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Linfoadenectomia e nefrectomia citoriduttiva

Linfoadenectomia e nefrectomia citoriduttiva. Vincenzo Ficarra Associate Professor of Urology, University of Udine, Italy Associate Editor BJU International. Radical nephrectomy for RCC: the Robson criteria.

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Linfoadenectomia e nefrectomia citoriduttiva

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  1. Linfoadenectomia e nefrectomia citoriduttiva Vincenzo Ficarra Associate Professor of Urology, University of Udine, Italy Associate Editor BJU International

  2. Radical nephrectomy for RCC: the Robson criteria " ... to occlude the renalarteryat an early stage of the procedure and remove the renaltumor en bloc with the lymphatics" "The para-aortic (left) and para-caval (right) lymphnodesshould be removed from the crus of the diaphragmdistally to the biforcation of the aorta". Robson CJ J Urol 1963; 89: 37-42

  3. Lymphatic drainage of the Kidney and extended LND dissection

  4. Template for extended LND dissection Crispen PL. et al. EurUrol. 2011; 59: 18-23

  5. Imaging techniques and nodal metastases staging • The availabletechnologyiscapable of accuratelyidentifyingonly large lymphnodemetastases • Patients with (micro)metastases in normal-sizednodeswhomight benefit from LND cannot be visualized by any of the availableimagingtechniques (US, CT, MRI) Capitanio U. et al. EurUrol. 2011; 60: 1212-1220

  6. Nomogram predicting hilar LNI in RCC (externalvalidation) Accuracy: 78.4% Hutterer GC. et al. Int J Cancer 2007; 121: 2556-61

  7. Role of extended LND in cN0 RCC: EORTC trial 30881 383 RN + extended LND 85 % 772 cases (T1-3, N0M0) 1. Expected 5-year survival rate 389 RN alone 70 % Blom JHM et al. EurUrol. 2009; 55: 28-34

  8. Role of extended LND in cN0 RCC: EORTC trial 30881 Blom JHM et al. EurUrol. 2009; 55: 28-34

  9. EORTC trial 30881: clinical characteristics * * TNM, 1978 Blom JHM et al. EurUrol. 2009; 55: 28-34

  10. EORTC trial 30881: Pathological characteristics * * TNM, 1978 Blom JHM et al. EurUrol. 2009; 55: 28-34

  11. Pathological LNI prevalence according to pathological characteristics Capitanio U. et al. EurUrol. 2011; 60: 1212-1220

  12. High-risk clear cell RCC for LNI • pT3-4 tumors • Grade 3-4 • Sarcomatoiddediff. • Size >10 cm • Coagulative necrosis Crispen PL. et al. EurUrol. 2011; 59: 18-23

  13. Rational algorithm for RCC patient candidates for LND Capitanio U. et al. EurUrol. 2011; 60: 1212-1220

  14. Rational algorithm for RCC patient candidates for LND Capitanio U. et al. EurUrol. 2011; 60: 1212-1220

  15. Rational algorithm for RCC patient candidates for LND • cT2b (>10 cm); N0 • cT3-4; N0 • cN+ • M+

  16. Role of extended LND in cN+ RCC

  17. Role of extended LND in cN+M0 RCC Pantuck AJ J Urol 2003; 169: 2076-83

  18. Rational algorithm for RCC patient candidates for LND Capitanio U. et al. EurUrol. 2011; 60: 1212-1220

  19. Role of LND in patients with distan metastases: fractional percentage of tumour volume removed Pierorazio PM et al BJU Inter 2007; 100: 755-759

  20. Recommendations for lymph node dissection? EAU, 2013 NCCN, 2013 • Lymph node dissection is recommended for patients with palpable or CT detected enlarged lymph nodes and to obtain adequate staging information in those with nodes that appear normal • Extended lymphadenectomy does not improve survival and can be restricted to staging purposes. NCCN KidneyCancerGuidelines, Veersion 1.2013 Ljungberg B. et al EAU Guidelines, 2013

  21. Role of Nephrectomy in mRCC • Curative (Nephrectomy + metastasectomy) • Cytoreductive (To resect primary tumor in the • prior to the initiation of systemic therapy for • unresectable metastases) • Palliative (To improve symptoms) • - pain related to the kidney mass • - intractable hematuria • - paraneoplastic syndrome

  22. Palliative Nephrectomy in mRCC 492/5378 (9.1%) cases surgically treated from 1995-2007 SATURN database – LUNA fundation (unpublished data)

  23. Combined analysis (SWOG/EORTC) 13.6 months + 5.8 months 7.8 months Flanigan RC et al J Urol 2004; 171: 1071-1076

  24. Combined analysis (SWOG/EORTC) • Cytoreductive nephrectomy significantly improve • overall survival in patients with mRCC treated • with IFN-alpha independent of patients • - performance status • - site of metastasis (lung) • - presence of measurable disease • - (?) single Vs multiple metastases Flanigan RC et al J Urol 2004; 171: 1071-1076

  25. Population-based assessment (SEER - 1988-2004) Zini L. et al Urology 2009; 73: 342-346

  26. Guidelines on Renal Cell Carcinoma

  27. Cytoreductive Nephrectomy in the era of Targeted molecular agents

  28. A population-based study examining the role of nephrectomy prior to treatment Warren M. et al Can UrolAssoc J 2009; 3 (4): 281-89

  29. A population-based study examining the role of nephrectomy prior to treatment Warren M. et al Can UrolAssoc J 2009; 3 (4): 281-89

  30. Sunitinib in patients with or without prior nephrectomy in an expanded-access study 1.0 0.8 0.6 0.4 0.2 0 Patients with prior Nx (n=1,020)Median = 19.0 months(95% CI: 18.2−21.4) Patients without prior Nx (n=146)Median = 11.1 months(95% CI: 8.4−15.1) P<0.0001 OS probability 0 5 10 15 20 25 30 Time (months) Szcylik C. et al EurUrol (Suppl) 2009; abstract # 248

  31. Value of Cytoreductive Nephrectomy for mRCC in the Era of Targeted Therapy Choueiri TK. et al J Urol 2011; 185: 60-66

  32. Value of Cytoreductive Nephrectomy for mRCC in the Era of Targeted Therapy CN: 20% sarcomatoid features Non CN: 3% sarcomatoid feature Sarcomatoid feature: HR 2.7 (1.2-6.7) You D. et al J Urol 2011; 185: 54-59

  33. Ideal candidate for cytoreductive nephrectomy MD Anderson: 470 CN and 88 medical therapy only • Lactate dehydrogenase • Albumin level • Symptoms (S3) • Liver metastasis • N+ retroperitoneal • N+ supradiaphragmatic • ≥ T3 Culp SH et al Cancer 2010; 116: 3378-88

  34. Temsirolimus as first line therapy in poor-risk mRCC

  35. Candidate for cytoreductive nephrectomy • Good surgical risk (good performance status) • Limited metastatic tumor burden to lung or bone • Extensive metastatic disease with systemic • therapy planned • Symptoms related to the primary tumor NCCN Guidelines, 2013

  36. CARMENA (NCT00930033) Trial Study start data: May 2009 – Estimated Study completition: May 2013 Eligibility Criteria • ECOG PS of 0 or 1 • Clear cell histology • Resectable primary tumour • No prior systemic treatment • Adequate organ function Cytoreductive Nephrectomy + Sunitinib (N=576) Randomization Sunitinib alone Primary endpoint: Overall Survival Secondary endpoints: Objective response, PFS, Safety Hopitaux de Paris and Pfizer – www.clinicaltrials.gov

  37. SURTIME (EORTC 30073) Trial Study start data: April 2010 – Estimated Study completition: October 2014 Eligibility Criteria • Clear cell histology • Resectable primary tumour • Asymptomatic primary tumour • Measurable disease • No prior systemic treatment • Adequate organ function Sunitinib (3 course) + Deferred CN (N= 458) Randomization Immediate CN + Sunitinib (3 course) Primary endpoint: Overall Survival Secondary endpoints: Objective response, PFS, Safety Hopitaux de Paris and Pfizer – www.clinicaltrials.gov

  38. Conclusions • Nephrectomy is still an important part of • the multidisciplinary treatment of RCC • Targeted agents represent a substantial • improvement but since they are not • curative, the cytoreductive paradigm is • still relevant • Today, the more relevant question should • address the timing of and appropriate • patient selection for cytoreductive • nephrectomy

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