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Cytoreductive nephrectomy for metastatic RCC in the era of targeted therapy

Abstract

Metastatic renal cell carcinoma (RCC) has traditionally been associated with a poor prognosis with few effective treatments. In the multimodal treatment of metastatic RCC, cytoreductive nephrectomy (CN) became the standard of care after two randomized trials demonstrated a benefit in overall survival in patients who received CN prior to treatment with interferon. More recently, several agents (sunitinib, sorafenib, temsirolimus, everolimus and bevacizumab) have been developed that target angiogenesis and the cellular growth pathways involved in metastatic RCC. These targeted agents have demonstrated improved outcomes compared to cytokine therapy, and have transformed metastatic RCC treatment. Targeted agents are being used as a first-line systemic treatment in patients with metastatic RCC with unprecedented success, and many studies are now focusing on the role of CN in combination with these agents for patients with metastatic RCC.

Key Points

  • CN for patients with metastatic RCC is the current standard of care, based on improved overall survival in two randomized trials

  • CN is safe in properly selected patients, but morbidity of surgery is not insignificant, and may delay initiation of systemic treatment in some patients

  • Targeted therapy has dramatically changed treatment and improved outcomes for patients with metastatic RCC

  • Presurgical therapy with targeted agents has many theoretical advantages, but poor primary tumor response with current agents might limit its effectiveness

  • Randomized prospective trials are needed to investigate the most appropriate timing of surgery in patients treated with targeted therapy

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Figure 1: Current treatment algorithm for patients with metastatic renal cell carcinoma.
Figure 2: Clinical trials designed to examine the value of cytoreductive nephrectomy combined with targeted therapies.

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Abel, E., Wood, C. Cytoreductive nephrectomy for metastatic RCC in the era of targeted therapy. Nat Rev Urol 6, 375–383 (2009). https://doi.org/10.1038/nrurol.2009.102

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