HJNO Mar/Apr 2024

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAR / APR 2024 55 Sukesh Manthri, MD Medical Oncologist Terrebonne General | Mary Bird Perkins Cancer Center patients treated with molecularly tar- geted agents is less promising. Removal of the primary tumor — cytoreductive or debulking nephrectomy — may be indicated prior to initiating systemic therapy in select few patients (e.g., good performance status, 75% debulk- ing possible, no symptomatic meta- static disease, low risk group). • Metastasectomy: Surgical resection of a single or limited number of metasta- ses is a reasonable option for carefully selected patients. Among patients with completed resected oligometastatic clear cell renal carcinoma treated with nephrectomy and complete resection of all distant disease, we suggest one year of adjuvant pembrolizumab rather than observation. Radiation therapy (RT). Although RCC has been characterized as radioresistant tumor, conventional and stereotactic RT are fre- quently useful to treat a single or limited number of metastases. Example painful bone metastases, brain metastases, painful recurrences in the renal bed. n SukeshManthri,MD,practicesatTerrebonneGeneral| Mary Bird Perkins Cancer Center where he serves as themedical director.He is board-certified in internal medicine, medical oncology, hospice, and palliative care. He specializes in a wide array of cancers, in- cluding breast, lung, GI, lymphoma, and myeloma. Manthri received amedical degree from the Prathima Institute of Medical Sciences in India.He completed a clinical research fellowship in Cleveland Clinic Florida followed by an internal medicine residency at South- ern Illinois University in Springfield.Subsequently,he completed a hospice and palliative medicine fellow- ship at Saint Louis University,St.Louis.Manthri also completed an oncology fellowship at EastTennessee State University,Johnson City where he was honored with the designation of chief medical oncology fellow for the year 2019-2020. He is amember of theAmericanMedicalAssociation, American Society of Clinical Oncology,andAmerican Society of Hematology. nephrectomy to patients who are at lower risk for disease recurrence (<30%) or do not meet pathologic cri- teria for intermediate-high or high risk of disease recurrence. Advanced disease, including tumor in- vading beyond Gerota’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: Treat- ment-naïve patients with advanced or metastatic disease will receive sys- temic treatment with immunothera- py — checkpoint inhibitors — and/or molecularly targeted/antiangiogenic 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 car- cinoma; translocation; and unclassified. • Renal cell carcinoma with sarcomatoid features: Sarcomatoid features can be seen in any histologic subtype of RCC, including clear cell and non-clear cell histologies. Sarcomatoid RCC is clini- cally responsive to immunotherapy- based regimens. Surgery for advanced disease. Surgery has a role in the management of some patients: • Cytoreductive nephrectomy: The role of cytoreductive nephrectomy among include bone scan, CT of the chest, mag- netic resonance imaging (MRI), and positron 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 periodic monitoring with abdominal ultra- sonography, CT, MRI to detect early disease. General treatment approach Localized disease, including 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 disease. 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 (eg, 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 sur- vival (DFS) and was well tolerated in a phase III trial. • We offer active surveillance after