A Urologic Perspective on Management of Localized and Metastatic RCC

Drs. Dutcher, Mourad, and Ennis have provided an excellent review of current and potential future treatments of renal cell carcinoma (RCC); we would like to highlight some salient points from a urologic perspective.

As the authors stated, the incidence of RCC is increasing, and the greatest increase in incidence is in masses smaller than 4 cm.[1] With the increased diagnosis of small renal masses (SRM), the paradigm for treatment has shifted from radical nephrectomy to nephron-sparing surgery (NSS), to better preserve renal function and avoid the morbidity of long-standing renal insufficiency. Recent and updated guidelines released by both the American Urological Association (AUA) and the European Association of Urology (EAU) state that the current standard-of-care treatment for an SRM is partial nephrectomy, in the appropriately selected patient. The type of partial nephrectomy-via an open, laparoscopic, or robot-assisted laparoscopic approach-is mainly determined by surgeon comfort and experience as well as by the clinical characteristics (size, location) of the renal mass in question.[2,3]

The authors also review other forms of NSS such as cyroablation (CA) and radiofrequency ablation (RFA). Both ablative therapies offer minimal morbidity in the treatment of SRMs, and the cited studies report promising results for cancer-free and recurrence-free survival. However, there are three important points to keep in mind when considering ablative treatment: 1) the studied follow-up period after treatment with ablative therapies is limited, 2) the local recurrence rate is higher with ablative therapy than with partial nephrectomy, and 3) under-treatment or treatment failure by either modality may require secondary treatments with an increased risk of complications.[2-4] Thus, the AUA and EAU state that use of CA and RFA should be considered options, not standards, in healthy patients with an SRM.[2,3]

Unfortunately, even though the incidence of SRMs is on the rise, a significant proportion of RCC patients are metastatic at presentation. Dutcher et al have nicely reviewed the literature regarding the advantages of cytoreductive nephrectomy (CRN) in the setting of immunotherapy, and they are correct in stating that the benefit of CRN in the era of targeted therapy is still unknown. The CARMENA trial (Clinical Trial to Assess the Importance of Nephrectomy, NCT00930033) is currently recruiting patients to answer this exact question. In the trial, patients are being randomized to CRN and sunitinib (Sutent) vs sunitinib alone, with overall survival as the primary endpoint. The trial is projected to finish recruiting in 2013 and should offer more information regarding use of CRN in the era of targeted therapy.

Although many therapeutic options exist for RCC, ultimately it will be the patient’s antecedent medical comorbidities and intense discussions with his or her surgeon and oncologist that will determine the best course of treatment. As surgical and medical technologies advance, it is critical to continue to conduct high-level-of-evidence studies into the treatment of RCC to maximize the prospect of cure while limiting morbidity.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst. 2006:98:1331-4.

2. Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol. 2009;182:1271-9.

3. Ljungberg B, Cowan NC, Hanbury DC, et al. EAU guidelines on renal cell carcinoma: the 2010 update. Eur Urol. 2010;58:398-406.

4. Van Poppel H, Becker F, Caddedu JA, et al. Treatment of localized renal cell carcinoma. Eur Urol. 2011;60:662-72.