The Concept Of Surgery In Kidney Cancer
Renal Cell Carcinoma (RCC) is one of those diseases where surgery is the only curative modality of treatment. Even when metastasis (distant spread) is present, surgical therapy in the form of cytoreductive nephrectomy is helpful for the patient. Traditionally open radical nephrectomy has been practiced. This involves removal of the kidney along with the Gerota’s fascia (fat cover around kidney) as envelop. This envelop avoids exposure of tumor tissue and prevents spillage. Dissection of para-aortic and para-caval lymphnodes have not shown survival advantage. However, they need to be removed when they are enlarged or positive. Unlike many other cancers there is no effective adjuvant therapy like chemotherapy or radiotherapy for RCC. Only in metastatic cases targetted therapies (sunitinib, sorafenib, everolimus, etc.) have shown some results.
Less than 7cm sized tumor (T1): The widespread use of contemporary imaging techniques has resulted in an increased detection of small incidental renal tumors. In the past few years the concept of cancer surgery has taken a U-turn giving way to the concept of Nephron Sparing Surgery (NSS). This is a procedure where only the diseased portion of the kidney is removed along with Gerota’s fascia adjoining it, sparing health tissue. Renal vessels are clamped after packing the kidneys with ice to reduce ischemia.This is especially useful in patients with single kidney, bilateral RCC, hereditary renal cancers or in those patients where there is a risk of kidney failure in future. Recent research has shown that in properly selected cases the survival outcomes of NSS are similar to radical nephrectomy. Thus NSS has become standard of care even for patients with normal opposite kidney when tumor size if favorable and is recomended by American Urological Association and European Association of Urology. Though NSS is the standard of care for tumors upto 4 cm in size, many centers have extended the indications to RCC’s less than 7cm. Definite contraindication for NSS would be presence of distant or nodal metastasis. Nephron Sparing Surgery can be repeated on ipsilateral recurrent RCC in previously performed NSS.
More than 7 cm sized tumor: Radical nephrectomy remains the standard of care for tumors larger than 7cm in size. However, some centers have tried NSS upto 10cm tumor size. It is not standard of care.
Nodal disease: When spread to regional lymph nodes (paraaortic or caval) detected prior to surgery or on table, a complete lymphnode dissection is performed. Reduction in tumor burden helps the outcomes in renal cancer.
Metastatic Renal Cancer: Cytoreductive nephrectomy to reduce the tumor burden is performed when overall condition of the patient permits the same. Patient is placed on targeted therapy following the surgery.