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A 55-year-old woman in excellent overall health underwent a CT urogram for evaluation of gross hematuria. Imaging demonstrates a 13 cm left renal mass extending into the left renal vein.
The patient had no significant comorbidies and had excellent renal function with a creatinine level of 0.7 mg/dL and a calculated glomerular filtration rate (using the MDRD study equation) of 92 mL/min/1.73m2.
Cross-sectional imaging of the chest revealed several pulmonary nodules consistent with metastatic disease.
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Two prospective randomized clinical trials showed a survival benefit for patients with metastatic RCC treated with nephrectomy followed by interferon vs. patients who received interferon alone.
Since, FDA approval of new therapies that target angiogenic pathways has improved survival in patients with metastatic renal cell carcinoma from about 10 to more than 24 months. The survival advantage for cytoreductive nephrectomy in conjunction with targeted therapies has not yet been confirmed; however, the overwhelming majority of patients enrolled in the phase 2-3 studies, which evaluated the role of targeted agents in metastatic RCC, had undergone previous nephrectomy. Thus, the multimodal approach of cytoreductive nephrectomy followed by systemic treatment has been extrapolated to the era of targeted therapy.
Currently, the international ADAPT trial (Phase 3 Randomized, Study of Autologous Dendritic Cell Immunotherapy (AGS-003) Plus Standard Treatment versus Standard Treatment Alone for Advanced RCC) is enrolling patients eligible for cytoreductive nephrectomy. The trial is supported by the Society of Urologic Oncology Clinical Trials Consortium and is enrolling patients at kidney cancer centers of excellence.
Answer: Cytoreductive radical nephrectomy should be strongly considered
This case was prepared by Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia.
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