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Nephrectomy after complete response to immune checkpoint inhibitors for metastatic renal cell carcinoma: A new surgical challenge?

  • Geraldine Pignot 1,
  • Antoine Thiery-Vuillemin 2,
  • Jochen Walz 1,
  • Hervé Lang 3,
  • Pierre Werle 3,
  • Loïc Balssa 2,
  • Lionnel Geoffrois 5,
  • Louis Leblanc 5,
  • Laurence Albigès 7,
  • Vincenzo di Nunno 7,
  • Karim Bensalah 8,
  • Sylvain Ladoire 9,
  • Gwenaelle Gravis 10,
  • Philippe Barthélémy 3
1 Department of Surgical Oncology 2, Institut Paoli-Calmettes, Marseille, France 2 Medical Oncology Department, CHRU Besancon-Hopital Jean Minjoz, Besançon, France 3 Urology Department, University Hospital of Strasbourg, Strasbourg, France 4 Urology Department, CHRU Besancon-Hopital Jean Minjoz, Besançon, France 5 Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre lès Nancy, France 6 Department of Urology, CHRU Nancy-Hôpitaux de Brabois, Vandoeuvre lès Nancy, France 7 Department of Medical Oncology, Institut Gustave Roussy, Villejuif, France 8 Department of Urology, CHU Rennes-Hopital Pontchaillou, Rennes, France 9 Department of Medical Oncology, Centre Georges-François Leclerc, Dijon, France 10 Department of Medical Oncology, Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France 11 Medical Oncology Unit, University Hospital of Strasbourg, Strasbourg, France

The management of metastatic renal cell carcinoma (mRCC) is evolving rapidly. On the basis of results from the CARMENA trial, cytoreductive nephrectomy is debated and the question of delayed surgery is of new interest for selected patients [1]. The SURTIME trial showed that patients did not have more surgical complications after prior treatment with sunitinib [2]. In the current era of immune checkpoint inhibitors (ICIs), the role and timing of nephrectomy for kidney residual disease for patients with a radiological complete response (CR) at metastatic sites are still unknown.

Commentary by Dr. Pignot

We evaluated the feasibility of delayed nephrectomy in 11 patients with metastatic renal cell carcinoma (mRCC) and complete response (CR) on metastatic sites following ICI. 

In 81.8% (n=9) of the cases, surgeons experienced technical difficulties due to inflammatory infiltration. The 30-day postoperative complication rate was 54.6%, including 1 surgery-related death. A complete pathological response was observed in 2 cases. At 1 year, 73% of patients were free from progression and 54% free from systemic treatment.

In conclusion, if nephrectomy after ICI for mRCC can achieve CR in selected patients, this surgery should be performed in centers with extensive experience due to technical complexity.