CARMENA

Removing the primary kidney tumour before systemic therapy had been standard since trials in the interferon era showed a survival benefit. CARMENA, a French non-inferiority phase 3 trial, randomised 450 patients with metastatic clear cell renal cell carcinoma of MSKCC intermediate or poor risk to nephrectomy followed by sunitinib or to sunitinib alone. The primary endpoint was overall survival.

Sunitinib alone was non-inferior to nephrectomy plus sunitinib for overall survival, and the poor-risk group did numerically better without surgery. Together with the SURTIME trial it moved practice towards starting systemic therapy first and reserving nephrectomy for selected patients with a good response or few metastases; the question is being revisited in the immunotherapy era.