Erik P. Castle, MD, professor of urology, Mayo Clinic, discusses minimally invasive surgical approaches in renal cell carcinoma (RCC).

Robotic surgery is used in any stage III or higher RCC or renal mass, as it allows surgeons to reconstruct the vena cava if there is caval thrombus and do an extensive lymphadenectomy. Although lymphadenectomy has not been shown to confer a significant survival advantage, it does help with staging, says Castle. The procedure also helps determine whether adjuvant therapy is necessary in patients with locally advanced disease. At Mayo Clinic, thoracic surgeons can perform a minimally invasive lung resection in a patient who has metastases on the ipsilateral side of the lung during cytoreductive nephrectomy, adds Castle.

In a patient who has a solitary kidney mass, with oligometastatic disease and a lesion that could be resected with partial nephrectomy, surgeons will perform partial cytoreductive nephrectomy, local disease resection, and potentially a metastasectomy. The goal of the procedure is to preserve the patient’s kidney function, so that they can receive systemic therapy. In addition to less aggressive surgical approaches, the field is going to move towards image guidance throughout surgery, concludes Castle.

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Erik P. Castle, MD, discusses minimally invasive surgical approaches in renal cell carcinoma.

Dr. Castle on Minimally Invasive Surgical Approaches in RCC

Erik P. Castle, MD, professor of urology, Mayo Clinic, discusses traditional imaging modalities and newer counterparts that are used to detect prostate cancer.

Unless a patient with high-risk prostate cancer has a life expectancy of less than 5 to 10 years, they’re likely to undergo treatment, Castle says. For those patients, standard imaging like CT scans and bone imaging are used. However, physicians are slowly transitioning from classic technetium-99 bone scans to sodium-fluoride PET imaging.

There are other PET imaging modalities such as prostate-specific membrane antigen PET; this has yet to be fully FDA approved. Choline C-11 PET is available at Mayo Clinic for patients who have been treated for high-risk prostate cancer and have had a biochemical recurrence. There’s also 18F-Fluciclovine PET/CT.

Using these imaging studies to help better identify patients who are going to benefit from combined therapy with androgen-deprivation therapy (ADT), and the sequence of radiation, surgery, and ADT will become prominent over the course of the next few years.

Dr. Castle on Staging Modalities for Men With High-Risk Prostate Cancer

Erik P. Castle, MD, professor of urology, Mayo Clinic, discusses the use of adjuvant versus early salvage therapy in patients with prostate cancer, citing his own preference for early salvage therapy.

Though there are data that demonstrate a survival benefit in adjuvant radiotherapy in post-prostatectomy patients with high-risk features such as stage III disease, positive margins, and positive lymph nodes, Castle prefers to observe his patients and give early salvage if necessary.

There are data that have yet to be fully analyzed in ongoing and accruing clinical trials comparing early salvage to adjuvant therapy. Many patients with high-risk features were followed until they were symptomatic in the open prostatectomy series. A large percentage of patients will not recur and won’t be at risk of dying, even though they have some of these high-risk features.

Though there is a role for adjuvant therapy, especially in patients who have a high risk for recurrence and young patients who are going to need trimodality therapy, Castle advocates monitoring patients very closely in a very tight schedule of prostate-specific antigen (PSA) testing, utilizing their time to recurrence, and their PSA kinetics to determine how aggressive to be with radiation.

Erik P. Castle, MD

Articles

Dr. Castle on Minimally Invasive Surgical Approaches in RCC

Dr. Castle on Staging Modalities for Men With High-Risk Prostate Cancer

Dr. Castle on Adjuvant Versus Early Salvage Therapy in Prostate Cancer