Transcript SURGICAL MANAGEMENT OF NEPHROLITHIASIS

Evaluation and Management of the
Small Renal Mass
Jeffrey A. Cadeddu, M.D.
Professor of Urology and Radiology
UT Southwestern Medical Center
Differential of the Renal Incidental
Mass
• Cyst (vast majority of ‘masses’)
– Simple
– Complex
• Tumor
– Carcinoma
– Benign
Renal Cysts
“Kidney Cancer”
• Not all “Kidney Cancer”
created equally
• Histologic subtyping is
critical to understanding
natural history of disease
The Heidelberg classification of renal
cortical tumors
• Subdivides renal cell tumors into benign and malignant
neoplasms by documented genetic abnormalities
• Benign: Angiomyolipoma and Oncocytoma
• Malignant tumors sub-classified into:
– conventional RCC
– papillary RCC
– chromophobe RCC
– collecting duct carcinoma
– medullary carcinoma
– unclassifiable
Kovacs G, J Pathol 1997
Histologic Findings in 21st Century
Duchene et al. UTSW, Urology 62: 827, 2003
Modern series 1999 - 2002
Epidemiology of RCT
Lack of Mortality Reduction
40,000
35,000
33% Rise
30,000
25,000
Cases
Deaths
20,000
15,000
10,000
25% Rise
5,000
0
1990
1997
2001 2003
2004
Jemal A, CA Cancer J Clin 2005
2005
Not All Malignant RCT are Created Equal
• McKiernan, et al. J Urol 2002
– Partial nephrectomy for renal cortical tumors (T1a) pathologic findings and impact on outcome
– Histological findings
• conventional 148 cases (51%)
• papillary 54 (18%)
• oncocytoma 32 (11%)
• chromophobe carcinoma 21 (7%)
– 5-year recurrence rate of 12% for conventional
– No recurrence seen in any other RCT
• Caveat – presumably papillary were all Type 1
– Type 2 present higher grade and stage
Biopsy in 2012
• High suspicion for benign dz
– Young women with solid tumor – AML?
• Suspect tumor of low metastatic potential
– Chromophobe RCC
– Papillary RCC, Type 1
• Poor surgical risk
• High risk of chronic kidney dz
New Descriptive Evaluation Tool
• RENAL Nephrometry (Uzzo et al)
2012: Nephron-sparing for Small
Renal Tumors
(< 4 cm = T1a)
• Partial Nephrectomy
• Ablation – Cryo or RFA
• Surveillance
• Appropriate surgical choice MUST weigh
concern for CRI and GFR?
– Thus nephrectomy should be rare
• High RENAL score and high GFR
Why is maintaining GFR important?
Clinical impact: Increased cardiovascular death
Weiner et al, 2004 N = 22,634, pooled from 4 community studies
(composite includes MI, fatal CHD, nonfatal and fatal stroke, mortality)
Clinical impact: Increase in mortality, morbidity
Go et al NEJM, 2004
Impact of Preserving GFR in Patients
with Renal Tumors
• Huang, Russo et al. J Urol 181:55, 2009
– 2500 RN vs. 500 PN (SEER and Medicare)
Fundamentals of Renal Cortical Tumor
Management
• 20% are benign
• 30% of T1a RCC are low metastatic potential
• No impact of detecting incidentalomas on RCC
stage migration or mortality reduction
• Standard surgical treatments increase risk of
developing CKD
• CKD Stage 3 associated with 20% increase risk
of death and 40% increase risk of cardiac event
• Saving kidney function more likely to impact
survival!!!
Active Surveillance: The Ultimate
Nephron-Sparing Rx
• Volpe and Jewett, Nat Clin Prac Urol 2005.
Incidental Tumors at Autopsy
• Incidence at autopsy of RCC before
widespread imaging
– Hellsten et al. Eur Urol 1990
– Wunderlich et al. Eur Urol 1998
– 67 – 74% of RCC undetected until death!
Active Surveillance: The Ultimate
Nephron-Sparing Rx
• Kunkle, Uzzo, et al. J Urol 177849, 2007.
• 106 tumors, median 2 cm, observed > 12 mo
– 33% NO growth median 25 months
– Median growth = 0.2 cm/yr
– Of surgery case, ~ 85% RCC
– 1 case progressed to mets (3 in literature)
• 54 month f/u, increase 2 to 8 cm!
Active Surveillance: The Ultimate
Nephron-Sparing Rx
• Hollingsworth et al. Cancer 109:1763, 2007
– Competing risk analysis 26,000 pts
• T1a – 5% risk death w/i 5 years
• T2 – 27% risk death w/i 5 yrs, despite
surgery
• > 70 yo, 28% competing-cause mortality,
regardless tumor size
AUA Guidelines: Oncologic Efficacy
Progression Risk of Active Surveillance
• Uzzo et al. Cancer 2009
– Metastatic progression 1.3% (2/154)
• 1 during active surveillance
• 1 after delayed intervention
• Rosales, Benson, McKiernan, Landman et al. J Urol
183:1698, 2010.
– Median f/u 35 mo
– 2% metastases
Progression Risk of Active Surveillance
• Zini et al. BJUI 103:899, 2009
– SEER analysis (> 10k pts T1a)
– Compared 433 with AS to 9858 nephrectomy
– At 1, 2 and 5 yrs survival advantage of Surgery vs.
AS was 5.2%, 6.5% and 9.4%
• Advantage same when matched by age, size and
yr diagnosis.
Disadvantages to Active Surveillance
• Real metastatic potential
• Patient longevity variable and not accurately predictable
• Cost of frequent surveillance studies (+ biopsy?)
• Anxiety
Laparoscopic/Robotic Partial
Nephrectomy
• State-of-the-Art!
– Alternative to Open Partial Nephrectomy
LPN: Open Duplication
Video Technique
Robotic Partial Nephrectomy
Robotic Partial Nephrectomy
Complications of LPN:
CCF 200 cases
(Ramani et al. J Urol 2005)
R.E.N.A.L
NS
Perioperative
Outcomes
FollowingHigh
Lap/Robotic
Low
Medium
category
(4-6)
(7-9)
(10-12)
Partial Nephrectomy:
role of R.E.N.A.L
NSp value
(Liu et
Total number of
104
cases
ASA score, median
2(1-4)
(range)
Mean estimated
206
blood loss, ml
Warm ischemia
29
time, min
decrease in
13
HCT,%
Total
complications, no
6 (5.8)
(%)
No.requiring
5
transfusion (%)
Complications classified to Clavien scale
I/II, no (%)
III, no (%)
al, WJU in press)
75
2
2(1-4)
2(2-3)
0.95
231
600
0.33
33
39
0.02
15
22
0.14
12 (16.2)
2 (100)
0.01
6
1
0.20
5 (83)
9 (75)
1 (50)
0.08
1 (17)
3 (25)
1 (50)
0.05
Metastasis-Free Survival
Cancer-Specific Survival
Myths
(Simmons et al, J Urol 2008)
• Pneumoperitoneum
– No study reported long term detrimental effects of
pneumo on human kidneys
– Maybe renoprotective (preconditioning)?
• Artery only vs. artery and vein clamping
– No study shows improved ischemia or renal function
– Increases risk of obscured visualization
• Manual Compresion / Regional Ischemia
– No study demonstrating renal function benefit
Current Thoughts on Importance of
Ischemia Time
• Does warm ischemia really matter?
• 117 patients – pre and post op renal scans at 6 months
– 52 OPN, 62 LPN
– Multivariate analysis to study factors affection GFR
• 39 patients – normal Cr, LPN or OPN
– Ischemia time 24.5 min LPN, 38 min OPN
– Estimated GFR at 1 yr
– Volumetric calculations based on pre and post CT
So what strategy works?
Alternative to Partial Nephrectomy??
• TUMOR ABLATION
– LAPAROSCOPIC or PERCUTANEOUS
– freeze or heat
• Cryosurgery
• Radiofrequency ablation (RFA)
Advantages of Ablation
• Nephron-sparing
• Many tumors are slow growing/ low aggressiveness
• Low morbidity
• Fewer complications
• Outpatient (or overnight stay only)
• Ease of radiographic follow up
Possible Risks
• Tumor left in situ
• Ablation success defined as NO enhancement
on CT/MRI and tumor shrinkage
• Long term RCC control unknown
Laparoscopic Cryoablation Technique
• Usually mobilize kidney to
place US probe on opposite
side from tumor
• Expertise in US and
manipulation of
laparoscopic probe (and/or
need radiologist)
• Ablation completed = ice
ball beyond tumor margins
Pre Cryo
Cryo at one year
Promising alternative to surgical excision
Laparoscopic RFA Technique
• Mobilize only tissue near
tumor (unlike cryo)
• RF probe positioned per
manufacturer, US to
visualize probe/tines
optional
• Visualize changes during
ablation
Pre-ablation
RFA Results
3 Months Post
Lesion Progression:
12 Months Post
1. Wedge/spherical
non-enhancing
2. Gradual contraction
residual scar
(Matsumoto et al. J Urol, 172:45, 2004)
Perc RFA Technique
Perc RFA Technique
Tracy CR, et al. Durable oncologic outcomes following
radiofrequency ablation(RFA): experience from
treating 243 small renal masses over 7.5 years. Cancer
2010.
All ablations
≥3 yrs follow-up
No. tumors ablated
243
84
No. patients
208
66
156/87
54/30
0.99a
64±12.5 (18-84
64±13.5 (20-85)
0.78b
No. right/left side*
139/104
44/40
0.16a
Surgical approach
Percutaneous
Laparoscopic
Open
172 (71%)
68 (28%)
3 (1%)
55 (65%)
26 (31%)
3 (4%)
0.36a
0.36a
0.17a
Mean tumor size
(SD, range)
2.4 cm ± 0.8 (1.0-5.4)
2.4 cm ± 0.9 (1.0-5.4)
0.65b
Mean follow-up (SD,
range)
27 mos ± 23 (1.5-90)
53 mos ± 15 (36-90)
<0.001
No. men/women*
Mean age (SD/range)
p-value
Baseline characteristics of tumors treated with RFA separated by total
number of patients and those with ≥3 years of follow-up.
Local Recurrence
• Growth or
enhancement after 6
weeks: 3.7% (n=9)
– 3- and 5- year
recurrence-free
survival rates of
93%
Month follow-up
Events
Patients at risk
<12
13-24
25-36
37-48
49-60
61-72
73-84
85-96
5
2
2
0
0
0
0
0
243
144
97
72
41
24
5
1
Local Recurrence
• All recurrences were
biopsy-proven RCC at
initial biopsy
– Recurrence-free
survival for 179
biopsy-proven
RCCs (160
patients): 90% at 3
and 5 years
Month follow-up
Events
Patients at risk
<12
13-24
25-36
37-48
49-60
61-72
73-84
5
2
2
0
0
0
0
179
108
67
48
26
12
3
Metastatic Progression and Death
(Tracy et al)
• 5-year metastasis-free rate: 95%*
– 3 patients with metastases
• Cancer-specific survival rate: 99%*
– 1 RCC death
• Overall 5-year survival rate: 85%
*160 patients with biopsy-proven RCC
AUA Guidelines: Oncologic Efficacy
Revisiting Importance of Patient
Selection
• Best, Park, Yousseff, Olweny et al. (J Urol, 2012)
– Impact of Tumor Size on Long Term Efficacy of
Local Disease Control (all tumors)
• 159 tumors, mean 2.4 cm, > 3 yr DFS (when
recurrence occur)
< 2.5 cm
2.5-2.9 cm
> 3 cm
Single
Ablation
99%
88%
73%
Repeat
Ablation
99%
96%
78%
Renal Function Outcomes for T1a Tumors
Treated by Ablation or Resection
(Lucas et al, J Urol 179:75, 2008)
GFR < 60 == CKD stage 3
Take Home
• Algorithm
– Should include benign tumor potential in discussion
– 15-20%, biopsy
– Active Surveillance = Option #1 for poor
health/elderly (< 3cm)
– If treat, Nephron-Sparing
• Radical nephrectomy should be rare!
• Ablation truly minimally invasive
• Robotic partial neph for healthy patients