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    Practice Pearls: Renal Cell Carcinoma

    Practice Pearl
    Welcome to MDCalc’s Practice Pearls: Renal Cell Carcinoma. RCC management is rapidly evolving, with newer treatment paradigms replacing the old, novel surgical techniques, new indications for biopsy, broader treatment options for metastatic disease, and beyond. We’ve boiled it down to the following high-yield areas:
    • Controversies: Outlines of key debates in current RCC management and the evidence behind them, as well as the latest in basic science and surgical techniques.
    • Guidelines: MDCalc-ified versions of standard practice guidelines at a glance, starting with NCCN and AUA recommendations for follow-up in RCC.
    • Quick Tips: Basics of RCC workup for the nonspecialist, including what labs to order, when to refer, when to obtain a bone scan, and more.
    • Evidence Summaries: The clinical bottom lines from the latest high-impact studies in the literature.
    Controversies
    Guidelines
    Quick Tips
    Evidence Summaries

    With the increasing volume of literature being published daily, it’s impossible to keep up with every paper, let alone figure out what’s clinically relevant. Our Evidence Summaries boil down the latest research to the clinical bottom line, in an easily digestible Q&A format. Think of it as the abstract... of the abstract.

    StudyClinical Bottom Line
    Haifler et al, J Urol, Sept 2017

    Q: Does tumor contact surface area (CSA, 2 × π × radius × depth) calculated from pre-op cross-sectional imaging predict post-op renal function in patients undergoing partial nephrectomy for RCC?

    A: Yes, and perhaps better than the RENAL Score (identifies >20% postoperative decline in eGFR with AUC 0.94, vs. 0.80 for RENAL Score).

    Haas et al, JAMA Oncol, Sept 2017

    Q: Does adjuvant therapy with sunitinib or sorafenib improve disease-free survival in patients with high-risk (≥pT3 or node-positive) clear cell RCC?

    A: No. 5-year disease-free survival rates were no different from placebo (sunitinib 47.7%, sorafenib 49.9%, placebo 50.0%).

    Nini et al, Eur Urol, Sept 2017

    Q: What is perioperative and long-term survival in patients undergoing radical nephrectomy and caval thrombectomy for RCC with IVC thrombus?

    A: In a retrospective study for 46 patients, 30-day mortality was 11%. Cancer-specific mortality free survival was 77% at 1 year and 56% at 3 years.

    Cirkel et al, JAMA Oncol, April 2017

    Q: In patients with metastatic clear cell RCC, does alternating pazopanib/everolimus improve survival and/or quality of life as compared with pazopanib monotherapy?

    A: No, neither. PFS (median) was 7.4 months with pazopanib/everolimus and 9.4 months with pazopanib alone, and mucositis, anorexia, and dizziness were more common in the pazopanib/everolimus arm.

    Parker et al, Eur Urol, April 2017

    Q: Is the SSIGN Score, originally derived in patients from as early as 1970 undergoing radical nephrectomy, still relevant in the contemporary era of partial nephrectomy?

    A: Yes. Increasing SSIGN Score still predicts death from RCC (HR 1.40, p<0.001).

    Research PaperHaifler M, Ristau BT, Higgins AM, et al. External Validation of Contact Surface Area as a Predictor of Post-Operative Renal Function in Patients Undergoing Partial Nephrectomy. J Urol. 2017;Research PaperHaas NB, Manola J, Dutcher JP, et al. Adjuvant Treatment for High-Risk Clear Cell Renal Cancer: Updated Results of a High-Risk Subset of the ASSURE Randomized Trial. JAMA Oncol. 2017;3(9):1249-1252.Research PaperNini A, Capitanio U, Larcher A, et al. Perioperative and Oncologic Outcomes of Nephrectomy and Caval Thrombectomy Using Extracorporeal Circulation and Deep Hypothermic Circulatory Arrest for Renal Cell Carcinoma Invading the Supradiaphragmatic Inferior Vena Cava and/or Right Atrium. Eur Urol. 2017;Research PaperCirkel GA, Hamberg P, Sleijfer S, et al. Alternating Treatment With Pazopanib and Everolimus vs Continuous Pazopanib to Delay Disease Progression in Patients With Metastatic Clear Cell Renal Cell Cancer: The ROPETAR Randomized Clinical Trial. JAMA Oncol. 2017;3(4):501-508.Research PaperParker WP, Cheville JC, Frank I, et al. Application of the Stage, Size, Grade, and Necrosis (SSIGN) Score for Clear Cell Renal Cell Carcinoma in Contemporary Patients. Eur Urol. 2017;71(4):665-673.