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Published in Renal Cell Carcinoma

Expert Opinion / Cases · July 03, 2014

Cytoreductive Surgery in Advanced RCC Patient With Lung Mets

Written by
Manjari Pandey MD

 

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  • Sylvia Richey MD

    Sylvia  Richey MD

    Jul 03, 2014

    Now that he has more extensive metastases and he has already had a nephrectomy and resection of a previous lung lesion and progressing on systemic therapy, in my opinion cytoreductive surgery would not be considered an option. Radiation therapy to the acromial metastasis may be reasonable for pain control (even though radiation is not the optimal modality in RCC).
  • Manjari Pandey MD

    Manjari  Pandey MD

    Jul 03, 2014

    Thanks Dr. Richey - I agree. Also, what would be a good choice for second line therapy in this case and how does first line therapy affect the choice of agent used in treating at progression?
  • Bradley Somer MD

    Bradley G. Somer MD

    Jul 03, 2014

    As he has already received treatment with a VEGF TKI, now an mTOR inhibitor like everolimus may be a good option for second line therapy. In the RECORD 1 Trial, everolimus was used compared to placebo for patients with  metastatic RCC who progressed on sunitinib or sorafenib , the primary end point was progression free survival that was significantly prolonged in the everolimus arm ( 4 vs. 1.9 months) Another good  option would be axitinib (NCCN Category 1).

  • Wolfgang Lilleby

    Aug 20, 2014

    Dear doctior Pandey, efficient radiotherapy depends on the size  of the lesions and fraction, so radiotherapy giving stereotactically could be still an option.

  • Sanjay Bangroo

    Aug 20, 2014

    mTOR inhibitor like Everolimus could be a good option.....however counter weightage needs to be given to patients hypertensive and diabetic status. Axitinib might be worth thinking about

  • Nick Antoniou

    Aug 20, 2014

    A second line therapy with everolimus  would be an appropriate choice for this patient although I don't believe it helps much.same as the old interleukin some partial response.thank you very much.
  • Comment deleted by Moderator.

  • Peggy Zuckerman

    Aug 20, 2014

    Rather than considering just additional surgery, would there not be a role for high-dose interleukin, given his general health status, age and limited response to sunitinb?  Perhaps ablation to the largest mets should precede the IL2.

  • YL3DB40N2X52587 YL3DB40N2X52587

    Aug 20, 2014

    A metastasectomy would result in cytoreduction. But whether it improves survival - that is a question that has not yet been adequately studied. A few studies have shown that metastasectomy does improve survival in some patients with advanced renal cell carcinoma. At this point, we still do not have enough information to rule out the benefit of cytoreductive surgery, even in the situation above.

  • franco morelli

    Aug 24, 2014

    In my opinion cytoreductive surgery would not be considered an option. A good chance for second line  therapy in this case may be axitinib.
  • Comment deleted by Moderator.

  • Sandro Cavallero

    Aug 26, 2014

    I agree that Axitinib could be a good choice, but it isn`t approved in Brazil. In this case i'll choose Sorafenib or Everolimus. The Switch trial show us that we can use another VEGFR TKI in second line, and in March 10, Hwang and Heath published at JCO "The judgment of Paris", and there they suggest that patients who used VEGF inhibitor for more than 6m, could use another VEGFR TKI. In this case I'll use Sorafenib in second line. In my opinion cytoreductive surgery would not be considered an option.
  • Manjari Pandey MD

    Manjari  Pandey MD

    Aug 27, 2014

    Thank you for all of your input and sorry for the delay in responding. I'll respond separately to your suggestions...
  • Manjari Pandey MD

    Manjari  Pandey MD

    Aug 27, 2014

    Dr. Lilleby: With his age (55yrs), comorbidities (HTN/DM)  I would be hesitant to use IL2. Further with the availability of the newer agents TKIs, mTOR inhibitors the role of IL2 is less clear, especially in this setting.
  • Manjari Pandey MD

    Manjari  Pandey MD

    Aug 27, 2014

    Dr. Bangroo:  I agree, axitinib will be a reasonable option for him and the choice can be made based on the toxicity profiles of these agents.
  • Manjari Pandey MD

    Manjari  Pandey MD

    Aug 27, 2014

    Dr. Cavallero: That is a good thought, one could consider switching to sorafenib per the results of the SWITCH trial. And now we also have the results of the RECORD-3 trial to guide us, that compared the use of everolimus followed by sunitinib to sunitinib first and then everolimus. This study failed to show non-inferiority of the everolimus followed by sunitinib approach. Basically saying that most likely starting with sunitinib first and switching to everolimus only in the second-line, is the right choice.

  • erich lang

    Aug 27, 2014

    Sorafenib in second line may be the best option

  • 92TW5N19JA75933 92TW5N19JA75933

    Sep 13, 2014

    I think Axitinib the best choice - cytoreductive surgery would not be considered an option and not increases OS - Radiation therapy for pain control

  • Neil Halin

    Nov 28, 2014

    If his acromial lesion is his most symptomatic site, why not consider local ablation of the lesion with cemetoplasty. In this instance either cryo- or heat (pick your modality) could be utilized.

  • Apr 19, 2024

    Pending Moderator approval.
    Delete

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