Psutka Sarah P, Chang Steven L, Cahn David, Uzzo Robert G, McGregor Bradley A
1 Department of Urology, University of Washington, Seattle, WA.
2 Brigham and Women's Hospital, Boston, MA.
Am Soc Clin Oncol Educ Book. 2019 Jan;39:276-283. doi: 10.1200/EDBK_237453. Epub 2019 May 17.
Cytoreductive nephrectomy (CRN) has long been considered a standard of care in the management of mRCC. This is largely based on randomized trials in the era of interferon (IFN) that demonstrate an improvement in overall survival (OS). With the advent of targeted therapies, the role of CRN has been questioned and multiple retrospective analyses have shown a potential benefit, particularly in intermediate-risk disease. Two long-awaited prospective trials have been published in the past year that explore the role of CRN. The CARMENA trial randomly assigned patients to therapy with sunitinib with or without CRN, showing noninferiority of sunitinib alone versus sunitinib plus CRN with a median OS of 18.4 months versus 13.9 months, respectively (hazard ratio [HR] for mortality, 0.89; 95% CI, 0.71-1.1). The SURTIME trial randomly assigned patients to immediate CRN followed by sunitinib versus a deferred CRN after three cycles of sunitinib. Analysis is limited by early termination as a result of low accrual. Although there was no difference in progression-free survival (PFS), median OS was significantly improved among patients in the deferred CRN arm (HR, 0.57; 95% CI, 0.34-0.95; p = .032). Early systemic therapy is paramount, but there are patients who may derive benefit by incorporating the removal of the primary tumor in their multimodal therapy, perhaps in a deferred setting. As systemic treatment paradigms shift and immunotherapy again moves to the frontline setting with the potential for novel therapeutic approaches, the role of CRN will continue to evolve with the potential to offer surgical interventions with minimal, if any, delay in systemic treatment.
减瘤性肾切除术（CRN）长期以来一直被视为转移性肾细胞癌（mRCC）治疗的标准方法。这主要基于干扰素（IFN）时代的随机试验，这些试验证明总生存期（OS）有所改善。随着靶向治疗的出现，CRN的作用受到质疑，多项回顾性分析显示了其潜在益处，特别是在中危疾病中。在过去一年中发表了两项期待已久的前瞻性试验，探讨了CRN的作用。CARMENA试验将患者随机分配接受舒尼替尼治疗，无论是否进行CRN，结果显示单独使用舒尼替尼与舒尼替尼加CRN的疗效相当，中位OS分别为18.4个月和13.9个月（死亡风险比[HR]为0.89；95%CI，0.71-1.1）。SURTIME试验将患者随机分配接受立即CRN后再接受舒尼替尼治疗，或在接受三个周期舒尼替尼治疗后延迟CRN。由于入组率低导致早期终止，分析受到限制。尽管无进展生存期（PFS）没有差异，但延迟CRN组患者的中位OS显著改善（HR，0.57；95%CI，0.34-0.95；p = 0.032）。早期全身治疗至关重要，但有些患者可能通过在多模式治疗中加入原发性肿瘤切除术而获益，或许是在延迟治疗的情况下。随着全身治疗模式的转变以及免疫疗法再次成为一线治疗方法并有可能采用新的治疗方法，CRN的作用将继续演变，有可能在全身治疗延迟最小（如果有的话）的情况下提供手术干预。
