Surgical Treatment for Metastatic Kidney Cancer

The introduction of systemic targeted therapies and immunotherapies over the last two decades has led to major advancements in the treatment of metastatic renal cell carcinoma. The role of cytoreductive nephrectomy and metastasectomy for patients with metastatic disease has evolved accordingly. Historically, level 1 evidence supported the use of cytoreductive nephrectomy in patients treated with interferon. While retrospective studies suggest cytoreductive nephrectomy may be beneficial in patients treated with targeted therapies, the phase 3 CARMENA trial showed sunitinib alone was not inferior to cytoreductive nephrectomy followed by sunitinib, and the SURTIME trial supported the use of sunitinib prior to cytoreductive nephrectomy. The trials have been criticized for their slow accrual and inclusion of only intermediate- and high-risk patients, highlighting the importance of patient selection for cytoreductive nephrectomy. The role of cytoreductive nephrectomy in patients treated with immunotherapy is still under investigation and will be addressed by the phase 2 NORDIC-SUN and the phase 3 PROBE trials. Retrospective studies involving well-selected patients support the role of metastasectomy; however, these studies are prone to selection bias; thus, the true role of metastasectomy in the immunotherapy era should be further studied.