Ficarra_final_Layout 1 13/10/2009 12:47 Page 46
Renal Cell Carcinoma
therapy with cytokine
31
or vascular endothelial growth factor treatment for their primary tumour. Recently, compelling data
(VEGF)/mammalian target of rapamycin (mTOR) inhibitors.
32
highlighted the possibility of expaning the indication of NSS to
patients with tumours between 4.1 and 7cm in size. In this subgroup
However, some authors suggest the potential use of neoadjuvant of patients, the efficacy of the conservative treatment is strongly
medical therapy in the treatment of mRCC with the aim of reaching a related to the careful selection of patients suitable for this kind of
significant downsizing of the primary tumour and selecting surgery. According to the available guidelines, this option should be
responders who probably would gain more from a subsequent restricted to experienced centres only.
surgery.
33
Waiting for the results of the ongoing randomised controlled
trials, we can consider two points against the neoadjuvant therapy. LPN is a challenging procedure and it should be considered as a
First, the results of the phase III trials using the VEGF/mTOR inhibitors potential alternative to open surgery only in patients with T1a tumours
reported that stable disease was more frequent than partial or and if performed by expert laparoscopists. Laparoscopic radical
complete response, according to Response Evaluation Criteria In Solid nephrectomy should be preferred to open surgery in all T1b–3a
Tumours (RECIST) criteria. This evidence does not support the concept patients. Lymphadenectomy should be reserved only for patients with
of downsizing of the primary tumour. Second, the neoadjuvant use of clinically positive lymph nodes, while it should be omitted in all the
tirosin-chinase inhibitors may significantly increase of the risk of other ones. In the era of multitargeted therapies, surgery retains an
peri-operative complications (bleeding and deep venous or important role in the complementary treatment of patients with good
pulmonary embolisms) due to the interference of these drugs with performance status and metastatic disease. ■
repair mechanisms. Finally, most mRCC patients are symptomatic at
diagnosis and the ablation of the primary tumour can have an
Vincenzo Ficarra is an Associate Professor of Urology at
important palliative effect, allowing optimal control of pain,
the Urology Clinic of the University of Padua. He is a
haematuria and paraneoplastic symptoms. member of the European Association of Urology (EAU),
the Italian Association of Urology (SIU) and the Italian
Conclusions
Association of Andrology (SIA). In 2007, Dr Ficarra was
selected by European Urology as Reviewer of the Year and
Surgical therapy is the only curative approach for the treatment was the winner of the Crystal Matula Award. He is the
of RCC. Elective NSS is the gold standard treatment of small renal
author of 156 papers published in international journals
indexed in Medline.
tumours ≤4cm in size. Consequently, in the last three years more than
50% of patients with RCC have received partial nephrectomy as the
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5. Beldegrun A, Tsui KH, deKernion JB, Smith RB, Efficacy of literature, Eur Urol, 2008;53(4):732–42. with retroperitoneal lymph nodes. Impact on survival and
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based on the new 1997 tumor-node-metastasis staging Partial Nephrectomy with Sliding-Clip Renorrhaphy: 2995–3002.
system, J Clin Oncol, 1999;17(9):2868–75. Technique and Outcomes, Eur Urol, 2009; in press. 28. Motzer RJ, Hutson TE, Tomczak P, et al., Sunitinib versus
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international multicenter experience, J Urol, 2004;171: single-surgeon analysis of >100 consecutive procedures, 29. Escudier B, Pluzanska A, Koralewski P, et al., AVOREN Trial
2181–5. Urology, 2009;73(2):306–10. investigators. Bevacizumab plus interferon alfa-2a for
7. Zini L, Patard JJ, Capitanio U, et al., The use of partial 19. Leibovich BC, Blute ML, Cheville JC, et al., Nephron sparing treatment of metastatic renal cell carcinoma: a
nephrectomy in European tertiary care centers, Eur J Surg surgery for appropriately selected renal cell carcinoma randomised, double-blind phase III trial, Lancet,
Oncol, 2009;35(6):636–42. between 4 and 7 cm results in outcome similar to radical 2007;370(9605):2103–11.
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Association of Urology Guideline Group for renal cell 20. Antonelli A, Cozzoli A, Nicolai M, et al., Nephron-sparing Temsirolimus, interferon alfa, or both for advanced renal
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2007;51(6):1502–10. intracapsular renal cell carcinoma up to 7cm, Eur Urol, 31. Escudier B, Eisen T, Stadler WM, et al., TARGET Study
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1315–18. Nephrectomy with and without Lymph-Node Dissection:
12. Castilla EA, Liou LS, Abrahams NA, et al., Prognostic Final Results of European Organization for Research and
46 EUROPEAN UROLOGICAL REVIEW
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