Panel Discusses Other RCC Treatment Options: Radiation Techniques, Surgery, and More

A roundtable discussion, moderated by Brad McGregor, MD, focused on the latest data in RCC treatment and management, including data from the American Society of Clinical Oncology Genitourinary Cancers Symposium 2024. Dr. McGregor was joined by Rana McKay, MD; Elizabeth Wulff-Burchfield, MD; and Alan Tan, MD.

In the next segment of the roundtable series, the panel discussed the role of SBRT and some exciting studies like SAMURAI.

Watch the next segment in this series.

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Dr. McGregor: Another key aspect that we think about is, we see this great data for CheckMate 214 and all the IO/TKIs that was part of the follow up, but one of the unanswered questions is what do we do with a primary in this situation? Pre-CARMENA, aside from CheckMate 9ER, a majority patients had local control. How we put this into the setting of current era with upfront control. Rana, I know you have some trials looking at alternative options to surgery.

Dr. McKay: Absolutely. We don’t know the role of cytoreductive nephrectomy in the modern era. I think retrospective databases have suggested that it continues to be impactful, but those are very biased regarding who’s getting surgery or not. I think the general practice for people that are presenting with de novo metastatic disease is to start them on systemic therapy and assess them over time and kind of see what happens.

I think a lot of us in clinical practice for those patients that have done really well potentially considering a consolidative cytoreductive nephrectomy down the road, or if patients do well everywhere else but the kidney, potentially considering surgery in that context. Not all patients are candidates for surgery or want surgery. I think surgery also usually mandates a discontinuation of their TKI if they’re on therapy. The radiation techniques have really just exploded. It’s been a renaissance of the technology around SBRT. While historically I think renal cell carcinoma tumors have been labeled as radioresistant with SBRT, where now we can deliver much higher dose per fraction.

That is no longer really a reality. We can successfully treat these tumors and get local disease control. We have a trial called SAMURAI through the Cooperative Groups that is having patients get standard of care immunotherapy at physician’s choice with a randomization to SBRT to the renal primary, very simple 1 to 3 fractions and then could go on to continue to get their systemic treatment. I think it’s an important question that we need to answer.

There was even excitement in the room today during the sarcomatoid and variant histology lecture about doing clinical trials that answer the question about how do we do SBRT appropriately? Everybody’s got their one off scenarios of what they do, but can we actually conduct studies that look at treating oligoprogressive disease or oligometastatic disease?

Dr. McGregor: To your point, I’m really excited for SAMURAI also because it’s going to allow the variant histologies. This is not going to be just those patients with clear cell, but there’s a variant where our treatment options may not be as good and getting that better local control may be critical. I think it’d be really exciting to see the results play out.

Dr. McKay: I’m going to show up and support it.

Dr. Tan: I love how our trials are becoming more inclusive, more pragmatic and more simple.

Dr. McGregor: We do have the PROBE trial that’s ongoing trying to look at the role of consolidative surgery. Should we do surgery down the line? Hopefully we’ll get some answers and it’s great for cooperative Groups. Starting to answer some of these questions.