Presurgical therapy in metastatic renal cell carcinoma

New surgical horizons: the role of cytoreductive nephrectomy for metastatic kidney cancer

Renal cell carcinoma is the most lethal urologic malignancy. Up to 30% of patients with kidney cancer have metastatic disease and 30% of those treated for local or locally advanced disease will progress to metastases. Radical nephrectomy is the standard treatment for the management of nondisseminated kidney cancer, but the role of cytoreductive nephrectomy for patients with metastatic disease is controversial. In this paper, the rationale for cytoreductive nephrectomy is described and the currently available evidence for and against it is evaluated. The different approaches to defining prognostic factors to select which patients will benefit from cytoreductive nephrectomy will also be described. Finally, the role of cytoreductive nephrectomy in the era of new targeted therapies is discussed.

Molecular targeted therapy in advanced renal cell carcinoma: A review of its recent past and a glimpse into the near future

Renal cell carcinoma (RCC) is the most lethal of all urologic malignancies. Recent translational research in RCC has led to the discovery of a new class of therapeutics that specifically target important signaling molecules critical in the pathogenesis of the disease. It is now clear that these new molecular targeted agents have revolutionized the management of patients with metastatic RCC. However, the exact molecular mechanism accounting for their clinical effect is largely unknown and a significant proportion of patients with metastatic RCC do not respond to these therapeutics. This review presents the relevant background leading to the development of molecular targeted therapy for patients with advanced RCC and summarizes current management issues in particular relating to the emerging problem of treatment resistance and the need for clinical and laboratory biomarkers to predict treatment outcomes in these patients. In addition, this paper will also address surgical issues in the era of molecular targeted therapy including the role of cytoreductive surgery and surgical safety issues post-molecular therapy. Lastly, this review will also address the need to explore new molecular treatment targets in RCC and briefly present our work on one of the promising molecular targets - the type 1 insulin-like growth factor receptor (IGF1R), which may in the near future lead to the development of anti-IGF1R therapy for patients with advanced RCC.

Role of cytoreductive nephrectomy in renal cell carcinoma

Cytoreductive nephrectomy prior to cytokine therapy has a well-established role in the treatment of appropriately selected patients with metastatic renal cell carcinoma (RCC). Recent use of novel molecular targeted agents in the management of metastatic RCC has challenged the current dogma of treatment with regards to the necessity, patient selection for and timing of cytoreductive nephrectomy. Current evidence suggests that cytoreductive nephrectomy still plays an integral part in the multimodal paradigm of management for metastatic RCC. This review highlights the role of cytoreductive nephrectomy, and discusses controversial issues surrounding cytoreductive nephrectomy in the treatment of metastatic RCC, in the context of immunotherapy and also in the new era of targeted therapy. It also gives updates on the changing concepts of surgical approaches to cytoreductive nephrectomy in metastatic RCC.

Neoadjuvant (presurgical) therapy for renal cell carcinoma: a new treatment paradigm for locally advanced and metastatic disease

BACKGROUND

Although upfront cytoreductive nephrectomy followed by systemic therapy remains the standard of care for metastatic renal cell carcinoma, the addition of novel targeted therapy has prompted a reevaluation of this treatment paradigm. The authors reviewed their experience with neoadjuvant systemic therapy administered before cytoreductive surgery for metastatic, locally recurrent, or regionally advanced renal cell carcinoma.

METHODS

The authors compared patients treated with presurgical targeted therapy (with sunitinib, sorafenib, or bevacizumab) with a contemporary group that underwent up-front cytoreductive surgery.

RESULTS

The authors found no difference in any perioperative surgical parameters indicative of morbidity or mortality between the 2 groups. Laboratory models of renal cell carcinoma treated with systemic targeted therapy demonstrate specific protein expression profiles that correlate with response to therapy and the development of therapy resistance.

CONCLUSIONS

Neoadjuvant (presurgical) targeted therapy before cytoreductive surgery appears safe in the setting of metastatic renal cell carcinoma. It identifies patients who respond to systemic therapy before surgery, thus avoiding highly morbid surgery in patients destined for a poor outcome. Further studies are needed to identify the molecular endpoints associated with treatment response and the development of the resistant phenotype, which will in turn identify novel transduction pathways worthy of therapeutic development.

Cytoreductive nephrectomy for metastatic RCC in the era of targeted therapy

Metastatic renal cell carcinoma (RCC) has traditionally been associated with a poor prognosis with few effective treatments. In the multimodal treatment of metastatic RCC, cytoreductive nephrectomy (CN) became the standard of care after two randomized trials demonstrated a benefit in overall survival in patients who received CN prior to treatment with interferon. More recently, several agents (sunitinib, sorafenib, temsirolimus, everolimus and bevacizumab) have been developed that target angiogenesis and the cellular growth pathways involved in metastatic RCC. These targeted agents have demonstrated improved outcomes compared to cytokine therapy, and have transformed metastatic RCC treatment. Targeted agents are being used as a first-line systemic treatment in patients with metastatic RCC with unprecedented success, and many studies are now focusing on the role of CN in combination with these agents for patients with metastatic RCC.

Pre-surgical targeted molecular therapy in renal cell carcinoma

Pre-surgical systemic therapy with targeted molecular agents is an attractive option as an approach to the treatment of patients with renal cell carcinoma. This treatment strategy offers a rational approach for selecting patients with metastatic disease who are most likely to benefit from cytoreductive nephrectomy, but also allows access to treated tumour tissue to study the molecular mechanisms of response and resistance. In patients with locally advanced disease, this strategy offers the potential for improved resectability and timely delivery of systemic therapy to treat subclinical metastatic disease. Preliminary evidence indicates that the use of targeted therapies before nephrectomy is safe. Reliable therapy-specific prognostic biomarkers are needed for the optimal integration of aggressive surgical intervention and systemic therapy to maximize the oncological benefits for the patient.

Cytoreductive nephrectomy in metastatic renal cell carcinoma

PURPOSE OF REVIEW

Cytoreductive nephrectomy has an established role in management of metastatic renal cell carcinoma when performed in properly selected patients prior to administration of systemic cytokine therapy. Within the past several years, novel molecular targeted agents have not only revolutionized management of metastatic renal cell carcinoma but also created controversy regarding the necessity, patient selection for and timing of cytoreductive nephrectomy.

RECENT FINDINGS

Benefits of targeted molecular therapeutics have largely been observed in the context of prior cytoreductive nephrectomy, and limited available evidence supports cytoreductive nephrectomy in appropriately selected patients with metastatic renal cell carcinoma who are candidates for targeted systemic therapy. Presurgical systemic therapy with targeted molecular agents is an attractive paradigm, which not only offers a rational approach to select patients who are most likely to benefit from cytoreductive nephrectomy but also allows access to treated tumor tissue to study molecular mechanisms of response and resistance. Surgical approaches increasingly utilized in patients with localized kidney cancer, such as nephron-sparing and minimally invasive techniques are similarly relevant and should be utilized, when appropriate, in patients with metastatic renal cell carcinoma.

SUMMARY

Cytoreductive nephrectomy should be considered to provide a survival benefit for patients with metastatic renal cell carcinoma and should be used in patients who are candidates for systemic therapy before or after surgery.

Surgical morbidity associated with administration of targeted molecular therapies before cytoreductive nephrectomy or resection of locally recurrent renal cell carcinoma

PURPOSE

Targeted molecular therapies such as bevacizumab, sunitinib and sorafenib before surgical resection hold promise as rational treatment paradigms for patients with metastatic or locally recurrent renal cell carcinoma. To analyze the safety of this approach we evaluated surgical parameters and perioperative complications in patients treated with targeted molecular therapies before cytoreductive nephrectomy or resection of retroperitoneal renal cell carcinoma recurrence, and compared them to a matched patient cohort who underwent up-front surgical resection.

MATERIALS AND METHODS

We evaluated surgical parameters and perioperative complications in 44 patients treated with targeted molecular therapies before cytoreductive nephrectomy or resection of local renal cell carcinoma recurrence, and in a matched cohort of 58 patients who underwent up-front surgery.

RESULTS

Cohorts of patients treated with preoperative targeted molecular therapy and initial surgical resection were matched in terms of clinical characteristics, burden of metastatic disease and number of adverse prognostic factors. A total of 39 complications occurred in 17 (39%) patients treated with preoperative targeted molecular therapy and in 16 (28%) who underwent up-front resection (p = 0.287). There were no statistically significant differences in surgical parameters, incidence of perioperative mortality, re-exploration, readmission, thromboembolic, cardiovascular, pulmonary, gastrointestinal, infectious or incision related complications between patients treated with preoperative targeted molecular therapy and those who underwent up-front surgery. Duration, type and interval from targeted molecular therapy to surgical intervention were not associated with the risk of perioperative morbidity.

CONCLUSIONS

Preoperative administration of targeted molecular therapies is safe, and does not increase surgical morbidity or perioperative complications in patients treated with cytoreductive nephrectomy or resection of recurrent retroperitoneal renal cell carcinoma.

Current status of debulking nephrectomy in the era of tyrosine kinase inhibitors

Cytoreductive nephrectomy (CN) has an established role against metastatic renal cell carcinoma (mRCC) in properly selected patients and offers a survival advantage when performed prior to cytokine therapy. With the emergence of new, effective targeted molecular therapies for mRCC, well-designed prospective trials are needed to clarify the biologic effects of CN to determine when and for whom CN should be performed in the context of targeted systemic therapy. Consequently, a thorough characterization of the systemic effects afforded by CN is imperative for developing individualized treatment strategies that effectively address the underlying biology of mRCC while maximizing patient quality of life during therapy. Until then, debulking surgery, which provides a survival benefit for select patients with mRCC, should continue to be used in patients before or after targeted systemic therapy.