Dr. Shuch on Role of Cytoreductive Nephrectomy in RCC

Brian M. Shuch, MD, director of the Kidney Cancer Program, Alvin & Carrie Meinhardt Endowed Chair of Kidney Cancer Research, University of California, Los Angeles Institute of Urologic Oncology, discusses the role of cytoreductive nephrectomy in the treatment of patients with renal cell carcinoma (RCC).

Starting in 2005, this paradigm entered a new era with the approval of VEGF TKIs such as sorafenib (Nexavar) and sunitinib (Sutent), tolerable agents that offer high response rates and promising progression-free survival benefit. That advancement prompted the question of: Would surgery still have a role in the new treatment era? Data from several recent trials have suggested that it was still imperative to remove the primary tumor. With the phase III CARMENA trial, investigators hoped to better define the role of cytoreductive nephrectomy in this space, but that was not the case.

In terms of enrollment for that study, investigators were nonselective in that they allowed patients with very advanced disease or those with intermediate- and poor-risk disease to participate, said Shuch; in fact, 44% of patients enrolled in the trial were poor-risk he added. Patients were randomized to receive either upfront sunitinib or nephrectomy followed by sunitinib. Results showed that sunitinib was noninferior to cytoreductive nephrectomy followed by systemic therapy. However, with immunotherapy making headway in RCC, TKIs are now moving to the second-line setting.