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Genitourinary Research With Ben Garmezy, MD

Oncology / Hematology

Dr. Garmezy joined Sarah Cannon Research Institute (SCRI) in 2021 and serves as the Associate Director of Genitourinary Research. In his role, Dr. Garmezy oversees investigational therapy trials, as well as standard of care treatments, for GU cancers, including prostate, kidney, bladder, and testicular cancers.

How Do We Treat Oligometastatic Clear Cell Renal Cell Carcinoma in the Community?

Dear readers,

At the Uromigos Live & Unplugged 2024 conference, Drs. Powles, Choueiri, Albiges, Hammers, and Zhang had a great discussion of what a definition of oligometastatic clear cell renal cell carcinoma might be. Unfortunately, the panelists and the audience could not agree on the definition. Why? (1) a lack of high-quality data, and (2) perhaps oligometastatic disease means different things to different providers.

In my practice, I view oligometastatic as two opposite ends on a clinical spectrum. On one end is the definition we were going for at Uromigos: can we delay systemic therapy and spare toxicity? These are patients with likely IMDC favorable risk, and only a few sites of disease that can be safely radiated (see data from Tan et al, Eur Urol Oncol 2024 on the data of radiation to the primary – we used to view ccRCC as radio-resistant 0No, just the dose was wrong – and  Tang et al, Lancet Oncol 2021. SBRT in selected patients can lead to a median PFS of 22 months). In all patients, we should consider this. Perhaps, in the future, we can even better select very favorable risk patients (see abstract from Schmidt et al, GU ASCO 2021): patients who are more than 3 years out from diagnosis to systemic therapy, KBS >80, and no brain/none/liver metastases. However, in my practice, I view this as overly restrictive and we should be more generous in trying oligometastatic SBRT in ccRCC.

What about the other end of the spectrum? Can we do nephrectomy and metastasectomy and consider adjuvant pembrolizumab for one year (KEYNOTE-564)? If we can’t do surgery, can we do SBRT? I think it is reasonable to consider. What about a patient on ipilimumab and nivolumab front line with 4-5 lesions, should we start immunotherapy and then try and cytoreduce with radiation? I think we don’t know the answer yet. In prostate cancer, we are now doing definitive radiation to the prostate and then SBRT to oligometastatic lesions with ADT + ARSI. So maybe it’s possible to imagine a similar paradigm in more aggressive oligometastatic RCC. We need data! But it is not unreasonable to consider this end of the spectrum as well, with an intent to cure.

Best,

Ben Garmezy, MD

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