SUO - AUA 2020 Summer Webcast: Three Papers in the Past Year that Have Changed My Practice: Kidney Cancer

(UroToday.com) The Society of Urologic Oncology (SUO) held a virtual meeting on Saturday, July 18, 2020 in place of the usual meeting held at the American Urological Association (AUA) annual meeting. This virtual meeting was divided into sessions on bladder cancer, kidney cancer, and prostate cancer. In the session on prostate cancer, Sarah Psutka, MD, presented three papers in kidney cancer which most significantly changed her practice in the past year.

Dr. Psutka first highlighted the 2019 update of the Bosniak classification for cystic renal masses.1 The goal of this stratification schema is to provide guidance on the underlying malignancy risk of these lesions. However, prior versions were limited by significant inter-reader variability and a reliance on computed tomography imaging as masses diagnosed based on ultrasound or magnetic resonance imaging were not considered.

The updated version included explicit analogous classifications for masses diagnosed based on computed tomography (CT) and based on magnetic resonance imaging (MRI).

Further, this updated guideline provided much more explicit guidance on specific definitions used to define characteristics necessary for classification. This was done in order to reduce inter-reader variability, which has previously been has high as 70%.


SUO-AUA2020_Psutka_1.png

This update more accurately addresses the underlying goal of the Bosniak classification to predict the likelihood of cancer by utilizing commonly used imaging with more detail and specific criteria for interpretation.

The second highlighted paper from Bhindi et al. assessed the role of cytoreductive nephrectomy in patients receiving sunitinib in the IMDC cohort.2  While there are limitation based on the observational design and immortal time bias, the authors demonstrated that patients who had deferred nephrectomy following initial sunitinib had better outcomes than those who received upfront surgery followed by sunitinib or sunitinib alone.

SUO-AUA2020_Psutka_2.png

Delayed cytoreduction also prolonged time to sunitinib failure.

Finally, she highlighted data from MD Anderson on patient selection for cytoreductive nephrectomy.3 Among a highly selected group of patients with a low burden of metastatic disease (70% of patients with a single site of disease), the authors examined granular pre-operative clinicopathologic and laboratory data to assess associations with all-cause mortality, adverse pathologic features, and perioperative outcomes. Among the 608 included patients, 115 had surgery alone, 187 received pre-operative systemic therapy, and 481 received post-operative systemic therapy (with a median of 45 days between surgery and systemic therapy start date).

The authors identified nine predictive factors, grouped as;

  1. burden of mRCC: retroperitoneal adenopathy, supradiaphragmatic adenopathy, bone metastasis, LDH >ULN, and cT4 disease
  2. patient response to disease: systemic symptoms at diagnosis, hemoglobin <LLN, albumin <LLN, and neutrophil to lymphocyte ration >4.

Risk of death, as well as other secondary outcomes, were proportional to the number of these risk factors.

SUO-AUA2020_Psutka_3.png

Dr. Psutka concluded that these data highlight the importance of patient selection among this already rigorously selected cohort. Further, it is feasible to initiate systemic therapy in a timely manner following surgery.

Presented by: Sarah Psutka, MD, Assistant Professor of Urology, Urologic Oncologist, University of Washington, Seattle Cancer Care Alliance, UW Medicine, Seattle, Washington, USA 

Written by: Christopher J.D. Wallis, MD, PhD, Urologic Oncology Fellow, Vanderbilt University Medical Center, Nashville, Tennessee, USA, Twitter: @WallisCJD, at the Society of Urologic Oncology (SUO) - American Urologic Association (AUA) 2020 Summer Webcast Program, July 18, 2020.

References:

  1. Silverman S, Pedrosa I, Ellis J, et al. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment. Radiology. 2019  292(2)
  2. Bhindi B, Graham J, Wells J, et al. Deferred Cytoreductive Nephrectomy in Patients with Newly Diagnosed Metastatic Renal Cell Carcinoma. Eur Uruol. 2020 Apr 30;S0302-2838(20)30301-8. 
  3. McIntosh A, Umbreit E, Holland L, et al. Optimizing patient selection for cytoreductive nephrectomy based on outcomes in the contemporary era of systemic therapy. Cancer. 2020 Jun 9. Online ahead of print. doi: 10.1002/cncr.32991
email news signup