6th International Kidney Cancer Association Symposium, 6—7 May, 2011, Warsaw

Surgery for renal cell carcinoma

Professor Bradley Leibovich (Mayo Clinic, Rochester, USA)

Surgery remains the mainstay of therapy for renal cell carcinoma. Thankfully, if you operate on somebody who has clinically localised disease, the majority of the time we cure patients. So, surgery has recently focussed on ways to minimise morbidity and to maximise renal function for these potentially curable patients.

So along the lines of minimising morbidity, there are two main points. One is to assure that the surgery has a minimal impact on the patient in terms of pain and recovery, and the big advances there are with minimally invasive therapies, mainly minimally invasive surgical techniques but also percutaneous ablative techniques. The other side is to maximise patient function and minimise long term morbidity of surgery by maximising renal function and, of course, the main objective there is to preserve as many nephrons as possible while eliminating the tumour.

So surgeons have a big interest in both minimally invasive surgery and nephron preservation; sometimes these are at odds with each other and unfortunately many patients will have a minimally invasive surgery when an organ sparing approach with nephron sparing surgery may have been feasible as an open surgery.

Many surgeons, including myself and my colleagues at Mayo Clinic, are doing minimally invasive partial nephrectomy, however, it’s technically challenging and often it’s much easier, minimally invasively, to remove the entire kidney. Unfortunately some people have a radical nephrectomy minimally invasively when an open partial nephrectomy may be a better option.

How do you decide between partial and radical nephrectomy?

The data is relatively unequivocal regarding partial nephrectomy and the data indicates that in terms of an oncologic perspective, cure is equally good with partial nephrectomy as it is with radical nephrectomy. Our approach is basically to perform a partial nephrectomy whenever technically feasible, if that’s possible with a minimally invasive approach then we do it minimally invasively. If a partial nephrectomy is possible but better performed as an open approach then we would do it as an open partial nephrectomy.

How does lymph node removal affect the outcome of surgery?

Much like surgical technique can sometimes interfere with doing the right thing regarding partial nephrectomy or radical nephrectomy, the evolution of minimally invasive surgery for renal cell carcinoma has resulted in many people not performing a lymphadenectomy at the time of a radical nephrectomy. It is feasible to do a lymphadenectomy with a minimally invasive technique but it’s quite a bit more difficult and most urologic oncologists would say that the amount of lymph node tissue removed and the adequacy of resection may not be as complete with a laparoscopic or robotic approach as with an open approach.

The data regarding the need for lymphadenectomy is quite confusing. Clearly patients with lower stage disease do not need a lymphadenectomy; patients with low risk disease do not need a lymphadenectomy. Patients with advanced disease may very well benefit from a lymphadenectomy and that may be one reason why we would choose to do an open surgery rather than a minimally invasive approach.

Can the lymphatic spread be used in kidney cancer treatment as with breast?

This is one of the big problems with kidney cancer, unlike some other cancers – breast cancer and several others, where the lymphatic spread is somewhat predictable. In kidney cancer the lymphatic spread is very unpredictable so kidney tumours tend to be quite large and due to variable lymphatics in the first place, and large size of tumours which will allow lymphatic spread to go in places where one might not expect, the ability to simply look at a sentinel node is not usually present for a patient with a renal mass. In fact, in some of our data we’ve shown that a significant proportion of patients will have no involvement of lymph nodes right next to the kidney and with the area called the hilar lymph nodes around the renal vessels, but may have disease beyond this area already on the lymph nodes.

What’s your opinion on cytoreductive nephrectomy?

In the absence of a clinical trial setting, I think there is no data to refute the paradigm of patients presenting with metastatic disease with the primary tumour in place should probably proceed to have a cytoreductive nephrectomy followed by systemic therapy, assuming they meet the criteria that we’ve always used which is good performance status, relatively small bulk of metastatic disease relative to primary tumour. Obviously we have on-going clinical trials that may answer the question but until those results are available, I think the old paradigm probably fits best still.

And the future for surgery?

I think we will be able to do more and more minimally invasively than we can now with the ability to perform some of these open surgical procedures that are currently reserved for only open surgery, minimally invasively. Certainly as the technology with robotics and miniaturisation of equipment evolves, our ability to do more minimally invasively will evolve. The future of surgery for renal cell carcinoma remains that it will be the mainstay of therapy for the foreseeable future, although our colleagues in medical oncology and pharmaceutical industries are making great strides in the ability to treat patients with systemic therapies. So far a cure with new targeted therapies is not expected and surgery will remain the mainstay of therapy for localised disease for quite a long time.