Management of locally advanced renal cell carcinoma

With the increased use of cross-sectional imaging, renal masses are increasingly detected when they are still clinically localized. However, a large portion of patients still have locally advanced or metastatic disease at the time of diagnosis. This includes both locally invasive disease as well as vena caval thrombus extension. Currently, surgical management offers the only chance of cure for tumors with direct invasion into adjacent structures and vena caval thrombus. This chapter will discuss this management including the surgical approach and techniques in these procedures, which can sometimes require a multidisciplinary approach and even bypass. Though surgical management might present the only chance for cure, frail patients might not be suitable candidates therefore not benefit from invasive intervention. The role of cytoreductive nephrectomy in metastatic disease is uncertain in the immunotherapy era, though it may offer benefit to some patients with good-risk features. This chapter will discuss the treatment of locally advanced renal cell carcinoma, risk assessment to reduce unnecessary morbidity and mortality, the role of lymph node dissection, caval thrombectomy, renal mass biopsy, and the changing landscape with the advent of targeted therapy and immunotherapy.