Management of Localised Kidney Cancer
Alexander Kutikov, MD is a Surgical Oncologist and Associate Professor of Urologic Oncology at the Fox Chase Cancer Center in Philadelphia. He is a highly published author and experienced presenter on the topic of Urological Cancer, and is very active in Social Media in Urology. In this Guest Post, Alex gives a concise account of the diagnosis and treatment options for localised kidney cancer. He explains what you need to know, and what you should ask your surgeon.
Details of the Fox Chase Cancer Center can be found here : Fox Chase Cancer Center.
"If you or your loved one has been diagnosed with a kidney tumor / mass, reliable information regarding this condition is often difficult to obtain. It is important that you have a good understanding of the diagnostic and treatment options available in order to make an educated choice on how to best proceed with your treatment.
"Generally, when patients are diagnosed with a kidney mass, it is apparent on imaging studies whether the tumor is localized to the kidney or if it has spread beyond the kidney to other parts of the body. For patients with localized disease, surgical resection remains the gold standard, and is largely superior to therapies such as cryotherapy or radiofrequency ablation.
"The following points are important to remember:
1. Understand that not All Kidney Tumors are Malignant.
- Approximately 15-20% of newly diagnosed localized kidney masses are benign. Such lesions - largely complex cysts, oncocytomas, and angiomyolipomas - are often indistinguishable from kidney cancer with modern imaging. However, at times, expert radiologists are able to review a patient's imaging study and make a diagnosis of a benign lesion, saving an individual from unnecessary treatment.
- A percutaneous biopsy performed under expert radiographic guidance and interpreted by experienced pathologists can sometimes provide valuable information to guide treatment decisions in select cases.
- Predictive tools that are able to separate high risk cancers from tumors that do not pose an immediate risk to patients are emerging, but are yet to be perfected (Anatomic Features of Enhancing Renal Masses Predict Malignant and High-Grade Pathology: A Preoperative Nomogram Using the RENAL Nephrometry Score) Here's a link to a web widget for point-of-care use: What is the likelihood that my enhancing renal mass is malignant or high grade?
2. Understand Goals of Treatment:
- Primary treatment goal: Oncologic cure - cancer control must never be compromised and surgical resection is the gold standard treatment for patients with kidney tumors. Yet, for some patients "active surveillance" is often an ideal initial option of choice (Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis).
- Secondary treatment goal: Kidney preservation - years of experience with kidney (aka: nephron) preserving surgery (partial nephrectomy) demonstrates that this approach is oncologically safe and is associated with long-term benefits to overall health. A standardized system to classify features of kidney tumors as they relate to ability to safely perform partial nephrectomy was developed at Fox Chase Cancer Center in 2009 (The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.) and is currently used by kidney surgeons all over the globe.
- Tertiary treatment goal: Utilization of minimally invasive surgical approaches - . Both transperitoneal and retroperitoneal minimally-invasive (laparoscopic / robotic) surgical approaches are currently utilized by expert kidney surgeons. Finding the right surgeon may help avoid a large painful incision, albeit traditional open kidney surgery continues to play an important role in management of some patients with large / anatomically complex kidney tumors.
3. Be Prepared During Your Visit.
Here are some questions to pose to your treating physician when you or your family member is diagnosed with a renal mass:
- Understand characteristics of your mass: size of tumor, clinical stage of tumor, RENAL nephrometry score. If your tumor has been resected, be sure to obtain information regarding pathologic stage, grade and histology. Pathology review by expert pathologists at times can make a critical difference in guiding further treatments.
- Why or why not do a biopsy?
- Treatment Options:
- Active Surveillance - am I a candidate?
- Medical Therapy (generally reserved for tumors that have spread)
- Renal mass ablation (generally reserved for frail patients whose surgical risks are prohibitive).
- partial nephrectomy: is your surgeon familiar and experienced with kidney preservation techniques? Is he/she comfortable performing partial nephrectomy minimally-invasively, thus accelerating your recovery and minimizing pain?
- radical nephrectomy: if radical nephrectomy is offered, be sure to establish that partial nephrectomy is not possible at a more experienced center. If kidney preservation is not possible, can radical nephrectomy be performed with minimally-invasive techniques?
- Risks of treatment: be sure to understand risks associated with each option.
"In summary, kidney cancer is curable in the majority of cases and its treatment is rapidly evolving. Finding an expert urologic surgeon who not only understands this complex disease, but also possesses the needed surgical skills to appropriately manage this condition is critical to successful outcomes."
This post was adapted by Alex Kutikov from an original Fox Chase Cancer Center Cancer Conversations blog post which appears at: Understanding Your Kidney Cancer Treatment Options