How kidney Ca management strategies compare

Megan M. Merrill, DOAn updated guideline on localized kidney cancer as well as a look at active surveillance as initial management for renal masses <2 cm were among the noteworthy kidney cancer studies at the AUA annual meeting in Boston. The take-home messages were presented by Megan M. Merrill, DO, of Ohio State University, Columbus.   

In an evaluation of circulating “cell-free” tumor DNA (liquid biopsy) and known mutations found in RCC, researchers determined that 67% of their cohort had detectable DNA mutations versus 3% of control patients. They were able to detect RCC in patients with both early and advanced stages and were able to detect RCC in a tumor as small as 1.1 cm.

Intravenous osmitrol (Mannitol) infusion during nephron-sparing surgery does not lead to clinically relevant improvement in renal function outcomes and should be discontinued.

While off-clamp and clamped robotic partial nephrectomy were equally safe, a relevant number of off-clamp partial nephrectomy cases were not feasible due to later bleeding.

When comparing partial nephrectomy, radical nephrectomy, ablative therapies, and active surveillance through a large registry, cancer-specific survival was comparable in all groups when adjusting for age and comorbidities. Overall survival was worse in the active surveillance group, but this was likely attributable to older age and worse health status at baseline. Radical nephrectomy resulted in significantly worse kidney function in patients with a small renal mass.

In patients with locoregional renal cell carcinoma (RCC) who were at high risk of tumor recurrence after nephrectomy, adjuvant sunitinib (Sutent) showed a 2-year advantage in median survival versus placebo.

Axitinib (Inlyta) appears to be well tolerated and effective for the treatment of patients with metastatic RCC who were unsuitable for nephrectomy. The drug appears to have a 3-month longer median progression-free survival than temsirolimus (Torisel).

A study of whether current follow-up guidelines are sufficient for organ-confined renal cancer found the recurrence rate to be only 4.4%, but 42% of those occurred after 60 months.

The panel that developed an updated AUA guideline on localized kidney cancer has recognized great variance in patient/oncologic/functional characteristics and recommends individual counseling on therapeutic choices rather than basing such decisions on index (healthy vs. unhealthy) patients. Also new in the guideline: The guideline prioritizes partial nephrectomy in the management of cT1a renal masses and nephron-sparing approaches for patients with solitary kidneys, bilateral tumors, known familial RCC, pre-existing chronic kidney disease (CKD), or proteinuria.

Tumor enucleation can be considered specifically for patients with familial RCC, multifocal disease, or severe CKD, although more research is needed to conclude whether this is oncologically safe.

Radical nephrectomy should be considered when there is increased oncologic potential. In addition, radical surgery is preferred if three criteria are present: high tumor complexity in which a partial nephrectomy would be challenging even in experienced hands, no pre-existing CKD or proteinuria, and a normal contralateral kidney that would provide an eGFR of >45 ml/min/1.73 m².

In patients with renal masses <2 cm, active surveillance is an option for initial management, even in healthy patients.

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