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Surgery (and other treatments) For The Kidney Tumor
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Urologists are primarily responsible for surgical and ablative treatment of kidney tumors so I went to the 2004 American Urological Association conference to get more information on treating the kidney tumor. What I learned there is a major source for this article. |
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:
- Completely removing or destroying the tumor or tumors.
- Preservation of adequate kidney function.
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.
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Laparoscopic kidney surgery uses a video camera / light source and instruments placed into the abdomen through several small punctures (called ports) to perform the surgery. Ports are usually only half an inch or so in diameter and can be smaller than that. Laparoscopic surgery is less invasive than open surgery, but still definitely requires general anesthesia. In laparoscopic nephrectomy the kidney is removed through a somewhat larger incision (but still much smaller then for open nephrectomy). Often one of the ports is enlarged to make this incision. Advantages of laproscopic surgery include:
Disadvantages include:
Variations
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Nephrectomy
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.
Open Nephrectomy
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
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.
Partial Nephrectomy
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:
- Solitary Kidney: If you already only have one kidney, saving part of
your kidney will keep you off of dialysis. You can live a normal life with less
than half of a single kidney.
- Tumors in Both Kidneys: If you have tumors in both kidneys, then
partial nephrectomy for at least one and if possible both will keep you off
dialysis.
- Hereditary Kidney Cancer: People who have hereditary kidney cancer
are usually prone to developing multiple kidney tumors over the course of their
life. Even if there happens to be only one tumor now or tumors in only one kidney
people who are known to prone to developing multiple tumors should try to preserve
as much kidney as possible.
- Diseases Which Reduce Kidney Function: If you already have reduced
kidney function due to some other disease, partial nephrectomy may help stave
off dialysis.
- Diseases Which Increase Risk of Kidney Failure: Diabetes and High Blood Pressure increase the risk of kidney failure in the future and would increase the chance of getting a major benefit from keeping part of the kidney. This is not as strong an indicator as the above, but still makes partial nephrectomy worth considering when reasonable.
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
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
Gill IS, Matin SF, Desai MM, Kaouk JH, Steinberg A, Mascha E, Thornton J,
Sherief MH, Strzempkowski B, Novick AC.
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
- "Minimally Invasive": In some cases ablation can be done by
inserting a probe through the skin into the tumor under CT or MRI guidance.
This "percutaneous" ablation can be done when the tumor to be ablated isn't too
close to any adjacent organ and when no organs are in the path of the probe
as would the case for tumors on the part of the kidney closest to your back
("posterior") or closest to your side ("lateral"). Percutaneous cryoablation
still usually requires general anesthesia, perhaps because of the thickness of
the probe, but percutaneous RFA can be done with IV sedation. This could be
important if you have medical problems which make general anesthesia risky.
Percutaneous ablation even with general anesthesia has a faster recovery than
laparoscopic surgery. Sometimes percutaneous RFA can even be an outpatient
procedure while percutaneous cryoablation usually requires an overnight in the
hospital.
Ablation can be also be done laparoscopically and has to be when the location of the tumor precludes percutaneous ablation. Frankly, I see little advantage to this over laparoscopic partial nephrectomy (if available from an expert) which offers more certain tumor destruction though laparoscopic partial nephrectomy is more technically difficult to perform.
- "Nephron Sparing": The objective of ablation is to destroy the tumor along with a safety margin of normal tissue while sparing the rest of the kidney, so this also has the benefits of partial nephrectomy.
Limitations
- Size: Currently ablation is usually limited to tumors about 4cm or
smaller. Because both technology and technique are improving rapidly, I expect
this to be relaxed in the future.
- Tumor Location: Tumors located in the center of the kidney or close to it are difficult to treat and those which are invading the urine collecting system, or close to it, probably cannot be treated by ablation. Attempts to treat these tumors have had a high complication and failure rate. According expert in ablation who I talked to at the 2004 AUA conference, only rarely could a tumor be gotten with ablation that couldn't also be gotten with partial nephrectomy (assuming the patient could withstand either procedure).
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.
Serious Uncertainties
- Uncertain Tumor Destruction: With surgery. whatever is removed is
most assuredly completely gone! With ablation it is possible that some cancer
cells in the ablation zone survive the process. In fact, two recent studies
where experimental radiofrequency ablation was followed by surgery to remove
the entire tumor showed that some cancer cells survived in most cases
[Michaels 2002, Rendon 2002]. Another
study [Matlaga 2002] was much more reassuring, but I
don't think there is enough data to give good advice about what makes for
effective total ablation. I found only one similar study for cryosurgery [Edmunds 2000]. Although unlike RFA all of the tumors
were completely ablated in this study, the study was limited to such small
tumors (<2cm) that it's not enough to prove that Cryosurgery is more
effective than RFA. It is good evidence for true tumor kill with
cryosurgery in very small tumors.
- Difficulty Assessing Tumor Destruction: With surgery, the pathologist examines the edges of the removed tissue to determine if the whole tumor was removed. With ablation, all you get are imaging results - during and after the procedure. There is no way to be sure whether the entire tumor was destroyed or whether there are viable cells in the ablated zone. More often then not, the lesion does not completely go away on CT scan - not even after months. Most studies rely on whether the area of the tumor still "enhances" after contrast CT scan after the procedure. If it does, they consider the treatment to have failed, but no enhancement can't guarantee an actual success. In some cases areas which were missed can simply be retreated. In the end, only time will tell whether the tumors have really been definitively treated but it could take years for tumors to regrow from a single cell that escaped ablation and most of these studies have rely primarily on CT scans and have very, very short follow-up, sometimes much less than even one year.
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
- Can't Withstand Surgery: Ablation can make sense for patients with
small tumors who might not be strong enough to withstand surgery due to medical
problems or advanced age. I think this is the most important reason for ablation
at this time since these patients might not be able to have curative surgery
other than by ablation.
- An Interesting Story: On a cross country ski trip not too long ago I
met a man whose elderly father was planning to get RFA for a very small kidney
tumor that had just been found. His tumor was only one or two centimeters. The
patient was in his mid 80s but in reasonable health. The risk of metastasis is
very low with such small tumors, and they figured it made a lot of sense to
take a small risk with the new technology to avoid the certain risks and
quality of life costs of major surgery at his age, even though he probably
would have survived surgery.
- An Interesting Story: On a cross country ski trip not too long ago I
met a man whose elderly father was planning to get RFA for a very small kidney
tumor that had just been found. His tumor was only one or two centimeters. The
patient was in his mid 80s but in reasonable health. The risk of metastasis is
very low with such small tumors, and they figured it made a lot of sense to
take a small risk with the new technology to avoid the certain risks and
quality of life costs of major surgery at his age, even though he probably
would have survived surgery.
- Multiple Tumors: Ablation of small tumors could be used to avoid multiple open surgeries over time in patients who tend to develop multiple primary tumors over time, perhaps due to a hereditary kidney cancer syndrome. What is unclear to me is whether there are cases where ablation can better preserve renal mass significantly better than surgery. It'd be worth getting an opinion about this from an expert.
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
Cryosurgery
Radiofrequency Ablation
Farrell MA, Charboneau WJ, DiMarco DS, Chow GK, Zincke
H, Callstrom MR, Lewis BD, Lee RA, Reading CC.
Rendon RA, Kachura JR, Sweet JM,
Gertner MR, Sherar MD, Robinette M, Tsihlias J, Trachtenberg J, Sampson H,
Jewett MA.
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.
- Very Large Tumors: Size alone is no bar to surgery! Huge kidney tumors
are routinely removed. This should not be a reason you can't have surgery.
- Vena Cava or Renal Vein: Almost all of these tumors can be removed -
see my discussion under open nephrectomy above.
- Would Lose Kidney Function: If removing the kidney would cause you to
need dialysis, partial nephrectomy or non-surgical ablation could be options
for you. See the discussion of these techniques above.
- Would Not Withstand Surgery: If you have other medical conditions
and are told the surgery itself is too risky, you should consider the risk of
the disease which is often curable if the surgery can be done and usually
incurable if it metastasizes, which is the expected result without treatment.
Non-surgical ablation or laparoscopic surgery might be options and another
surgeon might have a different opinion of whether you could tolerate the
surgery. Note that since very occasionally laparoscopic surgeries have to be
converted to open, most surgeons would still require that you could withstand
an open surgery even if it is not desirable.
- Direct Extension to Other Organs: Here the tumor has grown out of the
kidney and directly invaded other nearby organs such as the liver. This is a
different situation than metastasis where cells which have escaped from the
kidney tumor have started new tumors elsewhere in the body. Sometimes direct
extension really is inoperable, but definitely don't accept the first judgment
you get on that.
- Metastatic Disease: If you have been told you kidney tumor is "inoperable" because you have metastatic disease this does not mean it would actually be impossible to have a nephrectomy. Instead, nephrectomy alone is not a useful treatment once the disease has spread. In some cases, initial nephrectomy as part of an integrated plan which combines the surgery with immunotherapy has been advocated. This is an extremely complex and difficult area - see my article Surgery & Immunotherapy for the details.
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!
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This CancerGuide Page By Steve Dunn. © Steve Dunn
Page Created: August 22, 2003, Last Updated: June 2, 2004
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.