Christopher G. Wood

International consultation on urologic diseases and the European association of urology international consultation on locally advanced renal cell carcinoma

CONTEXT Although an ever-increasing number of patients are being incidentally diagnosed with small renal masses, there is still a sizable portion of patients with renal cell carcinoma (RCC) who present with locally advanced or metastatic disease. Those with locally advanced disease present a challenge because they may be difficult to distinguish from those with organ-confined disease at the time of diagnosis. However, this distinction is important because they may require a different management strategy. These advanced RCC patients include those with venous tumour thrombi, extracapsular tumour extension, adjacent organ involvement, as well as nodal disease. EVIDENCE ACQUISITION A thorough literature search of the following terms was undertaken: advanced renal cell carcinoma, renal cell carcinoma venous tumour thrombi, renal cell carcinoma extra-capsular extension, renal cell carcinoma nodal metastasis, and locally recurrent renal cell carcinoma. An international expert panel convened by the International Consultation on Urologic Diseases and the European Association of Urology reviewed these articles. EVIDENCE SYNTHESIS Review of the available literature allowed for assessment of the level of evidence for the diagnosis, management, and therapy of locally advanced RCC with the ultimate goal of providing a synthesis of this information with a consensus statement from leaders in the field. CONCLUSIONS Despite the advances in prognostic markers and targeted molecular therapies for RCC, currently the only curative treatment for locally advanced RCC is aggressive surgical resection.

Treating the two extremes in renal cell carcinoma: management of small renal masses and cytoreductive nephrectomy in metastatic disease.

The incidental renal mass represents a heterogeneous group that contains both benign and malignant pathologies. The majority of renal cell carcinomas are discovered incidentally, without the presence of symptoms directly related to the mass, and are closely associated with the term small renal masses because of the discovery before the onset of symptoms. In general, small renal masses are defined as 4 cm or smaller, and may account for greater than half of renal cell carcinoma diagnosis. The use of renal mass biopsy may offer additional pathological information but the clinician must be reminded of the technical and diagnostic limitations of renal mass biopsy. Patient-dependent factors, such as life expectancy and comorbidities, guide the management of small renal masses, which include active surveillance, partial nephrectomy, radical nephrectomy, and ablative techniques (cryoablation and radiofrequency ablation). Partial nephrectomy has demonstrated durable oncologic control for small renal masses while preserving renal function and, if feasible, is the current treatment of choice. In the other extreme of the renal cell carcinomas spectrum and in the presence of metastatic disease, the removal of the renal primary tumor is termed cytoreductive nephrectomy. Two randomized trials (SWOG 8949 and EORTC 30947) have demonstrated a survival benefit with cytoreductive nephrectomy before the initiation of immunotherapy. These two studies have also been the motivation to perform cytoreductive nephrectomy in the targeted therapy era. Currently, there are two ongoing randomized prospective trials accruing to investigate the timing and relevance of cytoreductive nephrectomy in the contemporary setting of targeted therapy.

Surgical Treatment for Renal Cell Carcinoma

Systemic therapies for renal cell carcinoma have made modest improvements in patient survival but rarely offer durable cure. Thus, surgical excision of renal cell carcinoma is an integral component of oncologic management. The spectrum of renal cell carcinoma presentation from small renal masses, locally advanced disease, and in the presence of metastasis varies with the surgical armamentarium needed to treat this diverse group of patients. In general for small renal masses, a nephron-sparing approach is preferred if it can be completed safely with negative margins, and for locally advanced tumors, radical nephrectomy is preferred with excision of the affected kidney, lymph nodes, and venous thrombi if present. With metastatic disease, cytoreductive nephrectomy has been shown to prolong survival in carefully selected patients, usually with good performance status and with oligometastasis. The surgical nuances, indication, and motivation for each surgical technique will be discussed in this chapter.

Surgical Complications of Presurgical Systemic Therapy for Renal Cell Carcinoma: A Systematic Review

Background: Locally advanced and metastatic renal cell carcinoma (RCC) is associated with poor survival outcomes. The integration of presurgical systemic therapy with targeted molecular agents prior to surgical resection of RCC tumors has been utilized to improve on these outcomes. These agents may be associated with an increased risk of perioperative complications due to their action on angiogenesis and cell proliferation. Objective: To examine the evidence for the incidence and severity of perioperative complications following presurgical targeted therapy for locally advanced or metastatic RCC. Methods: We performed a systematic review of retrospective studies, prospective clinical trials, and meta-analyses using key search terms in PubMed and Medline. Studies were screened for eligibility and data were extracted by the authors. A qualitative analysis was performed and the complications for available targeted agents was reported. Results: Retrospective analyses and small prospective trials indicate varying complication rates and types based on presurgical therapies. While some studies indicate a possible increase in wound-related complications, other studies did not show similar results. Additional unique complications reported include an increase in surgical adhesions. There was not any significant difference in overall or bleeding complications. Conclusions: Overall, these studies demonstrate an acceptable level of surgical complications that should not discourage the clinician considering presurgical therapy. The results of pending trials looking at presurgical therapies will provide further information.

Primitive Neuroectodermal Tumors and Other Sarcomas of the Kidney

Although extremely rare, renal sarcomas can cause high rates of morbidity and death. The diagnosis of these entities remains challenging and findings illustrate the importance of obtaining a preoperative biopsy given the various range of prognosis. Furthermore, there is no standardized treatment for renal sarcomas, and evidence from the literature to help clinicians manage renal sarcomas is limited. Here, we summarize the clinical knowledge about the major clinicopathological characteristics, outcomes, and management of primary renal primitive neuroectodermal tumors and other rare types of kidney sarcomas, including leiomyosarcoma, liposarcoma, hemangiopericytoma, fibrosarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma, and primary renal synovial sarcoma.

Combination therapy and function-sparing surgery for muscle-invasive bladder cancer

The American Cancer Society has estimated that there will be 53,200 new cases of bladder cancer diagnosed in the United States this year.1 Of these, approximately 70% will be of the superficial subtype that can frequently be managed with transurethral resection (TUR), intravesical therapy in selected cases, and careful surveillance for recurrence or progression. The remaining 30% of patients, however, are diagnosed with a far more virulent phenotype of bladder cancer that is invasive into the muscular wall of the bladder, demonstrates significantly increased metastatic potential, and is responsible in large part for the considerable morbidity and mortality associated with the disease. Over 12,200 people are estimated to die from bladder cancer this year, and the overwhelming majority of these patients represent those who present with an invasive phenotype that progresses to metastatic disease.1