Optimal approach for renal cancer

In the European Union there are some 84,400 new cases of kidney cancer with 34,700 deaths yearly [1]. With increasing knowledge of the mechanisms that drive renal cancer biology and the development of agents that target angiogenesis, growth and metastases, hope has been given to patients with this disease. Enormous progress has been made in the last few years for patients with advanced and metastatic renal cell cancer (RCC). Since the era of cytokine therapy, overall survival has now doubled, with the approval of many new agents targeting cell signalling pathways. Six agents which target either the vascular endothelial growth factor (VEGF) pathway or the mammalian target of rapamycin (mTOR) pathway have been developed and approved for use in advanced and metastatic RCC. Increasing knowledge of how to actively manage the side effects of these agents has also greatly added to improving survival. In addition, the realistic hope of novel treatments – such as novel immunotherapy (anti-programmed cell death protein 1 (PD-1), anti-programmed cell death 1 ligand (PD-1L) and inhibition of fibroblast growth factor receptor (FGFR) – may also add to our therapeutic armamentarium. Improvements in surgical techniques have likewise been important. Notably, cytoreductive nephrectomy remains the standard of care as compared with drug treatment alone, although trials addressing this question are ongoing. Metastasectomy has become common practice, as local therapy of metastases can often be integral to the treatment of metastatic RCC. Surgical resection has traditionally been the preferred approach to metastasectomy, but recent data on stereotactic radiosurgery (SRS) indicate that this treatment modality is a valuable non-invasive alternative. Definite guidelines for surgery of metastatic lesions do not exist, but recommendations can be made. The available evidence for common metastatic sites will be reviewed, including metastasectomy following targeted therapy and non-invasive approaches such as SRS. This educational section comprises four excellent presentations that review factors which guide treatment selection, the algorithm for advanced RCC from first- to third-line therapies, proper sequencing, novel immunotherapy and details of how therapy may be individualised and surgery integrated in the optimal approach for renal cancer.