[Symptomatic renal tumours in metastatic renal cell carcinoma - surgical options]

Between 15 and 20 % of patients diagnosed with renal cell carcinoma suffer from metastatic disease by the time of diagnosis. In addition to systemic therapy, there are various surgical strategies to treat the primary tumour, e. g. cytoreductive nephrectomy (CN) or palliative nephrectomy (PN). In the immunotherapy era, the standard treatment was to perform CN followed by interferon therapy, based on 2 prospective randomised trials and their combined analysis. Since the introduction of targeted therapy around 2005, data of that quality has been missing and clinicians have had to rely on big retrospective studies, which have confirmed the benefit of CN except for patients with low performance status, cerebral metastases, low life expectancy, and old age. The recently published results of the CARMENA trial, which compared the use of sunitinib versus CN followed by sunitinib in a prospective randomised trial, have now demonstrated non-inferiority of sunitinib alone in patients classified as having intermediate-risk or poor-risk disease. Nevertheless, these results remain debatable given the large number of patients with poor-risk disease and a higher percentage of locally advanced tumours in the nephrectomy-sunitinib group. Indications for palliative nephrectomy are pain, haemorrhage, or severe paraneoplastic syndrome. Since there are excellent supportive and less invasive therapies, e. g. angioembolisation in case of haemorrhage, the decision in favour of surgical intervention should be based on the characteristics of the primary tumour, individual risk factors, and alternative therapies. Technically, palliative nephrectomy can be performed as an open or laparoscopic procedure and even as a partial nephrectomy, if indicated.