Management of Bilateral and Multifocal RCC: Family Matters

Gennaday Bratslavsky, MD

Gennaday Bratslavsky, MD

Managing bilateral and multifocal renal cell carcinoma (RCC) is as much a matter of family history as deciding which patients need a biopsy and which tumor to start treating first, according to Gennaday Bratslavsky, MD. Bratslavsky directed a course exploring the treatment of this complex condition at the 2017 American Urological Association meeting.

“The genetic profile of kidney cancer is now becoming much more prevalent in identification of therapeutic targets,” he said. “As we move forward to precision medicine, there are numerous tests, profiles, categories, and strategies that we're all working on to be able to pinpoint a better treatment for the right patient.”

OncLive: Can you give an overview of your presentation?

In an interview with OncLive, Bratslavsky, professor and chair of urology, chief of urologic oncology, and division chief of urologic male health, SUNY Upstate Medical University, discussed the evaluation and management of RCC and highlighted genetic testing for the patient’s family.Bratslavsky: We have a course this year on the evaluation and management of bilateral multifocal and hereditary RCC. This has many implications because quite a few patients that we see in a urologist’s office do present with more than one tumor. When a patient has more than one tumor, it raises the question of what side to start with, who to biopsy, and who to test.

To answer those questions, you start by doing a comprehensive history and physical. A huge importance in evaluating these patients is recognition of a family history or certain potential signs of syndromes that could be associated.

Not every patient who presents with tumors on each side of the kidney will have a genetic disorder. As we’re learning more about the genetics of patients with kidney cancer, we’re sometimes able to trace it down to some history in the family, for example, a family member who had the removal of the uterus at a young age. That can guide us into appropriate testing.

Why is it important for a patient to understand his or her family history?

Sometimes you need to start with a biopsy since having knowledge of the specific histology from the biopsy can direct you further into additional genetic testing. Additionally, the surgical incision may direct your next step of management once you have more than one tumor. All of this is individualized, but there are several specific algorithms that we have developed that will hopefully help practitioners, urologists, and those who run into these complex issues identify the best next steps.Having a family history of kidney cancer would qualify patients for what is known as hereditary kidney cancer. Kidney cancer is still quite prevalent. There will be over 60,000 new cases of kidney cancer diagnosed in the United States this year. For this reason, to say that anyone who had a family member with kidney cancer does not necessarily qualify these patients for tests. Nevertheless, it is something to keep in mind.

What advancements are being made in the management of kidney cancer?

Are there any ongoing trials looking at answering the remaining questions?

Where do you see the field going in next 5 to 10 years?

We have done several studies and have several publications evaluating how frequently one may identify mutlifocality or the presence of more than one kidney tumor in a patient. We have found that if you look across numerous studies that have been published, the possibility of finding mutlifocality is somewhere between 6% to 7% higher than previously believed. Overall, the condition is quite prevalent and the appropriate evaluation is important since that leads to the appropriate management for the patient.One of the bigger advantages is the opportunity to perform some specific genetic tests for numerous established genes that have been known to cause kidney cancer. We're looking more into genotype/phenotype characteristics, in how these patients present, when they present, who needs to be tested, what age they need to be tested, and what defines the early onset of kidney cancer. Those are probably the most exciting things happening in this population of patients with kidney cancer. Our opportunity to diagnose these patients early via methods of genetic testing will have implications, not only for the specific patient’s treatment, but also for treatment tests and follow-up surveillance of the entire family. This is particularly important for children who may be affected or may be reassured by having an opportunity to have access to such tests.I am unaware of specific trials that are looking at diagnosing or surgery for kidney cancer genes, but the research is ongoing at all times. There are several trials that are based on the knowledge of specific genetic mutations that the patient may possess. The genetic profile of kidney cancer is now becoming much more prevalent in the identification of therapeutic targets. As we move toward precision medicine, there are numerous tests, profiles, categories, and strategies that we're all working on to be able to pinpoint a better treatment for the right patient. It's well known that not all kidneys are equal. I think we will start moving much farther away from these blanket statements of risk categories just based on size and histology alone. We will become much more refined in our ability to prognosticate these cancers and design the appropriate treatment follow-up based on the propensity of the tumor to either spread or be receptive to a certain therapy.