BERKELEY, CA (UroToday.com) - In this review article, we explored the contemporary role of surgical management of large renal tumors in both the clinically localized and metastatic settings. While radical surgery of the primary tumor has traditionally had a significant role in all aspects of the management of RCC, surgical management has dynamically changed in response to improved understanding of the underlying behavior of the disease, importance of adrenal preservation, advances in surgical technique, the evolution of systemic therapy, and a growing appreciation of the importance of renal functional preservation.
We specifically highlight the growing role of nephron-sparing strategies in localized tumors of large size. Many patients with RCC already have underlying renal insufficiency upon initial diagnosis, and subsequent radical nephrectomy results in a major cause of chronic renal insufficiency. This coupled with emerging evidence of the deleterious chronic health impact of renal insufficiency (increased all-cause hospitalization, as well as cardiovascular morbidity and mortality) has served as impetus for consideration of nephron-sparing approaches in a larger number of settings. In addition, a growing appreciation of the concept of micrometastatic disease has suggested that removal of normal renal parenchyma may not protect from the development of distant metastatic spread. This is consistent with emerging data that has failed to demonstrate diminished oncologic outcomes of nephron sparing for larger than 4cm or even 7cm renal tumors. Thus, while large renal tumors are currently preferentially treated with radical nephrectomy, we believe that understanding of the RCC behavior coupled with technical advances in instrumentation and technologies will lead to improved utilization of the minimally-invasive nephron-sparing approach even in the setting of large tumors. As our experience with nephron-sparing surgery increases and outcomes data matures, the long-term consequences of renal functional preservation will become increasingly apparent. Our hope is that prospective trials can be thoughtfully designed in order to replace hypotheses gleaned from retrospective series and the dogma of expert surgical opinion.
However, it is more likely that the greatest advances in the management of large renal tumors will not come from improvements in surgical technique, but rather from improved prognostication, better patient selection for surgery versus early systemic therapy, and improved targeted systemic therapies. Further scrutiny of the underlying biology of RCC will undoubtedly uncover more useful targets within cancer pathways, new agents that can effectively disrupt them, and methods aimed at overcoming resistance to current therapies. In addition, combinations of agents will need to be studied, as synergies in tumor control may be achievable with acceptable side effects.
As we acquire more data from prospective randomized trials on the role of new systemic or targeted agents in neoadjuvant, adjuvant, and cytoreductive settings, the role and timing of the surgical management of large renal tumors will continue to evolve.
Srinivas Vourganti, Brian Shuch, and Gennady Bratslavsky as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Surgical management of large renal tumors - Abstract