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Title: Diapositiva 1


1
Kidney cancer prognostic factors and new
surgical approaches
Clinica Urologica ed Andrologica UniversitĂ 
degli Studi di Chieti-Pescara Scuola di
Specializzazione in Urologia Direttore. Prof.
R.Tenaglia Mediterranean School f Oncology ROMA
24 Novembre 2007
2
What Is Kidney Cancer (Renal Cell Carcinoma)?
Kidney cancer is a cancer that starts in the
kidneys. In order to understand kidney cancer, it
helps to know about the normal structure and
function of the kidneys.
Renal Cell Carcinoma (RCC) Renal cell carcinoma
(also known as renal cell cancer or renal cell
adenocarcinoma) is by far the most common type of
kidney cancer. It accounts for about 9 out of 10
kidney cancers. Although RCC usually grows as a
single mass within the kidney, sometimes tumors
are found in more than one part of the kidney or
even in both kidneys at the same time. Some renal
cell carcinomas are noticed only after they have
become quite large, but most are found before
they metastasize (spread) to distant organs in
the body. Like most cancers, RCC is hard to treat
once it has metastasized.
3
There are five subtypes of RCC, based mainly on
how the cancer cells look under a
microscope Clear Cell Papillary Chromophobe
Collecting Duct Unclassified
This subtype accounts for about 5 of RCCs. The
cells of these cancers are also pale, like the
clear cells, but are much larger and have certain
other features that can be recognized.
This is the most common form of renal cell
carcinoma. About 8 out of 10 people with renal
cell carcinoma have this kind of cancer. When
viewed under a microscope, the cells that make up
clear cell RCC appear very pale or clear.
This subtype is very rare. The major feature is
that the cancer cells can form irregular tubes.
The second most common subtype -- about 10 to
15 of people have this kind. These cancers form
little finger-like projections (called papillae)
in some, if not most, of the tumor. Some doctors
call these cancers chromophilic because the cells
take up certain dyes used in preparing the tissue
to be viewed under the microscope, causing them
to appear pink.
In rare cases, renal cell cancers are labeled as
"unclassified" because their appearance doesn't
fit into any of the other categories or because
there is more than one type of cell present.
4
Other Cancerous Kidney Tumors Less common
cancers of the kidney include Transitional
cell carcinomas Wilms tumors And Renal Sarcomas
5
RCC - Epidemiology
  • Approximately 40,000 cases per year
  • 12,900 deaths per year
  • 2 - 3 of all cancers
  • Average age at diagnosis 50-70
  • Nearly 40 of patients with RCC will eventually
    die from the disease
  • Associated with inherited syndrome in 2

6
RCC Age Distribution
Source BAUS 2001
7
Von Hippel Lindau (VHL) Renal Carcinoma Gene
Localization Studies Inherited Renal Cancer To
identify the disease gene for kidney cancer the
familial form of renal cell carcinoma associated
with von Hippel Lindau disease was studied. Von
Hippel Lindau syndrome is an autosomal dominant
disease in which affected individuals develop
kidney cancers as well as tumors in a number of
different organs. VHL patients develop multiple,
bilateral renal carcinomas and cysts, cerebellar
and spinal hemangioblastomas, pheochromocytomas,
retinal angiomas, epididymal cystadenomas,
pancreatic cysts and islet cell tumors and tumors
in the inner ear, endolymphatic sac
tumors. Clinical Evaluation VHL - MRI of the
brain and spine - Abdominal CT and ultrasound -
Ophthalmologic evaluation - Audiometric and ENT
evaluation - Testicular Ultrasound - Metabolic
evaluation
8
It is important that VHL patients undergo a
complete screening and metabolic evaluation
PRIOR TO A SURGICAL PROCEDURE to rule out such
unsuspected manifestations as a CNS
hemangioblastoma orpheochromocytoma. The VHL
Gene Has Characteristics of a Tumor suppressor
Gene.
9
VHL Surgical Management Surgical management of
the renal manifestations of VHL patients involves
nephron sparing surgery whenever possible.
Patients with small renal tumors, generally
under 2.5 cm, are often managed with expectant
management. When the tumors reach 3 cm, surgery
is often recommended. As it has been estimated
that there can be up to 600 tumors per kidney in
VHL patients, surgical resection of renal lesions
is not considered curative. Rather, it is
considered that surgical management will
hopefully set back the clock i.e. help prevent
metastasis. Historically 35 to 45 of VHL
patients have died of complications of metastatic
renal cell carcinoma. The decision to recommend
surgery must balance the risk of metastasis with
the morbidity of surgery. When surgery is
performed, thorough evaluation of the kidney with
intraoperative ultrasound is considered a
valuable adjunct to the surgical procedure. This
allows the surgeon to localize renal tumors and
cysts and to perform as thorough and safe a
procedure as possible.
10
  • Clinical Applications of Cancer
  • Gene Mutation Detection
  • 1) Molecular Genetic Classification of Kidney
    Cancer
  • The findings have lead to the introduction of a
    molecular genetic classification of kidney
    cancer, papillary versus clear, with clear cell
    renal carcinoma being characterized by mutation
    of the VHL gene.
  • Molecular Genetic Classification Of Renal
    Carcinoma Gene RCC
  • VHL Clear Cells/Compact Growth
  • Met Type I Papillary Growth Pattern
  • BHD Chromophobe renal cell carcinoma,
    Oncocytoma
  • FH Type II Papillary Growth Pattern
  • Somatic VHL Gene Mutation Analysis

11
  • Potential Clinical Applications
  • Detection of VHL gene abnormalities in
  • - Formalin fixed tissues
  • Tissue aspirates
  • Early Diagnosis
  • - Circulation Cells
  • - Urine

12
Renal Carcinoma Associated with Birt Hogg Dube
Syndrome (BHDS) We have recently noted an
associated of kidney cancer with an inherited
familial syndrome known as Birt Hogg Dube
Syndrome (BHDS). BHDS is an autosomal dominantly
inherited syndrome in which affected individuals
are known to be at risk for a cutaneous
manifestation, the presence of fibrofolliculomas.
13
Familial Renal Carcinoma (FRC) Recently
scientists in Iceland have performed studies
suggesting that genetic susceptibility may be a
major component in the development of ordinary,
sporadic renal carcinoma. In their initial
study, 68 of individuals in Iceland who had
kidney cancer had up to a second degree relative
(a second cousin) with kidney cancer. This work
suggests that it is important to ask all patients
with renal carcinoma whether any other family
member also was affected with renal carcinoma.
Urologic surgeons at the NCI are currently
studying families in which multiple members are
affected with kidney cancer (FRC) in order to
identify the genetic basis of this form of kidney
cancer.
14
Risk Factors for RCC
  • Smoking
  • Occupational exposure to toxic compounds
  • Obesity
  • Acquired cystic kidney disease
  • Analgesic abuse nephropathy
  • Genetic predisposition

15
Risk Factors for RCC
  • Smoking
  • Cigarette smoking doubles the risk
  • Occupational exposure
  • cadmium RR 2.0
  • asbestos RR 1.4
  • gasoline RR 1.6
  • increased exposure may be associated with gene
    mutations such as vHL tumor suppressor gene

16
D i a g n o s i s
  • CT scan
  • Ultrasonography
  • MRI
  • Renal arteriography
  • Percutaneous cyst puncture

17
RCC Genetics Biology
  • Pathogenesis
  • VHL
  • Autosomal dominant
  • inheritance of one copy of a mutated allele
    followed by a second somatic gene alteration in
    the remaining allele leads to various cancers,
    including RCC
  • genetic abnormality localized to 3p25 to 3p26

18
RCC Genetics Biology
  • Pathogenesis
  • Sporadic Clear Cell RCC
  • chromosomal losses often spanning 3p14 to 3p26
  • VHL mutations found in up to 80 of sporadic
    clear cell RCC
  • (Gnarra Nat Genet 94 785)

19
TNM Staging system Primary Tumor (T) T1 Tumor 7
cm or less in greatest dimension, limited to the
kidney T2 Tumor more than 7 cm in greatest
dimension limited to the kidney T3 Tumor extends
into major veins or invades the adrenal gland or
perinephric tissues, but not beyond Gerotas
fascia T3A Tumor invades adrenal gland or
perinephric tissue but not beyond Gerotas
fascia T3B Tumor grossly extends into the renal
vein (s) or vena cava below the diaphragm T3C
Tumor grossly extends into the renal vein (s) or
vena cava above the diaphragm T4 Tumor invades
beyond Gerotas fascia
20
Regional Lymph Nodes (N) N0 No regional lymph
node metastases N1 Metastases in a single
regional lymp h node N2 Metastases in more than
one regional lymph node
21
Distant Metastases (M) M0 No distant
metastases M1 Distant Metastases The prognostic
value of size was further emphasized by
introducing an optional division of stage T1 into
stage T1a (4 cm or less) and stage T1b (4 to 7
cm). Five-year survival for stage T1a and T1b was
98 and 88, respectively.
22
Staging - Prognoses Predictors of Response
  • Historically, clinical factors alone were used as
    prognostic markers for RCC
  • 1999 MSKCC (Motzer et al, J Clin Oncol)
  • PS
  • LDH
  • Hgb
  • Corrected serum Ca
  • Nephrectomy status
  • (0 favorable risk, 1-2 intermediate risk, gt3
    poor risk)
  • Median Survival
  • favorable 20 months
  • intermediate 10 months
  • poor 5 months

23
Staging - Prognoses Predictors of Response
  • International Kidney Cancer Working Group
    currently creating a
  • comprehensive data base of gt4,000 patients with
    metastatic RCC to provide and
  • validate a single model that can be used to
    predict survival.
  • Biomarkers being evaluated for their potential as
    prognostic factors
  • tumor proliferation
  • tumor growth
  • angiogenesis
  • loss of cell adhesion
  • CA-IX is highly expressed in RCC, may be a useful
    prognostic and predictive marker.

24

Promising Therapies
Target Specific mTOR, VEGF, EGFR, PDGF, RAF, KIT,
proteosome
Antibody Therapy VEGF / EGFR TKI EGFR CAIX
?
Renal CA cell

Dendritic cell
Vaccine gp 96 HSP CAIX/GM-CSF
T cell Systemic cytokines (IL-2, IFN) Allogeneic
stem cell transplant
T Cell
25
Treatment
  • Surgery is the standard treatment for contained
    kidney cancer.
  • Various surgical options may be available to you,
    depending on tumor size and location within the
    kidney capsule. Such surgery is performed by a
    urologic surgeon.
  • Radiation and chemotherapy are not very effective
    in treating kidney cancer. Biologic therapies are
    used more frequently.

26
Treatment Options
  • Surgery is best option
  • Radical nephrectomy is the established therapy
    for localized renal carcinoma

27
Surgical Treatment
Radical nephrectomy has been the standard of
care for localized renal cell carcinoma since
the description by Robson. Partial nephrectomy
has been used to avoid dialysis in patients with
a solitary kidney, compromised renal func tion,
or bilateral multifocal (hereditary) tumors.
However, performed in patients with small renal
tumors (less than 4 cm) has been associated with
survival similar to that found after radical
nephrectomy.
28
Treatment Options
  • Other treatments include
  • Radiation therapy for renal cell carcinoma
  • Chemotherapy not effective
  • Treatment with interleukin II and interferon can
    be used and at times renal cell carcinoma will
    respond
  • Interleukin II has resulted in 14 remission
    rate, 5 complete response and 9 partial
    response approved by FDA

29
Five- year survival for localized renal cancers
is related to size 100 (lt 2.5 cm) 83 (2.5-
4.9cm) 61 (5.0- 7.4 cm) 51 (7.5- 10.0 cm) 27
(greater than 10.0 cm) These and other
observations led to a change in the TMN
classification of stage T1 renal tumors from 2.5
cm in diameter to 7.0 cm in diameter.
30
Partial Nephrectomy Sporadic renal cancer A
solitary small renal tumor is ideally suited for
partial nephrectomy with an adequate margin.
Surface cooling for 10 minutes with ice slush
will then provide up to 3 hours safe ischemia.
Excision of the renal tumor with a 1 cm margin is
performed by the appropriate technique, including
wedge resection, transverse or amputation, or
segmental renal artery occlusion with resection
of the appropriate renal segment. Small polar
tumors may be exc ised with local pressure in the
absence of renal artery occlusion. Extracorporeal
partial nephrectomy with renal autotransplantation
is seldom performed now except in the setting of
the Jehovahs witness with multiple or complex
tumors. Five- year cancer specific survival after
partial nephrectomy has been reported to be 87 to
90, with a local recurrence in 4 to 6.
31
Hereditary renal cancer Hereditary renal cancer
syndromes are characterized by the presence of
bilateral, multiple renal tumors, often
presenting in the third and fourth decade of
life. Examples of hereditary renal cancer
syndromes include Von Hippel-Lindau disease
(VHL) Hereditary Papillary Renal Cancer (HPRC)
Hereditary Renal Oncocytoma (HRO) Burt-Hogg-Dubé.
Examination of normal renal tissue from patients
with renal cancer and VHL has shown microscopic
renal tumors are frequently present.
Extrapolations based on these studies predict as
many as 600 clear cell renal cancers and 1100
clear cell cysts per kidney. These cysts are
found only in VHL patients, and are
microscopically and genetically similar to clear
cell renal cancer. .
32
Treatment options Bilateral nephrectomy Included
observation, or renal parenchymal sparing surgery
to remove renal tumors while sparing normal
tissue. Before the widespread use of computerized
tomography, VHL renal tumors were not well
imaged, and 35 to 45 of VHL patients died of
metastatic renal cancer. Median age at death was
44 years and the youngest reported patient died
at age 23 years. These data represent the best
available estimate of the natural history of
untreated VHL. HP RC is a recently described
hereditary cancer syndrome inherited in an
autosomal dominant fashion.
33
The treatment strategy of bilateral nephrectomy
and renal replacement removes all tissue at risk
of developing renal cancer and metastases. The
one-year survival in 30 to 40 year old,
white,nondiabetic renal failure patients
(characteristics similar to those of VHL patients
detected by screening) is 78 with dialysis. Two-
year survival with a living related or cadaver
transplant is 96 and 78, respectively.
Similarly, a 65 5-year survival of VHL patients
has been reported after bilateral nephrectomy and
renal replacement.
34
The treatment strategy
In order to delay surgeries and improve quality
of life, a strategy consisting of observing
patients with hereditary renal cancer until the
largest tumor was 3 cm in diameter before
recommending surgery, regardless of the
recurrence pattern or number of tumors was
implemented. Fifty-two VHL patients had renal
tumors less than 3 cm in diameter (group 1), and
were followed a median of 5 years. No metastases
were observed in these patients
35
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36
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37
Nephrectomy in Metastatic RCC
  • Nephrectomy in pts with metastatic RCC
  • palliation of symptoms
  • therapeutic
  • Metastatic disease Resection of solitary mets
    5-yr. survival of 35-50
  • (Kavolius J Clin Oncol 99 162261)

38
Nephrectomy in Metastatic RCC
  • a-IFN /- Nephrectomy in Metastatic Dz
  • SWOG 8949 (246 pts)
  • Survival (months)
  • No
  • Nephrectomy Nephrectomy
  • All Pts 8.1 12.5
  • PS 0 12.8 17.4
  • 1 4.8 6.9

39
Radiofrequency Ablation Tissue radiofrequency
ablation (RFA) takes advantage of the same
technology present in the surgical Bovie we use
every day, when tissue is cauterized or cut.
Fourteen to eighteen gauge needles, some with
deployable arrays, are inserted in the tumor
using ultrasound or CT guidance. Power output has
increased from 50 watts in early models to 250
watt generators that will soon be available,
allowing increases heat delivery to tissues. The
ablation process is monitored using temperature
feedback from thermocouples located in the tips
of the catheter prongs or by changes in impedance
during treatment. At least two 10-minute
treatments per tumor are performed. The needle
tract is cauterized to avoid bleeding and prevent
tumor seeding. Energy delivered to tissues
resulting in heating tissues to 60- 70o C,
causing cell death. Currently, tumors up to 5- 6
cm in diameter may be treated with a single
needle insertion. Three companies have
commercially available radiofrequency ablation
generators and needles Radionics,
Radiotherapeutics, and RITA Medical Systems.
40
The greatest experience with RFA has been in the
treatment of normal and malignant liver tissue.
RITA was the first device available for soft
tissue treatment. The lesions induced by RITA are
well demarcated and well seen as early as one day
after treatment. Gross examination of treated
porcine liver tissue has shown a central firm
core of cooked tissue, with a surrounding 1-2 mm
hemorrhagic, well demarcated perimeter.
Microscopic examination demonstrates
microvascular thrombosis and coagulative
necrosis. In the porcine model, 3.5 to 4 cm
lesions could be reproducibly generated, and
larger lesions in humans have undergone
treatment. The greatest human experience with
this system is in the treatment of liver
metastases. Few complications have been reported
in treating liver tumors, except for mild
discomfort at the skin site, when percutaneous
RITA is performed. A similar, although limited,
experience has been observed in radiofrequency
ablation of renal cancers.
41
Histologic exam of treated tumors is very
limited. We have recently excised tumors from
previously treated patients that responded or did
not respond to RFA. Tumors with a halo sign
consisted of a fibrous capsule containing
necrotic fluid and tumor. Enhancing tumors had
focal areas of residual tumor.
42
Laparoscopic Radical Nephrectomy Localized Renal
Cancer
Laparoscopic radical nephrectomy was first
performed by Clayman in 1990, and a growing
worldwide experience has shown laparoscopic
surgery is safe and associated with similar
survival as open surgery. Patients eligible for
laparoscopic radical nephrectomy have similar
characteristics as those undergoing open
nephrectomy, with the exception of a vena caval
thrombus. While local invasion of tumor, large
tumors, metastatic disease, and extensive
retroperitoneal lymphadenopathy add significantly
to the degree of difficulty, they are not
absolute contraindications to laparoscopic
radical nephrectomy. Hand assisted laparoscopic
surgery and retroperitoneal or transperitoneal
approaches can be used at the surgeons
preference. Small localized tumors are best
suited to gain experience with this approach.
43
Laparoscopic Radical Nephrectomy
Several hundred laparoscopic nephrectomies have
been reported for cancer. Laparoscopic radical
nephrectomy has been associated with a decrease
in blood loss, postoperative analgesic
requirements, hospital stay, and time to return
to normal activities, compared to open radical
nephrectomy. Two-year follow-up has shown an over
95 cure rate, similar to open nephrectomy. The
nephrectomy specimen may be removed through a
small incision, or fragmented and removed in
pieces through a 10 mm port. Placement of the
kidney in an impermeable sac prior to
morcellation is performed to prevent tumor
spillage. Tumor morcellation has been performed
with ring forceps or a high-speed electrical
tissue morcellator. Pathologic evaluation of
morcellated tissue can be performed, although
very small tumors may not be identified. Staging
information is lost during morcellation.
44
Metastatic Renal Cancer 1 Tumor bleeding and
pain can often adversely affect the ability to
treat patients with metastatic renal cancer. At
the NIH, over 200 patients with metastatic renal
cancer underwent cytoreductive nephrectomy as
preparation for systemic treatment with
Interleukin-2, chemotherapy based regimens, or
anti-angiogenic based regimens. These were bulky
tumors usually required a chevron incision. 23
of patients required an additional resection,
most commonly a regional lymph node dissectio n
or vena caval thrombus extraction. While there
was similar morbidity to surgery performed in
patients with localized renal cancer, 38 were
not eligible for high dose Interleukin-2, usually
because of progression of disease during the
6-week recovery time prior to treatment. We
looked at laparoscopic surgery as a way to
decrease morbidity and shorten time to treatment.
The benefit of laparoscopic nephrectomy in terms
of time to recovery and completeness of resection
has been demonstrated in patients with small
renal tumors and no local invasion or metastases,
but has not been reported in patients with
metastatic disease. Tumor morcellation further
reduces surgical trauma, since tumor
dissemination is not a primary concern in
patients with metastatic cancer. Laparoscopic
techniques thus offer the possibility of lower
morbidity, faster recovery, and more rapid
patient availability for systemic treatment
45
Others strategy From January, 1995 to November,
1997, 44 patients with metastatic renal cell
carcinoma and renal primary in place underwent
cytoreductive surgery prior to systemic treatment
with Interleukin-2. Patients undergoing open
cytoreductive nephrectomy served as historical
controls.
  • Schmidt, L et al. Germline and somatic mutations
    in the tyrosine kinase domain of the MET
    proto-oncogene in papillary renal carcinomas.
    Nat.Gen., 16 68-73,1997.
  • Schmidt, L. et al .Novel mutations of the MET
    proto-oncogene in papillary renal carcinomas.
    Oncogene, 18 2343- 2350, 1999.
  • Latif, F et al. Identification of the von
    Hippel-Lindau disease tumor suppressor gene.
    Science, 260 1317-1320, 1993.

46
Large renal tumors Could not be lifted and
placed into the 8 by 10 inch "lapsac" surgical
tissue pouch used for morcellation. Instead, with
the patient in the Trendelenburg position, one or
two additional ports were used to facilitate
opening the morcellation sac, allowing the
specimen to slide in. The mouth of the sac was
draped with towels and an occlusive adhesive
barrier. A COOK Tissue MorcellatorTM (COOK,
Spencer, IN) was used to extract the tumor from
the "lapsac". The use of twelve- inch tissue
forceps alternating with the morcellator greatly
facilitated tissue removal. Contaminated drapes,
gloves, gowns and instruments were removed after
tumor morcellation. Patients undergoing
laparoscopic surgery had their tumor removed
without an incision using morcellation, or
through a small incision. Patients undergoing
radical nephrectomy by an open, laparoscopic, or
laparoscopic assisted technique had similar
gender, age, performance status, tumor size, and
number of metastatic sites. Six patients had
laparoscopic ports placed and the tumor specimen
removed with morcellation. Five additional
patients did not undergo morcellation and had
their tumors removed intact.
47
Laparoscopic Radical Nephrectomy The year 1990
ushered in the minimally invasive management of
renal malignancy. Clayman and colleagues reported
the first laparoscopic radical nephrectomy for
suspected renal cell carcinoma. Over the last
decade, we have seen a rapid movement toward
minimally invasive surgery of the kidney. The
decreased perioperative morbidity, less pain, and
shorter hospitalization and convalescence have
primarily been responsible for this movement. As
surgeons seek to expand their surgical
armamentarium, we have seen the development of
Hand Assisted Laparoscopic techniques.
Indications for miminally invasive surgery have
also expanded to other indications such as
nephron sparing surgery. The mo st recent
direction of the minimally invasive movement has
been toward incorporating ablative technologies
such as cryoablation and Radiafrequency thermal
ablation into laparoscopic and even percutaneous
treatment of small renal lesions.
48
Laparoscopic Radical Nephrectomy The gold
standard for surgical management of T1 T3N0M0
RCC is the removal of the kidney and surrounding
tissues as originally described by Robson in the
1960s. Clayman and collegues applied
laparoscopic techniques to perform a laparoscopic
radical nephrectomy for suspected RCC in 1990.
The initial reports were met with some
skepticism, but now multiple institutions have
adopted the minimally invasive approach for the
treatment of RCC. There is a growing body of
evidence that demonstrates the safety and
efficacy of laparoscopic radical nephrectomy.
49
In 2001, Chan et al reported on 67 laparoscopic
nephrectomies performed for renal cell carcinoma.
The authors reported a 5 year disease free
survival of 95 for this series, despite at least
some degree of understaging in the laparoscopic
cases done with specimen morcellization. This was
consistent with earlier results from Ono (1999)
and Cadeddu (1998) demonstrating 97.5 and 91 5
year disease free survival rates. Portis et al
reported a multicenter experience with 64
patients undergoing laparoscopic radical
nephrectomy, comparing these cases to a series of
69 comparable open radical nephrectomy patients.
The authors noted excellent oncologic results
noting no positive margins in the laparoscopic
group, no port site or local recurrence. The
disease free survival overall was 92 in the
laparoscopic group (91 in the open cohort) and
cancer specific survival was 98 (laparoscopic)
vs. 92 (open). The laparoscopic group has
slightly smaller tumors but analysis of survival
by tumor size (gt or lt 7cm) demonstrated
comparable results in the open and laparoscopic
cohorts. All of these series continue to
demonstrate the acceptable morbidity, shorter
hospitalization, faster convalescence and less
pain associated with the laparoscopic vs. open
radical nephrectomy. With the emergence of 5 year
data demonstating excellent oncologic results,
the move toward minimally invasive surgery of the
kidney as first line therapy for T1 T2 renal
cell carcinoma appears justified.
50
Partial Nephrectomy Nephron sparing surgery
(NSS) is an accepted method of treatment for
selected renal masses. Long term results for
properly selected masses reveal oncologic control
comparable to the golden standard, radical
nephrectomy. Laparoscopic partial nephrectomy
(LPN), has been shown to be technically feasible
by several authors including Janetschek,
McDougall, Gill, Rassweiler, and others. The goal
of LPN is to maintain the principles of open NSS
in order to maintain the excellent oncologic
control associated with NSS. The challenge with
LPN is attainment of suitable hemostasis. The
indications for LPN are fairly straightforward.
The patient must be able to tolerate a
laparoscopic procedure. The properly selected
renal lesion should be less than 4cm in size and
peripheral in nature. Polar lesions are
preferable, especially early in the laparoscopic
surgeons experience with this technique. Renal
masses abutting the hilar vessels and central
collecting system can be safely resected by the
experienced surgeon. Patients with prior renal
surgery or history of anyinflammatory conditions
of the operative kidney should be avoided.
51
Survival with renal cell carcinoma
  • Factors affecting survival
  • Stage
  • Performance status
  • Pathology
  • Treatment given

52
Conclusions
  • Good prognostic models available
  • Assessment of prognosis important in choosing
    treatment
  • Palliative nephrectomy
  • Immunotherapy
  • Other palliative surgery
  • Previous therapy may influence anticipated
    survival
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