A significant proportion of patients undergoing nephrectomy for renal cell carcinoma remain at high risk of developing metastatic disease. Accurate staging and use of validated prognostic systems are helpful in estimating risk after surgery. At the current time, observation alone remains the standard-of-care after nephrectomy. Numerous systemic strategies have been investigated in the adjuvant setting. Treatment with interferon or interleukin-2, once the mainstay of treating advanced disease, has not shown any benefit in the adjuvant setting. Autologous tumor-derived vaccines have held promise as adjuvant therapy, but while improvements in tumor progression have been suggested in some trials, the data are difficult to interpret and no overall survival advantage has been proven. Small molecules targeting the VEGF and mTOR pathways have significant activity in metastatic renal carcinoma and have changed management of this stage of the disease. Many of these agents are currently being investigated in placebo-controlled adjuvant studies. While results of these trials are still several years away, there is optimism that these agents may prove effective and change the paradigm for treatment of localized renal cell carcinoma.
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