Beyond the Abstract - Downsizing a thrombus of advanced renal cell carcinoma in a presurgical setting with sorafenib, by Hirokazu Takeda, MD

BERKELEY, CA (UroToday.com) - In our recent journal article, we report on our experience with two patients with multiple pulmonary metastases of renal cell carcinoma (RCC) who achieved complete disappearance, based on CT scan, of pulmonary metastases three years after initiation of presurgical targeted therapy with VEGF-TKI and salvage therapy with cytokines.

"In order to optimize presurgical targeted therapeutic benefits in patients with mRCC, it is important to carefully consider the characteristics and parameters relevant to each individual patient."

Presurgical targeted therapy rarely produces either a partial (PR) or complete (CR) response, and has thus been regarded as providing limited benefit. Therefore, resection of renal cancer after presurgical targeted therapy is important, and a method of salvage therapy (including cytokine therapy) must be established. This is of particular importance in Japan, where the response rate of patients with pulmonary metastasis of RCC has exceeded 40% following treatment with cytokines. Presurgical targeted therapy may thus prove to be one of the components of combined modality therapy.

Presurgical targeted therapy with VEGF-TKI was effective for inferior vena cava thrombus in our two cases. To achieve similar effectiveness with presurgical targeted therapy, treatment should be based mainly on the patient characteristics, especially

  • clear cell RCC,
  • low or intermediate MSKCC risk, and
  • the presence of pulmonary metastases.   

 At this time, there are three concerns with regard to the effectiveness of presurgical targeted therapy:

  1. Considering the recent study in New England Journal of Medicine which found genotype differences between the primary tumors and the metastatic tumors,[1] it is unclear whether separate treatments should be provided for the primary tumors and the residual and metastatic tumors, as we did in our two cases.
  2. There were no viable cells in the tumor in the surgical specimens of either of our two patients, suggesting some relationship to the achievement of a CR and subsequent cytokine therapy.
  3. The potential of presurgical targeted therapy to prevent intraoperative tumor cell spillage and subsequently improve prognosis, as well as providing visible treatment effects such as downsizing by preoperatively inhibiting VEGF activity in the tumor, has not been determined. 

In the era of systemic targeted therapy, both cytoreductive nephrectomy and presurgical targeted therapy are effective for mRCC. Moreover, presurgical targeted therapy may be beneficial to some patients who are candidates for cytoreductive nephrectomy.

In conclusion, we need to determine the effects of presurgical targeted therapy before initiation of targeted therapy. In order to optimize presurgical targeted therapeutic benefits in patients with mRCC, it is important to carefully consider the characteristics and parameters relevant to each individual patient.

Reference

  1. Gerlinger M, et al. N Engl J Med. 2012 Mar 8;366(10):883-92.

 


 Written by:

Hirokazu Takeda, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Tosei General Hospital
Seto, Japan 


 

Downsizing a thrombus of advanced renal cell carcinoma in a presurgical setting with sorafenib - Abstract

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