Editorial Comment on Combination of an Antivascular Endothelial Growth Factor Tyrosine Kinase Inhibitor and Immunotherapy as a Neoadjuvant Approach in Renal Cell Carcinoma With Associated IVC Tumor Thrombus: A Single-Center Experience and Review of Literature
Year: 2023
Type: editorial
Abstract: Surgical management of renal cell carcinoma (RCC) with associated tumor thrombus (TT) is one of the most challenging and morbid surgeries in urology. The extent of TT increases the complexity of surgery and affects outcomes.1 Treatment modalities such as angioembolization and systemic therapies have been used to facilitate thrombus shrinkage to help decrease surgical morbidity and improve perioperative outcomes associated with nephrectomy with IVC tumor thrombectomy. The authors present a retrospective case series of 5 patients with RCC and TT who underwent a combination of neoadjuvant anti-VEGF TKI and checkpoint inhibitor.2 Eighty percent of patients had TT shrinkage, with a Mayo Classification grading reduction in 2 patients. Four of 5 patients underwent surgery, and 2 patients experienced major perioperative complications. One patient was ultimately made inoperable because of toxicities of systemic therapy. Despite the small sample size and retrospective nature of this study, the authors address important topics in the management of RCC with TT. Shrinkage of a TT to a lower level can dramatically improve the safety and technical considerations during surgery, and there remains a critical need for effective neoadjuvant treatments to assist with TT downstaging. Techniques used to achieve TT reduction, including angioembolization and systemic therapy with immunotherapy and targeted agents, are associated with notable adverse effects. Angioembolization can cause pain, fevers, and inflammation that can make surgical extirpation more difficult. Immunotherapy and targeted agents harbor significant risk of serious adverse effects.3,4 Although the authors found TT size reduction in all patients, this study raises concerns about systemic therapy toxicities preventing patients from undergoing definitive surgery. As experience with neoadjuvant treatments grow, we must carefully monitor and weigh the tradeoffs between improving morbidity and outcomes of surgery for most patients while also rendering some patients inoperable secondary to systemic therapy side effects or disease progression.
Source: JU Open Plus
Authors: Emily Bochner, Xiaosong Meng
Institution: The University of Texas Southwestern Medical Center
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4388564998