Expert discusses sequencing surgery and systemic therapy in RCC

In this video, Harras B. Zaid, MD, discusses sequencing surgery and systemic therapy in patients with renal cell carcinoma, which was discussed during a session at SUO titled, “Panel Discussion: Salvage Therapies for Recurrence Following Local Therapy (Ablation, Systemic Therapy, XRT, Surgery).” Zaid is an assistant professor in the department of surgery and perioperative care at the University of Texas, Austin and a urologic oncologist at Dell Seton Medical Center.

Video Transcript:

Thinking about patients who present with metastatic disease and they have their primary tumor intact, if there's a certain list of criteria, at least in my practice, where I assess their candidacy for undergoing a cytoreductive nephrectomy. Is surgery feasible? Is there going to be a potential oncologic or symptomatic benefit? And is it in lines with what the patient wants? There's a component of shared discussion. But generally speaking, patients who have large volume metastatic disease at presentation who have visceral metastatic disease, for example, liver mets, and those who have a poor performance status, I'm usually going to defer upfront surgery. In those patients, a biopsy of either the primary or metastatic site is what I would recommend if they have a site that's metastatic and biopsy can be obtained. I usually prefer a biopsy of the metastatic sites; it's not always feasible. Then, engage our medical oncology colleagues with regards to initiation of systemic treatment.

Their specific case scenarios where radiation oncology may be involved. For example, a patient who has a locally advanced renal cell carcinoma with a large tumor thrombus, engaging them to discuss the role of SBRT, at least in palliation and keeping the tumor thrombus from getting larger. More common for me now, and I think other urologists do favor upfront systemic treatment, especially as those treatments have gotten better in metastatic renal cell carcinoma.

Now, when it comes to patients who have been treated with nephrectomy and then develop a delayed metastasis, the sequencing of systemic treatment vs surgery, again, depends on the sites of metastases, the number of metastases, patient's performance status, and feasibility of metastasectomy. I think we should all be pretty selective in whom we're operating on in the metastasectomy setting. It should be feasible without significant undue harm or risk, and also with the understanding that even with metastasectomy, surgically resecting a metastatic lesion, many of these patients will relapse and may need systemic treatment.

This transcription has been edited for clarity.