The Role of Cytoreductive Nephrectomy in Renal Cell Carcinoma with Sarcomatoid Histology: A Case Series and Review of the Literature

Abstract

Background: Renal cell carcinoma with sarcomatoid dedifferentiation represents a rare histological entity characterized by aggressive behavior, limited efficacy of tyrosine kinase inhibitors or mTOR inhibitors, and poor outcome. The immune checkpoint inhibitor therapy regimen combining ipilimumab with nivolumab represents a new standard of care for this patient population due to a hitherto unprecedented response rate and overall survival. On the other hand, the role of cytoreductive nephrectomy in metastatic renal cell carcinoma, in particular, with sarcomatoid histology, remains controversial.

Patient and methods: In the present case series, we report six patients with locally advanced or synchronous metastatic sarcomatoid renal cell carcinoma and intermediate or poor International Metastatic RCC Database Consortium (IMDC) risk score, five of whom were successfully subjected to cytoreductive nephrectomy.

Results: All six patients received the combination regimen of ipilimumab with nivolumab. Five of these patients underwent upfront cytoreductive nephrectomy followed by systemic treatment without any significant delay, with a durable treatment outcome. Notably, two patients with poor prognostic features achieved a long-term major partial response to therapy. We also performed a review of the literature on optimal treatment strategies for patients with sarcomatoid renal cell carcinoma.

Conclusion: Herein, we highlight the feasibility of performing cytoreductive nephrectomy in patients with intermediate/poor prognosis metastatic renal cell carcinoma with sarcomatoid dedifferentiation followed by immunotherapy with ipilimumab and nivolumab. To enhance the chances of immunotherapy success, cytoreductive nephrectomy should also be considered for patients presenting with a disease with adverse prognostic parameters.

Keywords: checkpoint inhibitors; cytoreductive nephrectomy; immunotherapy; renal cell carcinoma; sarcomatoid.

Figure 1

(a) Patient 1, pretreatment CT of the chest demonstrating lung metastases. (b) Patient 1, marked tumor reduction after the combination regimen of ipilimumab with nivolumab.

Figure 2

(a) Patient 2, pretreatment CT of the renal tumor. (b) Patient 2, pretreatment CT of the chest demonstrating lung metastases. (c) Patient 2, a large mass in the retroperitoneum. (d) Patient 2, major partial response after the combination regimen of ipilimumab with nivolumab.

Figure 2

(a) Patient 2, pretreatment CT of the renal tumor. (b) Patient 2, pretreatment CT of the chest demonstrating lung metastases. (c) Patient 2, a large mass in the retroperitoneum. (d) Patient 2, major partial response after the combination regimen of ipilimumab with nivolumab.