Renal Cell Carcinoma; Surgery For Recurrent And Metastatic Renal Cell Cancer: Has The Role Changed In The Face Of New Systemic Agents?
Dr. Uzzo stated that the natural history of RCC requires that patients are stratified by risk for both systemic and surgical treatment.
Dr. Wood reviewed the indications and outcomes for cytoreductive nephrectomy (CRN). He argued that this approach palliates local symptoms and that the primary tumor rarely responds to systemic therapy. The latter is the main reason that cytoreductive nephrectomy became important. Most patients who had CRN proceed to systemic therapy (93% in one trial). When they compared older and younger patients, the older patients undergoing CRN had a 21% mortality rate compared to 1% in the younger group. Regarding T4 disease, resecting multiple organs invariably had a poor outcome. Those with nodal metastasis did worse whether they had other metastasis or not. A node dissection did not improve survival unless there was clinical evidence of LN metastasis. In those with stage N+M1 disease, a node dissection improved survival by 8 months. The exception was those with sarcomatoid RCC, who all did poorly.
He cited that the primary tumor in the TARGET trial using Sorafenib did not show complete resolution of the primary tumor (in the few who did not have a CRN). He stated that nephrectomy after systemic therapy may have potentially more difficult surgery and wound healing. Ultimately CRN benefits selected patients, he said.
Dr. Uzzo led a panel comprised of Drs. Wood, Arie Belldegrun, UCLA, Robert Figlin, City of Hope Cancer Center, and Nicholas Vogelzang, Nevada Cancer Institute. The first case was cT3bN0M1. Dr. Figlin would do a brain MRI and use renal tissue from the CRN to characterize histologic type. A biopsy was not favored by the panel. Dr. Belldegrun was not in favor of neoadjuvant systemic therapy, rather do a CRN and give adjuvant therapy. Surgery after TKI inhibitors may relate to a higher risk of wound complications. Despite being N0, Dr. Belldegrun would do a node dissection while Dr. Wood would not. Dr. Uzzo pointed out that young patient age would likely influence a surgeon doing a CRN. The patient did undergo a laparoscopic CRN for a pT3bN0M1 clear cell RCC. Most felt that the decision to do the surgery laparoscopically should be left up to the surgeon. A post-op headache in the discussed case led to a brain MRI and a metastatic lesion was found. Having known this pre-op, Dr. Wood would not have performed the CRN. Treatment of this brain lesion was discussed. Stereotactic surgery and whole brain radiotherapy was given followed by systemic Sunitinib. 5 months later he had visceral recurrence and Dr. Vogelzang favored high-dose IL-2 over switching to Sorafinib.
Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS
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Carcinom cu celule renale; intervenþii chirurgicale pentru recurente ºi cancer metastatic cu celule renale: are rolul de a fost schimbat în faþa unor noi agenþi sistemice? - Renal Cell Carcinoma; Surgery For Recurrent And Metastatic Renal Cell Cancer: Has The Role Changed In The Face Of New Systemic Agents? - articole medicale engleza - startsanatate