Dr. Zaid on the surgical management of locally advanced RCC

In this video, Harras B. Zaid, MD, discusses the surgical management of locally advanced renal cell carcinoma, which was discusses during a session at SUO 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 at Austin and a urologic oncologist at Dell Seton Medical Center.

Video Transcript:

Urologists are often the gatekeepers of this disease space. We are initially seen these patients when they present upfront. The patients who are presenting with de novo locally advanced renal cell carcinoma may have symptoms like gross hematuria, weight loss, abdominal or flank pain. The majority of renal cell carcinoma diagnoses nowadays are in earlier stages. There has been a stage migration in part related to the availability of cross-sectional imaging, but there's still a proportion of patients who present with locally advanced disease. As urologists, we are often the initial care providers who are evaluating and receiving these patients in consultation.

When patients have locally advanced renal cell carcinoma, which I'll talk a little bit about, urologists have to make an assessment as to the appropriateness of surgical intervention. Locally advanced renal cell carcinoma includes very large infiltrative tumors, for example tumors that are beyond Gerota’s, renal vein involvement, IVC thrombus, or involvement of contiguous structures. This could involve the liver, adjacent segments of bowel, most specifically colon. When assessing candidacy for surgical resection in these patients, a lot of things come into play. First off, patient expectations. Many of these patients will have symptoms, and an upfront goal of these operations may in part be palliative. Part of the expectation setting with regards to patient discussion is also surgery can be quite morbid, meaning there is going to be a high risk of complication, especially if we're talking about multivisceral resection, resecting a part of colon with our surgical oncology colleagues, part of liver, etc.

And also understanding that these surgeries may not be curative. Patients who have locally advanced disease who undergo surgical resection even with negative margins are at high risk for local and distant relapse. However, when assessing candidacy for surgical resection, first off comes the discussion with the patient. What are we hoping to accomplish? What are the risks involved? Will this be curative? The other thing is feasibility. Is it feasible to do a resection? Not all of these locally advanced renal cell carcinomas can be resected. In those particular cases, we may forego surgical intervention and favor upfront biopsy and systemic combination treatments with medical oncology and/or SBRT by radiation oncology. With regards to expectations, even when we go through and do a major exterpretive operation, are patients going to have long-term cancer control? That in part will be driven by the disease specific factors of the tumor that's resected. I counsel most patients that they are at high risk for relapse. There were a couple of patients on this discussion where that in fact was the case.

This transcription has been edited for clarity.