San Antonio, Texas USA (UroToday.com) Moderated by Dr. Boorjian, this panel sought to explore challenges related to the surgical management of advanced kidney cancer. First, the panel addressed how best to approach patients with a venous tumor thrombus.
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To the question of anticoagulation in patients with venous tumor thrombus, Dr. Leibovich offers anticoagulation during the interval between diagnosis and surgery to anyone with history of PE or DVT, those with complete IVC occlusion, those with bland thrombus, and those with lower extremity edema or impending occlusion. He advised against ever placing an inferior vena cava (IVC) filter as more harm than good is likely to ensue. Regarding neoadjuvant systemic therapy, Dr. Jonasch considers a pre-surgical systemic therapy or radiation approach in patients with unresectable or borderline resectable tumors. Dr. Margulis countered that only rarely has neoadjuvant therapy influenced his surgical approach. To the question of a minimally invasive versus an open approach, Dr. Desai prefers a robotic approach provided that there is adequate clearance (2cm) from the main hepatic veins and no thrombus in the main IVC tributaries. Further, he noted that obesity and bulky mesentery may be predictive of open conversion. In his mind, the volume of the tumor thrombus within the IVC is not the limiting factor for application of minimally invasive approach. Rather, he uses clearance from the main hepatic veins when making the decision on surgical approach. Dr. Leibovich vehemently disagrees. He is a supporter of minimally invasive approaches for freely mobile tumors. However, he strongly advocated for open surgery in cases of complete/impended IVC occlusion, contralateral renal vein involvement, and lower extremity edema.
The panel then addressed the challenges associated with selecting patients for cytoreductive nephrectomy (CN) versus systemic therapy along. Dr. Margulis bases his decision-making on the degree of debulking that can be provided and the patient’s performance status/overall comorbidities. In general, he would not offer CN to MSKCC poor risk patients. Dr. Jonasch prefers the “litmus test” approach. This consist of upfront systemic therapy followed by interval imaging. If there is no tumor growth for 6-9 months, patients are advised to move forward with cytoreduction. Most (~80%) of patients ultimately move forward to CN, but some of the “bad actors” are able to avoid a surgery which would have been of questionable benefit. Dr. Leibovich concurred with this approach and advocated CN in patients who are responders. The panelists agreed that for most TKIs, stopping therapy within a week of surgery and restarting therapy 2 weeks after surgery was an acceptable approach.
Finally, the question of lymphadenectomy at the time of surgery was discussed. Dr. Leibovich was a large proponent of extended lymphadenectomy for much of his career. However, a recent paper looking at the Mayo clinic demonstrated no benefit to lymphadenectomy regardless of how the data were considered (J Urol 2016, PMID: 27663461). Due to this evidence, he has changed his practice to only performing lymphadenectomy in the case of clinical lymph node involvement.
Moderator: Stephen A. Boorjian, MD
Panelists: Mihir M. Desai, MD, Eric Jonasch, MD, Bradley C. Leibovich, MD, and Vitaly Margulis, MD
Written By: Benjamin T. Ristau, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center
17th Annual Meeting of the Society of Urologic Oncology - November 30 -December 2, 2016 – San Antonio, Texas USA