KCRNC CS 2018 cytoreductive nephrectomy for patients with metastatic RCC

Question 1

who should be offered a cytoreductive nephrectomy upfront?

Answer 1

Patient with ECOG 1 or Karnofsky score 80 performance status. Minimal symptoms related to metastasis and a limited metastatic burden. followed by metastasis directed therapy/ surveillance or systemic therapy.

Question 2

What was the design and findings of CARMENA trial?

Answer 2

RCT CN followed by sunitinib vs sunitinib. no survival advantage to undergoing CN. Patients were intermediate or poor risk group as per MSKCC model. treatment given was sunitinib.

Question 3

Have IMDC or MSKCC prognostic model been validated to predict response to CYTOREDUCTIVE nephrectomy?

Answer 3

NO

Question 4

What was the design of SURTIME study?

Answer 4

upfront CN then Sunitinib vs sunitinib followed by CN. no difference found in disease progression(primary outcome) but OS better in deferred CN arm.

Question 5

Upfront CN is recommended against for which patients?

Answer 5

Brain mets, poor clinical status( ECOG>1, Karnosky<80), small renal burden in comparison to overall burden of the disease, limited life expectancy. ( if they get better can reconsider after systemic therapy)

Question 6

Is there a role for CN in patients with non-clear-cell mRCC?

Answer 6

YEs, treat them just like clear cell metastatic RCC. ( CARMENA and SURTIME did not have non ccRCC)

Question 7

IS there a role for LND at the time of CN?

Answer 7

In patients with no evidence of nodal disease it is not recommended. In patients with evidence of nodal disease can be considered after thoughtful consideration of morbidity associated and unknown clinical benefit.

Question 8

Do you have to do the CN open?

Answer 8

NO, it is at the discretion of the surgeon. ADRENAL sparing when there is no involvement is appropriate.