Are there any special concerns related to surgery after TKIs?

TKIs such as sunitinib and pazopanib block the VEGF pathway. VEGF is not only needed for tumor angiogenesis but also required for wound healing and for the natural regeneration of the microvasculature throughout the body. Hence, inhibition of the VEGF pathway could predispose to poor wound healing or thrombotic events. Bevacizumab has been associated with poor healing (disruption of bowel anastomosis in patients with metastatic colon cancer) and thrombotic events (when used along with chemotherapy) in special populations. The general experience with consolidative surgery for RCC after TKI’s has been safe but there is some evidence that the incidence of wound-related complications may be higher. Given these concerns, meticulous surgical technique is necessary to optimize hemostasis and thereby allow for aggressive VTE prophylaxis. Retention sutures may also be considered in some circumstances. Finally, the patient should be taken off therapy for a least a few half lives before and after surgery. The T ½ for bevacizumab is 17–21 days and for the active metabolite of sunitinib it is 80–100 hours.