Expert Point of View: Daniel J. Canter, MD

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Daniel J. Canter, MD

“Cytoreductive nephrectomy is routinely used in metastatic renal cell carcinoma, but its use is not as firmly established in the targeted therapy era. And its use is not without risk,” said formal discussant of the International Metastatatic Renal Cell Carcinoma Database Consortium (IMDC) trial, Daniel J. Canter, MD, at the Genitourinary Cancers Symposium. Dr. Canter is Vice Chairman of the Urologic Institute of Southeastern Pennsylvania and the Department of Urology of the Einstein Healthcare Network, and Associate Professor at the Fox Chase Cancer Center, Philadelphia.

“Perioperative complications may impact patients’ ability to receive adjuvant or systemic therapy,” he noted. “According to two large studies, the perioperative complication rates range from 26% to 31%, and perioperative mortality is 1.5% to 2.4%.”

At Fox Chase, approximately 30% of patients who undergo cytoreductive nephrectomy never receive systemic chemotherapy, usually because of death or rapid disease progression, Dr. Canter continued.

“The procedure carries risk and we need to be careful about patient selection,” he emphasized.

Study Strengths

Dr. Canter cited two strengths of the study reported by Dr. Heng: It represents the largest cohort undergoing cytoreductive nephrectomy to date, and survival was stratified according to IMDC risk status.

Overall survival showed a benefit for cytoreductive nephrectomy, but there was a selection bias, Dr. Canter continued, because the majority of poor-risk patients do not undergo the procedure.

“The take-home message from this study is that we need to make better choices and risk-stratify patients before surgery. Those with zero to three prognostic factors will probably benefit, whereas those with more than three factors will not. By better selection, we can reduce the risk of complications and mortality,” Dr. Canter stated.

Another point he made was that perhaps the IMDC criteria–based risk groups should be redefined. “Poor-risk patients are currently defined as having three or more risk factors, but today’s data show that patients with three risk factors have a benefit from [cytoreductive nephrectomy],” he said. “In addition, considering the data on complication rates would be important for future decision-making.” ■

Disclosure: Dr. Canter reported no potential conflicts of interest.

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