Christos Georgiades

Point of View

Christos Georgiades (Johns Hopkins University, Baltimore, USA), delves into the various national society guidelines for treating renal cell carcinoma (RCC), what the ‘gold standard’ of treatment is currently considered to be, and what he believes is the route to ensuring the best outcomes for patients.

The answer to the question of “where do we stand on cryoablation for stage 1A RCC?” can best be found by deploying the ultimate litmus test. Ask those who treat RCC what they would choose for themselves if their life depended on it. And in the case of RCC, it would. I would not be going out on a particularly long limb if I presumed to answer for them—“cryoablation”. This, however, may not satisfy the data-driven, or more accurately, data-dominated decision-makers. So, let us look at the ‘guidelines’. With or without qualifications, all major relevant associations—the National Comprehensive Cancer Network, American Urological

Association (AUA), European Association of Urology (EAU), Society of Interventional Radiology (SIR), and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE)—include ablation as a treatment option for stage 1A RCC. The guidelines worth exploring a bit deeper, however, are those from the American Society of Clinical Oncology, which recommends ablation for stage 1A RCC “if a complete ablation can be achieved”. The wisdom of this last statement is that it gets to the heart of an important issue. Implicitly, it brings up the crucial factor for good oncologic outcomes—operator experience. While no study addresses this issue rigorously, statistically significant reduction in pain. The mean VAS of 8.58 decreased to 5.02, while the mean WOMAC score decreased from 66.6 to 41. The greatest increase in functionality and decrease in pain was recorded for patients 50 and older compared to younger participants.

“Roughly one in four US adults have knee pain,” said John B Smirniotopoulos, an interventional radiologist at MedStar Georgetown University Hospital. “This treatment can offer many of those people a chance to enjoy everyday activities and regain a higher quality of life by decreasing the pain that they experience on a daily basis.” there is a common understanding among interventional radiologists and urologists on “where we currently stand”— for stage 1A RCC, an experienced interventional radiologist will deliver the same oncologic outcomes as an experienced surgeon. Yet, admittedly, this is not the case everywhere. Many places, especially community settings, lack experienced interventional radiologists. But then again, the same holds true for surgeons experienced in partial nephrectomy, the current ‘gold standard’ of treatment. Which brings us to the second part of the question— “where are we going?”

During a dedicated media briefing held by SIR, Smirniotopoulos commented on how “rewarding” it is to see the patients return to the clinic for follow-up at regular intervals following their ablation treatment. The progress seen now, overall, at over a year in most cases is “possibly to a degree that [patients] did not expect and maybe that we did not even expect”.

The researchers are currently conducting long-term studies into this treatment that dive deeper into what other factors could predict how well the treatment will work. The same treatment is also conducted with shoulder, hip and sacroiliac joints, where the spine connects to the pelvis.

Twenty years ago, partial nephrectomy was the new ‘gold standard’ for treating stage 1A RCC. Yet, due to the unavailability of experienced surgeons, nearly 54% of patients had radical nephrectomy, which led to them unnecessarily losing a lot of healthy nephrons. Today, after a 20-year push for nephron-sparing options, the situation is not much better, with about 42% of patients with stage 1A RCC still receiving radical nephrectomy. What a disappointment! More relevantly, while 3% of such patients were treated with ablation 20 years ago, today, and despite the evolving guidelines, only 12% are. One could very well argue we are going nowhere. But at the same time, it ought to be clear where we should be going. If we are truly committed to patient care, our collective efforts should be focused towards offering all stage 1A RCC patients a nephronsparing option, whichever one that may be. The practical solution is neither easy nor obvious. The most feasible and logical answer seems to be the setup and promotion of regional centres that provide these nephron-sparing options—small, incentivised groups of interventional radiologists and urologists working together to offer nephronsparing options to their respective population parcel. A committed effort by the AUA/EAU and SIR/Society of Interventional Oncology (SIO)/CIRSE/ European Society of Interventional Oncology (ECIO) would indeed have tremendous benefits for patients, many of whom would be spared short-term complications and, importantly, potential renal failure and the need for chronic renal replacement treatment.

In closing, reading between the (guide)lines, one appreciates the essence of them can be distilled down to the oncological equivalence of ablation and surgery for stage 1A RCC. This is provided that interventional radiologists possess the necessary expertise to maintain published oncological outcomes. More crucially, however, the question “where are we going?” reveals a failing, an opportunity, and a challenge to interventional radiologists and urologists—make nephron-sparing options available to the nearly-50% of stage 1A RCC patients who unnecessarily undergo radical nephrectomy.

Disclosures:

Georgiades is a consultant for Boston Scientific. Christos Georgiades is professor of vascular and interventional radiology at Johns Hopkins University.