Her first case was of a 72-year-old man who had undergone a left nephrectomy 15 years prior for clear cell renal cell carcinoma (RCC.) His PCP detected microscopic hematuria on routine labs, and eventual upper tract imaging showed a new central renal mass in his remaining kidney. The patient is asymptomatic with no other renal issues. Dr. Maranchie emphasized that to decide what is the right treatment for the patient, one needs to assess his values in priority. He may ask that his team do everything they can to get rid of this cancer, or he may have a strong preference against the risk of dialysis. Therapeutic decision-making must be a shared process.
The second case offered was that of a 58-year-old woman who was admitted with acute diverticulitis, and imaging showed an incidental finding of a 1.7 cm left renal nodule. While amenable to surgical excision, she was initially counseled that monitoring would be reasonable to see if it grows before deciding on surgery. The patient calls back 6 weeks later asking for surgery, as since her diagnosis she has been crippled with anxiety at work and in her personal life by worry about the renal mass. A biopsy ordered by her primary care doctor was non-diagnostic. She underwent surgery, which revealed a small clear cell renal cell carcinoma, and her quality of life was drastically improved.
The final case was that of a 55-year-old man who presented with stabbing left flank pain, gross hematuria, and a 20-pound weight loss. He was remaining active, standing on his feet 10 hours a day for work. Imaging showed a large left renal mass and sub-centimeter pulmonary nodules. His renal mass was still in situ when he presented for consultation as his consulting oncologist felt cytoreductive nephrectomy had no role in management per the CARMENA study. Dr. Maranchie noted that the CARMENA study only measured quantity of life and not quality of life changes with nephrectomy. She did not discuss the ongoing debate surrounding the utility of cytoreductive nephrectomy but did discuss that patients with good performance status often enjoy a significant symptomatic improvement after tumor debulking. She cited a study from Larcher and colleagues1 which assessed the tradeoff between symptomatic improvement and perioperative morbidity in patients with metastatic RCC who underwent cytoreductive nephrectomy. The study authors found that approximately two-thirds of patients with mRCC suffer from disease-related symptoms and that 91% of these complaints completely resolved, with 95% of complaints improving, with surgery. This was balanced against a 37% rate of any complication, and a 10% rate of major complication. The presence of symptoms was not associated with risk of complication after nephrectomy.
Dr. Maranchie concluded that more work is needed to develop a more holistic way to determine the benefits of treatment in addition to looking at quantity of life.
Presented by: Jodi Maranchie, MD, Associate Professor, University of Pittsburgh School of Medicine
Written by: Alok Tewari, MD, PhD, Medical Oncologist at the Dana-Farber Cancer Institute, during the 2021 American Society of Clinical Oncology Genitourinary Cancers Symposium (#GU21), February 11th-February 13th, 2021
References:
- Larcher A, Fallara G, Rosiello G et al. "Cytoreductive Nephrectomy in Metastatic Patients with Signs or Symptoms: Implications for Renal Cell Carcinoma Guidelines." European Urology. 2020.78, 3, 321-326.