The Surgical Management of RCC

Transcription

1 The Surgical Management of RCC From Robson to Radiofrequency Ablation Tony Finelli, MD, MSc, FRCSC University Health Network University of Toronto

2 Background Renal cell carcinoma (RCC) is 9 th most common malignancy new cases/yr. (Can.) 700+ s rgeries/ r ~ 700+ surgeries/yr. (Ontario)

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4 Renal Cell Carcinoma in Canada 3% of malignancies; peaks in 6th and 7th decades 3:2 male-to-female incidence Extent of disease at diagnosis: local 60 70%; regional 15 20%; metastatic 15 20% Common symptoms: Hematuria (50%) Weakness (28%) Weight loss (28%) Anemia (21%) Fever (7%) Paraneoplastic syndromes (up to 25%) 1. Canadian Cancer Stats, Available at: 2. Cavalli F, Hansen HH, Kaye SB, eds. Textbook of Medical Oncology. 3rd ed. London, UK: Martin Dunitz; 2004:

5 RCC Staging: Stage I Tumor < 7 cm in greatest dimension and limited to kidney; 5-year survival, 95% Stage II Tumor > 7 cm in greatest dimension and limited to kidney; 5-year survival, 88% Stage III Tumor in major veins or adrenal gland, tumor within Gerota s fascia, or 1 regional lymph node involved; 5-year survival, 59% Cohen HT, McGovern FJ. N Engl J Med. 2005;353: Stage IV Tumor beyond Gerota s fascia or > 1 regional lymph node involved; 5-year survival, 20%

6 Localized RCC TNM (2002)

7 Surgery for Kidney Cancer Robson, Churchill, Anderson J Urol 1969;101;

8 Conventional Nephrectomy

9 Large Flank Incision

10 Partial Nephrectomy Novick, Stewart, Straffon J Urol 1977;118;932

11 Open Partial Nephrectomy 1981 marked the beginning of the elective NSS era Licht and Novick (1993) 241 cases of elective NSS Early evidence of oncologic efficacy

12 Open Partial Nephrectomy Fergany, Hafez, and Novick (1999) 10 yr. followup after elective NSS Equivalent to oncologic results to radical nephrectomy for tumours < 4 cm

13 Expanding Indications for Elective Partial Nephrectomy

14 Elective Partial Nephrectomy: Tumours 4 7 cm Retrospective review of NSS and RN for tumors 4-7 cm at the Mayo Clinic Results: After adjusting for stage, grade, necrosis, type: 5 yr. cancer specific survival was similar 5 yr. metastases-free survival equivalent Local recurrence no different for < 4 or 4-7cm Elective NSS can be applied to tumors 4-7 cm especially if exophytic

15 Contemporary Complication Rates with Open Partial Nephrectomy

16 Contemporary Complication Rates with Open Partial Nephrectomy 1985 to 2001 (compare 85-95, 96-01) N = 823 open NSS Intraop blood loss (550 v. 350cc, p<0.001) CRF (14.6 v 8.1%, p=0.003) 003) Early comp (13.4 v 6.9%, p=0.002) Late comp (32.4 v 24.6%, p=0.014)

17 Emerging Data on Long-term Renal Function 662 patients w/ 2 kidneys and normal function RN or PN for a solid cortical tumour < 4cm CRF defined as: GFR < 60 ml/min or < 45 ml/min/1.73m 2

18 Long-term Renal Function 3-year probability of freedom from CRF : GFR < 60: 80% vs. 35% for PN and RN, resp. GFR < 45: 95% vs. 64% for PN and RN, resp. Multivariate analysis procedure independent predictor of CRF Median time to GFR < 60 was 18 months for RN, not reached for PN No patient in this cohort has gone on to dialysis

19 Is partial nephrectomy underutilized? J Urol, Mar SEER database review N = 14,647 (primary tumour < 7 cm)

20 Tumours < 2 cm

21 Tumours 2 4 cm

22 Is partial nephrectomy underutilized? Ontario Partial Nx 166 (5.7) Radical Nx 2743 (94.3) Partial Nx 345 (10.1) Radical Nx 3078 (89.9) * Partial Nx 284 (14.1) Radical Nx 1731 (85.9) Abouassaly et al. (unpublished)

23 Laparoscopic p Radical Nephrectomy

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25 Flank Bulge Chatterjee et al., Urol Onc 22: (2004) Historically 3% N=70 ( ) 50% of patients reported a flank bulge 24% experienced durable flank pain Median pain magnitude = 5/10 Pain persisted greater than 1 year Impacted QOL, especially in those < 60 yrs.

26 Flank Bulge Yoshimura et al., J Urol (169): 182-5, Jan 2003

27 Radical Nephrectomy Laparoscopic nephrectomy: initial case report. Clayman RV, Kavoussi, LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, et al. J Urol, 146:278, 1991

28 Laparoscopic Radical Nephrectomy Diminished: postoperative pain, analgesic requirement length of hospital stay and convalescence Equivalent: Rate of complications* Blood loss* Surgical time* Oncologic results

29 Laparoscopic Radical Nephrectomy p p p y Transperitoneal

30 Port Placement (Left)

31 Left Renal Hilar Dissection

32 LAPAROSCOPIC RADICAL NEPHRECTOMY Specimen Extraction

33 Evidence Supporting LRN

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35 Equal cancer-specific outcomes for 3 years.

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37 Portis et al.

38 LRN Oncologic Outcomes Portis et al., J Urol (167): , Mar 2002

39 LRN Tumours > 7cm Steinberg, Finelli, Desai et al, J Urol (172):2172-6, 2172 Dec 2004

40 LRN Oncologic Outcomes pt2-3b RCC 1.0 Stage Specific Survival.8 Survival.6.4 STAGE pt3b.2 pt3a pt Months From Nephrectomy Finelli et al. (unpublished)

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42 Laparoscopic Cytoreductive Nephrectomy

43 Laparoscopic Cytoreductive Nephrectomy

44 Laparoscopic Cytoreductive Nephrectomy

45 Conclusions LRN has been performed for > 10 years Oncologic outcomes equivalent Diminished morbidity Idi Indications i are expanding Caution in selecting patients

46 LRN Standard of care for T2 RCC in the absence of imperative indications for NSS Caution: Large hilar tumour Hilar adenopathy > 12 cm Multiple parasitic vessels

47 LAPAROSCOPIC PARTIAL NEPHRECTOMY

48 Laparoscopic p Partial Nephrectomy Laparoscopic partial nephrectomy is NOT new... Winfield, et al, 1995 Gill, et al, 1995 McDougall, et al, 1998 Janetschek, et al, 2000 Harmon et al, 2000

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50 Laparoscopic p Partial Nephrectomy RETROSPECTIVE COMPARISON J Urol 170:64-8, July 2003 Laparoscopy vs. Open (n=200)

51 33% had > 1 complication Overall 18% had a urologic complication Hemorrhage 9.5% (3.5, 2, and 4%) Urine leak 4.5% Open conversion 1% Reoperation 2%

52 Oncologic Outcomes N = 100 Mean tumour size 3.1 cm Mean WIT 27 minutes 2 positive margins (oncocytoma, RCC) Median f/u 42 months 86 % survival, 100% cancer specific survival

53 Laparoscopic Partial Nephrectomy

54 Laparoscopic Partial Nephrectomy The most demanding laparoscopic procedure Potential for hemorrhage Time pressure of warm ischemia Requires complete comfort with lap Must master suturing angles Set-up is critical Requires efficient intracorporeal suturing

55 Laparoscopic Partial Nephrectomy Initially LPN was applied to: Small tumours Solid tumours Exophytic tumours In the setting of two kidneys

56 Expanding the Application of Laparoscopic Partial Nephrectomy

57 Laparoscopic Heminephrectomy for Tumor Finelli et al. Urol 2005 Laparoscopic Partial Nephrectomy for Centrally Located Renal Tumors Frank et al. J Urol 2006 Laparoscopic p Partial Nephrectomy for Hilar Tumors Gill et al., J Urol 2005 Laparoscopic Partial Nephrectomy in Solitary Kidney Solitary Kidney Gill et al. J Urol 2006

58 LAPAROSCOPIC PARTIAL NEPHRECTOMY CONCLUSION When indicated, the majority of small renal tumors can be effectively managed with LPN

59 CRYOABLATION

60 Renal Cryoablation Resurgence of visceral cryosurgery: Improved cryo-delivery systems: N 2, Argon Superior intraoperative (ultrasound/mri) Superior intraoperative (ultrasound/mri) and postoperative (MRI) imaging systems

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63 LAPAROSCOPIC RENAL CRYOABLATION CLEVELAND CLINIC EXPERIENCE Total No. Cases: patients (60 tumors) completed min. 3 yrs f/u Mean patient age: 65 years Mean tumor size: 23cm 2.3 No. Solitary kidneys: 11 (20%)

64 Laparoscopic Renal Cryoablation FOLLOW-UP RADIOLOGIC : MRI day 1 month 3 month 6 month 12 annual MRI, CXR HISTOLOGY: CT guided needle biopsy: month 6

65 Laparoscopic Renal Cyoablation RADIOLOGIC FOLLOW-UP Lesion Size on MRI % Reduction Actual size Day cm Month 3 26% 2.8 cm Month 6 39% 2.3 cm Month 12 56% 1.7 cm Month 24 69% 1.2 cm Month 36 75% 0.9 cm 17 (38%) cryolesions undetectable at 3rd year MRI

66 Laparoscopic Renal Cryoablation Post-operative ti MRI Imaging Preoperative 24 hours post-op op 3 months post-op op

67 LAPAROSCOPIC RENAL CRYOABLATION FOLLOW-UP BIOPSY (n=56) 39 patients (70%) had a CT - guided core needle biopsy 6 months postoperatively 2 positive biopsies (RCC Radical nx)

68 LAPAROSCOPIC RENAL CRYOABLATION Summary 56 Patients with minimum 3 year followup Renal cryolesions decreased in size by 75% Completely disappeared in 38%

69 LAPAROSCOPIC RENAL CRYOABLATION Summary Locally persistent / recurrent cancer 3.6% Overall survival 89% Cancer-specific survival 100%

70 Summary of Cryoablation Reference N Age Tumor Biopsy Approach Follow-up Failure (%) Complications Rodriquez % RCC Lap/Open (0) pelvic thrombus Urol 2000 (29% -ve) CVA Shingleton J Urol NA MRI (5) abscess Nadler J Urol % RCC (13% -ve) Lap 15 1 (6.7) resp failure ileus Lee 20 NA NA 55% RCC Lap (5) pancreatic injury Urol 2003 (25% -ve) Cestari J Urol % RCC (5% -ve) Lap (2.7) UPJO renal # Gill J Urol % RCC (36% -ve) Lap 36 2 (3.6) nil Lawatsch J Urol % RCC (10% -ve) Lap (3.4) open conversion, nephrectomy, MI TOTAL (3.5)

71 RADIOFREQUENCY ABLATION (RFA)

72 Impedance and Power Monitoring

73 RF Ablation with Infusion T A T A A T A = Active electrode T = Passive Temperature probes = Infusion conduction

74 RFA Outpatient procedure IV sedation and local anesthetic CT guidance Radiologist +/- Urologist present

75 Clinical RFA- Concerns Michaels et al, J Urol 168:2406, 2002 Residual viable cells seen in all 20 tumors undergoing open partial ilnephrectomy after RFA Rendon et al, J Urol 167:1592:2002** Residual viable tumor cells seen in 4/5 tumors undergoing immediate nephrectomy after RFA and 3/6 tumors undergoing delayed nephrectomy after RFA

76 7 Institutions (616 patients) Residual or recurrent disease RFA 13.4% Cryoablation 3.9% 70% were detected in first 3 months Salvage ablation 4.2% failure

77 Summary of RFA Reference N Age Tumor Biopsy Approach Follow-up Failure (%) Complications Rendon J Urol NA 2.4 NA open, US, CT NA 8 (80) liver infarct Michaels 15 NA % RCC open, US NA 4 (27) thermal injury J Urol 2002 calyceal leaks Matlaga J Urol NA % RCC open, US NA 2 (20) Roy-Choudury NA US, CT (12) renal infarcts AJR 2003 psoas injury Mayo-Smith AJR % RCC (44% -ve) US, CT 9 2 (6) hematomas probe site met Hwang NA lap, US, (6) UPJO J Urol 2004 CT Lewin Rad % RCC (11% -ve) MRI 25 0 (0) hematomas Zagoria % RCC CT 7 2 (9) pneumothorax AJR 2004 (15% -ve) hematoma Varkarakis J Urol NA 57% RCC (34% -ve) CT (7) aspiration/death 16 minor Gervais % RCC US, CT (9) hemorrhages AJR 2005 ureter stricture TOTAL (9)

78 Epidemiology Increasing incidence id of RCC worldwide with only modest increase in mortality. 6.3 to 9.1 per 100, from 1975 to 1995 Over past 30 yrs., increase in asymptomatic ti cases from 10% to 57%. Usually smaller, low stage and low grade.

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80 Localized RCC TNM (2002)

81 Natural History of SRMs

82 J Urol, 175:425, reports (9 institutions) 6 40 patients (mean 25/series) Mean followup: 30 months (25 39 months) Means tumor size: 2.6 cm Mean growth rate: 0.28 cm/year Path available in 46%, confirmed RCC in 92%

83 Natural History of Small Renal Tumors Year (n ) Prosp. or Retro. Growth rate Follow up (months) Remarks Bosniak R 0.36cm/yr No mets Takebayas hi et al P median 65% <1yr cm 3 doubling Rendon et P 1.32cm/yr al Oda 2001/ R cm/ yr Yamada R median Volpe et al P cm/yr PI/AI ratio 27.9 No Kassouf R 0.49cm/ yr 24 & 31.6 median 100% 10 yr survival progression No mets Kato R 0.42cm/ yr 22.5 AI & median grade

84 Meta-analysis Natural History Combined

85 Rationale a for Active Surveillance Most tumors now diagnosed at < 3-4cm 20-40% are benign Most small tumors grow slowly Good treatment results are therefore biased by benign tumours and the benign behaviour of small tumors

86 Conclusions Surgery is the cornerstone of management in RCC Localized tumours, especially T1a, carry an excellent prognosis regardless of treatment used The majority renal tumours can be managed with minimally invasive techniques Larger and advanced tumours require conventional surgery as described by Robson

87 Acknowledgements CCF Inderbir Gill, MD Andrew dewnovc, Novick, MD PMH Neil Fleshner, MD Michael Jewett, MD Michael Robinette, MD John Trachtenberg, MD

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