Overview

Surgery is the mainstay of treatment for renal cell cancers (RCC), a type of cancer that is typically resistant to radiation and chemotherapy. Surgery is almost always utilized unless patients are unable to tolerate the procedure.

Historically, surgical treatment of RCC consisted of a radical nephrectomy, which involves removal of the entire kidney, local lymph nodes, and any cancer in the area surrounding the kidney. The trend in the surgical management of RCC however, is to perform less aggressive surgery when possible. Less aggressive surgery, which removes only the part of the kidney affected with cancer, is referred to as a partial nephrectomy or nephron-sparing surgery.

In patients with Stage I and II renal cell cancer, surgery can cure the majority of patients; 75-96% of patients with Stage I disease and 63-95% of patients with Stage II disease are cured with surgery alone. Surgery can be curative for Stage III renal cancer depending on the extent of disease, but the percentage of patients with this stage who are cured with surgery alone drops to 38-70%.1 Surgical removal of some metastatic cancers can also be curative. Surgery can also relieve symptoms caused by the cancer in patients with Stage III and IV renal cell cancer and in those with recurrent disease.

There are several surgical approaches that are utilized, depending on the extent of disease and the condition of the patient.

• Partial Nephrectomy (nephron-sparing surgery)
• Radical Nephrectomy
• Surgery to Remove Metastases

Partial Nephrectomy (Nephron-Sparing Surgery)

Removing only the cancer and some surrounding healthy tissue—a procedure called a partial nephrectomy—is now considered the standard of care for the treatment of smaller cancers. The benefits of this approach are shorter hospitalization and recovery time and, importantly, kidney function is preserved; preservation of kidney function is particularly valuable for patients who already have poor function or only one kidney. Preserving the affected kidney is also valuable in the event that the cancer should recur in the opposite (contralateral) kidney.

The benefits and safety of this approach have been repeatedly demonstrated in the treatment of patients with Stage T1a renal cancer (cancer that is less than 4 centimeters in diameter).2,3

Partial nephrectomy also appears to be a viable treatment option for patients with Stage T1b cancers (cancers that are 4-7 centimeters in diameter) if an adequate amount of normal tissue surrounding the cancer can be removed.4 Patients with these slightly larger Stage I cancers who are treated with partial nephrectomy have been shown to live as long and experience a similar cancer-free duration as patients treated with radical nephrectomy.5 However, longer follow up aimed at confirming these findings is ongoing.

For those patients with Stage T1b cancer that is more centrally located or those with multiple tumors, radical nephrectomy may be a better option.

Radical Nephrectomy

Surgery for Stage II renal cell cancer typically involves removing the entire affected kidney, local lymph nodes, and the attached adrenal gland, a procedure called a radical nephrectomy.

In some cases, the adrenal gland may not need to be removed. The adrenal glands are complex organs that work with the brain to produce and regulate important hormones.

Researchers have reported that patients who underwent nephrectomy but did not have the adrenal gland removed survived as long as patients who underwent nephrectomy with removal of the adrenal gland , and were not at any higher risk of postoperative complications.6

Surgery to Remove Metastases

Some patients can experience long-term cancer-free survival after surgical resection of metastatic cancers. Results of a clinical trial indicate that renal cell cancer that has spread to the lungs can be removed with surgery. Among patients treated with surgery for lung metastases but no evidence of cancer elsewhere in the body, including the kidney, nearly 40% survived five years or more. Patients with only a single site of cancer in the lung experienced the best outcomes; nearly 50% survived five years or more compared to 19% of patients who had more than one site of cancer removed.7

Strategies to Improve Surgical Treatment of Renal Cell Cancer

The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the treatment of renal cell cancer will result from the continued evaluation of new treatments in clinical trials.

Patients may gain access to better treatments by participating in a clinical trial. Participation in a clinical trial also contributes to the cancer community’s understanding of optimal cancer care and may lead to better standard treatments. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation aimed at improving the surgical treatment of renal cell cancer include the following:

• Partial nephrectomy (nephron-sparing surgery)
• Laparoscopic surgery
• Radiofrequency ablation
• Cryoablation

Partial nephrectomy (nephron-sparing surgery): Removing only the cancer and some surrounding healthy tissue—a procedure called a partial nephrectomy—is now considered the standard of care for the treatment of small renal cancers. The benefits of this approach are shorter hospitalization and recovery time and, importantly, preservation of kidney function, which is particularly valuable for patients who already have poor function or only one kidney. Preserving the affected kidney is also valuable in the event that the cancer should recur in the opposite (contralateral) kidney. The benefits and safety of this approach have been demonstrated8,9,10,11 in Stage I cancers, and some research is ongoing to determine if any patients with Stage III renal cancers may also benefit from partial nephrectomy.

Laparoscopic surgery: Laparoscopic surgery is a technique that is less extensive and invasive than traditional, open surgery. During a laparoscopic surgery for renal cancer, the surgeon makes small, one-centimeter incisions in the abdomen and side. The surgeon then inserts a very small tube that holds a video camera, which creates a live picture of the inside of the patient’s body. This picture is continually displayed on a television screen, so that surgeons can perform the entire surgery by watching the screen.

Both radical nephrectomy and partial nephrectomy may be conducted using laparoscopy. In the case of a radical nephrectomy, the incision is enlarged to allow passage of the kidney. A small bulk of tissue is removed with a partial nephrectomy and the incision can remain small.

Laparoscopic radical nephrectomy has emerged as an alternative to open surgery in the management of smaller (less than 8 centimeters in diameter), localized renal cancers. Patients treated with the laparoscopic approach do not appear to be at greater risk for cancer recurrence 5-10 years after treatment compared to patients treated open radical nephrectomy. The two approaches have also been shown to result in similar survival.12 However, patients who are candidates for laparoscopic radical nephrectomy would also do well with partial nephrectomy. Thus the advantages of laparoscopic radical nephrectomy (shorter hospital stay and faster recovery) must be balanced with the advantage of partial nephrectomy, which is better long-term renal function.13

Laparoscopic partial nephrectomy appears to provide outcomes comparable to conventional open partial nephrectomy. Results of a clinical trial involving 100 patients with an average cancer size of 3.1 cm who underwent laparoscopic surgery showed that all patients survived three and one-half years or more after treatment without evidence of cancer recurrence.14 Laparoscopic partial nephrectomy is a specialized technique and should only be conducted by a surgeon who is experienced in this procedure.

Radiofrequency ablation: Radiofrequency ablation is a minimally invasive technique that uses heat to destroy cancer cells. During radiofrequency-ablation, an electrode is placed directly into the cancer under the guidance of a CT scan, ultrasound, or laparoscopy. The electrode emits high frequency radio waves, creating intense heat that destroys the cancer cells.

Radiofrequency ablation appears to be a promising technique for the treatment of patients with small kidney cancers (less than 4 centimeters in diameter) who are ineligible for surgery. Clinical trial results indicate that two years after surgery, cancer recurrence occurred in fewer than 10% of patients. Larger tumors (more than 3 centimeters) are more challenging to treat with this approach and are more prone to recurrence afterwards.15

Cryoablation: Cryoablation is a minimally invasive technique that uses extremely cold temperatures to “freeze” small cancers. In patients with cancer that is less than or equal to 5.0 cm in diameter, cryoablation appears to be a promising approach for removing the cancer. However, long-term research is necessary to confirm the benefits of cryoablation.16

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