Cytoreductive nephrectomy in metastatic renal cell carcinoma: the evolving role of surgery in the era of molecular targeted therapy

PURPOSE OF REVIEW: Despite contemporary surgical and therapeutic innovation, renal cell carcinoma remains the most lethal of the urologic malignancies. Up to a third of patients with renal cell carcinoma have metastatic disease at presentation and 30% with localized disease will eventually progress to metastatic disease. In the past, cytoreductive nephrectomy was reserved for palliative circumstances. RECENT FINDINGS: With the emergence and integration of targeted therapies into current treatment protocols, the role of cytoreductive nephrectomy should be reexamined. Three targeted therapy trials revolutionized the management of metastatic renal cell carcinoma by showing unprecedented efficacy and tolerable therapeutic options. SUMMARY: The benefits of targeted therapy observed in clinical trials have been in the setting of prior cytoreductive nephrectomy. Therefore, any evidence for the potential benefit of cytoreductive nephrectomy in the era of targeted therapy is currently extrapolated and it is unclear where surgery integrates into the current treatment ladder. Other surgical approaches such as laparoscopy and nephron-sparing surgery have also been transferred to a carefully selected metastatic disease population. The concept of presurgical systemic therapy, though not new to oncology, is novel for metastatic renal cell carcinoma treated with targeted therapy. With the maturation of ongoing multicenter clinical trials, answers to these questions will hopefully be clarified.