Introduction: Surgical Approaches in mRCC

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When applicable, surgical approaches constitute an effective frontline approach to treatment. Cytoreductive nephrectomy, says Sumanta Kumar Pal, MD, is indicated in individuals with metastatic RCC who present with pain, excessive bleeding, or paraneoplastic syndromes. Pal adds that he may also recommend the procedure in the absence of these indications.

Complications, such as wound dehiscence and perforations, could complicate the use of targeted therapies following surgery, Saby George, MD, comments. Comorbidities, such as brain metastases or cardiovascular disease, may increase surgical risk. In these individuals, Pal states he may initially treat with targeted therapy rather than operate, but such decisions should be made on an individual basis.

Post-surgical treatment approaches have not yet demonstrated efficacy in clinical trials for patients with RCC. The randomized phase III ASSURE trial compared 1 year of adjuvant sunitinib, sorafenib, or placebo in patients with localized RCC. Outcomes from this analysis did not demonstrate an improvement in disease-free survival with adjuvant therapy compared with placebo. As a result of these findings, adjuvant therapy should not be considered standard of care, notes Pal.

Another key lesson that came out of the ASSURE trial was that patients in the adjuvant setting weren’t able to tolerate the same doses of drug as they are in the setting of metastatic disease, Pal notes. Future trials will likely examine the predictive value of certain biomarkers in the adjuvant settings.

Numerous new agents have received approval for metastatic renal cell carcinoma (RCC) over the past several years, with several agents approved as first-, second- and third-line therapies. Current guidelines remain vague on which therapy to utilized, with recommendations for sequential treatment using single agents, along with a long-term treatment plan that considers efficacy, safety, and quality of life, explains Robert A. Figlin, MD.