ESOU 2021: Surgical and Perioperative Challenges of Large Renal Tumors

(UroToday.com) At the European Association of Urology (EAU) Section of Oncological Urology (ESOU) 2021 virtual meeting, Dr. Arnaud Mejean discussed surgical and perioperative challenges of large renal tumors, particularly those with vena cava and lymph node involvement. Dr. Mejean notes that statistics from the SEER database suggest that 19% of patients present with locoregional disease, making this an important area of management. Historical data from an international multicenter study shows that based on UCLA Integrated Staging System (UISS) stratification for localized renal cell carcinoma (RCC), the 5-year survival rates were 92%, 67%, and 44% for low-, intermediate-, and high-risk groups, respectively.¹ For metastatic RCC, the 3-year survival rates were 37%, 23%, and 12% for low-, intermediate-, and high-risk groups, respectively:

Dr. Mejean highlights that, although a nuanced assessment, the median survival among those with high-risk localized disease is not that dissimilar from patients with low-risk metastatic disease. Similarly, patients with high-risk localized disease had comparable median survival as those in the CheckMate 214 study treated with nivolumab plus ipilimumab with 2 IMDC risk factors:²

Dr. Mejean notes that there are several important preoperative management points prior to operating on a patient with locally advanced renal cell carcinoma, including a clinical examination, laboratory tests, CT imaging, MRI, and occasionally the utilization of nomograms (which he does not find all that useful). The objectives of this preoperative evaluation include (with imaging the day before):

Confirming/ruling out metastasis/oligometastasis
To confirm patient is amenable to surgery
To confirm a “supposed” curative indication

Furthermore, it is important to have a high degree of preparation and a high level of expertise for these complex, risk operations since the goal is to be safe, confident, and to achieve negative margins. For these operations, there are two different situations: (i) a vena cava thrombus (often curable by surgery alone), and (ii) lymph node involvement (rarely localized and incurable by surgery alone).

With regards to neoadjuvant therapy, there is no recommendation although small studies have shown a primary tumor median size reduction of 10-30% with TKIs. However, there is a minimal effect on RCC with IVC thrombi, with a lack of published large series versus controls. The future includes clinical trials with immunotherapy alone or in combination (9 trials, including pembrolizumab, nivolumab, durvalumab plus tremelimumab, spartalizumab plus canakinumab, axitinib plus toripalimab, axitinib plus avelumab, sitravatinib plus nivolumab). Adjuvant therapy trials to date have been disappointing for overall survival benefit with only S-TRAC demonstrating a disease-free survival benefit (and only a FDA recommendation of sunitinib for very high-risk disease).

Dr. Mejean concluded that the future will the optimal sequencing of systemic therapy and surgery with the goal of making surgery easier and optimizing overall survival.

Presented by: Arnaud Mejean, MD, PhD, CHU de Bordeaux-Direction generale, Paris, France

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia Twitter: @zklaassen_md during the 18th Meeting of the EAU Section of Oncological Urology (ESOU21), January 29-31, 2021

References:

Patard JJ, Kim HL, Lam JS, et al. Use of the University of California Los Angeles integrated staging system to predict survival in renal cell carcinoma: An international multicenter study. J Clin Oncol. 2004 Aug 15;22(16):3316-3322.
Escudier B, Motzer RJ, Tannir NM, et al. Efficacy of Nivolumab plus Ipilimumab According to Number of IMDC Risk Factors in CheckMate 214. Eur Urol. 2020 Apr;77(4):449-453.

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