Dr. Zaid on surgical considerations in patients with metastatic RCC

In this video, Harras B. Zaid, MD, discusses the surgical management of metastatic renal cell carcinoma, which was discussed during a session at this year’s Society of Urologic Oncology Annual Meeting titled, “Panel Discussion: Salvage Therapies for Recurrence Following Local Therapy (Ablation, Systemic Therapy, XRT, Surgery).” Zaid is an assistant professor in the department of surgery and perioperative care at the University of Texas, Austin and a urologic oncologist at Dell Seton Medical Center.

Video Transcript:

The field of metastatic renal cell carcinoma has evolved a lot. When thinking of metastatic renal cell carcinoma, there are patients who are de novo metastatic renal cell carcinoma­–meaning they're presenting with the primary tumor intact and metastatic disease–or patients who have been treated locally with nephrectomy and then developed metastases down the line. Thinking about patients who have de novo metastatic disease–meaning this is how they present, they still have the kidney intact–we have to be very selective in whom we are choosing to do a cytoreductive nephrectomy on. It comes down to patient expectations, feasibility, and morbidity of resection. By its very definition, cytoreductive nephrectomy in metastatic renal cell carcinoma is not curative.

Selecting patients for cytoreductive nephrectomy has evolved over the years. The CARMENA trial (NCT00930033) really cast an important set of discussion points in who we select for cytoreductive nephrectomy. But generally speaking, from a clinical standpoint, patients have to have pretty good performance status. For example, a patient who has significant cardiac disease, pulmonary disease, poor performance status, may not be the best candidate for cytoreductive nephrectomy. There are certain lab parameters that come into play, for example, hypercalcemia, anemia, thrombocytopenia, and thrombocytosis, [which] may be associated with poor prognosis. And also sites of metastases and the number of metastases. If a patient for example, has multiple visceral metastases, liver mets, contiguous involvement of surrounding organs, multiple lung mets, they may not be the best candidate. However, patients who have a solitary site of disease, for example, a solitary lung met or maybe a couple of enlarged lymph nodes, may be a preferred candidate. Of course, this all goes into expectations and goals of care with these patients.

Lastly, there's also a role of symptom management in many of these patients. With locally advanced renal cell carcinoma with or without metastases, some of these patients may have hematuria that's intractable or abdominal pain or systemic symptoms related to the tumor itself, paraneoplastic syndromes, for example. In these patients, that may be another factor where we're considering cytoreductive nephrectomy.

The second set of patients where there is metastatic renal cell carcinoma are those who have undergone definitive local treatment and have had a nephrectomy, and then they've subsequently developed metastasis. The question is, how do we manage those metastases? Again, a lot of it depends on feasibility [and] morbidity of resection. For example, if someone undergoes a nephrectomy and has an early recurrence within a year, doing a resection of a lymph node or a pulmonary lesion may not be as much of a benefit vs someone who's had a delayed recurrence. The thinking there is that early recurrence portends a more aggressive biology. This field has also evolved; there are some patients who may be a candidate for observation, as well. Again, operating has more and more taken a backseat as the armamentarium of systemic medications, especially checkpoint inhibitors [and] combination treatments, has exploded. And non-surgical metastasectomy, for example, in extending the role of SBRT or thermal ablation for metastatic lesions, has become more sophisticated. We really have to think long and hard before operating on these patients as well.

This transcription has been edited for clarity.