radical vs partial nephrectomy in small renal masses

8/14/2019 Radical vs Partial Nephrectomy in small renal masses

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Tamer Abou YoussifTamer Abou Youssif

26/4/200826/4/2008

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Surgical resection remains thecornerstone of treatment for RCC.

ORN was the gold standard of carefor localized RCC against which allother forms of surgery for RCC weremeasured.

This standard has been challengedby the introduction of elective NSS

for SRMs 2


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Pantuck, A. J., Zisman, A., Belldegrun, A. S.: The changing natural history ofPantuck, A. J., Zisman, A., Belldegrun, A. S.: The changing natural history of

renal cell carcinoma. J Urol, 166: 1611, 2001renal cell carcinoma. J Urol, 166: 1611, 2001

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Increase in survival after RN is true,whereas increase in survival due toimaging is false

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lead-time biaslength bias


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We are now sparing more adrenal glands, asadrenalectomy with RN is no longer necessaryfor most tumors

Unconditional ipsilateral adrenalectomy withradical nephrectomy for RCC should beavoided (poor response to the rapid ACTHstimulation test )

Preoperative efficacy of CT is effective inpredicting adrenal involvement with sensitivityand specificity of 87.5100% and 7698%,respectively.

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Lymphadenectomy in the treatment of RCC iscontroversial, but the prognostic role iswithout question.

Pantuck, A. J., Zisman, A., Dorey, F. et al.: Renal cell carcinoma with retroperitonealPantuck, A. J., Zisman, A., Dorey, F. et al.: Renal cell carcinoma with retroperitoneal

lymph nodes: role of lymph node dissection. J Urol,lymph nodes: role of lymph node dissection. J Urol, 169: 2076, 2003169: 2076, 20037


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Patients with micrometastatic lymphnode involvement (4.7%) who mightbenefit from prophylacticlymphadenectomy.

30% of patients with enlarged LNs onCT might have inflammatory nodalenlargement only.

EORTC 30881 ,A prospectiverandomized controlled study , failed toshow a survival difference betweenpatients treated with and without lymph

node dissection at the 5-year follow-up 8


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Schlichter et al* 372 RN specimens.

The nephrectomy specimens were cut into 3-mm sections

Cytogenetic and molecular genetic studieswere also performed

92 multifocal lesions were found in 61specimens (16.4%)

Multifocality was independent of primarytumor size

1/3 of all cases demonstrated concordanceregarding chromosomal aberrations between

the primary and secondary tumors 10


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Kletscher et al prospective study** 100 RN specimens with localized RCC.

preoperative CT /MRI, standard pathologicexamination , and 3-mm step-sectioning

under magnification were done. Multifocal RCC was found in 16 specimens.

Imaging studies suggested multifocal cancerin 7/16 cases (44%).

Standard pathology techniques identifiedmultifocal cancer in 10 /16 specimens (63%).

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Papillary and mixed histologic patternsoccurred at a significantly increased rate inspecimens with multifocal disease (P .011).

Tumor size and volume, histologic grade, andDNA ploidy did NOT correlate with thepresence or extent of multifocality

Risk of unknown multifocality in a surgicalsetting seems to be 6% that corresponds tothe incidence of locally recurrent disease in

published large series of NSS.

Kletscher BA, Qian J, Bostwick DG, et al: Prospective analysis of multifocality in renal cellcarcinoma: Influence of histological pattern, grade, number, size, volume anddeoxyribonucleic acid ploidy. J Urol 153:904-906, 1995

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LRN has emerged as a less morbidalternative to ORN

LRN is associated with Diminished postoperative discomfort

Shortened recovery

CSS after LRN is comparable to thatafter ORN

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Interest in elective NSSstimulated by

Shift in RCC stage and size

Risk of benign tumors in SRMsGood long-term survival

Preservation of Renal Function

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The introduction and mainstream use ofabdominal CT and US has resulted in anincrease in the incidental detection ofRCC in asymptomatic patients.

70% of the tumors are detectedincidentally with a median tumor size of

below 4.0 cm.

16.4 -23% of patients following surgicalresection of a SRM will have a benign

lesion. 17


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With each 1 cm increase there is 17% increase in the odds of

malignancy

32% increase in the odds of high

grade RCC

These data provide a pathological basisfor the use of

Minimally invasive techniques in thetreatment of SRMs

Conservative management in selectcases.

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Dechet et al studied the accuracy ofDechet et al studied the accuracy of

frozen section pathology for needlefrozen section pathology for needle

biopsy of renal tumorsbiopsy of renal tumorsprospective analysis of 106 renal masses.prospective analysis of 106 renal masses.

Each specimen was examined by two urologicEach specimen was examined by two urologicpathologists blinded to final pathologypathologists blinded to final pathology

15 lesions were considered benign after formal15 lesions were considered benign after formal

final pathologic reviewfinal pathologic review

one pathologist read 3/15 needle biopsies asone pathologist read 3/15 needle biopsies asmalignant, while the other read 5/15 needlemalignant, while the other read 5/15 needle

biopsies as malignantbiopsies as malignant

Both pathologists read 4/91 needle biopsies asBoth pathologists read 4/91 needle biopsies as

benign lesionsbenign lesions21


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100 patients with solid renal masses in whichrole of renal biopsy and imaging were studied

Final pathology: 85 lesions malignant and 15lesions benign

Sensitivity and specificity of CT imaging were74% and 20%, respectively.

Sensitivity and specificity of biopsy were 81%and 60% for one pathologist and 83% and33% for the other.

Imaging was considered non diagnostic in31% of cases for one radiologist and 23% forthe other radiologist.

Permanent section of the renal biopsies wasconsidered non diagnostic in 20% of the 22


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Results of NSS with normal oppositekidney 17 studies with 909 patients

Disease-specific survival 96.8% (90-100)

Local recurrence 1.4% (0-7.3) Tumour size was 2-4.3cm

Comparison of 5yr CSS in RN and PN Butler et al: RN 97% and PN 100%.

Lerner et al : RN 96% and NSS 92%.

Lau et al: Local tumor recurrence-freesurvival was slightly higher in the NSScohort (5.4% v 0.8%; P .18)

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Distinct differences between kidneydonors and renal tumor patients exist.

Donors tend to be carefully screenedfor medical comorbidities, are generally

young and healthy Renal tumor patients are not screened,

are older (mean age 61 years) andoften have significant comorbiditiesthat can affect the kidney function

As patients age, nephrons atrophy andGFR progressively decreases

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Harvard Medical School examined thenon tumor bearing kidney of patientsundergoing RN110 nephrectomy specimens of which 39 were

less than 5 cmOnly 10% of patients had completely normaladjacent renal tissue

28% were found to have vascular sclerotic

changes.In the remaining 62% of cases diabeticnephropathy, glomerular hypertrophy,mesangial expansion and diffuse

glomerosclerosis, was noted 25


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MSKCC investigators studied RF in theirpartial and radical nephrectomies

161 PN and 857 RN

Renal insuffeciency was defined as sCr

above 2mg/dl111 patients (10.9%), experienced renalinsufficiency at a median of 14.4 monthsfrom operation.

105/111 (95%) underwent RN

On multivariate analysis, age, sex,preoperative creatinine and percentagechange in kidney volume were all significantfactors associated with freedom from renal 26


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MSKCC compared PN & RN renal functionusing GFR

MDRD formula was used to estimate GFR in aretrospective fashion

GFR


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Renal function & NxRenal function & Nx (Most(Most

recent article)recent article) 86 RFA, 85 PN & 71 RN Preoperatively stage 3

CKD in 65/242 patients(26.7%)

3-year freedom from aCKD

95.2% RFA

70.7% PN

39.9% RN

RN was an independentrisk factor for stage 3 CKD

RN vs RFA HR 34.3, 95% CI4.28275

RN vs PN HR 10.9, 95% CI1.3688.7 29Lucas SM, Stern JM, Adibi M, et al: Renal Function Outcomes in Patients Treated for Renal MassesLucas SM, Stern JM, Adibi M, et al: Renal Function Outcomes in Patients Treated for Renal Masses

Smaller Than 4 cm by Ablative and Extirpative Techniques. J UROL 179:75-80, 2008Smaller Than 4 cm by Ablative and Extirpative Techniques. J UROL 179:75-80, 2008


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Corman et al compared the morbidityand mortality of patients undergoingeither RN or NSS1,373 RN & 512 NSS

Rates of postoperative progressive renal failure,acute renal failure, urinary tract infection,

prolonged ileus, transfusion, deep woundinfection, or length of hospitalization were

comparable.The 30-day mortality rates were 2.0% and 1.6%for patients undergoing RN and NSS,respectively (P .58).

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Shinohara et alShinohara et al

15 RN and 51 NSS cases15 RN and 51 NSS cases

NSS had a significantly higher score onNSS had a significantly higher score on

physical function in a standardized quality-of-physical function in a standardized quality-of-life questionnaire than patients treated withlife questionnaire than patients treated with

RN (P .05).RN (P .05).

NSS patients were also found to have lessNSS patients were also found to have less

postoperative fatigue, sleep disturbance, pain,postoperative fatigue, sleep disturbance, pain,and constipation than patients who wereand constipation than patients who were

treated with RN.treated with RN.

Shinohara N, Harabayashi T, Sato S, et al: Impact of nephron-sparing surgery on quality of life inShinohara N, Harabayashi T, Sato S, et al: Impact of nephron-sparing surgery on quality of life inpatients with localized renal cell carcinoma.Eur Urol 39:114-119, 2001patients with localized renal cell carcinoma.Eur Urol 39:114-119, 2001 31


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Shekarriz et al compared the costs ofRN and NSS in a retrospective study

No significant differences were seenin the length of hospital stay, orcomplication rates between the RNand NSS patients

Cost of care was comparable

Shekarriz B, Upadhyay J, Shekarriz H, et al: Comparison of costs and complications of radical andpartial nephrectomy for treatment of localized renal cell carcinoma. Urology 59:211-215, 32


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Several improvements happened inthe field of PN Surgical margin

Tumor size

Tumor location

Renal imaging

Laparoscopic PN

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Traditionally, 1 cm of normalparenchyma is needed as a SM

In Centrally located tumors a 1 cmSM may be techniqually difficultLerner et al compared the outcomes of NSS 185

patients with RN in 209 matched patients

NSS consisted of PN in 82 patients andenucleation in 87 patients.

They found no difference in the rate of CSS orPFS between patients treated by PN vs.enucleation.

Lerner SE, Hawkins CA, Blute ML, et al: disease outcome in patients with low stage renal cellLerner SE, Hawkins CA, Blute ML, et al: disease outcome in patients with low stage renal cell

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Intra operative USMultiphasic CT with reconstruction

6.5mm (3D)6.5mm (3D)


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Several studies now show that theequivalent oncologic outcomes of PNmay extend to select 7 cm renalmasses

Leibovich et al (Mayo clinic, 2004)

NSS (n 91) vs RN (n 841) for tumors 4 to 7cm.

NSS for 4 to 7 cm RCC results in excellentoutcome in appropriately selected patients. 37

5 yr NSS RN SIGNF.

CSS 98% 86% NS

Recurrence-free

survival

94% 98% NS

metastasis-freesurvival

94% 83% NS


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19 central and 67 peripheral tumors.

Ischemia time (55 vs 34 minutes, p


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LPN offers Shorter hospitalization, more rapidconvalescence.

Decreased pain, and improved cosmesis.

Comparable CSS and RF with OPN(intermediate FU)

LPN is associated withTechniqually difficult

Longer warm renal ischemia time

More major intraoperative complication

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According to SEER database, only20% of all RCTs between 2 and 4cmwere treated by PN in 2001

In England, in 2002, only 108 (4%)

PN out of 2671 nephrectomies wereperformed .

Widespread training in partialnephrectomy and enhancedutilization, whether by open or

laparoscopic approaches, is clearly 40


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RCC remains primarily a surgicaldisease; however, the surgicalmanagement of RCC continues toevolve.

For appropriately selected tumors,NSS is equally effective for control of

cancer, diminishes the risk of renalfailure, and offers superior quality oflife with no significant differences incomplications or cost.

radical vs partial nephrectomy in small renal masses

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