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Management of Small renal tumors. Dr. NGAI Ho Yin Division of Urology Department of Surgery United Christian Hospital. Most common: Renal cell carcinoma Less common: Oncocytoma Renal cortical adenoma AML. Rare: Neoplasm: Transitional cell carcinoma Metastatic tumors Infection:

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management of small renal tumors

Management of Small renal tumors

Dr. NGAI Ho Yin

Division of Urology

Department of Surgery

United Christian Hospital

differential dx of solid renal mass
Most common:

Renal cell carcinoma

Less common:

Oncocytoma

Renal cortical adenoma

AML

Rare:

Neoplasm:

Transitional cell carcinoma

Metastatic tumors

Infection:

Renal abscess

Vascular

Infarct

Vascular malformation

Differential Dx of solid renal mass
natural history of small renal tumor
Natural history of small renal tumor
  • Meta-analysis from Uzzo et al. (2006)
  • 234 enhancing renal masses
  • From 9 series
  • Mean follow-up: 34 months
  • Mean initial size: 2.60cm
  • Mean growth rate 0.28cm/yr

Uzzo et al. The natural history of observed enhancing renal masses: Meta-analysis and review of the world literature. J Urol 175:425-431. Feb 2006

analysis of histology related to tumor size mayo clinic from 1970 2000 n 2935
Analysis of Histology related to Tumor size ( Mayo clinic, from 1970-2000, n=2935 )

Frank I et al. Solid Renal Tumors: an analysis of pathological features related to tumor size.J Urol 170:2217-2220. Feb 2003

natural history of small renal tumor1
Natural history of small renal tumor
  • For single, small solid renal tumor
    • Almost 50% are benign if <1cm
    • Most will grow slowly, ~0.28cm/yr
    •  size =  chance of RCC & high grade disease
    • Aggressive potential of RCC increase after 3cm
management strategy

Management strategy

What are the available options in dealing with small renal tumors ?

options
Options
  • Observation
  • Radical Nephrectomy
  • Nephron-Sparing Surgery
    • Tumor Excision
      • Open partial nephrectomy
      • Laparoscopic partial nephrectomy
    • Tumor Ablation
      • Laparoscopic cryoablation
      • Radiofrequency ablation (RFA)
radical nephrectomy1
Radical nephrectomy
  • Gold Standard curative operation
  • Described by Robson 1963
  • Surgical Principles
    • Early ligation of the renal artery & vein
    • Removal of the kidney outside Gerota’s fascia
    • +/- Removal of ipslateral adrenal gland
    • +/- Complete lymphadenectomy from the crus of diaphragm to aortic bifurcation
radical nephrectomy2
Radical nephrectomy
  • 5 yr survival ( organ-confined ) ~ 95%
nephron sparing surgery1
Nephron Sparing Surgery
  • Goal of NSS:
    • Complete oncological excision of tumor with minimal technical complications
    • Optimal functional preservation for renal remnant

Indication

nephron sparing surgery2

Nephron Sparing Surgery

1. Open partial nephrectomy

Principles

nephron sparing surgery open partial nephrectomy
Nephron Sparing SurgeryOpen partial nephrectomy
  • Data from 3 major centers including:
    • Cleveland clinic Hafez KS, Novick AC, Butler BP. Management of small solitary unilateral renal cell carcinomas: impact of central versus peripheral tumor location. J Urol 1998;159:1156–60
    • Mayo clinic Lerner SE, Hawkins CA, Blue ML, et al. Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J Urol 2002;167:884–9.
    • Memorial Sloan-Kettering Cancer Center Lee CT, Katz J, Shi W, Thaler HT, Reuter VE, Russo P. Surgical management of renal tumors 4 cm or less in a contemporary cohort. J Urol 2000;163:730–6.
  • NSS and radical nephrectomy provide equally effective curative treatment for single, small (<=4cm) localized RCC
nephron sparing surgery open partial nephrectomy1
Nephron Sparing SurgeryOpen partial nephrectomy
  • Novick AC. Laparoscopic and partial nephrectomy. Clin Cancer Res 2004; 10:6322S-7S
  • Review of 1262 patients with open NSS for RCC since 1990
  • Mean Cancer-specific survival for all patients undergoing open NSS for localized RCC
    •  88% to 97.5% at Mean Follow-up 4-6 years
nephron sparing surgery open partial nephrectomy2
Nephron Sparing SurgeryOpen partial nephrectomy
  • Benefit in decreasing risk of progression to chronic renal insufficiency and ESRF
    • Memorial Sloan-Kettering Cancer CenterMcKiernan J, Simmons R, Katz J, Russo P. Natural history of chronic renal insufficiency after partial and radical nephrectomy. Urology 2002;59:816–20.
    • Mayo clinicLau WK, Blute ML, Weaver AL, Torres VE, Zincke H. Matchedcomparison of radical nephrectomy vs nephron-sparing surgery in patientswith unilateral renal cell carcinoma and a normal contralateralkidney. Mayo Clin Proc 2000;75:1236–42.
      • Renal insufficiency (Increase in Serum Cr >2mg/dl)
        • At 10 years time :
          • 12.4% in radical nephrectomy group
          • 2.3% in NSS group
nephron sparing surgery open partial nephrectomy3
Nephron Sparing SurgeryOpen partial nephrectomy
  • Gold standard in nephron-sparing surgery
  • Comparable efficacy, morbidity & mortality as radical nephrectomy
  • Additional benefit in renal preservation
nephron sparing surgery3

Nephron Sparing Surgery

2. Laparoscopic partial nephrectomy

Principle

nephron sparing surgery laparoscopic partial nephrectomy
Nephron Sparing SurgeryLaparoscopic partial nephrectomy
  • Largest single institutional report of LPN by Gill et al. Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. Journal of Urology. 170(1):64-8, 2003 Jul.
  • Patients with solitary renal tumor (<=7cm) in size ( clinical T1 RCC )
    • LPN (n=100) : Sept 1999 to Jan 2002
    • OPN (n=100) : Apr 1998 to May 2001
nephron sparing surgery laparoscopic partial nephrectomy3
Nephron Sparing SurgeryLaparoscopic partial nephrectomy
  • Oncological efficacy of LPN by Allaf et al.

( John Hopkins Medical institution – 3-year follow-up)

  • 48 patients with RCC(Mean tumors size 2.4cm)treated by LPN
    • Intra-op FS margin : all negative
    • Mean FU 37.7 months
    • Final pathology:
      • 42 patients : pT1
      • 6 patients : pT3a

Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. Journal of Urology. 172(3):871-3, 2004 Sep.

nephron sparing surgery laparoscopic partial nephrectomy4
Nephron Sparing SurgeryLaparoscopic partial nephrectomy
  • Results :
    • No recurrence in 46 patients
    • 1 patient with VHL locally recurred at 18th months
    • 1 patient recurred at new location of same kidney at 4 yrs time
nephron sparing surgery laparoscopic partial nephrectomy5
Nephron Sparing SurgeryLaparoscopic partial nephrectomy
  • Benefits from LPN:
    • Less blood loss
    • Less analgesic requirement
    • Shorter hospital stay
    • Shorter convalescence
    • Short term data suggesting promising survival outcomes
  • Problems of LPN:
    • Longer warm ischaemic time
    • More major intra-op & post-op urological Cx
    • No long term data concerning the oncological efficacy
  • Laparoscopic NSS is an effective treatment for clinically small localized RCC despite long term result needed.
nephron sparing surgery4

Nephron Sparing Surgery

3. Laparoscopic Cryoablation

nephron sparing surgery laparoscopic cryoablation
Nephron Sparing SurgeryLaparoscopic Cryoablation
  • Method:
    • Usage of a liquid nitrogen-cooled cryoprobe
    • At temperature of –40 ‘C
      • By dual freeze-thaw cycle
      • Direct cellular injury &

Indirect damage to microvasculature

      • To ablate normal and cancerous tissues
    • Problems :
      • No histopathology to assume clearance
      • May Need extra biopsy for margin clearance
nephron sparing surgery laparoscopic cryoablation1
Nephron Sparing SurgeryLaparoscopic Cryoablation
  • Gill et al. Renal cryoablation: outcome at 3 years. Journal of Urology. 173(6):1903-7, 2005 Jun.
    • 3 yrs results
    • 56 patients with small renal tumors
      • 75% reduction in mean cryolesion size at 3 years
      • 38% (17 lesions) completely disappeared
      • Post-op needle biopsy: residual tumor in 2 patients
      • 3 years Cancer-specific survival ( unilateral sporadic renal tumor ) = 98%
nephron sparing surgery laparoscopic cryoablation2
Nephron Sparing SurgeryLaparoscopic Cryoablation
  • Laparoscopic Cryoablation:
    • Technically safe and intermediate results are encouraging
    • Longer term follow-up needed for oncological efficacy of cryoablation
nephron sparing surgery5

Nephron Sparing Surgery

4. Radio Frequency Ablation

nephron sparing surgery radio frequency ablation
Nephron Sparing SurgeryRadio Frequency Ablation
  • Using a RFA needle (Percutaneous> open / laparoscopic)
    • Deliver high-frequency alternating current to cancerous tissue
    • Induce ionic agitation  frictional heat
    •  intracellular temperature (60-100 ํC)
    • Desiccation, Cellular protein denaturation and membrane disintegration
nephron sparing surgery radio frequency ablation1
Nephron Sparing SurgeryRadio Frequency Ablation
  • Rendon et al.
  • 11 renal tumors
  • RFA  Immediate / Delayed nephrectomy
  • Found viable cancer cells in specimen :
    • 4/5 (80%) [immediate group]
    • 3/6 (50%) [delayed group]
nephron sparing surgery radio frequency ablation2
Nephron Sparing SurgeryRadio Frequency Ablation
  • Michaels et al.
  • 20 renal tumors (mean 2.4cm) in 15 pts
  • RFA  Open Partial Nephrectomy
  • Results:
    • All 20 specimens had evidence of morphologically unchanged tumors
nephron sparing surgery radio frequency ablation3
Nephron Sparing SurgeryRadio Frequency Ablation
  • Current RFA regimens:
    • Ineffective for total destruction of renal tumor tissue in a significant number of patients.
    • Still experimental in treatment of RCC
conclusion
Conclusion
  • For small solid renal tumor <= 4cm
    • Most are RCC
    • Evidence suggested NSS is equally effective as radical nephrectomy
    • NSS with better preservation of renal functions in long term
    • OPN is the gold standard among choices of NSS
    • LPN is promising technique with its potential advantages