Renal cell carcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Overview

Surgery is the mainstay of treatment for renal cell carcinoma. Partial nephrectomy and ablation are recommended for patients who develop small renal masses. For patients with locally advanced renal tumors, radical nephrectomy is recommended. Moreover, radical nephrectomy or organ sparing treatment, along with the use of interferon alfa, is also used as part of a more aggressive management plan in cases with metastatic renal tumors. However, metastasectomy is rarely performed.

Surgical Management

Active Surveillance

Active surveillance is currently emerging as an option for select patients in whom co-morbidities do not allow for surgical intervention. According to the 2013 American Urological Association (AUA) guidelines, the following patients may benefit mostly from active surveillance[1]:

  • Elderly patients
  • Patients with decreased life expectancy
  • Presence of medical co-morbidities

Additionally, the growth rate of the tumor following diagnosis may help identify whether patients benefit from active surveillance to delay surgical resection and before a surgical intervention is indicated.[1] Active surveillance by imaging and routine follow-up is also an important strategy post-surgical intervention for monitoring of disease recurrence, metastases, or paraneoplastic syndromes in patients with resected tumors.[1]

Small Renal Masses

Partial Nephrectomy

Small renal masses are defined as masses that are less than or equal to 4 cm on CT scan enhancement. Optimal management of small renal masses includes open or laparoscopic partial nephrectomy.[2][3][4]Partial nephrectomy is characterized by a low-complication rate. Most common complications include urinary leak and hemorrhage that occur in 3-5% and 1%, respectively.[2][3][4]Partial nephrectomy is associated with less chronic renal failure (CRF) than with radical nephrectomy, with a rate of CRF ranging between 5-20% and 36-65%, respectively.[5]

Special consideration must be made for patient subgroups, including the elderly and those with high surgical risk. Because the average growth rate of small renal tumors is considered slow - approaching 0.28 cm/year and a 1% rate of metastasis - partial nephrectomy may be spared in these patients.[6][4]

Probe-Based Thermal Ablation

Percutaneous or laparoscopic probe-based thermal ablation is a new management method for patients with small renal masses. The technique utilizes extreme temperatures, such as cryoablation or radiofrequency ablation.[7][8]Thermal ablation is still considered inferior to partial nephrectomy due to the following considerations:

  • Difficulty in ablation of large (>3.5 cm) tumors[4]
  • Higher local recurrence rate in thermal ablation[9]
  • Ill-defined radiographic parameters for success in thermal ablation[10]
  • Post-ablation surgery may be compromised due to presence of ablation fibrotic reactions[4]
  • Unavailable long-term data on patients undergoing ablation

Locally Advanced Renal Tumors

The chances of malignancy generally increase with the size of the tumor (> 7 cm) and with the extent of local invasion, especially along the inferior vena cava.[4]

Radical Nephrectomy

Total nephrectomy should always be considered as first line of cure in patients with locally advanced renal cell carcinoma. Radical nephrectomy is curative in 40-60% of all renal cell carcinoma cases.[11][12]Following resection of the tumor with no evidence of metastasis, observation has been shown to be the optimal management plan with insufficient evidence to support the use of adjuvant medical or radiation therapy.[13][14][15][16][17][18][19][20][21]

Metastatic Renal Tumors

According to two phase III studies, radical nephrectomy or debulking, along with use of interferon alfa, is also used as part of a more aggressive management plan in cases with positive metastasis.[22][23][24]However, radical nephrectomy in such cases is not curative and should be performed only when benefits outweigh the procedure's risks. Thus, radical nephrectomy in metastatic cases is reserved only for those with the following tumor features[25]:

  • Tumor invading > 75% of the involved kidney
  • Good cardiopulmonary function
  • Absent CNS or liver metastasis
  • Procedural difficulty and tumor proximity to other organs and anatomic structures

Several factors play an important role in increasing risk of recurrence of renal cell carcinoma following radical nephrectomy. Risk factors are listed below[26][12][27]:

  • Stage of tumor
  • Grade of tumor
  • Performance status
  • Presence of tumor-related symptoms

Resection of Metastasis

Metastasectomy is rarely performed in less than 5% of all cases.[4]Generally, the procedure is to be considered only in the following cases, with a 5-year survival of 30% of all cases:[28][29]

  • Chance of complete resection

References

  1. ↑ 1.0 1.1 1.2 Donat SM, Diaz M, Bishoff JT, Coleman JA, Dahm P, Derweesh IH; et al. (2013). "Follow-up for Clinically Localized Renal Neoplasms: AUA Guideline". J Urol. 190 (2): 407–16. doi:10.1016/j.juro.2013.04.121. PMID 23665399.
  2. ↑ 2.0 2.1 Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR; et al. (2007). "Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors". J Urol. 178 (1): 41–6. doi:10.1016/j.juro.2007.03.038. PMID 17574056.
  3. ↑ 3.0 3.1 Lane BR, Novick AC, Babineau D, Fergany AF, Kaouk JH, Gill IS (2008). "Comparison of laparoscopic and open partial nephrectomy for tumor in a solitary kidney". J Urol. 179 (3): 847–51, discussion 852. doi:10.1016/j.juro.2007.10.050. PMID 18221958.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Rini BI, Campbell SC, Escudier B (2009). "Renal cell carcinoma". Lancet. 373 (9669): 1119–32. doi:10.1016/S0140-6736(09)60229-4. PMID 19269025.
  5. ↑ Huang WC, Levey AS, Serio AM, Snyder M, Vickers AJ, Raj GV; et al. (2006). "Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study". Lancet Oncol. 7 (9): 735–40. doi:10.1016/S1470-2045(06)70803-8. PMC 2239298. PMID 16945768.
  6. ↑ Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DY, Uzzo RG (2006). "The natural history of observed enhancing renal masses: meta-analysis and review of the world literature". J Urol. 175 (2): 425–31. doi:10.1016/S0022-5347(05)00148-5. PMID 16406965.
  7. ↑ Gill IS, Novick AC, Meraney AM, Chen RN, Hobart MG, Sung GT; et al. (2000). "Laparoscopic renal cryoablation in 32 patients". Urology. 56 (5): 748–53. PMID 11068292.
  8. ↑ Gill IS, Remer EM, Hasan WA, Strzempkowski B, Spaliviero M, Steinberg AP; et al. (2005). "Renal cryoablation: outcome at 3 years". J Urol. 173 (6): 1903–7. doi:10.1097/01.ju.0000158154.28845.c9. PMID 15879772.
  9. ↑ Kunkle DA, Egleston BL, Uzzo RG (2008). "Excise, ablate or observe: the small renal mass dilemma--a meta-analysis and review". J Urol. 179 (4): 1227–33, discussion 1233-4. doi:10.1016/j.juro.2007.11.047. PMID 18280512.
  10. ↑ Weight CJ, Kaouk JH, Hegarty NJ, Remer EM, O'Malley CM, Lane BR; et al. (2008). "Correlation of radiographic imaging and histopathology following cryoablation and radio frequency ablation for renal tumors". J Urol. 179 (4): 1277–81, discussion 1281-3. doi:10.1016/j.juro.2007.11.075. PMID 18280507.
  11. ↑ Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H (2004). "The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus". BJU Int. 94 (1): 33–41. doi:10.1111/j.1464-410X.2004.04897.x. PMID 15217427.
  12. ↑ 12.0 12.1 Leibovich BC, Blute ML, Cheville JC, Lohse CM, Frank I, Kwon ED; et al. (2003). "Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma: a stratification tool for prospective clinical trials". Cancer. 97 (7): 1663–71. doi:10.1002/cncr.11234. PMID 12655523.
  13. ↑ Galligioni E, Quaia M, Merlo A, Carbone A, Spada A, Favaro D; et al. (1996). "Adjuvant immunotherapy treatment of renal carcinoma patients with autologous tumor cells and bacillus Calmette-Guèrin: five-year results of a prospective randomized study". Cancer. 77 (12): 2560–6. doi:10.1002/(SICI)1097-0142(19960615)77:12<2560::AID-CNCR20>3.0.CO;2-P. PMID 8640706.
  14. ↑ Messing EM, Manola J, Wilding G, Propert K, Fleischmann J, Crawford ED; et al. (2003). "Phase III study of interferon alfa-NL as adjuvant treatment for resectable renal cell carcinoma: an Eastern Cooperative Oncology Group/Intergroup trial". J Clin Oncol. 21 (7): 1214–22. PMID 12663707.
  15. ↑ Pizzocaro G, Piva L, Colavita M, Ferri S, Artusi R, Boracchi P; et al. (2001). "Interferon adjuvant to radical nephrectomy in Robson stages II and III renal cell carcinoma: a multicentric randomized study". J Clin Oncol. 19 (2): 425–31. PMID 11208835.
  16. ↑ Clark JI, Atkins MB, Urba WJ, Creech S, Figlin RA, Dutcher JP; et al. (2003). "Adjuvant high-dose bolus interleukin-2 for patients with high-risk renal cell carcinoma: a cytokine working group randomized trial". J Clin Oncol. 21 (16): 3133–40. doi:10.1200/JCO.2003.02.014. PMID 12810695.
  17. ↑ Atzpodien J, Schmitt E, Gertenbach U, Fornara P, Heynemann H, Maskow A; et al. (2005). "Adjuvant treatment with interleukin-2- and interferon-alpha2a-based chemoimmunotherapy in renal cell carcinoma post tumour nephrectomy: results of a prospectively randomised trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN)". Br J Cancer. 92 (5): 843–6. doi:10.1038/sj.bjc.6602443. PMC 2361915. PMID 15756254.
  18. ↑ Gez E, Libes M, Bar-Deroma R, Rubinov R, Stein M, Kuten A (2002). "Postoperative irradiation in localized renal cell carcinoma: the Rambam Medical Center experience". Tumori. 88 (6): 500–2. PMID 12597146.
  19. ↑ Kjaer M, Frederiksen PL, Engelholm SA (1987). "Postoperative radiotherapy in stage II and III renal adenocarcinoma. A randomized trial by the Copenhagen Renal Cancer Study Group". Int J Radiat Oncol Biol Phys. 13 (5): 665–72. PMID 3553111.
  20. ↑ Valentini V, Rosetto ME, Fares C, Mantini G, Salvi G, Turriziani A (1998). "Radiotherapy and local control in rectal cancer". Rays. 23 (3): 580–5. PMID 9932477.
  21. ↑ Pizzocaro G, Piva L, Di Fronzo G, Giongo A, Cozzoli A, Dormia E; et al. (1987). "Adjuvant medroxyprogesterone acetate to radical nephrectomy in renal cancer: 5-year results of a prospective randomized study". J Urol. 138 (6): 1379–81. PMID 2824861.
  22. ↑ Flanigan RC, Mickisch G, Sylvester R, Tangen C, Van Poppel H, Crawford ED (2004). "Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis". J Urol. 171 (3): 1071–6. doi:10.1097/01.ju.0000110610.61545.ae. PMID 14767273.
  23. ↑ Flanigan RC, Salmon SE, Blumenstein BA, Bearman SI, Roy V, McGrath PC; et al. (2001). "Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer". N Engl J Med. 345 (23): 1655–9. doi:10.1056/NEJMoa003013. PMID 11759643.
  24. ↑ Mickisch GH, Garin A, van Poppel H, de Prijck L, Sylvester R, European Organisation for Research and Treatment of Cancer (EORTC) Genitourinary Group (2001). "Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial". Lancet. 358 (9286): 966–70. PMID 11583750.
  25. ↑ Rini BI, Campbell SC (2007). "The evolving role of surgery for advanced renal cell carcinoma in the era of molecular targeted therapy". J Urol. 177 (6): 1978–84. doi:10.1016/j.juro.2007.01.136. PMID 17509276.
  26. ↑ Kattan MW, Reuter V, Motzer RJ, Katz J, Russo P (2001). "A postoperative prognostic nomogram for renal cell carcinoma". J Urol. 166 (1): 63–7. PMID 11435824.
  27. ↑ Zisman A, Pantuck AJ, Dorey F, Said JW, Shvarts O, Quintana D; et al. (2001). "Improved prognostication of renal cell carcinoma using an integrated staging system". J Clin Oncol. 19 (6): 1649–57. PMID 11250993.
  28. ↑ Murthy SC, Kim K, Rice TW, Rajeswaran J, Bukowski R, DeCamp MM; et al. (2005). "Can we predict long-term survival after pulmonary metastasectomy for renal cell carcinoma?". Ann Thorac Surg. 79 (3): 996–1003. doi:10.1016/j.athoracsur.2004.08.034. PMID 15734422.
  29. ↑ Pfannschmidt J, Hoffmann H, Muley T, Krysa S, Trainer C, Dienemann H (2002). "Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma". Ann Thorac Surg. 74 (5): 1653–7. PMID 12440625.

References

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