RCC 2018: Systemic therapy landscape sees rapid change

Editor’s note: Urology Times asked key opinion leaders in kidney cancer for what they felt were the most noteworthy developments in the field in 2018. We thank Alexander Kutikov, MD, Amr A. Elbakry, MBBCh, MSc, and Ketan K. Badani, MD, for their responses. Dr. Kutikov’s summary follows. To read the overview co-authored by Dr. Elbakry and Dr. Badani, click here.

Alexander Kutikov, MD

Dr. Kutikov is chief of urology and urologic oncology and professor of surgical oncology at Fox Chase Cancer Center, Philadelphia.

The CARMENA trial, which randomized metastatic renal cell carcinoma patients to sunitinib (Sutent) alone versus cytoreductive nephrectomy (CN) followed by sunitinib, demonstrated that CN can be harmful in a subset of patients (N Engl J Med 2018; 379:417-27). As these data are being debated, kidney surgeons must remember that CN needs to be offered with great caution to those patients for whom systemic therapy should not be delayed, especially as systemic therapy options are rapidly improving.

Indeed, the systemic therapy landscape for advanced renal cell carcinoma is quickly changing. New randomized trials are being reported in rapid succession. Perhaps the most notable trial of 2018 was CheckMate 214, which has now established the ipilimumab (Yervoy) plus nivolumab (Opdivo) immunotherapy combination as the first-line therapy for patients with intermediate- and poor-risk metastatic clear cell renal cell carcinoma (N Engl J Med 2018; 378:1277-90).

Read: Ablative RT could be alternative for solitary-kidney RCC

To dovetail with the rapid approval of novel systemic therapy agents in the renal cell carcinoma space over the last several years, a recent analysis of a large U.S. administrative dataset demonstrated improved survival for patient with metastatic renal cell carcinoma who were treated at a high-volume treatment facility (Eur Urol 2018; 74:387-93). These data suggest that the complexity and nuance that the care of these complex patients requires is best handled at centers that see such patients often, translating into better outcomes.

An eye-opening manuscript was recently published by Gershman et al, based on a very large cohort of patients (>2,400) who underwent radical and partial nephrectomy at the Mayo Clinic (Eur Urol 2018; 74:825-32). As expected, patients who underwent partial nephrectomy maintained better renal function, yet there was no detectable survival advantage to kidney preservation. This manuscript is relevant for critical clinical decision-making in patients with complex renal masses when immediate risks of complex partial nephrectomy (especially in patients who require antiplatelet and anticoagulation therapy) must be balanced against potential long-term benefits of renal parenchyma preservation.