Are you for or against performing cytoreductive nephrectomy for patients with metastatic clear cell- renal cell carcinoma who are treated with VEGF-TKI therapy !
In the absence of evidence, one would like to listen to the opinions and have an idea on the current practice. Any supporting evidences are highly appreciated.
Supportive data for benefit of cytoreductive nephrectomy is only for treatment with cytokines. If the patient has a symptomatic primary ie pain, haematuria, or systemic symptoms then I would definitely recommend it prior to TKIs. Our surgeons will often do the nephectomy before they are referred an oncologist in the presence of metastatic disease.
Dear Desmond Yip.
Thank you so much for your comment. As you mentioned, the evidence for the survival benefit of cytoreductive nephrectomy is for patients who are treated with interferon following the nephrectomy. We generally do cytoreductive nephrectomy in our center for patients with symptoms related to the primary tumour, or for patients with bulky primary and limited metastases, however; this is without evidence, and this is why I raised this questions, because I wanted to see what is the practice in other centers, especially because this is an issue that we discuss commonly in our genitourinary multi-disciplinary clinic. Thank you again for your opinion.
Even in the absence of strong evidence most centers followed the same strategy. The decision in our center generally depends on patients performance status, the spread of distant disease and the presence of symptoms from the primary tumor. We offer nephrectomy to fit patients with bulky/symptomatic tumors and/or limited distant disease, targeting improvement of QOL and reduced total tumor volume. However it is not clear whether this policy is beneficial, excluding two points: improved QOL in pts with bulky/symptomatic tumors and psychological benefit for most of the patients when the primary is removed.
Dear Alexander,
Thank you so much for your answer. I totally agree with your comment.
The best therapy is still an immune therapy with an autologous tumor vaccine. see attached paper.
Dear Stephan Kiessig,
Thank you so much for the attached article. Interesting data ! However, my question is about patients with METASTATIC renal cell carcinoma who are treated with the novel targeted therapies, and the evidence that you provided suggests a benefit of immune therapy as an adjuvant therapeutic strategy following nephrectomy in patients with NON-METASTATIC renal cell carcinoma.
There is debate regarding the necessity of performing a cytoreductive nephrectomy in patients with metastatic renal cell carcinoma who are treated with VEGF-TKI therapy. The evidence supporting survival advantage for cytoreductive nephrectomy in the metastatic setting is evident only for patients treated with Interferone Alfa (based on two randomized trials).
In the absence of evidence supporting the benefit in patients treated with targeted therapy, it is wise to see the opinions and the current practice of experts in the field, and to see what is their opinion in that clinical setting and whether there are subgroups of patients (depending on the extent of metastasis, the bulk of the primary, the MSKCC risk category, or any other factors) that are likely to derive benefit. And this is the main reason why I added this question for discussion.
Please check the attached reference which discusses this controversial issue.
http://www.ncbi.nlm.nih.gov/pubmed/17255295
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