Large cancer of the right kidney with caval thrombus up above the anastomosis of the hepatic veins

Treatment of Kidney cancer

Conventional chemotherapy is highly inefficient in kidney cancer.

Radiotherapy is contraindicated because this cancer is not radio-sensitive and in any case the very close relationship between the kidney and the intestine does not allow significant radiation doses due to the risk of intestinal necrosis.

The use of new anti-angiogenesis agents in possible association with an immunotherapy by interleukin and interferon (IFN) is great progress for patients with advanced and disseminated cancer.

But these treatments are most effective when they target a smaller volume of cancer and therefore a debulking surgery must usually be practiced first.

Is surgery still possible in patients with advanced kidney cancer?

Yes and it is usually the first kind of treatment.

Surgery can reduce tumor volume in these severe forms of kidney cancer, and thus increase the effectiveness of immunotherapy and anti-angiogenesis which have enabled recent and remarkable progress in terms of remission of this disease.

This operation is a radical nephrectomy with adrenalectomy, carrying the cancerous kidney, adrenal and the fat of renal loculus, as well as the satellite drainage areas of the lymphatic system by performing a lymph node dissection. It can also be particularly dangerous and difficult in cases with massively invaded ganglions attached to the inferior vena cava.

Large cancer of the right kidney with caval thrombus up above the anastomosis of the hepatic veins

       Legends of the magnetic resonance imaging of a large caval thrombus

This surgery can be expanded as needed to the removal of adjacent organs invaded by the tumor (spleen, colon, diaphragm, etc …). Resection of a venous tumor bud is just as difficult as the bud rises higher in the inferior vena cava and joins the vessel walls.

This is one of the characteristics of the extension of kidney cancer that preferentially spread the tumor to the venous system and lymph nodes.

The risks and difficulties are greatest when cancerous buds go back into the cardiac cavities, with the performance of both surgical teams (urology and cardiovascular) and extra members during the opening of the right atrium.

Can surgery save patients?

In many cases of kidney cancer, the prognosis is favorable because the cancer is limited to the kidney after results of the work-up, without any appearance of tumors beyond the renal loculus or lymph, or in neighboring organs or in distant organs through metastasis.

This is the ideal indication for the rapid achievement of a surgical treatment that ensures (as chemotherapy and radiotherapy are ineffective and immunotherapy and antiangiogenesis agents reserved for advanced forms) the recovery of patients in the majority of cases only:

  • The complete remission rate at 5 years is 90 to 95% for operated tumors of less than 4 cm. in diameter;
  • The rate is 80 to 85% for larger tumors that remain confined to the renal loculus.

Percutaneous treatments of localized kidney cancer are directed by ultrasound, scan, or magnetic resonance imaging, destroying the tumor with heat (radiofrequency) or cold (cryotherapy).

What is radiofrequency or cryotherapy?

LThey are currently under evaluation in the context of protocols and presently reserved only for subjects which cannot be considered for surgery without taking unreasonable risks due to their age or other pathologies they may have, in particular in the sphere of cardio-circulatory or respiratory.

Cancer is destroyed “in situ” and not withdrawn, which does not give anatomic pathology (or morbid anatomy) confirmation of the diagnosis or evaluate the histo-prognostic data results.

What is the extent of the classical surgical excision?

Surgical treatment of tumors larger than 4 cm in diameter is the realization of a radical nephro-adrenalectomy removing the entire kidney, adrenal and the whole cellulo-node atmosphere as well as the renal loculus fat that is removed at the end of the procedure, revealing the large adjacent vessel, the inferior vena cava for cancer of the right kidney and the abdominal aorta for cancer of the left kidney.

Adrenal may in special cases be preserved, especially for cancers of the lower pole of the kidney.

This complete excision with radical nephrectomy is also necessary in some cases with tumors less than 4 cm in diameter especially due to the location of the tumor, mid-renal, developed in the hilum of the kidney near the artery and renal vein or their side branches.

The fact sheet of the French Association of Urology (AFU): radical nephrectomy, explains the benefits, risks and possible complications, and even exceptional complications for this procedure.

Can a portion of the kidney be preserved? Yes.

In a number of cases, less extensive surgery than radical nephrectomy, removing only the portion of the kidney affected by cancer in order to keep most of the organ seems feasible: it is partial nephrectomy.
The portion of surgery of the kidney must spend sufficient distance from the tumor to maintain a margin of safety. The rate of cancer recurrence after conservative kidney surgery is not higher than that after complete removal of the organ.

The advantage of this partial nephrectomy is to preserve the patient’s nephron capital if possible (nephron-sparring surgery for Anglophones) and thereby preserving renal function.

Concerning ideally cancers of less than 4 cm in diameter located at one pole of the kidney.
But partial excisions are possible in each case when the location of the cancer appears to be less favorable, and the indications of this partial surgery will be pushed to the extreme in cases of cancer development in a single kidney function, or in cases of bilateral kidney cancer.

However, one must bear in mind that partial kidney dissection is technically more difficult than complete dissection; it is also more dangerous, especially if we consider the risk of hemorrhagic complications during or after the procedure, and it exposes the patient to an increased risk of postoperative complications, including urinary fistulas.

The patient is notified prior to the completion of this partial nephrectomy of the possibility that the surgeon might perform a complete dissection (total nephrectomy) during the procedure for which he must give his consent.
This is seen in cases where the surgeon is faced with unexpected difficulties during the intervention, usually caused by heavy bleeding that is uncontrollable without such a measure.

The fact sheet of the French Association of Urology (AFU): partial nephrectomy, explains the benefits, risks and possible complications, even in exceptional cases of this procedure.

What types of scars are caused by conventional surgery?

This renal exeresis surgery, partial or total and more or less extensive depending on the extent of the tumor, is conventionally carried out with an open body access.

The type of incision made depends on the characteristics of the tumor, the type of procedure performed and the surgeon habits.

There is usually a large anterior abdominal incision.
It can be vertical from the sternum to the pubis (xypho- pubic incision) possibly enlarged by a sternotomy of the thorax if the heart is necessary in case of extended venous bud.
It is usually slightly skewed in regards to the horizontal, as the lower edge of the ribs (subcostal incision limited to the side of the cancer of the kidney or projecting from the other side of the two-subcostal incision).

It can also consist of a lateral incision with the resection more or less extended to the last ribs: lumbotomy incision or lumbo-abdominal or thoraco-phrenolaparotomy, also allowing the venous buds back up into the inferior vena cava.

In all cases, the choice of the incision must enable the first renal vessels control and in particular the first ligation or first clamping of the renal artery before mobilization and renal excision.

It is always a major surgery.
The incisions are significant and entail their own risks of complications and consequences, including eventration and in particular difficult treatment of lumbar fossa eventrations.

Does surgery with laparoscopy have a place?

Laparoscopic surgery is taking an increasingly important role in the surgical therapeutic arsenal of kidney cancer.

It tackles localized tumors, whose diameter does not exceed 7 centimeters.
For larger tumors, laparoscopy is dangerous because the first large vessels become very difficult, and obsolete as the incision needed at the end of the procedure to take out the cancerous kidney is too large and meets the size of the incision required for traditional surgery.

However, the current conditions of the revelations of the disease, most often fortuitous during an imaging examination requested for any other reason, means that the diagnosis is most often brought to this relatively early stage where the cancer appears curable by surgery.

The type of surgery performed is the same as conventional open surgery.

Radical nephrectomy with or without adrenalectomy is the procedure of reference.

For tumors with a volume less than 4 centimeters in diameter, partial nephrectomy is envisaged in trained hands because it is a technically difficult surgery.

This renal surgery with laparoscopy for the introduction of the camera and necessary instruments requires five key hole incisions of 5 to 10 millimeters each for its implementation.

After surgery, the surgical specimen is extracted in a bag so that there is no contact between the cancer and the wall of the patient. This avoids the risk of parietal dissemination of the tumor. One of the trocar incisions is widened over a few centimeters to allow this extraction.
In addition to a significant reduction in scarring and limitation of subsequent risk of incisional hernia, laparoscopy enables us to avoid the use of lateral lumbar incision with rib resection, that has deteriorating effects.

Moreover postoperative comfort is well known amongst laparoscopic interventions including a significant reduction in postoperative pain, earlier resumption of intestinal transit and ultimately a shorter recovery and quicker return to regular activities including professional work.

Prior to the completion of this renal surgery with laparoscopy, the patient must be informed of the possible need to convert to conventional open surgery based on the difficulties encountered by the surgeon, especially due to hemorrhagic risks , and must give consent for this eventuality.

If a partial nephrectomy by laparoscopy is envisaged, the patient must also be notified (in the same manner previously indicated) of the eventual possibility of converting to conventional open partial nephrectomy and of the possibility of the surgeon needing to carry out a total nephrectomy based on the findings or intraoperative incidents.

SCIENTIFIC PUBLICATIONS:

    • ACTUALITÉS DANS LE CANCER DU REIN MÉTASTATIQUE
      B. ESCUDIER (Institut Gustave Roussy, Villejuif, France.)
      FLAMMARION MÉDECINE-SCIENCES — ACTUALITÉS NÉPHROLOGIQUES 2003 – pp. 267-283
    • A Randomized Trial of Bevacizumab, an Anti–Vascular Endothelial Growth Factor Antibody, for Metastatic Renal Cancer
      James C. Yang, M.D., Leah Haworth, B.S.N., Richard M. Sherry, M.D., Patrick Hwu, M.D., Douglas J. Schwartzentruber, M.D., Suzanne L. Topalian, M.D., Seth M. Steinberg, Ph.D., Helen X. Chen, M.D., and Steven A. Rosenberg, M.D., Ph.D.
      N Engl J Med. 2003 July 31; 349(5): 427–434.
    • Radiofrequency Interstitial Tumor Ablation (RITA) Is a Possible New Modality for Treatment of Renal Cancer: Ex Vivo and in Vivo Experience
      ALEXANDRE R. ZLOTTA, THIERRY WILDSCHUTZ, GIL RAVIV, MARIE-ODILE PENY, DANIEL van GANSBEKE, JEAN-CHRISTOPHE NOEL, CLAUDE C. SCHULMAN.
      Journal of Endourology. August 1997, 11(4): 251-258.
    • Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter?
      SUTHERLAND Suzette E. (1) ; RESNICK Martin I. (1) ; MACLENNAN Gregory T. (1) ; GOLDMAN Howard B. (1) ; ZINCKE Horst
      The Journal of urology   2002, vol. 167, no1, pp. 61-64 (32 ref)
    • Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience
      JEAN-JACQUES PATARD, OLEG SHVARTS, JOHN S. LAM, ALLAN J. PANTUCK, HYUNG L. KIM, VINCENZO FICARRA, LUCA CINDOLO, KEN-RYU HAN, ALEXANDRE DE LA TAILLE, JACQUES TOSTAIN, WALTER ARTIBANI, CLAUDE C. ABBOU, BERNARD LOBEL, DOMINIQUE K. CHOPIN, ROBERT A. FIGLIN, PETER F.A. MULDERS, ARIE S. BELLDEGRUN
      Journal of Urology, Volume 171, Issue 6, Part 1, Pages 2181-2185 (June 2004)
    • Partial Nephrectomy for Small Renal Masses: An Emerging Quality of Care Concern?
      David C. Miller, John M. Hollingsworth, Khaled S. Hafez, Stephanie Daignault, Brent K. Hollenbeck
      Journal of Urology, Volume 175, Issue 3, Pages 853-858 (March 2006)
    • Laparoscopic partial nephrectomy for cancer: techniques and outcomes
      Mauricio Rubinstein; Jose R. Colombo Jr; Antonio Finelli; Inderbir S. Gill
      Int. braz j urol. vol.31 no.2 Rio de Janeiro Mar./Apr. 2005

BOOKS:

Kidney Cancer
Eric M. Wallen, MD, Geoffrey F. Joyce, PhD, Matthew Wise, MPH
Urologic Diseases in America, chapter 10, pp. 337-376

in: Litwin MS, Saigal CS, editors. Urologic Diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 2007