Cytoreductive nephrectomy in the era of targeted therapies: a review

Abstract

In the pre-targeted therapy era, palliative cytoreductive nephrectomy combined with cytokine immunotherapy was the standard treatment protocol for the management of metastatic renal cell carcinoma. The introduction of targeted therapies has improved response rates, median survival and overall prognosis when compared to immunotherapy. The role of cytoreductive nephrectomy in providing an independent survival advantage when used alongside immunotherapy has been demonstrated by two randomised controlled trials. However, with the new shift in improved treatment outcomes from cytokine immunotherapy to targeted therapies, the continuing role of cytoreductive nephrectomy as a viable surgical treatment method remains controversial.

Hospital volume and short‐term outcomes after cytoreductive nephrectomy

“…It is implicit in our high‐risk patient population with mRCC that the causes of death within the 90‐day window were likely attributed to either surgery‐accounted adverse events or rapid progression of metastatic disease. As previous studies have reported, not all patients are likely to benefit from surgery, and patient selection is essential when considering CN for mRCC . The high 90‐day mortality rate suggests that there might be still room for improvement in CN patient selection in the real‐world practice.…”

“…surgery, and patient selection is essential when considering CN for mRCC. 3,4,6 The high 90-day mortality rate suggests that there might be still room for improvement in CN patient selection in the real-world practice. The difference in baseline patient characteristics between our two hospital volume groups also suggests that high-volume groups might be more selective in the patient selection.…”

“…In the United States, kidney cancer (mostly RCC) was reported as 6th most common cancer among males and 10th most common cancer among females, with approximately a total of 63 990 cases diagnosed in 2017 . Despite a significant stage migration with earlier diagnosis, 20‐30% of the patients still present with metastatic RCC (mRCC) at the time of diagnosis . Cytoreductive nephrectomy (CN) is recommended as part of the standard of care for appropriately selected patients with metastatic disease .…”

A retrospective comparative study of progression-free survival and overall survival between metachronous and synchronous metastatic renal cell carcinoma in intermediate- or poor-risk patients treated with VEGF-targeted therapy

“…The decreased tumor burden that occurred with the disappearance of the primary tumor lesion provided better prognostic outcomes with systemic TT. However, good performance status and a primary tumor accounting for >75% of the overall tumor burden without any metastatic lesions in the central nervous system and liver did not yield a better prognostic outcome for every mRCC patient after cytoreductive nephrectomy, which resulted in a low rate of nephrectomy in the targeted era [ 28 , 29 ].…”

The value of a cross‐discipline team‐based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single‐institution experience

“…Although the presence of metastases confers worse survival, the role of surgery in patients with advanced RCC has evolved and in select patients, plays an important role in modern management algorithms, even in the era of targeted therapy [23][24][25]. Proponents of cytoreductive surgery in RCC have cited such benefits as reduction in the burden of disease, removal of potential new metastatic sources, spontaneous tumor regression, reversal of host immune dysfunction, and symptom palliation to support the practice [26][27][28][29][30]. In addition,…”