Conclusiones y recomendaciones
7. CONCLUSIONES Y RECOMENDACIONES
11.3. ANEXO 3 LISTADO DE CENTROS HOSPITALARIOS INCLUIDOS
Prior to the cytokine era (the use of IL-2 and interferon alpha) cytoreductive nephrectomy (CN) was used primarily for palliation of symptoms; primarily bleeding and pain. There was the occasional regression of metastatic disease when the primary tumor was removed. The following study by Tufts University was the first to evaluate the role of CN in patients
undergoing systemic therapy with IL-2. Subsequent studies indicated that patients treated with existent systemic cytokine therapies did better if CN had been
previously undertaken. A 2001 UCLA study observed that if better systemic therapies were available better benefits could be expected. Today we have “better” systemic
therapies, but we lack any level one evidence for the continued use of CN in
advanced disease followed by TKI therapy.
2014 NCCN guidelines for stage IV state that for potentially surgically resectable primary with multiple metastatic sites… Cytoreductive nephrectomy in select patients prior to systemic therapy is acceptable.
Patients over 75 tend not to have surgery and surprisingly, African- Americans are much less likely to undergo surgery than other races. For each one-year increase in age in the SEER database of cytoreductive
nephrectomy there is a 5% decrease in the amount of surgeries. Unpublished data accumulated by Dr. Culp suggests
that despite the increasing use of targeted therapies the percentage of CN has been fairly stable.
Cytoreductive
Nephrectomy
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M.D.,
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H.D.
University of Virginia Charlottesville, VAThirteenth Annual International Kidney Cancer Symposium – 2014 Graff, Derr, Lawing 43
Some studies have shown that a patient undergoing CN and then taking TKI therapy has a 40% decrease in risk of death versus TKI therapy alone. However, CN is not for everyone;
retrospective studies of patients with poor performance status demonstrate virtually no benefits.
This slide shows almost all of the poor prognostic factors in advanced or metastatic RCC. While it is not one factor other than performance status that determines benefit, it is the additive nature of poor prognostic factors that translates to decreased patient survival.
The greatest benefit of CN is in patients who are expected to survive more than 12 months. In follow-up discussion Dr. José Karam pointed out that doctors often struggle in continuing with existing standards of care when the data has changed. However, in this situation the lack of evidence is not evidence that CN should not be performed; the procedure should still be utilized for carefully selected patients.
Thirteenth Annual International Kidney Cancer Symposium – 2014 Graff, Derr, Lawing 44
E
ach year since 2009 a keynote lecture in honor of Dr. Andrew C Novick (1948-2008) has been given at the International Kidney Cancer Symposium. The lecture is given by the recipient of the Andrew C Novick Award for that year; additionally, an award of $10,000 is made on behalf of the recipient by the Kidney Cancer Association to support the research of a young investigator through the Urology Care Foundation of the American Urological Association.Dr. Andrew C. Novick was chairman of the Glickman Institute of the Cleveland Clinic. Known worldwide for his dedication and contributions to kidney cancer research and innovative surgical procedures, he pioneered the use of ice baths in surgery to preserve kidney function. His expertise in treating kidney cancers and the use of nephron sparing surgery has been credited with giving many patients longer lives. These procedures are now used regularly on a worldwide basis. Dr. Drogo Montague of the Cleveland Clinic said in an interview in 2008 that Dr. Novick had “technically the best hands anyone had ever seen”.
A report of his death which appeared in the Cleveland Plain Dealer in October 2008 received many comments from readers; excerpts of a few of those comments follow.
I really believe that Dr. Novick saved my life 12 years ago by removing my cancerous kidney and lymph nodes. I am fortunate that I was able to be his patient…
… I would most likely not be alive today if it were not for Dr. Novick. He performed renal surgery on my kidney in 1988.I traveled to the Cleveland Clinic from Florida… Dr. Novick saved my husband's life in 2005 by performing partial nephrectomies on both kidneys. His passion for his work and for his family were exemplary. He adored [his family] and talked about them with such great love every time we saw him. I will be forever grateful for his pioneering expertise in the urological field. And I will miss his gentle demeanor, his kindness and his friendship.
The KCA is pleased to present Dr. Brad Leibovich of the Mayo Clinic this prestigious award in recognition of his work, service and dedication to his patients and the entire kidney cancer community.
Thirteenth Annual International Kidney Cancer Symposium – 2014 Graff, Derr, Lawing 45
25 patients with metastatic cancer treated with LAK and IL-2
Partial Response in 11/25 patients
1 Complete Response in melanoma
3 cases of mRCC
all with Partial Response
In his presentation Dr. Leibovich marked many of the milestones in the field of kidney cancer framed against milestones in his life during that same period. Below are some examples:
About the time I was born in 1967 there was a leap in the survival of kidney cancer as the procedure of radical nephrectomy pioneered by Dr. Charles Robson gained widespread acceptance and some other advances in surgical care took place.
When I graduated from high school in 1985 cross- sectional imaging was becoming more widely available, my future colleagues at Mayo Clinic were reporting on partial nephrectomies, and it was the beginning of an exciting time for immunotherapy in kidney cancer as work in the use of lymphokine-activated killer cells and interleukin-2 began.