Dr. Novick reviewed that the TNM staging for RCC has evolved and is important prognostically, especially when incorporated with clinical and molecular markers in algorithms. Tumor size is also important diagnostically, with 54% of renal lesions <1cm actually turning out not to be RCC. Small tumors have smaller growth rates and following small lesions in elderly patients may be more appropriate than presently practiced.

Dr. Novick presented data that laparoscopic radical nephrectomy has established itself as the standard approach for tumors of reasonable size. Partial nephrectomy, however is underutilized by many as published recently in a study by Hollenbeck and colleagues at the University of Michigan. No significant difference in cancer-specific survival or tumor recurrence is found between nephron-sparing surgeries compared to radical nephrectomy. Dr. Novick felt that open partial nephrectomy is still the gold standard and in 400 patients with a solitary kidney, his personal experience preserved renal function in 95.5 %. In 1,800 patients treated with either lap or open stage T1 tumors at 3 centers, the operative time was less with lap surgery but ischemia time and intra-op complications were less in the open group. Also, hemorrhage, renal loss and need for subsequent procedures were greater in the lap group. Surprisingly, the diagnosis of renal cancer was actually higher in the open surgery group. In summary the likelihood of several complications was 3 fold higher in the lap group.

Dr. Novick discussed the minimally invasive approaches to treating RCC. He stated that these modalities are still experimental and should be used only in patients who are not suitable for surgery. At the Cleveland Clinic, cryoablation resulted in overall and cancer-specific 5-year survival of 82% and 100%, respectively. Dr. Novick was concerned that radiofrequency ablation may leave residual cancer and the endpoints of lack of enhancement or growth may not correlate with the actual absence of viable tumor.

Dr. Novick pointed out that RCC is the most lethal of urologic cancers and is a heterogeneous disease. This heterogeneity has led to elucidation of mechanisms that have directed recent advances in targeted therapies. This is of great excitement for patients with metastatic renal cell cancer where cytotoxic chemotherapy has made no progress. Inhibitors of angiogenesis and signaling pathways are now in clinical practice with the introduction of Sorafenib and Sunitinib. Actual responses in the primary tumor are shown in patients treated with Sunitinib. Use of these agents as monotherapy, sequential therapy, combination therapy, neoadjuvant and adjuvant therapy require future investigation.

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

Please log-in or register in order to submit comments.

Powered by AkoComment!