UrologySchool.com

Metastatic Kidney Cancer: Difference between revisions

← Older edit
Visual
No edit summary
 
(10 intermediate revisions by the same user not shown)
Line 33: Line 33:
** '''<span style="color:#ff0000">Poor-risk: ≥3 risk factors</span>'''; median survival 9 months
** '''<span style="color:#ff0000">Poor-risk: ≥3 risk factors</span>'''; median survival 9 months


== Surgical management of metastatic renal cell carcinoma ==
== Surgical Management of Metastatic Renal Cell Carcinoma ==


=== Cytoreductive nephrectomy (CN) ===
=== Cytoreductive Nephrectomy (CN) ===


* '''The role of CN before systemic therapy (IFN-''' '''α) has been extensively studied in the era of cytokine therapy'''
==== Cytokine Therapy (IFN-'''α)''' ====
** '''SWOG 8949'''
*Meta-analysis of 2 trials (SWOG 8949 and EORTC 30947) found significantly improved OS by 5.8 months in CN followed by IFN- α group (13.6 months CN IFN α2b vs. 7.8 months IFN α2b, p=0.02) vs. IFN- α alone
*** Randomized 249 patients with metastatic RCC of any histology to IFN-α vs. CN followed by IFN- α
 
*** Results:
===== <span style="color:#ff00ff">SWOG 8949 =====
**** OS was improved, though not significantly, in the CN group (median OS 11 months CN + IFN α2b vs. 8 months IFN α2b, p=0.05)
* Randomized 249 patients with metastatic RCC of any histology to IFN-α vs. CN followed by IFN- α
** '''EORTC 30947'''
* Results:
*** Randomized 85 patients with metastatic RCC of any histology to IFN-α vs. CN followed by IFN-α
** OS was improved, though not significantly, in the CN group (median OS 11 months CN + IFN α2b vs. 8 months IFN α2b, p=0.05)
*** Results:
 
**** OS was significantly improved in the CN group (median OS 17 months CN + IFN-α vs. 7 months IFN-α, p=0.03)
===== <span style="color:#ff00ff">EORTC 30947 =====
** Meta-analysis of the 2 trials found '''significant improved OS in CN group by 5.8 months''' (13.6 months CN IFN α2b vs. 7.8 months IFN α2b, p=0.02)
* Randomized 85 patients with metastatic RCC of any histology to IFN-α vs. CN followed by IFN-α
* '''The introduction of effective targeted therapy has questioned the role of CN in the modern era'''
* Results:
** '''CARMENA''' (Clinical Trial to Assess the Importance of Nephrectomy)
** OS was significantly improved in the CN group (median OS 17 months CN + IFN-α vs. 7 months IFN-α, p=0.03)
*** '''Population: 452 patients with metastatic ccRCC'''
 
**** 44% had poor-risk disease, 56% had intermediate-risk
==== Targeted Therapy ====
***** '''Trial does not apply to patients with favourable-risk'''
*'''The introduction of effective targeted therapy questioned the role of CN in the modern era'''
*** '''Randomized to CN followed by sunitnib vs. sunitnib alone'''
 
*** '''Primary outcome: OS'''
===== CN followed by Targeted Therapy vs. Targeted Therapy alone =====
*** '''Median follow-up 50.2 months'''
 
*** '''Results'''
====== <span style="color:#ff00ff">CARMENA</span> (Clinical Trial to Assess the Importance of Nephrectomy) ======
**** '''OS: sunitinib alone was non-inferior to CN followed by sunitinib''' (HR 0.89; 95% CI 0.71–1.10)
* '''Population: 452 patients with metastatic ccRCC'''
**** '''No significant difference PFS or response to treatment'''
** 44% had poor-risk disease, 56% had intermediate-risk
*** Méjean, Arnaud, et al. "Sunitinib alone or after nephrectomy in metastatic renal-cell carcinoma." New England Journal of Medicine 379.5 (2018): 417-427.
*** '''Trial does not apply to patients with favourable-risk'''
** '''In patients with mRCC who are being considered for CN, the optimal timing relative to the initiation of systemic therapy also remains controversial.'''
* '''<span style="color:#ff0000">Randomized to CN followed by sunitnib vs. sunitnib alone'''
*** '''Advantages of initiating systemic therapy prior to CN:'''
* '''Primary outcome: OS'''
***# '''May provide symptomatic control and disease stabilization or regression for patients with a large tumour burden'''
* '''Median follow-up 50.2 months'''
***# '''May allow the identification of patients not likely to benefit from CN; specifically, patients who progress rapidly on systemic therapy have a poor prognosis and are unlikely to derive a survival advantage by undergoing CN'''
* '''<span style="color:#ff0000">Results'''
***# '''Decreases the size of the primary tumour in a proportion of patients'''
** '''<span style="color:#ff0000">OS: sunitinib alone was non-inferior to CN followed by sunitinib</span>''' (HR 0.89; 95% CI 0.71–1.10)
***#* The median decrease in size is estimated to be 7-32% and the clinical impact of this is questionable
** '''No significant difference PFS or response to treatment'''
***#* Tumour may also increase in size or complexity during systemic therapy, reducing the feasibility of resection
* [https://pubmed.ncbi.nlm.nih.gov/29860937/ Méjean, Arnaud, et al. "Sunitinib alone or after nephrectomy in metastatic renal-cell carcinoma." New England Journal of Medicine 379.5 (2018): 417-427.]
*** '''Advantages of upfront CN (3):'''
 
***# '''Palliating symptoms related to the primary tumour'''
===== CN before vs. after Targeted Therapy =====
***# '''Eliminating a source of secondary metastases'''
 
***# '''Improving host immune dysfunction'''
* In patients with mRCC who are being considered for CN, the optimal timing relative to the initiation of systemic therapy also remains controversial.
*** '''SURTIME''' (Immediate Surgery or Surgery After sunitinib Malate in Treating Patients With Metastatic Kidney Cancer) '''TIMING of CN'''
 
**** '''99 patients with metastatic ccRCC'''
* '''Advantages of initiating systemic therapy prior to CN:'''
**** '''Randomized to upfront CN followed by sunitnib vs. upfront sunitinib followed by CN (deferred CN)'''
*# '''May provide symptomatic control and disease stabilization or regression for patients with a large tumour burden'''
***** '''Investigated optimal timing of CN relative to initiation of systemic therapy'''
*# '''May allow the identification of patients not likely to benefit from CN; specifically, patients who progress rapidly on systemic therapy have a poor prognosis and are unlikely to derive a survival advantage by undergoing CN'''
**** '''Primary endpoint: disease progression at 28 weeks'''
*# '''Decreases the size of the primary tumour in a proportion of patients'''
**** '''Results:'''
*#* The median decrease in size is estimated to be 7-32% and the clinical impact of this is questionable
***** '''No difference in disease progression''' (42.0% vs. 42.9%, respectively at 28 weeks of follow-up; p>0.99) '''between upfront vs. deferred CN'''
*#* Tumour may also increase in size or complexity during systemic therapy, reducing the feasibility of resection
***** '''OS improved in deferred CN group (median OS 32.4 vs. 15 months; p=0.034)'''
* '''Advantages of upfront CN (3):'''
****** '''Difficult to interpret this result due to discordance with the disease progression results'''
*# '''Palliating symptoms related to the primary tumour'''
**** Bex, Axel, et al. "Comparison of immediate vs deferred cytoreductive nephrectomy in patients with synchronous metastatic renal cell carcinoma receiving sunitinib: the SURTIME randomized clinical trial." JAMA oncology 5.2 (2019): 164-170.
*# '''Eliminating a source of secondary metastases'''
** '''Several retrospective observational studies have identified a significant survival advantage in favour of CN for patients treated with targeted therapies'''
*# '''Improving host immune dysfunction'''
* '''As per the 2019 CUA Cytoreductive Nephrectomy Consensus Statement:'''
 
** '''Decisions regarding CN should ideally be made in a multidisciplinary setting'''
====== <span style="color:#ff00ff">SURTIME ======
** '''In patients with metastatic RCC, offer upfront CN''' followed by metastases-directed therapy, a period of surveillance, or systemic therapy '''in patients with (5):'''
* '''Population: 99 patients with metastatic ccRCC'''
**# '''Good performance status (Eastern Cooperative Oncology Group [ECOG] ≤1 or Karnofsky performance status (KPS) ≥80%)'''
* '''<span style="color:#ff0000">Randomized to upfront CN followed by sunitnib vs. upfront sunitinib followed by CN (deferred CN)'''
**# '''Resectable primary tumour'''
** '''Investigated optimal timing of CN relative to initiation of systemic therapy'''
**# '''Limited burden of metastatic disease'''
* '''Primary endpoint: disease progression at 28 weeks'''
**# '''Minimal symptoms related to metastases'''
* '''<span style="color:#ff0000">Results:'''
**# '''No active CNS metastases'''
** '''<span style="color:#ff0000">No difference in disease progression</span>''' (42.0% vs. 42.9%, respectively at 28 weeks of follow-up; p>0.99) '''between upfront vs. deferred CN'''
** '''CN should not be done in patients with (2):'''
** '''OS improved in deferred CN group (median OS 32.4 vs. 15 months; p=0.034)'''
**# '''Rapidly progressing disease'''
*** '''Difficult to interpret this result due to discordance with the disease progression results'''
**# '''Limited life expectancy'''
* [https://pubmed.ncbi.nlm.nih.gov/30543350/ Bex, Axel, et al. "Comparison of immediate vs deferred cytoreductive nephrectomy in patients with synchronous metastatic renal cell carcinoma receiving sunitinib: the SURTIME randomized clinical trial." JAMA oncology 5.2 (2019): 164-170.]
** 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'''
==== Guideline Recommendations ====
** '''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.
* '''Trials do not address whether there is a benefit to CN after targeted therapy (sunitnib alone vs. sunitnib followed by CN)'''
**** The 2 CN trials performed in the IFN-era mentioned above did not include information on histological subtypes
* '''Several retrospective observational studies have identified a significant survival advantage in favour of CN for patients treated with targeted therapies'''
**** '''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.
===== 2019 CUA Cytoreductive Nephrectomy Consensus Statement =====
** '''Histologic diagnosis before treatment'''
* '''Decisions regarding CN should ideally be made in a multidisciplinary setting'''
*** '''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'''
* '''In patients with metastatic RCC, offer upfront CN''' followed by metastases-directed therapy, a period of surveillance, or systemic therapy '''in patients with (5):'''
**** Systemic therapy will depend on the histologic subtype
*# '''Good performance status (Eastern Cooperative Oncology Group [ECOG] ≤1 or Karnofsky performance status (KPS) ≥80%)'''
*** '''For patients receiving upfront CN, histologic diagnosis MAY BE PERFORMED IF the results of the biopsy will influence management'''
*# '''Resectable primary tumour'''
**** 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.
*# '''Limited burden of metastatic disease'''
** 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.
*# '''Minimal symptoms related to metastases'''
** CN can be performed through both minimally invasive and open surgical approaches at the discretion of the treating surgeon
*# '''No active CNS metastases'''
*** Adrenal-sparing is appropriate when there is no evidence of tumour invasion or metastatic spread and when technically feasible.
* '''CN should not be done in patients with (2):'''
** '''Lymphadenectomy'''
*# '''Rapidly progressing disease'''
*** '''In patients with mRCC undergoing CN who do not have clinical evidence of nodal disease, retroperitoneal LND is not recommended.'''
*# '''Limited life expectancy'''
*** '''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.'''
* 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
**** '''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
* '''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


=== Metastatectomy for distant recurrence ===
=== Metastatectomy for distant recurrence ===
Retrieved from "https://urologyschool.com/wikiuro/index.php/Metastatic_Kidney_Cancer"