Editing Metastatic Kidney Cancer (section)

==== Guideline Recommendations ====

* '''Trials do not address whether there is a benefit to CN after targeted therapy (sunitnib alone vs. sunitnib followed by CN)'''
* '''Several retrospective observational studies have identified a significant survival advantage in favour of CN for patients treated with targeted therapies'''

===== 2019 CUA Cytoreductive Nephrectomy Consensus Statement =====
* '''Decisions regarding CN should ideally be made in a multidisciplinary setting'''
* '''In patients with metastatic RCC, offer upfront CN''' followed by metastases-directed therapy, a period of surveillance, or systemic therapy '''in patients with (5):'''
*# '''Good performance status (Eastern Cooperative Oncology Group [ECOG] ≤1 or Karnofsky performance status (KPS) ≥80%)'''
*# '''Resectable primary tumour'''
*# '''Limited burden of metastatic disease'''
*# '''Minimal symptoms related to metastases'''
*# '''No active CNS metastases'''
* '''CN should not be done in patients with (2):'''
*# '''Rapidly progressing disease'''
*# '''Limited life expectancy'''
* Also consider patient’s age, general health status, and competing health risks when making decisions regarding the role of CN, as these are surrogate markers of OS
* '''Patients with mRCC but without characteristics listed above (i.e. not optimal candidate but no contraindications) should be offered initial treatment with systemic therapy with consideration of CN given to those with a significant clinical response'''
* '''Patients with non-clear-cell mRCC should be offered CN with similar considerations to those with clear-cell mRCC.'''
** The majority of data on CN pertain to patients with clear-cell histology, and thus whether CN provides a survival advantage for appropriately selected patients with non-clear-cell mRCC remains uncertain.
*** The 2 CN trials performed in the IFN-era mentioned above did not include information on histological subtypes
*** '''CARMENA and SURTIME excluded patients with non-clear-cell mRCC.'''
*** Limited observational data do suggest that CN may provide a survival advantage in patients with non-clear mRCC.
* '''Histologic diagnosis before treatment'''
** '''In patients receiving initial systemic therapy, histologic diagnosis SHOULD be obtained''' (biopsy of the primary lesion or a metastatic deposit) '''prior to initiation of therapy to guide systemic treatment'''
*** Systemic therapy will depend on the histologic subtype
** '''For patients receiving upfront CN, histologic diagnosis MAY BE PERFORMED IF the results of the biopsy will influence management'''
*** As noted above, CN appears to play a role in treating non-clear-cell mRCC, and appropriately selected patients can thus proceed directly to CN without a biopsy. However, if a non-RCC histology is questioned (e.g., imaging characteristics suggestive of urothelial carcinoma, lymphoma, etc.), a biopsy prior to CN should be performed, as the results may significantly alter the patient’s subsequent management.
* In the setting of oligometastatic disease, the link between primary and secondary masses cannot be assumed reliably. Limited data are available with regards to the role of percutaneous biopsy in this setting.
* CN can be performed through both minimally invasive and open surgical approaches at the discretion of the treating surgeon
** Adrenal-sparing is appropriate when there is no evidence of tumour invasion or metastatic spread and when technically feasible.
* '''Lymphadenectomy'''
** '''In patients with mRCC undergoing CN who do not have clinical evidence of nodal disease, retroperitoneal LND is not recommended.'''
** '''Surgical resection of clinically positive lymph nodes may be considered at the time of CN after weighing the potential for increased surgical morbidity and the uncertain clinical benefit.'''
*** '''LND does not appear to provide a survival advantage in mRCC patients.''' Similar findings have been noted in patients with and without clinically positive lymph nodes