Comparison of immediate vs. deferred cytoreductive nephrectomy in patients with synchronous metastatic renal cell carcinoma

Abstract

Cytoreductive nephrectomy has been a mainstay in treating patients with synchronous metastatic renal cell carcinoma (mRCC) for over two decades. It was supported in part by level 1 evidence that showed improved survival for patients undergoing radical nephrectomy before initiation of systemic therapy dating back almost 20 years. Since that time, the landscape of systemic therapy for mRCC has shifted mainly from IL-2 based therapy to tyrosine kinase inhibitors (TKIs) targeting the vascular endothelial growth factor pathway, and now to immunotherapy with PD-L1 inhibitors. Given the significant advancements in systemic therapy for patients with mRCC, the role of cytoreductive nephrectomy and sequencing of treatment has been questioned. Recent randomized studies appear to disprove the theory that upfront cytoreduction improves overall survival, particularly in the TKI era, and thus treating physicians are faced with conflicting data to guide treatment decisions. The role of cytoreductive nephrectomy is in evolution, and so is the timing of surgery in selected patients. Familiarity with available evidence coupled with patient selection and targeted therapy should help to inform decision-making. Currently, an initial course of systemic therapy followed by consideration of nephrectomy in those with a favorable response may be the most prudent algorithm outside the context of a clinical trial.

Keywords

Metastatic kidney cancer / immediate vs. delayed cytoreductive nephrectomy / survival

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