Abstract
The targeted therapy of metastatic renal cell carcinoma (mRCC) was introduced 2006 and it has changed to a certain degree even surgical management of RCC. The purpose of this article is to summarize an integration of surgical and targeted therapy of mRCC.
The targeted therapy consists of 3 groups of drugs: tyrosine kinase (TK) inhibitors (sorafenib, pazopanib), mammalian target of rapamycin () inhibitors (temsirolimus a everolimus) and monoclonal antibiodies of VEGF (bevacizumab). We have evaluated available information gained especially from PubMed.
The majority of knowledge is concerned with sunitinib. The profit of a cytoreductive nephrectomy (CRNE) was proven during the period of cytokines.
In targeted therapy period, we haven't got results of ongoing prospective randomized trials yet, but some partial information from other trials show a possible profit of CRNE and targeted therapy. There are still no results about neoadjuvant and adjuvant therapy indication, some trials are ongoing.
The downsizing of inoperable tumour can be anticipated only in 30% of patients after 2-3 cycles. The CRNE is still indicated for patients in a good performance status.
Laparoscopic approach is well accepted. Nephron-sparing surgery is sufficient, if technically possible.
Insufficient effect of CRNE is in bad performance status patients, high-risk tumours, tumours > T3, liver metastases, symptomatic metastases, retroperitoneal and mediastinal lymph nodes involvement, LDH elevation and albumin decline. The preoperative downsizing of tumour using targeted therapy is indicated only in selected patients.
Neoadjuvant and adjuvant therapy are for the present purposes of clinical trials without indication in clinical practice. The preoperative withdrawal of TK inhibitor is recommended 24 hours at least, postoperative reuse minimally after 4 weeks.
Bevacizumab is necessary to withdraw minimally 4 weeks preoperatively.