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Surgical Challenges Remain Among Recent Successes in Kidney Cancer

Angelica Welch
Published: Monday, Apr 09, 2018

Hyung L. Kim, MD
Hyung L. Kim, MD
Nephrectomy remains an optimal option for the treatment of patients with localized kidney cancer, says Hyung L. Kim, MD, adding that although contested by many in the community, cytoreductive surgery is still considered bene cial for patients with metastatic disease.

“This is a very exciting time for kidney cancer,” said Kim. “The field is moving very fast, and our patients have more reason to be hopeful about their treatments than ever before.”

Novel surgical approaches have advanced the use of surgery in localized disease. However, with the advent of systemic treatments to the landscape, Kim says that he is unclear about the role that cytoreductive nephrectomy will have for these patients. Clinical trials to address this question are ongoing, he noted.

Additionally, the EORTC 30073 SURTIME study was stopped prematurely due to poor accrual (NCT01099423). This trial, which treated patients’ primary tumors by administering targeted therapy with sunitinib (Sutent) prior to cytoreductive nephrectomy, reported that this technique did not improve the progression-free rate at 28 weeks in patients with synchronous metastatic renal cell carcinoma. This was compared with a sequence of immediate cytoreductive nephrectomy followed by sunitinib.

In a presentation during the 2018 OncLive® State of the Science SummitTM on Genitourinary Cancers, Kim, the Medallion Group Chair in Urology, co-medical director of the Urologic Oncology Center, and associate director, Surgical Research in the Samuel Oschin Cancer Center at Cedars-Sinai Medical Center, discussed perioperative systemic therapy for patients with kidney cancer.

In an interview during the meeting, Kim touched on the impact of surgery in the localized and metastatic settings on patients with kidney cancer, as well as the importance of biomarkers.

OncLive®: Can you provide an overview of your presentation on perioperative and systemic therapy in kidney cancer?

Kim: I spoke about adjuvant therapy for kidney cancer. When someone presents with localized disease, we offer them surgery. The operation is called a nephrectomy, which is removing the kidney along with the tumor, but sometimes we can do a partial nephrectomy. The goal of surgery is cure. However, in patients with high-risk disease, the cancer can recur, and it can recur in the lungs or the lymph nodes. The goal of perioperative therapy, or adjuvant therapy, is to try and reduce the risk of metastatic recurrence.

Can you speak to the use of cytoreductive nephrectomy in this space?

A nephrectomy can be done in different settings. It can be done for clinically localized disease, where the goal of treatment is cure, or it can be done in patients who have metastatic disease, where the goal is not cure but to extend survival by reducing disease burden. The latter is called cytoreductive nephrectomy.

Cytoreductive nephrectomy was established as a standard of care based on [the results of] 2 large randomized studies conducted in the United States and Europe, where the standard systemic therapy was interferon. In the era of cytokine-based systemic therapy, cytoreductive nephrectomy extends life. However, we have moved on to other therapies such as tyrosine kinase inhibitors (TKIs), antiangiogenic agents, mTOR inhibitors, and immunotherapy.

In the era of these modern treatments, it is not quite clear if cytoreductive nephrectomy is beneficial. If you ask most urologic surgeons, they still operate the under the assumption that it is beneficial. There are some trials that are directly addressing this question, but those results are not available yet.

Can you discuss the CARMINA and SURTIME trials?

The CARMINA trial has closed enrollment, but we do not know the results yet. This study is looking at the role of cytoreduction in patients with kidney cancer who are receiving sunitinib. It will be very interesting to see what that shows.

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