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Abstract

Our study affirms the role of cytoreductive nephrectomy (CRN) in the setting of multimodal treatment of metastatic renal cell carcinoma (mRCC) in the targeted-therapy era. Indeed, although complete resection of metastatic disease at presentation may still represent the best approach in selected patients, 1 Alt A.L. Boorjian S.A. Lohse C.M. et al. Survival after complete surgical resection of multiple metastases from renal cell carcinoma. Cancer. 2011; 117: 2873-2882 Crossref PubMed Scopus (290) Google Scholar our study lends further support to a strategy that incorporates an up-front antiangiogenic challenge to patients with mRCC who are not amenable to a combination of CRN and complete metastectomy, the benefit of which is to avoid unnecessary surgery in patients with progressive metastatic disease. 2 Wood C.G. Margulis V. Neoadjuvant (presurgical) therapy for renal cell carcinoma: a new treatment paradigm for locally advanced and metastatic disease. Cancer. 2009; 115: 2355-2360 Crossref PubMed Scopus (57) Google Scholar This strategy is not without risk however, and the significant degree of toxicity associated with targeted agents, the potential for treatment-related delays and surgical morbidity, and the paucity 3 Hellenthal J. Underwood W. Penetrante R. et al. Prospective clinical trial of preoperative sunitinib in patients with renal cell carcinoma. J Urol. 2010; 184: 859-864 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar of high-level evidence supporting the approach are legitimate concerns. We look forward to the results of ongoing randomized trials being conducted by European Organisation for Research and Treatment of Cancer and the Assistance Publique-Hôpitaux de Paris, which should provide further insight regarding timing of CRN and systemic therapy, 4 Haanen JBAG, Bex A. European Organization for Research and Treatment of Cancer - EORTC. Randomized phase III trial comparing immediate versus deferred nephrectomy in patients with synchronous metastatic renal cell carcinoma. NLM Identifier: NCT01099423. ClinicalTrials.gov. Bethesda (MD): National Library of Medicine (US). Available at: http://clinicaltrials.gov/ct2/show/NCT01099423. Accessed July 22, 2012. Google Scholar , 5 Mejean A. Assistance Publique - Hôpitaux de Paris; Pfizer. Clinical Trial to Assess the Importance of Nephrectomy (CARMENA). NLM Identifier: NCT00930033. ClinicalTrials.gov. Bethesda (MD): National Library of Medicine (US). Available at: http://clinicaltrials.gov/ct2/show/NCT00930033. Accessed July 22, 2012. Google Scholar and we call for further randomized prospective investigation to evaluate the role of CRN and optimal agents(s) for primary targeted therapy for mRCC. Editorial CommentUrologyVol. 81Issue 4PreviewThis retrospective outcome analysis in a relatively small cohort of patients shows that patients with metastatic clear cell renal cell carcinoma (RCC), treated with neoadjuvant sunitinib tyrosine kinase inhibitor (TKI) therapy, followed by cytoreductive nephrectomy (CRN), fared significantly better than those treated with by CRN, followed by adjuvant TKI therapy, whereas patients who received TKI without CRN had a very grim outcome. Specifically, they observed that responders to neoadjuvant TKI therapy who underwent CRN had better disease-specific survival and overall survival than patients who underwent CRN, followed by adjuvant TKI therapy. Full-Text PDF