Surgical management in metastatic renal cell carcinoma

Area of Science:

• Oncology
• Surgical Oncology
• Nephrology

Background:

• Metastatic renal cell carcinoma (mRCC) management is rapidly evolving.
• Cytoreductive nephrectomy's role is debated, with trials like CARMENA and SURTIME challenging upfront surgery.
• The advent of immune checkpoint inhibitors (ICIs) introduces new questions regarding nephrectomy timing.

Purpose of the Study:

• To explore the evolving role and optimal timing of nephrectomy in metastatic renal cell carcinoma (mRCC).
• To evaluate delayed nephrectomy strategies in the context of modern systemic therapies, including ICIs.
• To assess the potential benefits and risks of integrating surgery into mRCC management.

Main Methods:

• Review of clinical trial data (e.g., CARMENA, SURTIME) concerning cytoreductive nephrectomy.
• Analysis of emerging strategies involving delayed nephrectomy post-systemic therapy (antiangiogenic and ICI).
• Consideration of surgical resection for mRCC metastases.

Main Results:

• Upfront cytoreductive nephrectomy showed no benefit over sunitinib alone in intermediate/poor prognosis mRCC.
• Deferred nephrectomy after systemic therapy initiation appears a potentially better strategy.
• Delayed nephrectomy post-ICI response may yield good oncological outcomes in selected patients with residual disease.

Conclusions:

• The role and timing of nephrectomy in mRCC are still under investigation, particularly with ICIs.
• Delayed nephrectomy after systemic therapy response is a promising approach for selected patients.
• Post-immunotherapy surgery demands high-volume, expert centers due to technical challenges and complication risks. Surgical resection of metastases may also be considered.