Kidney cancer: From diagnosis to progression

26 November 2016

Improving diagnosis and mapping out optimal treatment strategies for kidney cancer patients topped the second-day agenda of the 8th European Meeting on Urological Cancers (EMUC16) in Milan, Italy.

The fourth plenary session focused on the challenges in kidney cancer with Antonio Lopez-Beltran (PT), Laurence Albiges (FR) and Alex Bex (NL) chairing the session that covered a range of topics such as active surveillance, the role of nephron-sparing surgery, implications of new pathological findings, follow-up management and metastatic disease.

Speaker Tobias Klatte (AT) presented the case for discussion of a 73-year-old woman with a 3.5cm in the left kidney but with no evidence of metastases, a history of coronary heart disease (bypass), hypertension, fibromyalgia and obesity. Laboratory test results were normal with a creatinine of 0.86 mg/dl. Klatte said he looked for contrast enhancement (21 -76 HU), renal tumour complexity, perinephric fat, among others. Klatte then asked the audience to vote on the following questions, and which elicited the corresponding responses:

1. Would you recommend a renal tumour biopsy?

Yes– 75%

No– 25%

2. What would be your recommendation?

Partial nephrectomy 48%

Radical nephrectomy 19%

Active surveillance 23%

Renal tumour ablation 10%

The audience also responded ‘No’ (85%) to the question ‘Would you do an intra operative frozen section examination?,’ and around 46% said they would recommend abdominal CT/MRI in six months.

In the following presentations by speakers Phillip Peirorazio (USA), Hein Van Poppel (BE), Mahul Amin (USA), Antonio Alcaraz (ES) and Thomas Powles (GB), the issues of active surveillance, partial nephrectomy, pathological implications, follow-up management and treatment of metastatic disease were addressed.

Peirorazio discussed the safety and benefits of active surveillance (AS), patient selection for AS and follow-up care. “Active surveillance remains underutilized,” he said. “Oncologic outcomes from prospective studies indicate AS is non-inferior to primary intervention with intermediate-term follow-up.” He also noted that cancer-specific and metastases-free survival rates are excellent.

“AS is a management option for all patients with cT1a (<4cm) renal tumours and a primary option for elderly patients and for those with tumours less than 2cm,” said Pierorazio. He also mentioned that renal mass biopsy has a role but not essential for AS.

“Imaging intervals and modalities should be individualized,” he added.

Meanwhile, Van Poppel listed the benefits for partial nephrectomy vis-à-vis radical prostatectomy, although noting that the procedure poses technical challenge and requires surgical expertise. He said that preserving renal function is a goal and surgeons should not remove ‘too much healthy parenchyma.”

“We should not resect kidneys if it is safe to do otherwise, and small renal masses (SRMs) will often be amenable for an oncologically and technically safe partial nephrectomy,” said van Poppel. He also said that larger and more complex RCCs can be subjected to elective nephron-sparing surgery. “But this is allowed only if oncologically and technically 100% safe,” he stressed.

Mahul Amin stressed that staging and grading of renal cancer is important, as well as various factors such as histologic type, coagulative tumor necrosis, TNM staging, tumour size and ISUP/Fuhrman nuclear grade, among many others. “Accurate subtyping of renal epithelial tumours is a clinically important exercise,” he reiterated at the end of his presentation.

Antonio Alcaraz examined follow-up care in kidney cancer which he said is “not an easy topic because the science is not of high quality and studies were based on prospective studies.” He underlined the importance of using different imaging frequencies and strategies to reach the goals of good survival, less costs and radiation exposure.

Thomas Powles examined metastatic renal cell carcinoma and posed to the audience the query: “Which agent would you routinely use as first-line therapy?

Audience voting showed majority (64%) favored Sunitunib, 32% for Pazopanib and 4% voted for Cabozantinib. In another query, around 68% say they would not routinely use sunitinib as adjunct therapy in high-risk RCC, with 27% saying they would use some other agents, and 5% saying they would use most of the currently available agents (nivolumab, cabozantanib, axitinib, etc..).

Powles capped his lecture with the thought that there are some combination therapies which may emerged as frontline options in future strategies such as Ipilumumab + nivolumab, bevacizumab + atezolizumab, avelumab + axitinib, pembrolizumab + axitinib, and the combination pembrolizumab + lenvatinib.