**6. Oligometastatic disease in kidney cancer**

An interesting development across oncology in all tumour groups has been the change in approach to the management of oligometastatic disease [41]. Oligometastatic disease is a term used to describe a patient with a small number of metastatic lesions; in most studies, this is defined as 1–3 or 1–5 lesions [41]. Aggressive resection of the metastasis can be attempted surgically or an increasing number of patients can be treated with high doses of radiotherapy using stereotactic ablative body radiotherapy (SABR) [41, 42]. Traditionally, RCC has been thought to be a radio-resistant disease; however, large ablative doses of radiotherapy used in an SABR technique induce different pathways of apoptosis and as such good long-term control can be achieved in certain patients. Metastasis in bone, lungs, brain, lymph nodes, and adrenal glands are all potentially treatable with SABR [43–45].

Metastasectomy can be employed for metastatic disease in a number of sites including bone, lungs and brain. Good long-term outcomes have been observed, especially with careful patient selection [46, 47].

show a statistically significant improvement in DFS [53]. In the ATLAS trial, using axitinib in the adjuvant setting, the primary end point was not reached and the study was abandoned due to futility at the interim assessment point [54]. It is also worth noting that the majority of patients in these adjuvant trials had ccRCC histology. A summary of the reported trials is

Medical Management of Renal Cell Cancer http://dx.doi.org/10.5772/intechopen.85931 165

Several trials are still ongoing using targeted therapies in high-risk patients post-nephrectomy including: SORCE trial (NCT00492258) assessing sorafenib and EVEREST trial (NCT01120249) investigating everolimus [50]. Further trials are underway to assess the use of immunotherapy in the adjuvant setting using a variety of checkpoint inhibitors. These include the IMmotion101 trial (NCT03024996) with atezolizumab, PROSPER trial (NCT03055013) comparing neoadjuvant and adjuvant nivolumab versus observation, KEYNOTE-564 trial (NCT03142334) evaluating pembrolizumab versus placebo and CheckMate 914 trial (NCT03138512) comparing nivolumab with ipilimumab versus placebo [50]. The results of these trials are likely to be reported in the coming years; however, the standard of care at present is not to prescribe

An area of particular interest for oncologist is the search for reliable biomarkers, which will guide us into targeting our treatments to the patients who will benefit from them the most. Renal cell carcinoma is no exception and the hunt for a biomarker is of high interest to academics and drug companies alike. Biomarkers are being investigated in the areas of imaging serum, histology, and urine, both to determine treatment strategies and to differentiate between benign and malignant processes [55]. One biomarker of particular interest is carbonic anhydrase IX, which has demonstrated excellent specificity and ability to predict treatment response [56]. Researchers are also keen to identify reliable biomarkers for use with immune checkpoint inhibitors in the treatment of RCC, especially to help differentiate between the

Research has been conducted on the use of vaccine therapy in RCC. Vaccines are designed to induce a specific immune response in the patient; however, this is yet to translate into an overall survival benefit [58, 59]. In the new era of targeted medicine and next-generation immunotherapy, the role of vaccines remains uncertain and only further research in this area, with associated success in randomised trials, will confirm vaccine therapy as a viable treat-

Interesting evidence has been published on the use of SABR in patients who are not fit for partial nephrectomy. High doses of highly targeted radiotherapy are given to the tumour patients with the hope of ablation of the tumour. The treatment was well tolerated with low toxicity and good local control rates in 2 years [60]. Further ongoing evaluation of this technique is needed, but it is likely that use of SABR in this format will increase in

adjuvant therapy, of any kind, post-nephrectomy in renal cell carcinoma.

**8. Emerging treatments and trends**

progression and pseudoprogression on treatment [57].

ment strategy for the future.

the future.

shown in **Table 4**.

A combination of metastasectomy and post-operative SABR for brain metastasis has been employed with excellent results and has been shown to have less side effects than post-operative treatment with whole brain radiotherapy [48].
