Should radical nephrectomy be performed in the face of surgically incurable disease?

Cytoreductive nephrectomy in metastatic renal cell carcinoma

Metastatic renal cell carcinoma is associated with a poor prognosis and a median survival time of only 6-12 months. However, the emergence of immunotherapies has rekindled interest in cytoreductive nephrectomy as a therapeutic option. Phase III randomized trials have demonstrated that cytoreductive nephrectomy significantly improves overall survival in selected patients with metastatic renal cell carcinoma treated with interferon immunotherapy. While cytokine-based immunotherapy may be considered the standard systemic therapy, clinical studies are ongoing to develop molecular biomarkers and new therapies with improved efficacy and tolerability. With further advances in our understanding of the pathogenesis, behavior and molecular biology of renal cell carcinoma, cytoreductive nephrectomy, in combination with molecular targeted therapies, may become the new standard of care for patients with metastatic renal cell carcinoma.

Neoadjuvant sunitinib for surgically complex advanced renal cell cancer of doubtful resectability: initial experience with downsizing to reconsider cytoreductive surgery

OBJECTIVE

To evaluate neoadjuvant sunitinib in patients with synchronous metastatic renal cell cancer (mRCC) to downsize surgically complex tumours and reconsider cytoreductive surgery.

PATIENTS AND METHODS

Retrospective analysis of ten consecutive mRCC patients treated with sunitinib in an expanded access program who presented with surgically complex primary tumours or bulky locoregional metastases. Surgery-limiting tumour sites (SLTSs) were defined as primary or retroperitoneal lesions with direct invasion of adjacent organs or encasement of vital structures on imaging. Patients received sunitinib 50 mg/day for 4 weeks on and 2 weeks off to be followed by cytoreductive surgery after downsizing and individual reassessment. Response was measured according to Response Evaluation Criteria in Solid Tumours (RECIST).

RESULTS

Six out of ten SLTSs revealed a reduction of tumour size with a median of 14% according to RECIST. None of the ten SLTSs had a partial response (PR), whilst at distant metastatic sites one complete remission and two PRs occurred. Downsizing of SLTSs appeared most prominent in the first 2-4 months, which resulted in reconsidering cytoreductive nephrectomy in three patients. These three tumours invaded the liver on imaging and were reduced by 11, 18 and 20%.

CONCLUSIONS

In this patient group with mRCC and surgically complex primary tumours or locoregional metastases, downsizing of SLTSs by neoadjuvant sunitinib was limited. Cytoreductive surgery was reconsidered in three patients. Given the overall reduction in tumour burden by sunitinib alone, further investigation to define the role of cytoreductive surgery is warranted.

Sunitinib for treatment of advanced renal cell cancer: primary tumor response

PURPOSE

Nephrectomy before immunotherapy in patients with metastatic renal cell cancer (RCC) will improve patient outcome. In addition, the primary tumor is known to be refractory to cytokines. Sunitinib is now approved for treatment of advanced RCC, but its effect on the primary tumor has yet to be reported.

EXPERIMENTAL DESIGN

All patients treated with sunitinib for advanced RCC without prior nephrectomy were reviewed and sequential computed tomography scans were evaluated for response in the primary tumor as well as metastases according to Response Evaluation Criteria in Solid Tumors. Volumes of primary tumors and central necrotic areas were measured with the perimeter method.

RESULTS

Computed tomography scans were available for evaluation of response in 17 of 22 patients with a primary tumor in situ (1 patient with two primaries). According to Response Evaluation Criteria in Solid Tumors, 4 patients had a partial response, 12 had stable disease, and 1 had progressive disease. The one-dimensional longest diameter of the primary tumor correlated with the volumetric measurements both at baseline and at the time of evaluation of response. Excluding the patient with progressive disease, the median volume reduction was 31% associated with a median increase in the volume of necrosis of 39%. Three patients underwent nephrectomy and tumors showed extensive necrotic areas next to small fields of vital tumor cells.

CONCLUSIONS

Sunitinib can induce a significant reduction in volume of primary renal cell tumors. Further trials need to address the role of nephrectomy in advanced RCC patients on sunitinib treatment.

Status of pretreatment evaluation, treatment and follow-up regimens for renal cell carcinoma in the Nordic countries

OBJECTIVE

One prerequisite for performing multicentre studies is that the clinical handling of the patients must be uniform. We therefore evaluated possible differences in pretreatment evaluation, surgical treatment and follow-up regimes between the Nordic countries and between the different departments that performed nephrectomy due to renal cell carcinoma.

MATERIAL AND METHODS

A questionnaire comprising 21 different questions was sent to all hospitals in the five Nordic countries performing nephrectomy. The questionnaires were returned by 195/226 (86%) departments.

RESULTS

In total, 24% of the departments performed fewer than five tumour nephrectomies per year. The main differences were as follows. I.v. pyelography was never used in Finland in clinics with urologists while preoperative CT scans were performed by most departments and in most countries. Cytology/biopsy examinations were never used in urological clinics in Finland and Iceland in contrast to 31% of urological clinics in Denmark. In Finland, 69% of the departments performed nephrectomy in patients with multiple distant metastases, compared to only 15% in the other Nordic countries. Follow-up after nephrectomy was done in 38% of Danish departments and in 96% of departments in the other Nordic countries.

CONCLUSION

There were evident differences between the urological/surgical departments in the five Nordic countries, especially concerning radiological evaluation, treatment of patients with metastases and postoperative follow-up.

Modulation of mitogen-activated protein kinases by 6-nitro-7-hydroxycoumarin mediates apoptosis in renal carcinoma cells

6-Nitro-7-hydroxycoumarin has previously been shown to be a selective anti-proliferative agent capable of activating p38, stress-activated protein kinase (SAPK) and mitogen-activated protein (MAP) kinase in the human renal cell carcinoma cell line, A-498. Here, the role of p38 MAP kinase was further investigated in relation to its participation in 6-nitro-7-hydroxycoumarin induced apoptosis. 6-Nitro-7-hydroxycoumarin was shown to alter cell cycle progression, leading to the appearance of a sub-G(1) peak, containing hypodiploid DNA, accompanied by increases in both poly(ADP-ribose)polymerase cleavage and decreased expression of cyclin D1. Drug treatment also lead to a rise in the expression in the cyclin-dependent kinase inhibitor, p21(WAF1/CIP1), and the appearance of inter-nucleosomal DNA cleavage and morphological changes, consistent with apoptotic cell death. Using a p38 MAP kinase inhibitor, SB203580, caused expression of p21(WAF1/CIP1) to be suppressed and both cleaved poly(ADP-ribose)polymerase and the numbers of apoptotic cells were decreased. In summary, this study shows the participation of p38 MAP kinase in 6-nitro-7-hydroxycoumarin induced apoptosis of A-498 cells and suggests that targeting of p38 may represent a novel mechanism to inhibit renal cell carcinoma and that coumarin type drugs require further investigation as potential anticancer agents directed against renal cell carcinoma.

The timing of immunotherapy and nephrectomy in multimodality treatment of metastatic renal cell carcinoma

Multimodality treatment of metastatic renal cell carcinoma with immunotherapy and cytoreductive surgery is controversial. Especially the benefit of removing asymptomatic primary tumors in synchronous metastatic renal cell cancer has been debated since several non-randomized, retrospective studies revealed an improved response to immunotherapy and prolonged survival following initial nephrectomy. Two recent randomized prospective trials both demonstrated a prolonged survival in those who were randomly assigned to undergo nephrectomy of the primary tumor prior to treatment with interferon alfa-2b than in those who were assigned to undergo treatment with interferon alfa-2b alone. In these trials the survival benefit was limited and strongly influenced by overall performance score. The timing of immunotherapy, either as neoadjuvant (prior to nephrectomy) or adjuvant treatment (following nephrectomy) in the multimodality approach of synchronous metastatic renal cell carcinoma remains controversial. Selection of patients, the possible mechanisms underlying the survival advantage of the combination of nephrectomy and immunotherapy, and the timing of the treatment modalities are discussed herein.

Renal cancer: molecular mechanisms and newer therapeutic options

Renal cell carcinomas account for 80-85% of all primary renal neoplasms. Recent identification of VHL, c-met and TSC as candidate genes mutated in various types of renal carcinomas has greatly enhanced our understanding of the pathogenesis of renal carcinomas and has provided novel therapeutic options for patients with renal cancer. Furthermore, developments in angiogenesis and in tumor immunology have given us additional treatment modalities for cancer patients, especially those with renal cancer. This review highlights the genetic abnormalities seen in renal cell carcinomas and reviews current and future therapeutic options.