Monday, 5 November 2007 - The 1st European Multidisciplinary Meeting on Urological Cancers held in Barcelona from 1 to 4 November examined pertinent issues in renal cell carcinoma (RCC). The first-day plenary session tackled the surgical, medical and radiation management of RCC patients.

Chairing the session on surgical management were Peter Mulders (Netherlands) and Hein Van Poppel (Belgium) with lectures delivered by John Fitzpatrick (Ireland) on “Surgical management of T1 lesions,” Inderbir Gill (US) on “Laparoscopic partial and radical nephrectomy,” and Didier Jacqmin (France) on "Open surgery and vena caval involvement."

The medical management of RCC was chaired by Ronald Bukowski (US) and Peter Mulders with lectures from Mulders on "Immunotherapy in RCC," Cora Sternberg (Italy) on "Targeted therapy in RCC," Joaquim Bellmunt Molins (Spain) on "Combination therapies," Tim Eisen (UK) on "Adjuvant therapy," and Jürgen Dunst (Germany) on "Radiation treatment in the management of RCC." The session concluded with Bukowski’s State-of-the-Art lecture titled "RCC: what does the future hold?"

The following are excerpted highlights and summaries from the RCC session lectures:
Discussing the surgical management of  T1 lesions, Fitzpatrick said nephron sparing surgery (NSS) is an acceptable therapeutic approach with single small (less than 4cm) tumours and normal contralateral kidney. Noting that there are no biological differences between central and pheriperal tumours, he said that treatment with NSS or radical nephrectomy are equally effective regardless of tumour location. He also said that in patients with VHL (Von Hippel-Lindau) disease, NSS is an effective initial treatment but many patients develop local recurrences.

Gill assessed laparoscopic partial and radical nephrectomy saying that laparascopic radical nephrectomy (LRN) is now standard of care. He also noted that in pT1b tumours (4-7 cm) partial vs. radical nephrectomy has similar cancer-specific survival and recurrence rates, adding that patient selection and surgical expertise play crucial roles. Ten-year outcome of LRN is also comparable with open surgery. "In my view, minimal invasive NSS is a strong and viable partner to open surgery," he said. 

Jacqmin discussed open surgery and vena caval involvement saying that inferior vena cava (IVC) involvement worsened significantly the prognosis of RCC. He concluded: “Open surgery is still a good option in RCC and is the gold standard for NSS. (It is also) recommended for big tumours and caval involvement.

In immunotherapy in RCC, Mulders recommended that in the treatment of metastasis RCC prognostic factors should be regarded and that the physician should take notice of the natural history of the disease. He added that interferon-alpha (INF-alpha) monotherapy gives a small but significant survival advantage.

On targeted therapy in RCC, Sternberg noted that although there are many developments and improvements in treatment strategies, a lot of questions remain unanswered such as major toxicities involved with new agents, the role of combination therapy and response/resistance mechanisms. Stressing that new targeted agents are not cytotoxic but cytostatic, she concluded: “There is strong rationale for targeting angiogenesis and multiple pathways in patients with advanced RCC. Novel targeted agents have demonstrated an increase in progression free survival (PFS) in 1st and 2nd line and an increase in survival in poor risk therapy naïve patients. They (targeted agents) are better tolerated than cytokines, but there is toxicity associated with these agents.”

Regarding combination therapies (targeted therapies plus immunotherapy), Bellmunt Molins noted that promising overall response rate and PFS were observed in phase 2 studies and phase 3 studies (Bevacizumab + IFN). He added that sorafenib combined with gemcitabine/capecitabine is feasible and has a high level of antitumour activity. He stressed however that further controlled trials are required to assess novel combinations.

Bukowski gave a comprehensive overview of RCC treatment. Looking ahead, he said: “Current strategy focuses on optimising PFS and open surgery to define standards of care….Definitions are needed for tyrosine kinase inhibitors (TKI) resistant/refractory disease at a pharmacologic, clinical and molecular level.” He also underlined the role of investigations on biomarkers to provide information to assist in developing molecular classifications of RCC.