Role of Surgery in Metastatic Renal Cell Carcinoma

The management of mRCC is continually evolving. While surgery was arguably the only effective treatment in the past, the changing landscape of systemic therapies over the past two decades has served to improved quality and quantity of life for patients with mRCC but at the same time created new challenges in formulating treatment plans by healthcare professionals. Until non-surgical therapies reliably achieve a durable complete response for patients with mRCC, surgery will remain a cornerstone of treatment. At this time, CN may be indicated as upfront therapy for patients with intractable symptoms, in those with nccRCC histology, and for cases of oligometastatic mRCC. However, the most common forms of surgery for patients with mRCC may be a consolidative CN and metastasectomy since upfront systemic therapy is now widely adopted. Following an approach favoring "personalization over protocolization," the treatment plan for each patient should be tailored through a multidisciplinary approach and established through shared decision making with patients and their families. Moving forward, more well-designed clinical trials are necessary to evaluate novel treatment options developed from the growing understanding of the molecular and immunological characteristics of mRCC. There are multiple ongoing clinical trials (see Table 1) aim to assess the benefit of CN in comparison to current treatment regimen comprised of IO and TKI agents. Interestingly, future advancements in immunotherapy, such as vaccines, may potentially increase the role of upfront surgery because a surgical specimen may be necessary to generate highly personalized treatments which are both effective and minimally toxic. Overall, the role of surgery will continue to change in concert with developments in systemic therapy and other non-surgical treatments.