Prognostic Impact of Initial Management Strategies in Metachronous Oligometastatic Renal Cell Carcinoma: A Real-World Evidence.

BACKGROUND: Patients with oligometastatic recurrence after primary renal surgery for renal cell carcinoma (RCC) have multiple treatment options, including systemic therapy (ST), active surveillance (AS), or metastasis-directed therapy (MDT), such as metastasectomy (MET) and radiotherapy (RT). However, comparative real-world evidence is limited, and it is unclear which strategy provides more survival benefit. METHODS: We retrospectively evaluated patients with metachronous oligometastatic RCC treated at a tertiary academic centre between 2006 and 2023. Patients received AS, MET, RT, or ST. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier methods. Multivariable Cox regression assessed associations between treatment and outcomes, adjusting for age, ECOG performance status, and number of lesions. RESULTS: Among 142 patients, 21% underwent AS, 34% MET, 21% RT, and 24% ST. After a median follow-up of 19.7 months, 75% experienced subsequent progression; subsequent treatments comprised AS (2%), MET (10%), RT (10%), and ST (77%). Median time to subsequent progression was 14, 18, 21, and 12 months for AS, MET, RT, and ST, respectively; corresponding 2-year PFS estimates were 28%, 41%, 45%, and 7.2%. Estimated 5-year OS was 57%, 73%, 57%, and 48%, respectively. On multivariable analysis, OS and PFS did not differ significantly among RT, MET, and ST. CONCLUSIONS: In metachronous oligometastatic RCC, initial treatment modality is not independently associated with PFS or OS after accounting for disease burden and clinical factors. These findings support the value of multidisciplinary discussion and the integration of individualized, biology-guided strategies that favor AS or MDTs to defer ST without compromising survival in well-selected patients.