The 8th EAU Section of Oncological Urology (ESOU) Meeting held over the weekend in London, United Kingdom, re-examined medical and surgical issues in renal cell cancer with topics covering targeted therapies, focal therapy, laparoscopic nephrectomy, small renal tumours, surgery for caval tumours and emerging trends such as transvaginal NOTES/LESS procedures.
Split in two half-session days, the renal session looked at a minimal invasive procedures such as laparoscopic radical nephrectomy (LRN) . Jean Jacques Patard (Rennes, France) discussed the trend of employing LRN instead of open partial nephrectomy. “The development of laparoscopy in urology is obvious. LRN is potentially less morbid for patients,” said Patard as he noted that open partial nephrectomy and laparoscopic partial nephrectomy (LPN) are technically challenging for surgeons. He also said that although partial nephrectmy (PN) was underused for a long time compared to radical nephrectomy, there is now am increasing use of PN.
Jan Roigas (Berlin, Germany) lectured on the role of biopsy and active surveillance in small renal tumours. “Renal biopsy is increasingly used for patients with small renal tumours. Although it is no standard diagnostic tool for patients with renal masses, it has a distinct meaning in patients with unclear renal masses when conventional imaging techniques such as CT or MRI failed and the question of surgery needs to be answered,” said Roigas. Moreover, Roigas said that although the malignant behaviour of small renal masses is generally low, a stratification model is needed. “Active surveillance and/or watchful waiting are options for selected patients (the elderly and those with co-morbidities),” he added.
Franck Bladou (Marseille, France) gave tips and tricks on laparoscopic/robotic partial nephrectomy. “LPN is emerging as a minimally invasive alternative with comparable oncological outcomes but limited by technical difficulty and learning curve,” said Bladou as he mentioned that the indications for LPH are SRMs less than 4 cm and cortical tumours.
Regarding focal therapy in RCC, Jean De la Rosette (Amsterdam, The Netherlands), said laparoscopic cryoablation and percutaneous RFA are the standard of treatment when focal therapy is the treatment of choice. “The complication rate for both approaches is the same, whereas the laparoscopic approach goes with a longer hospital stay. Both treatments have equal functional outcomes in terms of serum creatinine preservation,” he said.
Meanwhile, Antonio Alcaraz spoke on the possible trends in minimal surgery such as Natural orifice transluminal endoscopic surgery (NOTES) and Laparoendoscopic single site surgery (LESS). He cited the experience of his department at Hospital Clinic, University of Barcelona with NOTES where living kidney donor expressed satisfaction over the outcomes of transvaginal NOTES. “There is still limited data on these procedures, and we have to be careful about overestimating LESS/NOTES,” said Alcaraz whilst pointing out that technical issues in these procedures require further refinement.
In the second renal cancer session, the focus was on targeted therapies and small renal tumours with Tim O`Brien, Geral Mickisch, Tim Eisen, Ziya Kirkali and B`rje Ljungberg giving their views on various medical and surgical strategies in RCC.
In his lecture on “Surgery for caval and atrial tumour thrombus,” O`Brien (London, UK) gave the following practical tips regarding caval surgery:
- Careful review of up to date imaging
- Work with the same team
- Honesty with patients about outcomes
- Mercedes Benz incision is perfect for most cases
- Learn how to mobilise the liver and replace the IVC
- Sternotomy/bypass gives superb access
- The vascular surgery may be the easy bit
- Beware of the decompensating elderly patient
- Patients feel much better but recurrence is common
Mickisch (Bremen, Germany) spoke on the careful assessment of targeted therapies in metastatic renal cell carcinoma (mRCC) within the context of efficacy, patient tolerability and cost effectiveness. Mickisch said a lot of hype has accompanied the advent of so-called targeted therapies in mRCC as he underscored that these drugs remain palliative and not curative. He said that although lifespan in good/intermediate patients has now reached from around three to four years, there is still no change in the natural behaviour of tumour growth.
“Since progression-free survival (PFS) was the primary end point of all registration studies, OS-data are only hypothesis-generating. Due to the cross-over design of sunitinib, bevacizumab + IFN-alpha, or pazopanib pivotal studies there was no statistical significant difference. Both, the Cochran analysis and modern computer simulation models, suggest equivalent efficacy,” said Mickisch. He also emphasised that there are considerable adverse events and a high burden on health care systems. Regarding cost comparisons, Mickisch said it is more useful to look at secondary costs (i.e. costs of treating adverse events) since these are more accurate in a cross-country comparison.
In his concluding remarks, Mickisch said that if used wisely targeted drugs offer value for money, but that intelligent mechanisms of competition or reasonable regulation are needed for cost containment.
Eisen (Cambridge, UK) gave an overview on news and developments presented at the ASMO/ESMO meetings. In his summary, Eisen said there are now good agents available and new agents are on the way. But the ensuing questions are: in which order should these agents be used and how do physicians select the right agent for the patient? Eisen also stressed that there is a need to gain regulatory or funding agency approval for analyses compensating for cross-over. “Furthermore, stratification of patients may allow a study investigating `Trial of Time` approach,” he said.
In the closing debate of the renal cancer session, Kirkali (Izmir, Turkey) and Ljungberg (Umea, Sweden) argued over the EAU Guidelines on managing small renal tumours. The guidelines recommend radical excision, to which Kirkali responded by stating that radical nephrectomy does not protect from metastatic disease and that in elderly or frail patients, active surveillance is more suitable.
“Most of the time these patients die of cofounding causes rather than cancer. In other words, they may not live long enough for cancer to invade and metastasise,” said Kirkali. He also said that the urological community should be more proactive in defining priorities and methodologies to provide scientific evidence in the management of urologic diseases. In defending the EAU Guidelines, Ljungberg stressed that small RCCs can be locally aggressive, can have lymph node metastases or can metastasise. He reiterated that the EAU Guidelines recommend radical nephrectomy in patients when nephron-sparing surgery is not suitable, such as in those with locally advanced growth or unfavourable tumour location.
By: Joel Vega