A Narrative Review on Systemic Therapy for Renal Cell Carcinoma in the Perioperative Setting

Abstract

In patients with renal cell carcinoma (RCC), the use of immunotherapy (IO) and tyrosine kinase inhibitor (TKI) regimens has proven beneficial in treating metastatic disease. These advances have led to the evaluation of IO/IO and IO/TKI treatment combinations in the perioperative setting. Neoadjuvant systemic therapy can improve surgical outcomes for patients by shrinking the tumor and prior studies have shown that the use of TKI regimens reduced tumor size significantly, whereas IO monotherapy had less of an objective radiographic response. In a retrospective series, patients with locally advanced RCC treated with IO/TKI experienced a higher decrease in median tumor size than those treated with IO/IO. For patients with locally advanced bulky tumors or tumor thrombus involving renal vein or inferior vena cava, early systemic treatment may be beneficial (with several trials ongoing). Finally, pembrolizumab has also improved outcomes in the adjuvant RCC setting. These studies have opened the door to other perioperative studies. Using perioperative therapies can alter the course of RCC with neoadjuvant therapies (IO/TKI) facilitating surgical challenges and adjuvant therapy (IO) improving disease-free survival, but trials are in the process and will further evaluate the impact of these treatments. In the meantime, these systemic therapies can be discussed with patients for perioperative treatment of locally advanced and invasive RCCs.

Keywords

• systemic therapy
• renal cell carcinoma
• immunotherapy