Multiple retrospective trials have also supportive cytoreductive nephrectomy for clear cell renal cell carcinomas in the targeted therapy era. However CARMENA, the only prospective trial of the group, did not demonstrated any significant benefit in overall survival for cytoreductive nephrectomy in the sunitinib era.
Subsequently, the panel had an exceptional discussion focused on two patients in order to place the data into clinical context. Case 1 was a 73 year old male with a right renal mass, mild fatigue and anemia, with an ECOG of 1 and a KPS of 90. He was otherwise healthy. He had bilateral pulmonary nodules on a CT chest, with no other metastatic sites on a brain MRI or bone scan. His MSKCC risk was calculated to be intermediate. Overwhelmingly, the panel agreed that this patient would be a good candidate for cytoreductive nephrectomy given his low metastatic burden, location of his metastasis, performance status, and risk criteria. They also felt that no data supports neoadjuvant systemic therapy in this setting and a renal mass biopsy is likely not necessary, as both clear cell history and non-clear histology are likely to benefit from cytoreductive surgery for this patient.
The second case discussed was a 65 year old male with 6 months of fatigue, a 55lb weight loss and dyspnea on exertion. He was found to have a left renal mass and a large left pulmonary/pleural metastasis on CT chest. His MRI brain and bone scan were also negative, but was calculated to be MSKCC poor risk. Here, the panel agreed that a biopsy would be helpful, as the patient should have systemic therapy and not cytoreductive nephrectomy. The biopsy returned as grade 4 clear cell and the patient was subsequently treated with nivolumab/ipilimumab and had a near complete response with a residual 8cm renal mass and some small pleural based lung nodules. His lab normalized and his performance status and MSKCC risk group improved. The panel then discussed the role for cytoreductive nephrectomy in this patient, however this is a highly nuanced, multidisciplinary decision with both medical and urologic oncology.
Future clinical trials are needed to better understand the role of cytoreductive nephrectomy given the expanding forefront of various systemic agents in metastatic RCC.
Presented By: Vitaly Margulis, MD
Panelists: Michael Blute, Sr, MD; Robert Figlin, MD; Robert C. Flanigan, MD, FACS; Arnaud Mejean, MD, PhD
Written by: David B. Cahn, DO, MBS, Fox Chase Cancer Center, Philadelphia, PA, @dbcahn, at the 19th Annual Meeting of the Society of Urologic Oncology (SUO), November
28-30, 2018 – Phoenix, Arizona