Management of T1 Kidney CancerLaparoscopic Surgery

Karim Touijer, MDKarim Touijer, MD

Kidney Cancer is a Misnomer!!!Kidney Cancer is a Misnomer!!!

• Kidney cancer = is not a single disease

• Kidney cancer = Compendium of a number of different cancers that originate in the Kidney

• Each have a distinct: - Clinical course - Prognosis - Genetic background

Clear cell type or Conventional

• Most common (75%) +++

• Aggressive ++

• Accounts for most metastatic cases

• Mutation in VHL gene

Papillary Type 1

• 15% of kidney cancers

• Multifocal

• Bilateral

• Relatively low risk of Metastases

• Mutation of c-Met proto –oncogene on Chrs 7

Papillary Type 2

• Aggressive +++

• Metastatic potential

• Mutation of the Fumarate Hydratase gene

Chromophobe

• 5% of kidney cancers

• Less aggressive than conventional

• Could be associated to the Birt-Hogg-Dube

Oncocytoma

• Benign• Metastases are rare

Management of T1 RCC Management of T1 RCC - Ideal Scenario -- Ideal Scenario -

TreatmentTreatment

• Treat accordinglyTreat accordingly

DiagnosisDiagnosis

•Identify the histologic Identify the histologic subtypesubtype

Management of T1 RCC Management of T1 RCC - Current Status -- Current Status -

Pathology (+++)Pathology (+++)

Specific HistotypeSpecific Histotype•H&EH&E

•ImmunohistochemistryImmunohistochemistry

•Genetic probesGenetic probes

TreatmentTreatment

Renal TumorRenal Tumor

•SurgerySurgery

Diagnosis (-)Diagnosis (-)

Renal TumorRenal Tumor•ImagingImaging

•Needle BiopsyNeedle Biopsy

•G250 scanG250 scan

•Vascular density on Vascular density on USUS

Tyrosine Kinase inhibitors for Tyrosine Kinase inhibitors for metastatic Clear Cell RCCmetastatic Clear Cell RCC

Surgical Treatment of T1 RCCSurgical Treatment of T1 RCC

• Partial vs. radical NephrectomyPartial vs. radical Nephrectomy

• Laparoscopic vs. Open approachLaparoscopic vs. Open approach

• Investigative therapy

Partial vs. Radical NephrectomyPartial vs. Radical Nephrectomy

• Whenever possible Partial Nephrectomy should be the preferred treatment.

• Comparable long-term cancer control

• Lesser risks of Chronic renal insufficiency and proteinuria

Partial vs Radical NephrectomyPartial vs Radical Nephrectomy~ ~ Cancer ControlCancer Control ~ ~

Partial vs Radical NephrectomyPartial vs Radical Nephrectomy~ ~ Cancer ControlCancer Control ~ ~

Chronic Kidney DiseaseChronic Kidney Disease

Chronic Kidney DiseaseChronic Kidney Disease

Figure 2. Kaplan-Meier survival probabilities by operation typeFigure 2a. Freedom from new onset of GFR<60 Figure 2b. Freedom from new onset of GFR<45

Number at risk:287 134 62 23 11 6204 69 43 20 12

Number at risk:385 187 84 33 13 6262 130 86 56 33 21

ResultsNew Onset of GFR < 60

Solid: Partial Nephrectomy

Dashed: Radica1 Nephrectomy

Median Time to GFR < 60 RN: 18 monthsPN: Was not reached

Laparoscopic vs OpenLaparoscopic vs Open

No Randomized Trial !?No Randomized Trial !?

• Cancer control

• Morbidity and Convalescence

Oncologic Outcomes for T1 and T2 Oncologic Outcomes for T1 and T2 DiseaseDisease

LAPLAP

• 5 year cancer-specific survival for T1: 95% - 98%

• 5 year cancer-specific survival for T2: 92%

Portis et al. J Urol. 167:1257, 2002 Ono et al. J Urol. 169: 77, 2003

• Local recurrence rate up to 4.1%

OpenOpen

• 5 year cancer-specific survival for T1: 90%-95%

• 5 year cancer-specific survival for T2: 74%-88%

Tsui et al. J Urol. 163: 1090, 2000 Javidan et al. J urol. 162: 730, 1999

• Local recurrence for T1 and T2 is ~ 4%.

Lee et al. J Urol. 163: 730, 2000 Gogus et al. Urology 61: 926, 200

Morbidity of Partial NephrectomyLap vs. open

• Review of the recent MSKCC experience

Patient Characteristics

Open Laparoscopic p-value

n (%) 337 (90) 36 (10)

Age, years, mean (SD) 61 (13) 60 (11) 0.537

Gender Males (%) 204 (60) 27 (75)

Females (%) 133 (40) 9 (25)

Laterality Left 168 (50) 21 58 0.383

Right 169 (50) 15 42 0.289

Incidentally Detected (%) 278 (82) 27 (75) 1.0

Size, cm, mean (SD) 3.0 (1.5) 2.4 (1.0) 0.05

Location (%) Peripheral 161 (48) 18 (50) 0.118

Central 128 (38) 17 (47)

Missing 48 (14) 1 (3)

ASA Score>2 (%) 122 (36) 11 (31) 0.584

Operative/Postop Data

Open Laparoscopic p-value

n (%) 337 (90) 36 (10)

Clamp (%) 291 (89) 34 (94) 0.559

Clamp Time, min, mean (SD) 38 (18) 37 (18) 0.760

OR Time, min, mean (SD) 162 (49) 249* (83) <0.001

EBL, cc, mean (SD) 403 (378) 343 (398) 0.367

Conversion to Radical nephrectomy (%) 31/390 (8) 3/41 (7) 1.00

Positive Margins (%) 13 (4) 2 (5) 0.138

Length of Stay, days mean (SD) 4.8 (2.4) 3.1 (1.9) <0.001

*Includes time for cystoscopy and stent placement

Complications

• Laparoscopic group– 10 complications in 8 patients– 22% complication rate

• Open group– 80 complications in 69 patients– 20% complications rate

Complication MSKCC Grading System

• Grade I: Oral medication or bedrest

• Grade II: IV therapy or thoracostomy tube

• Grade III: Intubation, interventional radiology, endoscopy or reoperation

• Grade IV: Major organ resection or chronic disability

• Grade V: Death

Complications by Grade

Grade Open Laparoscopic

1 47 13.0% 5 13.9%

2 15 4.2% 1 2.8%

3 10 2.8% 2 5.6%

4 2 0.6% 0 0.0%

5 0 0.0% 0 0.0%

Conclusions

Priorities in the management of T1 renalPriorities in the management of T1 renal

cell carcinoma are:cell carcinoma are:

1. Identifying the histotype at the time of Diagnosis +++

2. Using a partial nephrectomy as much as possible ++

3. Lap vs. Open: depending on the available skills