Management of Locally Advanced Kidney Cancer

In this episode of BackTable Urology, Dr. Vitaly Margulis, professor of urology at UT Southwestern Medical Center, joins Dr. Aditya Bagrodia in a thorough discussion about locally advanced kidney cancer.

First, the doctors classify locally advanced kidney cancers and discuss various imaging modalities used in staging this type of cancer. Dr. Margulis uses MRI, chest CT, and direct radiographic imaging to visualize patient anatomy. He notes that PET scans have a very limited role in staging.

Although extensive metastasis is not present in locally advanced kidney cancer, small metastases--such as pulmonary nodules and small pancreatic/liver metastases--may be present. In these cases, Dr. Margulis emphasizes the importance of collaboration with interventional radiologists to choose the optimal site to biopsy, as biopsy can trigger a hemorrhage of the primary tumor site. He notes that the easiest site to access may not be the best site to biopsy.

Next, Dr. Margulis discusses pros and cons of the two broad types of general systemic therapy: targeted therapy and checkpoint inhibitors. In his clinical practice, he uses a combination of both therapies and continues until the maximal response is reached. He notes that pseudoprogression, or the process of the tumor initially swelling and then shrinking, may be possible.

Furthermore, Dr. Margulis discusses general surgical considerations for other types of locally advanced kidney cancers, such as the necessity of performing a lymph node dissection and whether to take an open or robotic surgical approach. Dr. Margulis also shares special surgical considerations in locally advanced kidney cancers that cause the formation of a tumor-thrombus. He first categorizes these thrombi into two categories--bland thrombus vs. pulmonary emboli--and explains how they can make surgical intervention more complicated. When operating on these cases, he always has a multidisciplinary team with echocardiogram capabilities.

Finally, he shares his clinical opinions about neoadjuvant and adjuvant therapies, two new approaches to locally advanced kidney cancer. He notes that neoadjuvant therapy may be useful, as it can shrink the primary tumor pre-operatively, but he does not use post-operative adjuvant therapy because of its inability to increase survival rates. However, he notes that using checkpoint inhibitors in an adjuvant setting may improve outcomes.