12th CEM: management issues in renal cell cancer

Management issues in renal cell cancer particularly the role of biopsy, active surveillance, partial nephrectomy and palliative surgery were taken up in the second-day plenary session of the 12th Central European Meeting (CEM) held in Dresden, Germany. Speakers Attila Szendroi (Budapest, HU), Piotr Dubrovnik (Warsaw, PL) Goran Stimac (Zagreb, HR) and Meeting Chairman Manfred Wirth (Dresden, DE) spoke on the challenges encountered in the surgical management of kidney cancer and how recent developments impact decision-making, diagnosis and ultimately the treatment of metastatic disease.

Szendroi discussed the pitfalls in biopsy such as the low negative predictive value, safety issues (I.e. bleeding, tumour cell seeding, etc..), and the lack of impact on treatment decisions, among others. On the other hand, he noted the utility of renal biopsy for small renal masses which have indeterminate characteristics on imaging, and in cases when there are unresectable retroperitoneal tumours. In his concluding remarks, Szendroi highlighted the following:

• There are increasing indications for renal biopsy
• Biopsy is underutilized in clinical practice
• There is a need for standardise patterns
• There is a need to improve accuracy
• Biopsy has a role in molecular and genetic analysis

Meanwhile, Dubrovnik discussed the role of active surveillance in small renal masses (SRMs) and said that current EAU guidelines recommend the initial monitoring of tumour size by serial imaging such as ultrasound, computer tomography (CT) or magnetic resonance imaging (MRI). He also spoke on active treatment upon progression of SRMs, and the expectations on blood/serum markers.

“There are a few promising reports about potential markers in peripheral blood such as CAIX (carbonic anhydrase-g) messenger RNA (mRNA), vascular endothelial growth factor (VEGF) and serum amyloid A (SAA), among others.

In his summary, Dubrovnik said active surveillance is an option for SRMs less than 3cm, and in patients who are unfit for surgery, and those who are young and unwilling to undergo active treatment. And in case of disease progression, the course of management usually are active treatment such as nephron-sparing surgery (NSS), cry ablation and nephrectomy if required.

Regarding the role of partial nephrectomy (PN) for T1b tumors, Goran Stimac said the indications for PN are expanding to larger and more complex tumours. “And we have level 2b evidence supporting PN for T1b tumours,” he added.

On the issue of palliative nephrectomy, Manfred Wirth spoke on the rationale for palliative surgery such as reducing overall tumour burden, reducing the main source of tumour cells and tumour growth factors and reducing immunosuppressant, and, potentially, the activation of natural killer cells.

“Palliative nephrectomy provides clear benefit in good prognosis patients, but patients with poor prognosis and bad performance score do have a limited benefit,” Wirth said, noting that at present there are only observational and retrospective studies in an era of target therapy. He also stressed that prospective, randomised trials are certainly needed.