HJNO Mar/Apr 2022

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAR / APR 2022 55 Sukesh Manthri, MD Medical Oncologist Terrebonne General Mary Bird Perkins Cancer Center preferred over biopsy because it provides the diagnosis, pathologic tumor (T) and nodal (N) staging, and definitive treatment. Preoperative needle biopsies are usually not used for resectable renal lesions because of their low specificity and concerns about tumor seeding of the peritoneum. Nephrec- tomy or partial nephrectomy is used inmost cases to obtain tissue for diagnosis of RCC prior to treatment. However, the diagnosis of RCC is occasionally established by a biopsy of a metastasis. STAGING STUDIES The extent of local and regional involve- ment is determined primarily by abdominal CT, which is extremely accurate in staging RCC. Other imaging studies that may be use- ful for assessing distant metastases include a bone scan, CT of the chest, MRI, and posi- tron emission tomography (PET)/CT. SCREENING Screening of asymptomatic individuals is not recommended because of the low prevalence of RCC in the general popula- tion. However, individuals at high risk for the development of RCC should undergo pe- riodic monitoring with abdominal ultraso- nography, CT, or MRI to detect early disease. GENERAL TREATMENT APPROACH Localized disease This includes stages I, II, and III • Surgery is curative in the majority of patients with RCC who do not have metastases. Surgery is, therefore, the preferred treatment for patients with stages I, II, and III diseases. Treatment may require a radical nephrectomy, al- though a partial nephrectomy to pre- serve renal parenchyma is preferred for appropriately selected patients. Other ablative procedures (e.g., cryotherapy, radiofrequency ablation [RFA]) may be an important alternative for patients with relatively small renal masses who are not surgical candidates. • For patients whomeet pathologic crite- ria for intermediate-high or high risk of disease recurrence, particularly those with a higher estimated risk of recur- rence at five years (≥30%), we suggest one year of adjuvant pembrolizumab rather than observation, as this ap- proach improved disease-free survival (DFS) and overall survival (OS) and was well tolerated in a phase III trial. • We offer active surveillance after ne- phrectomy to patients who are at lower risk for disease recurrence (<30%) or do not meet pathologic criteria for in- termediate-high or high risk of disease recurrence. Advanced disease This includes tumors invading beyond Gero- ta’s fascia or extending into the ipsilateral adrenal gland (T4) and metastatic disease (M1). Most patients with stage IV RCC have unresectable disease and require systemic therapy. • Clear cell renal cell carcinoma — Treatment-naïve patients with ad- vanced or metastatic disease will receive systemic treatment with im- munotherapy (checkpoint inhibitors) and/or molecularly targeted therapy. The choice of treatment for patients with advanced disease has been based on prognostic risk factors. • Non-clear cell renal cell carcinoma — The treatment approach to patients with metastatic non-clear cell RCC is varied and tailored to the histologic subtype and pathologic and molecular features of the tumor. The main histo- logic subtypes of non-clear cell RCC include papillary, chromophobe, col- lecting duct (including medullary carci- noma), translocation, and unclassified. Surgery for advanced disease Surgery has a role in the management of some patients. • Cytoreductive nephrectomy — The role of cytoreductive nephrectomy among patients treated with molecu- larly targeted agents is less promising. Removal of the primary tumor (cyto- reductive or debulking nephrectomy) may be indicated prior to initiating systemic therapy in select few pa- tients (e.g., good performance status, 75% debulking possible, no symptom- atic metastatic disease, low-risk group). • Metastasectomy — Surgical resection of a single or limited number of metas- tases is a reasonable option for care- fully selected patients. Among patients with completed resected oligometa- static clear cell renal carcinoma treated with nephrectomy and complete resec- tion of all distant disease, we suggest one year of adjuvant pembrolizumab rather than observation. n Sukesh Manthri, MD, is a medical oncologist at Ter- rebonne General Mary Bird Perkins Cancer Center in Houma, Louisiana. He received amedical degree from the Prathima Institute of Medical Sciences in India. He completed a clinical research fellowship at Cleveland Clinic Florida followed by an internal medicine residency at Southern Illinois University in Springfield. Subsequently, he completed a hos- pice and palliativemedicine fellowship at Saint Louis University, St. Louis, Missouri, and was a medical oncology fellow at East Tennessee State University in Johnson City. In 2020, Manthri received the Dr. Thomas G.RonaldAward for Excellence in the Care of the Cancer Patient.He is board certified in oncology, internal medicine, hospice, and palliative medicine.