Staging/Natural history

Tsui et al. (2000) validated the revised 1997 TNM staging criteria for renal cell carcinoma, reporting 5-year cancer specific survival of 91%, 74%, 67%, and 32% for TNM stages I, II, III and IV lesions, respectively. The natural history of small renal tumors (avg. 2.9 cm diameter) was reported by Rendon et al. (2000) in a series of patients who averaged 69 years of age. Two of 13 tumors grew rapidly, caused symptoms and were removed. The remainder of tumors grew by an average of 1.3 cc per year. These data support initial expectant management of small renal tumors in the frail or elderly. A study of more than 350,000 Swedish men reported in the New England Journal of Medicine demonstrated a relationship between renal cell carcinoma and higher body mass index as well hypertension (Chow et al., 2000.) Whether weight control would lower the risk is unknown.

Partial nephrectomy

The role of partial nephrectomy for small renal cell tumors was supported by results from Cleveland Clinic and Memorial Sloan-Kettering Cancer Center. Lee et al. (2000)demonstrated similar perioperative morbidity and outcome with radical or partial nephrectomy. Fergany et al. (2000) reported 10-year followup of 107 patients with localized sporadic renal cell carcniomas, many of whom had renal insufficiency preoperatively. Cancer-specific survival was 88% at 5 years and 73% at 10 years. These results were not affected by tumor stage, symptoms, tumor laterality or tumor size. The need for adrenalectomy during nephrectomy was reported by Tsui et al. from UCLA (Tsui et al., 2000) who showed that the negative value of CT scan for predicting absence of adrenal involvement was better than 99%. Positive findings on CT are less specific but should lead to consideration of adrenalectomy.

Laparoscopic nephrectomy

A comparative trial of 47 laparoscopic nephrectomies for renal cell carcinoma were compared in a contemporary series with open radical nephrectomies. Laparoscopy resulted in less blood loss, shorter hospital stay, analgesic requirement and shorter convalescence with fewer overall complications. A report on the frequency of metastatic renal cell cancer after laparoscopic morcellation in N0 M0 patients demonstrated a 5% metastasis rate, including a renal fossa recurrence and a laparoscopic port recurrence (Fentie et al., 2000.) These findings are of concern for a tumor that can only be effectively treated with surgery.

Metastatic disease

Management of isolated renal cell metastases to bone in patients with solitary metastases, intractable pain, impending or present pathologic fracture was reported in the Journal of Urology (Kollender et al., 2000.) Postoperative pain was significantly reduced in 91% of paitents with 89% having good or excellent functional results. This group of patients was highly selected before treatment. Another study from the Mayo Clinic confirmed the potential to perform excision of isolated renal fossa recurrences after nephrectomy (Itano et al., 2000.) The 5-year survival rate with surgical resection was 51% compared to 18% with adjuvant medical therapy and only 13% with observation in this retrospective study. Although surgical treatment is possible in a limited number of these patients, it is often a major intervention requiring removal of contiguous organs in many cases. The later after initial surgery, the better the prognosis of patients treated for solitary recurrences in most series. A multicenter randomized trial of adjuvant interferon a2b for stages II and III renal cell carcinoma was reported by Pizzocaro et al. (2001.) The results of this study demonstrated no benefit in 5-year overall and event-free survival for treated patients.

New treatment approaches

Novel approaches to management of localized renal tumors with radiofrequency ablation or embolization and ablation were reported by Hall et al. (2001) and Walther et al. (2000.) The NIH group demonstrated antitumor effect in 10 of 11 renal cell tumors. The remaining tumor had treatment effect of only 35% of the cancer.

More recently, the technique of partial nephrectomy has been performed using laparoscopy with "hand-assistance" - a minimally invasive technique popularized by Dr. Ernest Sosa. These procedures result in smaller incisions, less pain and more rapid return to work, compared to standard open procedures to remove the kidney or perform a partial nephrectomy.

Also at Cornell, a technique of three-dimensional reconstruction of kidney tumors by Dr. Deirdre Coll of The Department of Radiology is being applied. Three-d reconstruction provides a better picture of the relationship of the tumor to blood vessels and the urinary collecting area, which helps the surgeon to better plan a procedure to remove the tumor as a partial nephrectomy or determine whether partial nephrectomy is feasible.