The role of surgery in renal cell carcinoma
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Now the role of surgery in renal cell carcinoma is a little controversial. I think probably more controversial with me than perhaps with other speakers you may have up here. But certainly in stage I and II radical nephrectomy is the only effective therapy. Regional lymphadenectomy provides no clear survival benefit, although clearly there would be prognostic information gained if the regional lymph nodes were sampled. Especially if more than one lymph node was involved, I think given the natural history of this disease those patients would be stage IV NED if the patient was young and otherwise healthy, you’d have to consider at least potentially treating at that point. Although there is no data yet on that. For stage III, sometimes the tumor can be going up the inferior vena cave and very aggressive surgery, including cardiopulmonary bypass support is indicated in these patients. The presence of vascular thrombi in the inferior vena cava is not necessarily a poor prognostic factor. If you have tumor invasion into the vessel, into the inferior vena cava, that’s a different story. But if you just have clot propagated up the cava, that is not necessarily a poor prognostic factor and these patients do need aggressive surgery.
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For stage IV, the party line is that you do a palliative nephrectomy only for symptoms. I think this is still considered probably to be the standard answer to this question. So if patients are having hematuria or pain, a nephrectomy would be indicated for that. There is some experience in patients who have had resection of solitary, especially pulmonary, metastases that occur a long time after having their initial diagnosis. There is a role for surgery in that situation. I personally believe that these patients in general do better with a nephrectomy than without a nephrectomy. So the urologists love to consult me because I always recommend that patients undergo a nephrectomy. But I do think that in general if the patient is in reasonable health, the nephrectomy is a procedure that, in general, patients recover from fairly quickly. It’s a retroperitoneal dissection. The bowel is not violated and the recovery is usually pretty quick. And especially patients who have a fairly large primary tumor, even if those patients are asymptomatic at the time of presentation and they have metastatic disease, I typically will still recommend that those patients undergo a nephrectomy. I think they are in the best shape that they are going to be in right at that period of time. It’s a cellular bulk disease that you don’t have to contend with later, and if they do become symptomatic, frequently at that point their performance status is so poor that trying to do a nephrectomy at that time is very difficult. There are some people who believe that they respond better to immunotherapy or other treatment regimens if the kidney is out as well. That’s still an open point, but I think that in general I tend to recommend a nephrectomy even in the face of metastatic disease; assuming that the patients are reasonable surgical candidates.
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Now as far as treatment of metastatic disease; I think you are all aware that chemotherapy has little activity, as reported in the literature, in this disease. This is some data that Phil Keebler reviewed a number of years ago and reports the dismal activity of a number of different agents in renal cell carcinoma. There was some activity reported in a small series of patients with FUDR, patients who had been treated with nitrosoureas and vinblastine have response rates of less than 10%. Although these regimens were used a lot when I was in my training. The responses to hormonal therapy, I think, are also dismal. We sometimes will put patients on megestrol for their appetite. But I think that that’s pretty much all you are doing. Again, when I was in training there was some thought that hormones potentially did do something in this disease. The natural history of renal cell carcinoma is extremely variable. In this review that occurred in 1983 there was an overall 8% response rate reported to a variety of different hormonal types of manipulations. I think you have to realize also that the clinical trials methodology back when these studies were conducted is not what it is now. Some of these response rates, I think these response rates even at the 8% level, are unfortunately probably inflated somewhat. So I think that the true response rate is probably closer to half of that … if that.