Achieving no evidence of disease in metastatic renal cell carcinoma: Consolidative nephrectomy vs ablative therapy

Systemic therapies (ST¹) have improved outcomes in metastatic renal cell carcinoma (mRCC²) but have a limited effect on the primary renal tumor. As deeper responses improve survival, consolidative treatment (CT³) to achieve "No Evidence of Disease" is increasingly considered. While surgery remains the standard, renal cryoablation (CA⁴), a less invasive option, is gaining interest.

We conducted a retrospective single-center study (2010-2025) of synchronous mRCC patients undergoing CT after achieving a complete metastatic response with ICI±TKI. Evaluated modalities included partial nephrectomy (PN⁵), radical nephrectomy (RN⁶), and CA. The primary objective was the oncological efficacy of each modality, measured by the 1-year recurrence rate. Secondary objectives included overall recurrence-free survival (RFS⁷) and morbidity.

Twenty-one patients underwent CT: 10 PN, 7 RN, and 4 CA. Median age was 65 years. Seventeen patients (81%) received ICI±TKI, and four (19%) received TKI alone. Median preoperative tumor sizes were 43.5, 68, and 25mm in the PN, RN, and CA groups, respectively (P=0.01). Median follow-up was 31 (23.5-73.5) months. The 1-year recurrence rates were comparable: 22.2% (PN), 16.7% (RN), and 25% (CA) (P=0.61). ST was discontinued postoperatively in 84% (16/19) of patients. Although not statistically significant, CA showed a trend toward lower morbidity than consolidative nephrectomy (CN⁸), with better preservation of renal function, less blood loss, and shorter hospital stays.

Consolidative renal CA, with its reduced morbidity, could be a viable alternative for frail patients unfit for CN, warranting validation in larger prospective studies. LEVEL OF EVIDENCE (HAS): 4 (descriptive studies).