Highlights from the 15th Shanghai Urologic Oncology Academic Conference
Editor’s Note: The 15th Shanghai Urologic Oncology Academic Conference was grandly held in Pudong, Shanghai, bringing together leading experts in urologic oncology from China and abroad to engage in in-depth discussions on renal cancer, prostate cancer, and other key topics. Professor Hao Zeng, representing the multidisciplinary urologic oncology (MDT) team of West China Hospital, Sichuan University, was invited to present the team’s latest explorations and “West China experience” in cytoreductive surgery for both primary and metastatic lesions in non–clear cell renal cell carcinoma (NCC-RCC). His presentation offered new comprehensive treatment strategies for this rare renal cancer subtype, which is characterized by particularly poor prognosis and limited evidence-based guidance.
Surgical Opportunities Amid the Limitations of Systemic Therapy: The Unique Challenges of NCC-RCC
At the beginning of his presentation, Professor Zeng noted that despite significant advances in systemic therapy for renal cancer over the past three decades, the overall median survival of patients remains below 60 months, indicating that further improvement in outcomes remains a major clinical priority. From the perspective of molecular evolution, genitourinary malignancies—particularly renal cell carcinoma and prostate cancer—are uniquely suited for cytoreductive resection of primary or metastatic lesions, providing a broad arena for surgical intervention.
However, landmark trials such as CARMENA and SURTIME have at times created uncertainty among surgeons regarding the value of cytoreductive surgery. Professor Zeng emphasized that his team’s focus has been on the even more challenging and underexplored subtype of non–clear cell renal cell carcinoma (NCC-RCC), for which both prognosis and evidence are substantially worse than for clear cell RCC.
Compared with clear cell RCC, NCC-RCC presents a distinct clinical profile: younger age at onset, smaller primary tumors, larger metastatic burden, and limited responsiveness to current standard systemic therapies. More importantly, there is currently a near absence of high-level clinical evidence or guideline recommendations supporting cytoreductive treatment of either primary or metastatic lesions in NCC-RCC.
Professor Zeng explained:
“Our early observations showed that most NCC-RCC patients are young to middle-aged adults, typically between 37 and 39 years old. Their tumors follow a unique evolutionary pattern—a rapidly progressive, monoclonal evolution—making them particularly suitable for cytoreduction of the primary lesion. Moreover, NCC-RCC tends to metastasize preferentially to lymph nodes, bone, and liver, with relatively fewer lung metastases. This pattern of ‘small primary tumor but bulky metastases’ creates opportunities for local treatment of metastatic disease.”
The West China MDT Strategy: Precision Surgery Guided by Molecular Characteristics
Based on these distinctive biological and pathological features, the renal cancer team at West China Hospital has developed a multidisciplinary (MDT) treatment strategy over recent years. The core of this approach lies in integrating the cytoreductive benefits of surgery, the precision of local therapies, and molecularly guided systemic treatment.
This MDT strategy encompasses three major components:
- Cytoreductive treatment of the primary tumor: Resection of the primary lesion combined with extended lymph node dissection.
- Local treatment of metastatic lesions: Maximal local control of metastatic sites using surgery, radiotherapy (RT), stereotactic body radiotherapy (SBRT), and minimally invasive techniques such as cryoablation and radiofrequency ablation.
- Systemic therapy: Individualized systemic treatment tailored according to the patient’s molecular profile.
Accurate imaging is essential before surgical planning. The West China team works closely with radiologists to develop imaging-based early warning systems for aggressive NCC-RCC. Using specialized MRI sequences, they have achieved high diagnostic accuracy for FH-deficient RCC and certain TFE3-rearranged RCCs. For example, the diagnostic accuracy for FH-deficient RCC has improved from approximately 14% using CT alone to nearly 90% with MRI-based assessment.
Eight Key Surgical Scenarios from the “West China Experience”: From Prophylactic Dissection to Oligoprogression Management
Professor Zeng then illustrated the team’s experience through eight representative clinical scenarios, systematically demonstrating how cytoreductive surgery can be applied across different disease contexts.
1. Nephron-Sparing Surgery and R0 Resection Guided by Preoperative Risk Stratification
For highly aggressive NCC-RCC, precise preoperative risk assessment guided surgical decision-making. In patients requiring nephron preservation, wide-margin resection (approximately 1 cm margins) was performed to ensure tumor control while preserving renal function. One patient with PTEN-deficient chromophobe RCC achieved both kidney preservation and effective tumor control using this strategy.
2. Prophylactic Extended Lymph Node Dissection
Unlike clear cell RCC, NCC-RCC may harbor occult lymph node metastases even when imaging is negative. A 14-year-old girl with TFE3-rearranged RCC underwent radical resection with prophylactic retroperitoneal lymph node dissection based on preoperative risk assessment. Pathology revealed micrometastases in all 11 dissected lymph nodes. The patient achieved R0 resection without adjuvant therapy and currently remains with no evidence of disease (NED).
3. Synchronous Metastasectomy Assisted by 3D Printing
In patients with synchronous metastases, surgical precision is critical. NCC-RCC retroperitoneal lymph node metastases often have relatively clear boundaries from surrounding tissues, facilitating meticulous dissection. With the aid of 3D printing to delineate perivascular lymph nodes, a patient with SMARCB1-deficient RCC and retroperitoneal nodal metastases achieved a median survival of 22 months—compared with the expected 5–6 months—highlighting the value of cytoreductive surgery.
4. Comprehensive Local Treatment for Metachronous Metastases
For patients with resectable metachronous metastases or recurrence, the team adheres to a principle of complete local treatment of all lesions. One patient with FH-deficient RCC developed local recurrence in the right kidney along with multiple retroperitoneal lymph node and bone metastases. The patient underwent radical nephrectomy, lymph node dissection, abdominal wall tumor resection, and SBRT for an isolated bone lesion, achieving more than three years of survival benefit. Even in patients with incomplete resection, maximal debulking allowed subsequent systemic therapy to extend overall survival beyond 60 months.
5. Management of Oligoprogression During Systemic Therapy
During systemic treatment, some patients develop oligoprogression—defined as progression in fewer than three lesions while other sites remain stable. Professor Zeng emphasized that these lesions should still be actively managed. One clinical trial participant experienced oligoprogression twice and underwent repeat laparoscopic cytoreductive surgery. At a third progression, the team again performed laparoscopic resection of iliac and inguinal lymph nodes and cryoablation of subcutaneous metastases. This aggressive local intervention strategy maximized the therapeutic window and prolonged survival.
Summary and Outlook: Extending the Survival Curve in NCC-RCC
Professor Zeng concluded that through five years of local treatment exploration in 295 NCC-RCC patients, median overall survival has increased from less than 30 months to 53.97 months. Across subgroups—including synchronous and metachronous metastases—results consistently demonstrated that, with adequate evaluation and preparation, surgery can provide substantial benefit for patients with NCC-RCC.
Local treatment strategies at West China Hospital are multimodal, integrating surgery, cryoablation, radiofrequency ablation, and radiotherapy. When combined with individualized, precision-guided systemic therapy, these approaches have collectively improved patient outcomes.
Professor Zeng noted:
“At present, all these cytoreductive local treatments remain exploratory and are not recommended in current guidelines. However, our clinical practice represents bold real-world exploration. Moving forward, larger patient cohorts are needed to identify the right populations for the right local treatments, integrated with systemic therapy, to ensure that young patients with non–clear cell renal cell carcinoma achieve the survival benefit they deserve.”
The innovative progress in cytoreductive surgery for NCC-RCC not only expands therapeutic options for clinicians but also highlights the significant contributions of Chinese teams to global urologic oncology research.
Professor Hao Zeng
