A 55-year-old man presents with a 3 cm enhancing renal mass in the left kidney, staged cT1bN0M0. What approach is supported by the CARMENA trial regarding nephrectomy in metastatic disease, and what is the primary treatment for this localized lesion?

• A Cytoreductive nephrectomy is essential before sunitinib in intermediate-risk mRCC; partial nephrectomy for the localized T1b tumor
• B CARMENA showed cytoreductive nephrectomy non-inferior to sunitinib alone in poor-risk mRCC; nephron-sparing surgery preferred for T1b
• C CARMENA showed sunitinib alone non-inferior to nephrectomy plus sunitinib in intermediate/poor-risk mRCC; partial nephrectomy preferred for T1b ✓
• D Radiofrequency ablation is the only appropriate treatment for a T1b RCC

Explanation

The CARMENA trial (NEJM 2018) demonstrated that sunitinib alone was non-inferior to cytoreductive nephrectomy followed by sunitinib in IMDC intermediate- and poor-risk metastatic RCC, shifting practice away from routine cytoreductive nephrectomy. For this localized cT1bN0M0 lesion, current guidelines (EAU/AUA) favor partial (nephron-sparing) nephrectomy as the gold standard to preserve renal function. Radical nephrectomy is a fallback when partial is technically not feasible. RFA is an alternative for smaller tumors (<3 cm) but is second-line to surgery for T1b. Option A incorrectly implies nephrectomy is essential in metastatic disease.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.