AUA 2018: 3 Articles Last Year that Changed My Practice
1. Motzer et al.1 – Updated analysis of the S-TRAC data, comparing adjuvant sunitinib against placebo for patients with high-risk localized clear cell RCC. In this publication, they completed an exploratory sub-group analysis of the original cohort. Metastatic disease development in the sunitinib arm was less (31.4% vs. 39.9%). Adjuvant sunitinib improved disease-free survival (DFS) vs. placebo (HR 0.76, p =0.03). Benefit seen in all subgroups. Median OS not reached – data not yet mature.
- However, conflicting results in other trials have been widely reported (ASSURE, PROTECT, ATLAS)
- Despite that, adjuvant sunitinib has been FDA-approved for clear cell RCC – the first of its kind!
- Guideline recommendations have now adapted to this – recent NCCN 2018 guidelines actually suggest adjuvant sunitinib as an alternative to a clinical trial for stage II or III ccRCC s/p nephrectomy. However, a clinical trial is still preferred treatment.
- His take-home point: in patients ineligible for trial (nuances inclusion criteria), at least we now have an option!
2. Spaliviero et al.2 – in this prospective, randomized, placebo-controlled double-blind study, the authors tested the impact of intra-operative 12.5 gm IV mannitol on postoperative renal function in patients with pre-op eGFR > 45. Despite very mild differences in the cohorts, there was no difference in renal function or complications!
- Limitations: low-dose mannitol (less than usual 25 gm dose), excluded patients with solitary kidney or abnormal renal function
- Therefore, results primarily applicable to patients with normal baseline renal function
- Take-home point: can stop giving mannitol for partial nephrectomy – especially in those with normal baseline function.
3. Wu et al.3 – ~4200 patients underwent renal cancer surgery, and the authors assessed the impact of chronic kidney disease (either surgical or medical) in outcomes. There were 3 cohorts – no CKD (pre- or post-op), CKD-S [surgical CKD] (normal pre-op but abnormal post-op), and CKD-M (CKD due to medical etiologies – baseline and post-op GFR abnormal). CKD status significantly impacts risk of non-RCC related deaths – CKD-M patients did the worst, but CKD-S patients with GFR < 45 did worse than patients with CKD-S and GFR > 45 and patients with no CKD.
- Take-home: Patients who developed surgical CKD represent a heterogeneous population. Patients with CKD-S and reduced new baseline GFR < 45 have compromised survival. Therefore, these are the patients that should push for nephron-sparing procedures.
Presented by: Ithaar Derweesh, MD, University of California San Diego School of Medicine
References:
1. Motzer RJ, Ravaud A, Patard JJ, Pandha HS, George DJ, Patel A, Chang YH, Escudier B, Donskov F, Magheli A, Carteni G, Laguerre B, Tomczak P, Breza J, Gerletti P, Lechuga M, Lin X, Casey M, Serfass L, Pantuck AJ, Staehler M. Adjuvant Sunitinib for High-risk Renal Cell Carcinoma After Nephrectomy: Subgroup Analyses and Updated Overall Survival Results. Eur Urol. 2018 Jan;73(1):62-68. doi: 10.1016/j.eururo.2017.09.008. Epub 2017 Sep 28.
2. Spaliviero M, Power NE, Murray KS, Sjoberg DD, Benfante NE, Bernstein ML, Wren J, Russo P, Coleman JA. Intravenous Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function: A Double-blind, Clinically-integrated, Randomized Trial. Eur Urol. 2018 Jan;73(1):53-59. doi: 10.1016/j.eururo.2017.07.038. Epub 2017 Aug 16.
3. Wu J, Suk-Ouichai C, Dong W, Antonio EC, Derweesh IH, Lane BR, Demirjian S, Li J, Campbell SC. Analysis of survival for patients with chronic kidney disease primarily related to renal cancer surgery. BJU Int. 2018 Jan;121(1):93-100. doi: 10.1111/bju.13994. Epub 2017 Sep 10.
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, | twitter: @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA