AUA 2019: Three Papers in the Past Year that Influenced My Practice in Renal Cancer

Chicago, IL (UroToday.com) Dr. Eggener gave a talk summarizing the three papers in the last year that made the most influence on him. The first paper discussed was on the natural history and management of complex renal cysts, by Chandrasekar T. et al.1 In this study, 336 complex renal cysts from 2001 to 2013 were analyzed with a median follow-up of 67 months. A total of 5/185 (3%) of Bosniak 2F cysts were upgraded to Bosniak 3, while 0% upgraded from Bosniak 3 to Bosniak 4. No pathologic T3 was shown following surgery, one cancer-specific death had occurred (in a VHL patient with bilateral tumors). One patient had developed metastases that were lost to follow-up and represented at the age of 87. Therefore, the metastasis-free survival was 99.1%, and the cancer-specific survival was 99.7%. Dr. Eggener concluded that since the publication of this paper, he operates much less on complex renal cysts.

The next paper discussed was the CARMENA trial by Mejean et al.,2 published in the New-England Journal of Medicine, and assessing sunitinib alone or after nephrectomy in metastatic renal cell carcinoma. In this study occurring between 2009 and 2017, 450 patients were enrolled (out of a target of 576 patients), after the trial had stopped due to slow accrual (likely because newer agents became available for first-line treatment). All patients had clear cell renal cell carcinoma (RCC) with adequate performance status (ECOG 0-1). All patients were suitable for nephrectomy (technically feasible) + eligible for sunitinib. A total of 56% of the patients had intermediate-risk disease, while 44% had poor risk disease. The patients were randomized 1:1 to either sunitinib alone or nephrectomy and then sunitinib. In the nephrectomy+sunitinib arm, 7% never received nephrectomy, and 17% never got sunitinib. In the sunitinib only arm, 5% never got sunitinib, and 17% got nephrectomy. The median follow-up was 51 months, and in the intention to treat analysis the median overall survival was 18.4 months for the sunitinib only group and 13.9 months for the sunitinib + nephrectomy arm, with a hazard ratio of 0.89 (95% CI 0.7-1.1). No advantage was seen in the progression-free survival and in the intermediate risk only group, and per-protocol analysis. However, grade 3-4 toxicity was lower in the nephrectomy+sunitinib arm. Dr. Eggener concluded that for intermediate/poor risk metastatic clear cell RCC tumors initial cytoreductive nephrectomy should have a limited role. The exceptions to that statement include the presence of local symptoms that can be palliated, limited metastatic burden, and candidates for metastasectomy or stereotactic body radiation therapy (SBRT).

The last paper discussed assessed the role of lymphadenectomy in radical nephrectomy by Gershman et al.3 This was a multicenter analysis assessing high-risk patients. A total of 2722 patients from the Mayo clinic and San-Rafaelle center (Milan) were analyzed. Overall, 45% of the patients underwent lymphadenectomy, with 9% having clinically N+, and 6% having pathologically N+. The median follow-up was 9.6 years, and a propensity score adjustment was prepared with inverse probability re-weighting. The results showed that lymphadenectomy was not associated with lower metastasis-free, cancer-specific, or all-cause mortality rates. Even when performing various sensitivity analysis, no advantage was seen for the lymphadenectomy. Dr. Eggener gave his take on this paper and stated that he does not perform lymphadenectomy for clinically node-negative disease, and less likely to perform lymphadenectomy for equivocal nodes, but might consider performing lymphadenectomy for a clinically node-positive disease but acknowledges that this is unlikely to help the patient.

Dr. Eggener concluded his talk with a single slide showing other meaningful papers that he could not discuss due to lack of timing (Table 1).

Table 1- Other additional meaningful papers in Renal Cancer:

AUA2019_meaningful_papers.png


Presented by: Scott Eggener, MD, Urologist, University of Chicago Medicine, Chicago, Illinois

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References:
  1. Chandrasekar T. et al. "Natural History of Complex Renal Cysts: Clinical Evidence Supporting Active Surveillance," The Journal of Urology, 2018 Mar;199(3):633-640. doi: 10.1016/j.juro.2017.09.078
  2. Mejean et al. "Sunitinib Alone or after Nephrectomy in Metastatic Renal-Cell Carcinoma," The New England Journal of Medicine, 2018; 379:417-427
    DOI: 10.1056/NEJMoa1803675
  3. Gershman et al. "Radical Nephrectomy with or without Lymph Node Dissection for High Risk Nonmetastatic Renal Cell Carcinoma: A Multi-Institutional Analysis," The Journal of Urology, 2018 May;199(5):1143-1148. doi: 10.1016/j.juro.2017.11.114.