PATIENTS with metastatic renal cell carcinoma do not experience worse outcomes when receiving pre-operative systemic therapy after deferred cytoreductive nephrectomy, according to data presented at the American Society of Clinical Oncology (ASCO)’s 2023 Genitourinary Cancers Symposium in San Francisco, California, USA.
Shawn Dason, Ohio State University, Columbus, USA, and colleagues analysed data from 505 patients from the 2019–2020 American College of Surgeons NSQIP Participant Use Data File. These patients had all undergone cytoreductive nephrectomy and 115 (23%) had also received pre-operative systemic therapy. They noted that 30-day mortality did not differ significantly in groups with pre-operative systemic therapy compared with those without. Furthermore, mean hospital stay, mean operative time, and the proportion of surgeries converted to open surgery, as well as patients with prolonged hospital stay were similar in both groups. The team also noted that those who received pre-operative systemic therapy were more likely to develop urinary tract infections (4.3% versus 0.5%) and take steroids (23% versus 7%). Complication rates, including wound dehiscence, surgical site infections, sepsis, septic shock, cardiovascular complications, pneumonia, pre-operative diabetes, and pre-operative hypertension were the same in both groups.
The investigators identified patients best suited for immediate cytoreductive nephrectomy as patients with significant local symptoms, particularly those requiring hospitalisation and preventing receipt of systemic therapy; those with limited metastatic disease amenable to active surveillance following cytoreductive nephrectomy; those with one International mRCC Database Consortium (IMDC) risk factor and the majority of tumour burden located in the kidney; those with oligoprogressive disease within the kidney following upfront systemic therapy; those with limited metastatic disease that can be controlled completely with metastasis-directed therapy following cytoreductive nephrectomy; and those with an inferior vena cava thrombus warranting additional considerations.
They also identified patients best suited for upfront systemic therapy with consideration of deferred cytoreductive nephrectomy to be those with excessive surgical morbidity, those with significant extrarenal disease, and those with poor performance status and/or multiple IMDC risk factors.
Dason stated: “Any patient [who] starts systemic therapy and does not receive upfront cytoreductive nephrectomy can be considered for a deferred cytoreductive nephrectomy down the line,” and “given the genuine equipoise in this topic and our need for prospective data I would encourage consideration of clinical trial enrolment for any patient being considered for cytoreductive nephrectomy. Clinical trials that we hope will inform us on this topic include Cyto-Kik, PROBE, and NORDIC-SUN.”
