• Expectant management
  • Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted.
• Percutaneous or laparoscopic ablation
  • CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up
  • Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up
  • These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally.
• Nephron-sparing surgery
  • Local recurrence rate 1-2%
  • 15% of small lesions may not be renal cell Ca
  • Preservation of renal function is laudable
  • Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney
  • Renal cooling and intraoperative ultrasound required in more difficult cases.
  • Open vs. laparoscopic approach based on tumor location, size, and operator experience.
• Laparoscopic nephrectomy
  • Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location.
  • Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision.
  • Learning curve associated with this approach
• Classic Radical Nephrectomy
  • Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated.
  • Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel.
  • Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney.
• Inferior vena cava extension
  • Sub classification based on cranial extent of lesion figure 1
  • Patient prognoses based on stage of lesion and not extent of thrombus
  • Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %.
    
    Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)
  
  
• Metastatic disease - Surgery
  • Outcome with metastatic disease depends on performance status
  • Low volume metastasis, especially pulmonary involvement tend to respond best.
  • Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit.
• Metastatic disease - Medical therapy
  • Few cytoreductive agents have any significant impact on renal cell carcinoma
  • Radiation therapy has little proven effect on renal cell carcinoma
  • Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients
  • Antiangiogenesis agents have theoretical promise for this disease

References

• Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999.
• Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998.
• Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998.
• Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989.
• Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996.
• Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993.
• Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994.
• Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989.
• Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989.
• Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

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