1. Campbell’s & Literature review

2. Campbell 9 th & 10 th edition Cytoreductive nephrectomy  Palliation for: 1. Severe bleeding. 2. Pain. 3. Paraneoplastic symptoms.

3. How would it affect survival ? Regression of mets in 2% pulmonary nodules w’ a median duration of 6 months. Cytoreductive nephrectomy (with interferon) followed by systemic Rx.  synchronous metastatic disease.

6. Advanced symptoms (performance status ≥ 2), metastases in critical areas (CNS, cord compression), major organ dysfunction, and significant comorbidities are not candidates.

7. ECOG PSActivity 0Normal 1Symptomatic but ambulatory 2Bedridden < 50 % of time 3Bedridden > 50 % of time 4Completely bedridden

8. Metastectomy long disease-free interval 35-50%. 1. Complete resection, 2. Solitary metastatic lesions. 3. Age < 60 yrs. 4. Smaller tumor size. 5. Pulmonary metastases, 6. Metachronous metastatic disease. All retrospective, no prospective trial !

10. Hormonal Therapy Progestational agents may be useful for symptom palliation, they do not appear to have any significant value in the treatment of patients with metastatic RCC  !

11. Chemotherapy Currently available data of chemotherapy do NOT demonstrate reproducible antitumor activity or improvement in survival of patients treated for metastatic clear cell carcinoma.

12. In patients with metastatic non–clear cell malignant neoplasms or tumors with sarcomatoid differentiation, various agents including doxorubicin and gemcitabine may have clinical activity.

13. Radiation Therapy 1. Spine 2. Brain 3. Cord compression 4. Bleeding.

14. Cytokine Combinations IL-2 and interferon alfa have been combined, and currently available data suggest an increase in response rate but no improvement in overall survival.

15. VACCINES Vaccine preparations that have been employed in patients with RCC include: 1) Autologous tumor cells. 2) Autologous tumor cells fused with allogeneic dendritic cells. 3) Autologous dendritic cells. 4) Heat shock protein. Currently, use of tumor vaccines in patients with advanced renal cancer remains investigational ?

16. May 2011

18. Method Prospective 25 % response ! CN after 2 cycles of sunitinib 50 mg/d. 1. Primary tumor. 2. Metastatic sites. 3. Change of longest diameter of the primary tumor. 4. Progression-free survival (PFS).

19. Conclusion Downsizing of primary tumors after 2 cycles of sunitinib is associated with long-term survival. Patients with progression of metastases after pretreatment have short survival and are unlikely to benefit from CN 