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Editorial Comment on: A Review on Follow-Up Strategies for Renal Cell Carcinoma after Nephrectomy
european urology 51 (2007) 1490–1501
Editorial Comment on: A Review on Follow-Up Strategies for Renal Cell Carcinoma after Nephrectomy Tobias Klatte, Allan J. Pantuck Department of Urology, University of California Los Angeles, Los Angeles, CA [email protected] In this timely review article, Skolarikos et al [1] provide an in-depth summary of issues pertaining to surveillance for disease recurrence following nephrectomy for patients with localized renal cell carcinoma (RCC). The reviewed topic is of paramount importance for the urologic community because it is estimated that 30% of patients undergoing nephrectomy for presumed localized disease eventually experience recurrence. Furthermore, there is still uncertainty regarding the optimum approach to detect recurrence early. Based on a comprehensive analysis of the relevant literature, the authors discuss the rationale for surveillance and the timing, intensity, duration, and methods of surveillance appropriate for various patient groupings. The authors emphasize that, at the present time, no prospective or randomized studies have been conducted to address these important questions. All currently available recommendations on surveillance are based on retrospective, mostly single-center studies achieving a maximum evidence level of only III/B. However, until the time that high-level evidence becomes available (and there are currently no plans for prospective studies to evaluate this question of which we are aware), patients must be followed using the best data available. In the distant past, the majority of clinicians followed all patients according to the same general plan, regardless of tumor histology, tumor stage, tumor grade, or other factors of tumor biology that drive the risk of tumor recurrence. At the present time, the most widespread surveillance strategies are based on stage-based protocols [2] because tumor stage is the most important predictor for recurrence after nephrectomy, allowing the intensity and duration of surveillance strategies to be tailored according to the tumor’s stage. However, in the last few years, integrated staging systems that combine multiple clinical and pathologic variables have
1501
become the favored tool for postoperative risk group assessment. These nomograms, which place patients into groups having high, intermediate, and low risk of disease recurrence, are beginning to be applied to the surveillance arena [3]. As the authors note, however, it is evident that, even using sophisticated nomograms, each patient risk group still is a heterogeneous mix of patients having different risks for recurrence. In the future, it is quite probable that molecular markers such as p53 [4] will further improve the predictive ability of clinical and pathologic nomograms, which may permit further smoothing of this heterogeneity and allow for a surveillance protocol that is better tailored to the individual patient. As a final note, it should be emphasized that surveillance strategies at present should be applied only to tumors managed by extirpative surgeries. The lack of long-term data on outcomes for tumor ablative therapies, such as cryotherapy or radiofrequency ablation, dictates that patients undergoing these still experimental therapies will require more intensive follow-up for distant as well as local recurrence than one might recommend based on tumor biology alone.
References [1] Skolarikos A, Alivizatos G, Laguna P, de la Rosette J. A review on follow-up strategies for renal cell carcinoma after nephrectomy. Eur Urol 2007;51:1490–501. [2] Janzen NK, Kim HL, Figlin RA, Belldegrun AS. Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease. Urol Clin North Am 2003;30:843–52. [3] Lam JS, Shvarts O, Leppert JT, Pantuck AJ, Figlin RA, Belldegrun AS. Postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma based on a validated prognostic nomogram and risk group stratification system. J Urol 2005;174: 466–72. [4] Shvarts O, Seligson D, Lam J, et al. p53 is an independent predictor of tumor recurrence and progression after nephrectomy in patients with localized renal cell carcinoma. J Urol 2005;173:725–8. DOI: 10.1016/j.eururo.2006.12.032 DOI of original article: 10.1016/j.eururo.2006.12.031
Editorial Comment on: A Review on Follow-Up Strategies for Renal Cell Carcinoma after Nephrectomy Tobias Klatte, Allan J. Pantuck Department of Urology, University of California Los Angeles, Los Angeles, CA [email protected] In this timely review article, Skolarikos et al [1] provide an in-depth summary of issues pertaining to surveillance for disease recurrence following nephrectomy for patients with localized renal cell carcinoma (RCC). The reviewed topic is of paramount importance for the urologic community because it is estimated that 30% of patients undergoing nephrectomy for presumed localized disease eventually experience recurrence. Furthermore, there is still uncertainty regarding the optimum approach to detect recurrence early. Based on a comprehensive analysis of the relevant literature, the authors discuss the rationale for surveillance and the timing, intensity, duration, and methods of surveillance appropriate for various patient groupings. The authors emphasize that, at the present time, no prospective or randomized studies have been conducted to address these important questions. All currently available recommendations on surveillance are based on retrospective, mostly single-center studies achieving a maximum evidence level of only III/B. However, until the time that high-level evidence becomes available (and there are currently no plans for prospective studies to evaluate this question of which we are aware), patients must be followed using the best data available. In the distant past, the majority of clinicians followed all patients according to the same general plan, regardless of tumor histology, tumor stage, tumor grade, or other factors of tumor biology that drive the risk of tumor recurrence. At the present time, the most widespread surveillance strategies are based on stage-based protocols [2] because tumor stage is the most important predictor for recurrence after nephrectomy, allowing the intensity and duration of surveillance strategies to be tailored according to the tumor’s stage. However, in the last few years, integrated staging systems that combine multiple clinical and pathologic variables have
1501
become the favored tool for postoperative risk group assessment. These nomograms, which place patients into groups having high, intermediate, and low risk of disease recurrence, are beginning to be applied to the surveillance arena [3]. As the authors note, however, it is evident that, even using sophisticated nomograms, each patient risk group still is a heterogeneous mix of patients having different risks for recurrence. In the future, it is quite probable that molecular markers such as p53 [4] will further improve the predictive ability of clinical and pathologic nomograms, which may permit further smoothing of this heterogeneity and allow for a surveillance protocol that is better tailored to the individual patient. As a final note, it should be emphasized that surveillance strategies at present should be applied only to tumors managed by extirpative surgeries. The lack of long-term data on outcomes for tumor ablative therapies, such as cryotherapy or radiofrequency ablation, dictates that patients undergoing these still experimental therapies will require more intensive follow-up for distant as well as local recurrence than one might recommend based on tumor biology alone.
References [1] Skolarikos A, Alivizatos G, Laguna P, de la Rosette J. A review on follow-up strategies for renal cell carcinoma after nephrectomy. Eur Urol 2007;51:1490–501. [2] Janzen NK, Kim HL, Figlin RA, Belldegrun AS. Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease. Urol Clin North Am 2003;30:843–52. [3] Lam JS, Shvarts O, Leppert JT, Pantuck AJ, Figlin RA, Belldegrun AS. Postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma based on a validated prognostic nomogram and risk group stratification system. J Urol 2005;174: 466–72. [4] Shvarts O, Seligson D, Lam J, et al. p53 is an independent predictor of tumor recurrence and progression after nephrectomy in patients with localized renal cell carcinoma. J Urol 2005;173:725–8. DOI: 10.1016/j.eururo.2006.12.032 DOI of original article: 10.1016/j.eururo.2006.12.031