Treatment/Prognosis Flashcards
Describe 5 invasive Tx for locally confined RCC.
Invasive Tx for locally confined RCC:
- Open nephrectomy
- Laparoscopic nephrectomy
- Percutaneous CT-guided cryosurgery
- Percutaneous radiofrequency ablation
- Partial nephrectomy
Are there any studies comparing laparoscopic resection with that of open resection in pts with RCC?
Yes. There are retrospective data that compared laparoscopic resection vs. open resection of RCC. There was no difference in DFS. (Luo JH et al., World J Urol 2009; Marszalek M et al., Eur Urol 2009)
Are there surgical options for pts with bilat RCC or unilat RCC with a diseased contralat kidney?
Yes. Pts with bilat RCC or a diseased contralat kidney can be treated with a partial nephrectomy provided the lesion is amenable to a nephron-sparing approach.
When is recurrence most likely to occur following Sg for RCC?
The median time for recurrence after Sg for RCC is ∼2 yrs. Most recurrences occur within 5 yrs.
Name 4 predictors of RCC recurrence after nephrectomy.
Predictors of RCC recurrence after nephrectomy:
- Nuclear grade (Fuhrman grade)
- TNM stage
- DNA ploidy
- Genetic RCC syndromes
What are the most common sites of RCC recurrence after nephrectomy?
Most common sites of RCC recurrence after nephrectomy:
- Lung
- Bone
- Regional LNs
What f/u imaging is recommended for RCC pts after nephrectomy?
RCC pts after nephrectomy should be followed with CXR/CT chest and CT/MRI abdomen.
For how long should pts with RCC treated with nephrectomy be followed?
Pts with RCC treated with nephrectomy should be followed for life (sporadic RCC recurrences have been documented ≥40 yrs later).
Are there any prospective randomized studies examining the role for adj therapy in pts with RCC treated with initial nephrectomy?
Yes. IFN α-2b within 1 mo after Sg vs. Tx only after postsurgical relapse demonstrated no EFS or OS benefit (Messing EM et al., JCO 2003). 2 phase III trials of antiangiogenic therapy in the adj setting (ASSURE, Lancet 2016; S-TRAC, NEJM 2016) failed to demonstrate significant differences in OS from the use of a TKI compared to placebo, though in neither case was it the primary endpoint.
What is the 1st-line Tx for pts with metastatic RCC?
1st-line Tx for pts with metastatic RCC:
- Cytoreductive nephrectomy
- Metastasectomy for oligometastases
- Sunitinib
- Temsirolimus
- Bevacizumab and IFN
- High-dose recombinant interleukin-2
- Sorafenib
Cytotoxic chemo for non–clear cell histologies may be considered.
Is there a role for palliative nephrectomy in pts with RCC?
Yes. Palliative nephrectomy is still encouraged to relieve local Sx of pain or intractable hematuria; as well as systemic Sx related to the primary tumor.
What are the data for using cytoreductive Sg in combination with immunotherapy?
Cytoreductive Sg utilized before immunotherapy may delay time to progression and improve survival of pts with metastatic Dz (median duration of survival 17 mos vs. 7 mos, SS). (Mickisch GH et al., Lancet 2001)
Is there a role for resection of metastatic lesions in pts with RCC?
Yes. A retrospective study by Kavolius JP et al. suggests that curative resection of metastatic lesions in pts with RCC improves survival compared with the subtotal resection of pts or those with noncurative salvage attempts (44%, 14%, and 11%, respectively). (JCO 1998)
Is there a role for RT in pts with RCC in the definitive setting?
Generally not. 2 classic prospective trials (Finney et al., Br J Urol 1973; Kjaer et al., IJROBP 1987) evaluating the role of postop radiotherapy in localized RCC failed to demonstrate any LRC or OS benefit and RT was associated with Tx-related mortality. Ongoing work is evaluating SBRT in inoperable pts.
What fractionation schemes are under investigation in ongoing trials assessing the role of SBRT for primary RCC?
A range of fractionation schemes are under study, from 40–50 Gy in 5 fx to 48–60 Gy in 3 fx, as well as 23–25 Gy in 1 fx in 1 study. Retrospecitve data suggest better outcomes with higher BED regimens.
