
No. CMNo. No CMCMNo CMCMNo CM
Alt et al14 1976–2006 63 33.6 90.20 125 762 48 15.6 1 (48), 2 or More (52) Yes Yes
45.60
Eggener et al15 1989–2007 61.7 Not applicable 80 40 89 Pooled median OS 30 Not applicable Not applicable Not applicable
Kavolius et al16 1980–1993 58 Not applicable Not applicable 141 137 45 17 (no surgery), 20 (incomplete resection) 1 (55.8), 2 or More (44.2) Yes Yes
12
Kwak et al17 1990–2004 60 Not applicable 85.70 21 41 36.5 8.4 1 (41.9), 2 or More (58.1) Not applicable Not applicable
Meimarakis et al18 1986–2006 59.5 Not applicable 94.00 175 27 43.2 12.4 (R1 resection), 15.1 (R2 resection) 1 (lung) (100) Yes Yes
28
Naito et al19 1988–2009 61 34.3 91.80 357 168 Pooled median OS 80.1 1 (54.1), 2 or More (45.9) Yes Yes
74.10
Staehler et al20 1995–2006 58 26 88 68 20 142 27 1 (liver) (100) Yes Yes
81
Yu et al21 2004–2013 57 45 93.80 31 65 52 22 (no surgery), 16 (incomplete resection) 1 (63.5), 2 or More (36.5) Yes Yes
75

Supplementary Appendix 2 (http://jurology.com/) summarizes the Cox multivariable models for each study, with 4 inclusive of some component of performance status (Karnofsky or ECOG).

Kernpunten uit de meta analyse

  • “Patients who had surgery to remove metastases were about half as likely to have died from their metastatic disease at every point in time after diagnosis,” said researchers.
  • Total life expectancy for patients whose metastases weren't surgically removed was between 8 months and just over 2 years, but that jumped to 3 to 12 years for those who had the surgery.

Op de vraag of met de introductie van nieuwe medicijnen voor nierkanker de resultaten uit deze studie nu nog geldig zijn antwoordt dr. Leibovich het volgende en ik vertaal dit bewust niet om geen afbreuk te doen aan de uitspraak van dr. Leibovich:

Since the majority of the data analyzed in this study were published, immunotherapies and other drug therapies for kidney cancer have advanced considerably. The U.S. Food and Drug Administration approved the first drug for kidney cancer treatment in 1992, but there are more than 10 today, and most were approved in the past decade, according to the National Cancer Institute.

“Now that we have some better drugs for treating these patients, does our conclusion still hold true? We suspect that it will,” said Dr. Leibovich. “In people who haven't had complete removal of the metastases, drug therapy seems to benefit. But in patients who have that surgery, drug therapy doesn't seem to make a difference.”

Het volledige studierapport: Outcomes Following Complete Surgical Metastasectomy for Patients with Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis is gratis n te zien.

Hier het abstract van deze studie:

Complete surgical metastasectomy for metastatic renal cell carcinoma is associated with improved survival compared with incomplete surgical metastasectomy based on meta-analysis of observational data. Consideration should be given to performing complete surgical metastasectomy, when technically feasible, in patients with metastatic renal cell carcinoma who are surgical candidates.

January 2017Volume 197, Issue 1, Pages 44–49 

DOI: http://dx.doi.org/10.1016/j.juro.2016.07.079

Outcomes Following Complete Surgical Metastasectomy for Patients with Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Harras B. Zaid
,
William P. Parker
,
Nida S. Safdar
,
Boris Gershman
,
Patricia J. Erwin
,
M. Hassan Murad
,
Stephen A. Boorjian
,
Brian A. Costello
,
R. Houston Thompson
,
Bradley C. Leibovich'Correspondence information about the author Bradley C. Leibovich


Purpose

The benefit of complete surgical metastasectomy for patients with metastatic renal cell carcinoma remains controversial due to limited outcome data. We performed a systematic review and meta-analysis to determine whether complete surgical metastasectomy confers a survival benefit compared to incomplete or no metastasectomy for patients with metastatic renal cell carcinoma.

Materials and Methods

Ovid Embase®, MEDLINE®, Cochrane and Scopus® databases were searched for studies evaluating complete surgical metastasectomy for metastatic renal cell carcinoma through January 19, 2016. Only comparative studies reporting adjusted hazard ratios (aHRs) for all cause mortality of incomplete surgical metastasectomy vs complete surgical metastasectomy were included in the analysis. Generic inverse variance with random effects models was used to determine the pooled aHR. Risk of bias was assessed with the Newcastle-Ottawa Scale.

Results

Eight published cohort studies with a low or moderate potential for bias were included in the final analysis. The studies reported on a total of 2,267 patients (958 undergoing complete surgical metastasectomy and 1,309 incomplete surgical metastasectomy). Median overall survival ranged between 36.5 and 142 months for those undergoing complete surgical metastasectomy, compared to 8.4 to 27 months for incomplete surgical metastasectomy. Complete surgical metastasectomy was associated with a reduced risk of all cause mortality compared with incomplete surgical metastasectomy (pooled aHR 2.37, 95% CI 2.03–2.87, p <0.001), with low heterogeneity (I2 = 0%). Complete surgical metastasectomy remained independently associated with a reduction in mortality across a priori subgroup and sensitivity analyses, and regardless of whether we adjusted for performance status.

Conclusions

Complete surgical metastasectomy for metastatic renal cell carcinoma is associated with improved survival compared with incomplete surgical metastasectomy based on meta-analysis of observational data. Consideration should be given to performing complete surgical metastasectomy, when technically feasible, in patients with metastatic renal cell carcinoma who are surgical candidates.

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No direct or indirect commercial incentive associated with publishing this article.

The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number.

Supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NIH.


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