CancerGuide: Special Kidney Cancer Section
Surgery is the cornerstone (and usually the whole shooting match - see my article on Adjuvant Therapy) of treatment for renal cell cancer localized to the kidney. Taking care of the primary tumor offers an excellent chance of a cure with smaller less advanced cancers and still a good shot at it in most cases even when the cancer is locally advanced.
Taking care of the primary tumor almost always means surgery to remove it but I didn't call this article, "Surgery for Localized Kidney Cancer" because a few patients, who for one reason or another can't have surgery, can be treated with innovative energy based ablation techniques instead of surgery, something I cover in detail later in this article.
More and more kidney cancers are being diagnosed when small. Very often the patient had no symptoms at all and their tumor was picked up on scans being done for another reason. In many other areas of medicine, it's the big complicated problems where new science and technology is bought to bear, but interestingly these small tumors are the current focus for innovations in treating the kidney tumor. Newer forms of surgery can save most of the affected kidney or be easier to recover from, or maybe even both. These aren't options for all patients but they are for many, particularly those with small tumors.
Anyway, this surveys the options for dealing with the kidney tumor including several types of surgery and energy ablation. Some of these options are exotic but a quick read might clue you into some options you didn't know you had. For detailed information on getting through surgery, see our Nephrectomy Tips. Towards the end of the article, I also suggest solutions for special situations such as "inoperable" tumors and multiple tumors.
Major Goals of Treating the Kidney Tumor
There are two major goals:
If there is a question of whether the tumor can be removed or whether removing the tumor will leave you with adequate kidney function, the situation is quite different. Here, in depth research of your options may make an absolutely critical difference. You could find a way to preserve your kidney function or "get" your tumor even if you've been told these goals are impossible to accomplish.
Open surgery has been the "gold standard" for many years, but more and more patients are having their surgery done laparoscopically instead of open because it offers a faster recovery with less scarring. Where feasible (and it isn't always) laparoscopic nephrectomy is becoming the standard technique for nephrectomy in an increasing number of centers. You should be aware that there is a dilemma between laparoscopic nephrectomy and open partial nephrectomy for some patients with smaller tumors. See below for a detailed discussion.
In the standard radical nephrectomy, the entire kidney, along with the associated adrenal gland, and regional lymph nodes are removed.
Many patients with smaller tumors get less radical surgery. My understanding is that when the tumor does not involve the upper part of the kidney near the adrenal, the adrenal can be left in place. Extended lymph node removal is increasingly being skipped for smaller tumors which are quite unlikely to have regional lymph node metastasis.
There are some cases in which an open nephrectomy is still necessary which I will discuss under laparoscopic nephrectomy below. These are mainly larger and more complex situations.
Involvement of the Inferior Vena Cava
One case which deserves special consideration here is tumor growth into the Inferior Vena Cava (IVC). Kidney cancer can actually get into the main vein draining the kidney and start growing inside the vein. This is called "tumor thrombus" (a thrombus is a clot). If this continues, the tumor thrombus will reach the IVC, which is the main vein draining the lower part of the body. The tumor thrombus can continue growing inside the IVC and it will grow in the direction of flow, upward towards the heart. In some cases, the tumor thrombus may even reach the heart. While all of this sounds both grim and gross, it turns out that removing the tumor thrombus is almost always possible. This is stage III not stage IV RCC and while serious there is also a real chance of cure or a long remission. Also surprisingly to me, the obstruction of the IVC does not cause severe problems. You may have a variocele, a benign mass of veins in the scrotum (I had IVC involvement and had this symptom).
You should know that complete removal is almost always possible even if tumor thrombus reaches all the way to the heart. If the thrombus is extensive you may need to be put on heart lung machine while the thrombus is extracted. Also sometimes a section of the IVC may have to be replaced by an artificial "graft". Particularly if involvement of the IVC is extensive you should find a surgeon at a major center with lots of experience doing this operation. Over the years I've encountered a few patients who were told that surgery was not possible. If you are in this situation, you definitely need to get a second opinion from an expert in this, no matter how extensive your IVC involvement.
Laparoscopic nephrectomy can be done when the tumor is small to medium sized usually up to about 8 cm. A few experts have done laparoscopic nephrectomy on huge tumors and if you have a large tumor and are going to have laparoscopic surgery anyway, you definitely want it from an expert (open surgery is also a good option). Laparoscopic surgery isn't always possible. If you have lymph node metastasis in the area around the kidney, if you have tumor growing inside the renal vein or vena cava, or if the tumor directly invades nearby organs laparoscopic surgery is not an option and you will need open surgery. There are many other factors which influence whether laparoscopic surgery will be feasible, so to be sure, you need an opinion from a surgeon with experience in laparoscopic nephrectomy.
The faster recovery, shorter hospital stay, and minimal scarring with laparoscopic nephrectomy are very real advantages but they are short term or cosmetic. If you have a relatively simple case but are going to get a total nephrectomy rather than a partial nephrectomy, I recommend laparoscopic surgery if you can get it from an experienced surgeon. Laparoscopy is also a specialized skill with a real learning curve. Many urologists see relatively few cases of kidney cancer, so be sure your surgeon has real experience with laparoscopic nephrectomy.
I also think that because the advantages of laparoscopic nephrectomy are usually not critical, long term advantages, you shouldn't feel as though it's necessary to go through heroic efforts to get this type of surgery (in most cases). The good news is finding someone in your area with experience may not be difficult and if you can travel certainly you can get this surgery if it's feasible in your case. If you are elderly or frail, though the advantages of an easier surgery could be very important and it would be especially worthwhile to seek out laparoscopic surgery. Again because the advantages of laparoscopic surgery are short term reasons, I don't recommend pushing the limits of laparoscopic nephrectomy with large tumors or otherwise complex cases, or any case which is at the margin of experience for your surgeon.
Particularly for small tumors, an increasing number of surgeons are doing partial nephrectomies rather than removing the whole kidney, although this is still far from standard practice for patients with normal kidney function. There may be some long term benefit from preserving more kidney mass, but keep in mind that most people do live a normal or near normal life span with one kidney as long as it's functioning normally, and healthy people are even allowed to donate a kidney to a relative.
I commonly have seen 4cm given as the size limit for partial nephrectomy for people with otherwise normal kidney function, one study at the 2004 AUA conference showed that this limit could be extended to 7cm. Whether that will become the standard I don't know. If it's a matter of keeping you off dialysis surgeons will push the limits, and you should also push the limits by finding an expert's expert if you're in this situation.
Whether a partial is possible depends on more than just size. The location of the tumor is important too. Tumors in the center of the kidney are harder to get out, but very experienced experts can get more of these tumors. If you need a partial nephrectomy to retain kidney function and your tumor is centrally located you need to see an expert's expert. Involvement of the renal vein or Inferior Vena Cava, or direct extension to nearby organs, preclude partial nephrectomy.
Partial nephrectomy becomes a truly important option when preserving kidney function is an issue. Some cases where partial nephrectomy may be an important option:
If you are interested in partial nephrectomy, I think it's important to find a surgeon who has a lot of experience with this technique because the surgery is substantially more complex than a regular nephrectomy.
Partial nephrectomy may carry a small risk of local recurrence in the remaining kidney due to cells which had escaped the main tumor. I recommend that follow-up after partial nephrectomy include special attention to the remainder of the kidney including appropriate imaging studies such as abdominal CT scan.
References on Partial Nephrectomy
Open surgical partial nephrectomy.
Semin Urol Oncol. 2001 May;19(2):103-13.
Nephron-sparing surgery for renal cell carcinoma.
Annu Rev Med. 2002 ;53:393-407.
Laparoscopic Partial Nephrectomy
Can laparoscopic surgery and partial nephrectomy be combined? According to a presentation at the 2003 Kidney Cancer Association meeting, the answer is yes. Laparoscopic partial nephrectomy is possible but requires special skill. It is necessary to cut-off the blood supply to the kidney while the tumor is being removed to prevent bleeding, and this strictly limits the amount of time to finish the job. In addition, controlling bleeding can be very difficult laparoscopically. The extremely technical nature of this surgery does not mean it is harder for the patient. If everything goes right, the operation still retains all of the advantages of laparoscopic surgery, faster recovery and minimal scarring.
Unfortunately, the best published report I have on this suggests a significantly higher rate of complications and failure to "get it all" for laparoscopic partials. At the 2004 AUA meeting Dr. Gill updated his experience and it appears that with improved methods of controlling bleeding and more experience, he has been able to greatly reduce the rate of complications and appears to have eliminated cases with positive margins. At the same time every presentation I attended at AUA 2004 strongly emphasized what a technically difficult and advanced procedure this is, along with its "steep learning curve". A steep learning curve means the risk of problems is much greater in the surgeons early cases.
My recommendation is to stay away from laparoscopic partial unless there is a specific reason this is important in your case or unless you are in the hands of one of the few world experts in this surgery. If you are one of the few who really would need a laparoscopic partial, you want one of those world class experts. I recommend asking how many procedures your surgeon has done, and what the rates of complications and positive margins have been.
References on Laparoscopic Partial Nephrectomy
Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques.
J Urol. 2002 Feb;167(2 Pt 1):469-7; discussion 475-6.
Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients.
J Urol. 2003 Jul;170(1):64-8.
Comment: This group of some of the world's most experienced experts in advanced kidney surgery had a higher rate of both complications and positive surgical margins (not "getting it all") for laparoscopic partial nephrectomy compared to open partial nephrectomy. While most of the complications were only a temporary setback for the patient, re-operation, or even losing the kidney also happened in a few cases.
At AUA 2004, Dr. Gill presented updated results with another 200 cases of laparoscopic partial and it appears he's worked out many of the bugs. There were no more cases of positive margins and also improved techniques greatly reduced the rate of complications due to bleeding. I think there are very few surgeons who could duplicate Dr. Gill's results right now, but over time I expect the ability to do this surgery with consistently excellent results will spread.
Laparoscopic partial nephrectomy: a new horizon.
Curr Opin Urol. 2003 May;13(3):215-9.
Laparoscopic partial nephrectomy and minimally invasive nephron-sparing surgery.
Curr Urol Rep. 2003 Feb;4(1):13-20.
Treatment of Small Tumors: A Dilemma
At the 2004 AUA conference there were two posters, back to back, each proclaiming different surgeries to be the new "gold standard" for smaller kidney tumors. They were laparoscopic nephrectomy and open partial nephrectomy. The thing is, each treatment has a different advantage over open nephrectomy.
If both treatments are an option for you, you are faced with mutually exclusive options, preserving the most kidney tissue versus the easiest recovery and a smaller scar. In some cases it will be obvious which is more important. If you have conditions which threaten kidney function then preserving kidney mass is most important. If your medical condition is such that major surgery will be particularly debilitating, then surgery which is easier on the patient is most important. For most patients the advantages of laparoscopic surgery are almost entirely short term and tactical. Preserving kidney function is a long-term strategic advantage. Whether saving kidney mass with a partial nephrectomy in the absence of any specific threat to kidney function is really a significant advantage I'm not sure of yet, but I do think long term strategic advantages are more important than short term tactical advantages.
Of course, in theory, laparoscopic partial nephrectomy is the best of both worlds, but as I discussed above, this technique is still in development, hard to find, and carries additional risks. For selected patients with both a threat to kidney function and who would find open surgery particularly debilitating, getting this treatment from an expert is an option.
Energy Based Ablation
I cover ablation in some detail even though it is appropriate for only a few patients because this is one of those things which is not be universally known and which could be very important for those few who need the information.
Radiofrequency Ablation (RFA) and Cryoablation are techniques for destroying tumors through the application of energy which have shown promise in treating smaller kidney tumors. Although equipment for both RFA and cryosurgery are FDA approved devices, these techniques are definitely experimental for treatment of kidney tumors. Both involve inserting a probe into the tumor usually using an imaging scan (CT, MRI, or ultrasound) to place the probe into the tumor. Cryoablation destroys the tumor by freezing it, while RFA destroys it by heating. The RFA probe isn't actually hot, but instead transmits radiofrequency energy which heats up the tissue surrounding it.
These techniques have two major advantages
There are many other factors which might affect whether ablation is technically feasible so of course you need an opinion from an expert to be sure.
One significant mitigating factor is that very small kidney tumors (under about 3cm) metastasize only rarely. With careful follow-up of the kidney, any local recurrence could probably be re-treated before it was dangerous. This is under the assumption the tumor was small to begin with. If you had ablation for a larger tumor it is possible that the cells have become more aggressive and that regrowth could be more dangerous.
Cryosurgery Versus RFA
Based on the published literature it appears to me that Cryosurgery has a better success rate (however measured) than RFA (see the commented references below), however because the technologies are new and evolving rapidly, it's impossible to know which is better. It will certainly depend on the practitioner's methods and experience as well your situation. Again, neither treatment comes with a guarantee.
On the other hand, RFA has the advantage that it can be done without general anesthesia in some cases. Unless you can't withstand general anesthesia, right now I think the slightly better success rate for cryo makes it the better option.
If ablation doesn't appear to be unusually complicated - e.g. small non-centrally located tumor, then I think either technique might completely destroy your tumor. For most people, "might" isn't nearly good enough since surgery will almost certainly eliminate the tumor. For a few with special situations which make surgery unattractive, "probably" may be a great advance over the alternative.
Some Situations In Which Ablation Could be Appropriate
Follow-Up After Ablation: Since energy ablation is new and is also a less definitive way of eliminating tumors than surgery, long-term very careful follow-up of the kidney to detect local recurrence is critical.
References on Ablation
General References and Reviews
Current status of cryoablation and radiofrequency ablation in the management of renal tumors.
Curr Opin Urol. 2002 Sep;12(5):387-93.
Minimally invasive ablative approaches in the treatment of renal cell carcinoma.
Curr Urol Rep. 2002 Feb;3(1):13-20.
Energy-based renal tumor ablation: a review.
Semin Urol Oncol. 2001 May;19(2):133-40.
Acute histologic changes in human renal tumors after cryoablation.
J Endourol. 2000 Mar;14(2):139-43.
Comment: This is the only study I've found on cryosurgery which tested removing the tumors after ablation to see if the procedure really killed all of the tumor cells. Very much unlike some of the studies for RFA, every tumor was completely killed. However, the study was limited to tiny tumors - less then 2cm - and I'm not sure the same result couldn't have been had with RFA for these tumors. So while I can't conclude from this that it proves cryosurgery is more effective than RFA it is reassuring news that cryosurgery can result in total tumor kill.
Laparoscopic renal cryoablation in 32 patients.
Urology. 2000 Nov 1;56(5):748-53.
Comment: Though the more recent percutaneous procedure is less invasive, this is one of the major cryosurgery papers due to the number of patients treated and relatively long follow-up (which averaged 16 months). Patients required 1-5 days in the hospital and the median time to recovery was two weeks. By the measurements they used, CT scan and needle biopsy, every procedure successfully destroyed the tumor. Complications were not a problem.
Preliminary experience with cryoablation of renal lesions smaller than 4 centimeters.
J Am Osteopath Assoc. 2002 May;102(5):277-81.
Comment: This reports on cryosurgery done during open surgery. The authors argue that open cryosurgery is safer and more controllable and that more areas of the kidney can be accessed with open surgery but I do not see that their results are superior. However, they had good follow-up in some patients, 8 of 17 had more than 20 months follow-up and in only one of their 17 patients was there any suspicion of incomplete ablation. This is more evidence that freezing effectively destroys the tumor though subject to the usual uncertainty associated with these procedures. They had two controllable complications which they attributed to learning curve and the use of multiple probes. They switched to single probe cryosurgery part way through the study. It remains unclear to me whether cryosurgery preserves more of the kidney than partial nephrectomy - if not there would seem to be no advantage to open cryosurgery.
Retroperitoneal laparoscopic cryoablation of small renal tumors: intermediate results.
Urology. 2003 Jan;61(1):83-8.
Comment: This paper has longer follow-up than some others which is important. Half the patients had two years or more. In one case they apparently missed the lesion (mistaking something else for it) but in all other cases they thought the ablation had gone well. Postoperative CT showed residual enhancement in two cases but very interestingly with long term follow-up both of these disappeared completely. In fact, in many of the cases with long term follow-up the tumor resolved completely by CT scan. I think the complete resolution of tumors seen here longer term follow-up bodes well for cryosurgery.
Percutaneous renal tumor cryoablation with magnetic resonance imaging guidance.
J Urol. 2001 Mar;165(3):773-6.
Comment: This is one of the more important papers on cryoablation. The use of open MRI to position the probe and monitor the freezing process seems to be a significant advance. Although this was apparently successful, follow-up was less than a year in most cases. The one apparent failure was in a patient with a larger tumor than they planned to accept (5cm) and residual tumor was handled by retreating. They used general anesthesia in most cases but made exceptions for patients too sick to tolerate it. They hospitalized their patients overnight for observation.
Cryoablation of renal tumours in patients with solitary kidneys.
BJU Int. 2003 Aug;92(3):237-9.
Comment: In this study there were two failed ablations as judged by CT scans out of 12 cases, one of which was in a larger than usual tumor, while the other was using an earlier technique. Several patients required more than one treatment to get a total ablation. Follow-up for most patients was a at least a year with 4 patients out two years or more.
Imaging-guided radiofrequency ablation of solid renal tumors.
AJR Am J Roentgenol. 2003 Jun;180(6):1509-13.
Comment: This is one of the largest RFA papers and certainly the most successful - all patients were thought to have a complete ablation by CT scan though follow-up was short. Most patients were treated percutaneously and almost all of them were able to go home the same day, even though general anesthesia was used in most cases. There were some complications caused by placement of the probe - in particular nerve damage. This was temporary in two of three patients with this complication, but one was still in pain 9 months after the procedure.
Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors.
Radiology. 2003 Feb;226(2):417-24.
Comment: This important RFA study claimed an 85% success rate based on CT imaging which is a bit low, but most of the failures involved tumors close to or in the center of the tumor (and half of these were scheduled to undergo another ablation which might finish the job). My impression from this paper is that these doctors were willing to attempt more difficult cases than most, including larger and more centrally located tumors. They also used advanced techniques such as multiple ablation zones and multiple ablations when needed though some of this may have been to compensate for earlier versions of the equipment. Follow-up was variable averaging a little over a year but up to 42 months. No patient judged to have a technically successful ablation had growth or recurrence although most tumors didn't shrink much after treatment. Four patients had complications which included permanent kidney damage in some.
Phase II trial of radio frequency ablation of renal cancer: evaluation of the kill zone
J Urol. 2002 Dec;168(6):2401-5.
Comment: This study removed the tumor surgically immediately after RFA. It was similar in design to Michaels 2002 below, but had much better results. In 8 of 10 cases the pathological examination of the tumor showed complete destruction. Of the two failures one was an 8cm tumor, far beyond the size RFA can treat. Actually, I think studies of this sort would be excellent for defining and expanding the maximum tumor size which can be treated.
Incomplete renal tumor destruction using radio frequency interstitial ablation
J Urol. 2002 Dec;168(6):2406-9; discussion 2409-10
Comment: This one is scary. They removed the tumor surgically immediately after doing RFA and found by that there were potentially viable cells remaining in the ablated area every case. It is possible that these cells would have died over time due to disruption of their blood supply and so forth. It is also possible that some of the cells which looked like they could be alive were actually not viable. Technique and equipment might also play a role here as suggested by Matlaga 2002 above, but it's hard to advise what is better. In sum, this study screams caution about RFA.
Percutaneous radio frequency ablation of small renal tumors: initial results.
J Urol. 2002 Jan;167(1):10-5.
Comment: Interestingly, all of the patients in this paper from NCI had hereditary RCC (which tends to form multiple tumors). 5 of the 24 tumors were considered to be failures based on CT follow-up and 4 of these 5 were due to inadequate heating which was observed at the time of the ablation. Follow-up time was astoundingly short - only two months which makes this report extremely preliminary. No major complications.
The uncertainty of radio frequency treatment of renal cell carcinoma: findings at immediate and delayed nephrectomy.
J Urol. 2002 Apr;167(4):1587-92.
Comment: Like Michaels 2002, this study found evidence of incomplete ablation after RFA by removing the tumor surgically after ablation and examining it for viable cancer cells. What is unique is that they did percutaneous ablation on 6 patients and removed the tumor a week later, which should give a more accurate picture of the success of the ablation after any delayed cell death. They also ablated 5 patients during open surgery and removed the tumor immediately afterwards. Unfortunately, in both cases a substantial fraction had incomplete ablation. Interestingly, all of the viable tumor was at the edge of the lesion which suggests technique and equipment might solve the problem. Also of the three patients who had viable tumor after percutaneous RFA, two showed no enhancement in a CT scan taken right before surgery. This means using non-enhancement by CT as a measure of success for RFA, as so many of these studies do, is dangerous.
Special Situation: "Inoperable"
Surgery is possible for almost everyone with localized disease, even when they have large tumors or other complications, and in fact relatively few are told they are inoperable, but if you are one of the few it is absolutely critical to take action! Anyone without metastasis who is told they are "inoperable" should vigorously seek second opinions and other options for treating the tumor since surgery is by far your best chance of cure. Leave no stone unturned! If you are in an HMO you should insist on opinions at major centers from experts in urological surgery, even if it's out of network, or if necessary pay for an opinion yourself.
Special Situation: Tumors In Both Kidneys or Multiple Kidney Tumors
If you have multiple tumors either in both kidneys or a single kidney, it is important to try to preserve enough kidney mass to allow you to live a normal life without dialysis. The presence of multiple primary tumors suggests that you have a pre-disposition to develop kidney tumors, which suggests you could develop more in the future, which in turn makes it even more important to preserve kidney mass to the extent possible. Multiple primary tumors can sometimes be a sign of Hereditary Kidney Cancer. Anyone in this situation definitely needs to be in the care of experts at a major center. The US National Cancer Institute has special expertise in this area.
Several techniques such as partial nephrectomy (including surgery to basically cherry pick "enucleate" multiple small tumors) or energy based ablation may be used separately or in combination to preserve as much of your kidneys as possible. In addition, careful follow-up of the kidneys to detect new or recurring tumors is important so they can be treated while they are still small. In people with many small masses it's not possible too rush into surgery the instant something new is discovered so patients are followed closely and only treated when their biggest tumor approaches 3cm, a size below which hereditary cancers don't seem to metastasize (and rarely for any kidney cancer).
Special Situation: Only One Kidney or Reduced Kidney Function
If at all possible get a partial nephrectomy. See Partial Nephrectomy above!
This CancerGuide Page By Steve Dunn. © Steve Dunn
Page Created: August 22, 2003, Last Updated: June 2, 2004