The goals of complete resection are primarily cure followed by improvement in disease-free survival, progression-free survival, and overall survival. Equally importantly, there are possibilities of delaying or discontinuing targeted therapy and palliating symptoms if they are present.
The incidence of primary metastatic RCC has been in decline. In Sweden, the rate was 23% in 2005 and was reduced to 15% in 2010. However, there has been a concomitant decrease in the use of cytoreductive nephrectomy (CN) above the reduced incidence level coinciding with the introduction of targeted therapy.
Selecting patients for CN remains challenging. In general, younger patients with lower tumor volume and good performance status are optimal candidates. In these patients, CN may reduce time to targeted therapy by a median of 14 months. It is important to realize that patients with IMDC scores (MSKCC) greater than 4 are not likely to benefit from CN.
Two randomized trials are soon to be reported. CARMENA is a non-inferiority trial that randomizes patients with metastatic RCC to nephrectomy + sunitinib versus sunitinib alone. SURTIME has recently closed accrual and randomizes patients to nephrectomy followed by sunitinib versus sunitinib followed by nephrectomy. Initial results are expected at the upcoming ESMO meeting.
With regard to metastatectomy, there are no prospective randomized data to guide treatment decisions. The major flaw of most data thus far is selection bias. Generally, patients who undergo metastatectomy are healthier and their tumors have favorable relative to those who did not have surgery. With recent data suggesting initial active surveillance is an option for select patients with metastatic RCC (Plimack et al., Lancet Oncology 2016), the optimal role of metatastectomy remains to be defined.
Presented by: Axel Bex
Written by: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA
at the #EAU17 -March 24-28, 2017- London, England