Page 6 - Kidney Cancer Research Network of Canada (KCRNC) consensus statement on the role of cytoreductive nephrectomy for patients with metastatic renal cell carcinoma

CUAJ – Consensus Statement Mason et al
KCRNC consensus: Cytoreductive nephrectomy for mRCC

In patients with a good performance status (ECOG >1 or KPS < 80), no systemic
symptoms, a primary tumor that is deemed resectable, and a limited burden of metastatic
disease, we recommend offering upfront CN. Following CN, a period of surveillance or
metastases directed therapy may be considered in patients with minimal residual
disease[47]. In patients with multiple metastatic deposits remaining, systemic therapy
should be initiated after CN.
Conversely, in patients with significant systemic symptoms from metastatic disease,
active central nervous system metastases, a limited burden of disease within the kidney
relative to the volume of metastases, rapidly progressing disease, a poor performance
status (ECOG >1 or KPS < 80%), and/or a limited life expectancy, we recommend
against performing CN. If a patient’s clinical condition improves, the role of CN can be
revisited.
For patients with mRCC who do not fall into one of these two groups, we recommend
initial treatment with systemic therapy before consideration of CN. For these patients the
duration of therapy before proceeding to CN remains uncertain but CN should ideally be
considered in the setting of a complete response or meaningful partial response.
In addition to these recommendations, we suggest clinicians take into account a
patient’s age, general health status, and competing health risks when making decisions
regarding the role of CN, as these are surrogate markers of overall survival. Finally,
although formal recommendations cannot be made based on the available evidence, the
complexity of surgery and the potential for increased morbidity due to anatomic factors
(e.g. venous thrombectomy, resection of surrounding organs) should also be considered.
The Consensus Panel also recognized that nephrectomy may provide a purely
palliative benefit in select patients with severe symptoms from their primary tumor (e.g.
intractable hematuria, paraneoplastic syndromes with majority of tumor burden within
the kidney). Decisions regarding surgery in these patients should be individualized, and
general recommendations regarding such scenarios cannot be made.

Special considerations

Is there a role for cytoreductive nephrectomy in patients with non-clear cell metastatic
renal cell carcinoma?

1. Patients with non-clear cell mRCC should be offered CN with similar
considerations to those with clear cell mRCC.

The majority of available data on CN pertain to patients with clear cell histology, and
thus whether CN provides a survival advantage for appropriately selected patients with
non-clear cell mRCC remains uncertain. Of note, the two aforementioned trials of