OncoLog, Volume 57, Number 5, May 2012 Page: 4
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hibitors. "Whereas conventional cytotoxic chemotherapy
targets the tumor cells, the anti-VEGF agents target the
microenvironment-the milieu in which they grow," said
Nizar M. Tannir, M.D., an associate professor in and deputy
chair of the Department of Genitourinary Medical Oncology.
The targeted agents are easier to administer (many are
oral agents) and have fewer side effects than traditional
immunotherapies. According to Surena E Matin, M.D., an
associate professor in the Department of Urology, the advent
of these new agents has changed the paradigm for the treat-
ment of advanced kidney cancers. "The old approach was
to remove the kidney first, even in patients with metastatic
disease," he said, "but the new classes of medicines available
today are changing that, and we have more options."
Treatment options
The standard treatment options for patients who present
with metastatic RCC are nephrectomy and metastasectomy,
cytoreductive surgery followed by systemic therapy, or first-
line systemic therapy.
The approach for an individual patient is best determined
by a multidisciplinary team in which medical and surgical
oncologists collaborate to weigh the many factors to be con-
sidered.
Surgery
Among the first tasks in weighing a patient's treatment
options are to assess whether the disease is resectable and to
determine the patient's ability to tolerate surgery. Resect-
ability depends largely on the location and distribution of
primary and metastatic disease. Dr. Matin said that surgery to
excise disease (nephrectomy and metastasectomy) is a rea-
sonable consideration for a patient whose disease is primarily
in the kidney with a small metastatic burden-perhaps a soli-
tary metastatic lesion-or for a patient who presents with a
solitary metastasis after a previous nephrectomy. Conversely,
a patient with a small primary tumor and a larger metastatic
burden-perhaps multifocal metastases-is less likely to ben-
efit from surgery.
Additional considerations can help identify patients who
will benefit from surgery and spare others from an ineffectual
operation. The following risk factors-which were identified
in a study led by Christopher Wood, M.D., a professor in and
deputy chair of the Department of Urology-indicate that
surgery is not likely to help, as survival outcomes are about
the same for patients with more than three of these factors
regardless of whether the patients do or do not undergo sur-
gery:
* symptoms from metastases,
* elevated lactate dehydrogenase (LDH) levels,
* metastases in the liver,
* retroperitoneal lymph node involvement,
* supradiaphragmatic lymph node involvement, or
* a locally advanced primary tumor.
For some patients, nephrectomy may be indicated toalleviate symptoms, notably pain and
hematuria.
Patients with potentially
resectable primary tumors and multi-
focal resectable metastases may bene-
fit from cytoreductive surgery fol-
lowed by systemic therapy. Cyto-
reductive surgery became part of the
therapeutic regimen for metastatic
renal cancers with the advent of
immunotherapies in the early 1990s.
According to Dr. Wood, the
cytoreductive surgery involves the
removal of as much tumor-bearing
tissue as possible, including that at
the primary site, lymph nodes, and
metastases.
Studies of cytoreductive surgery fol-
lowed by immunotherapy showed that
while not all patients benefited, some
had a clear survival benefit, and crite-CONTRIBUTING FACULTY, TI
Eric Jonasch, M.D.
Associate Professor,
Genitourinary
Medical Oncology
METASTATIC RENAA
DIAGNOSIS
Metastatic
Renal Cell
Carcinomaria to select candidates for this treatment emerged. These cri-
teria are good performance status; the presence of clear cell
histology; the absence of brain, liver, or bone metastases; and
the absence of sarcomatoid features.
Postoperative systemic therapy
Despite the advent of targeted agents, high-dose IL-2
therapy (preceded by cytoreductive surgery) remains the only
known cure for metastatic RCC. Because of the rigor and
toxicity of this treatment course, however, it must be used
judiciously in carefully selected patients. Although only a
small percentage of patients will be able to receive this treat-
ment, it is important to identify potential candidates before
any other agents are administered because studies indicate
that the benefit is less and the toxicity may be higher for
patients who have received targeted therapies prior to IL-2
than for those who have not. The selection criteria for IL-2
treatment are a good performance status without significant
comorbidities, clear cell histology, and adequate risk scores.
The two risk scoring systems most often used by clinicians
to direct RCC therapy are the Memorial Sloan-Kettering
Cancer Center (MSKCC) and the University of California
Los Angeles Survival after Nephrectomy and Immunother-
apy scales. The widely used MSKCC risk score takes into
account the patient's performance status, the length of time
from initial diagnosis of RCC to initiation of therapy, and
serum LDH, hemoglobin, and calcium levels to stratify pa-
tients as having favorable, intermediate, or poor risk. In addi-
tion to these factors, the patient's attitude toward risk must
be addressed and taken into account when high-dose IL-2
therapy is considered.
For patients who are not candidates for high-dose IL-2
therapy, postoperative systemic therapy options include the
newer targeted agents.4 OncoLog * May 2012
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University of Texas M.D. Anderson Cancer Center. OncoLog, Volume 57, Number 5, May 2012, periodical, May 2012; Houston, Texas. (https://texashistory.unt.edu/ark:/67531/metapth639680/m1/4/: accessed July 12, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.