The Surgical Management of RCC From Robson to Radiofrequency - - PowerPoint PPT Presentation

The Surgical Management of RCC

From Robson to Radiofrequency Ablation f q y Tony Finelli, MD, MSc, FRCSC

University Health Network y University of Toronto

Backgro nd Background

• Renal cell carcinoma

(RCC) is 9th most (RCC) is 9 most common malignancy

• 4600 new cases/yr (Can )
• 4600 new cases/yr. (Can.)

700+ s rgeries/ r

• ~ 700+ surgeries/yr.

(Ontario)

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%;
• local 60–70%; regional 15–20%;
• metastatic 15–20%
• Common symptoms:
• Hematuria (50%)
• Weakness (28%)
• Weight loss (28%)

g ( %)

• Anemia (21%)
• Fever (7%)
• Paraneoplastic syndromes (up to 25%)

1. Canadian Cancer Stats, 2006. Available at: http://www.cancer.ca. 2. Cavalli F, Hansen HH, Kaye SB, eds. Textbook of Medical Oncology. 3rd ed. London, UK: Martin Dunitz; 2004:221-226.

Paraneoplastic syndromes (up to 25%)

RCC Staging:

Stage I Tumor < 7 cm in greatest dimension and 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 i l 59% 5-year survival, 59% Stage IV Tumor beyond Gerota’s fascia or

Cohen HT, McGovern FJ. N Engl J Med. 2005;353:2477-2490.

Tumor beyond Gerota’s fascia or > 1 regional lymph node involved; 5-year survival, 20%

Localized RCC – TNM (2002) ( )

Surgery for Kidney Cancer

Robson, Churchill, Anderson Robson, Churchill, Anderson J Urol 1969;101;297 J Urol 1969;101;297 301 301 J Urol 1969;101;297 J Urol 1969;101;297-301 301

Conventional Nephrectomy

Large Flank Incision

Partial Nephrectomy

Novick Stewart Straffon Novick Stewart Straffon Novick, Stewart, Straffon Novick, Stewart, Straffon J Urol 1977;118;932 J Urol 1977;118;932

Open Partial Nephrectomy

• 1981 marked the beginning of the elective

1981 marked the beginning of the elective NSS era

• Licht and Novick (1993)

241 f l i NSS – 241 cases of elective NSS – Early evidence of oncologic efficacy

Open Partial Nephrectomy

• Fergany, Hafez, and Novick (1999)

– 10 yr. followup after elective NSS – Equivalent to oncologic results to radical Equivalent to oncologic results to radical nephrectomy for tumours < 4 cm

Expanding Indications for Elective p g Partial Nephrectomy

Elective Partial Nephrectomy: T 4 7 Tumours 4 – 7 cm

• Retrospective review of NSS and RN for
• Retrospective review of NSS and RN for

tumors 4 -7 cm at the Mayo Clinic

• Results:
• Results:

– After adjusting for stage, grade, necrosis, type: – 5 yr cancer specific survival was similar 5 yr. cancer specific survival was similar – 5 yr. metastases-free survival equivalent – Local recurrence no different for < 4 or 4 -7 cm Local recurrence no different for < 4 or 4 7 cm

• Elective NSS can be applied to tumors 4 -7

cm especially if exophytic cm especially if exophytic

Contemporary Complication Rates with Open Partial Nephrectomy

Contemporary Complication Rates with Open Partial Nephrectomy

• 1985 to 2001 (compare ’85-95, ’96-01)
• N = 823 open NSS

N 823 open NSS

• Intraop blood loss (550 v. 350cc, p<0.001)

CRF (14 6 8 1% 0 003)

• CRF (14.6 v 8.1%, p=0.003)
• Early comp (13.4 v 6.9%, p=0.002)
• Late comp (32.4 v 24.6%, p=0.014)

Emerging Data on L R l F i 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/1.73m2

Long-term Renal Function g

• 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

di t f CRF predictor of CRF

• Median time to GFR < 60 was 18 months for

RN t h d f PN RN, not reached for PN

• No patient in this cohort has gone on to dialysis

Is partial nephrectomy underutilized? Is partial nephrectomy underutilized?

l

1988 2001

J Urol, Mar. 2006

• 1988 – 2001
• SEER database review
• N = 14,647 (primary tumour < 7 cm)

Tumours < 2 cm

Tumours 2 – 4 cm

Is partial nephrectomy underutilized? O i Ontario

1995 – 1998 Partial Nx 166 (5.7) Radical Nx 2743 (94.3) ( ) 1999 – 2002 Partial Nx 345 (10.1) ( ) Radical Nx 3078 (89.9) 2003 – 2007* Partial Nx 284 (14.1) Radical Nx 1731 (85.9)

Abouassaly et al. (unpublished)

Laparoscopic Radical Nephrectomy p p p y

Flank B lge Flank Bulge

Chatterjee et al., Urol Onc 22: 36-9. (2004)

• Historically 3%
• N=70 (1996 – 2000)

N 70 (1996 2000)

• 50% of patients reported a flank bulge

24% i d d bl fl k i

• 24% experienced durable flank pain
• Median pain magnitude = 5/10
• Pain persisted greater than 1 year
• Impacted QOL especially in those < 60 yrs

Impacted QOL, especially in those < 60 yrs.

Flank B lge Flank Bulge

Y hi t l J U l (169) 182 5 J 2003 Yoshimura et al., J Urol (169): 182-5, Jan 2003

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

Laparoscopic Radical Nephrectomy

• Diminished:

– postoperative pain, analgesic requirement – length of hospital stay and convalescence

• Equivalent:

q

– Rate of complications* – Blood loss* – Surgical time* – Oncologic results

Laparoscopic Radical Nephrectomy p p p y

Transperitoneal

Port Placement (Left) Port Placement (Left)

Left Renal Hilar Dissection

LAPAROSCOPIC RADICAL NEPHRECTOMY

Specimen Extraction

Evidence Supporting LRN Evidence Supporting LRN

Equal cancer-specific outcomes for 3 years.

Portis et al.

LRN Oncologic O tcomes LRN – Oncologic Outcomes

P ti t l J U l (167) 1257 62 M 2002 Portis et al., J Urol (167): 1257-62, Mar 2002

LRN – Tumours > 7cm

St i b Fi lli D i t l J U l (172) 2172 6 D 2004 Steinberg, Finelli, Desai et al, J Urol (172):2172-6, Dec 2004

LRN – Oncologic Outcomes g

pT2-3b RCC

Stage Specific Survival g p

1.0 .8

Survival

.6 .4

STAGE

pT3b .2 pT3a pT2

Months From Nephrectomy

84 72 60 48 36 24 12 0.0

Finelli et al. (unpublished)

Laparoscopic Cytoreductive Nephrectomy

Laparoscopic Cytoreductive Laparoscopic Cytoreductive N h t N h t Nephrectomy Nephrectomy

Laparoscopic Cytoreductive Laparoscopic Cytoreductive N h t N h t Nephrectomy Nephrectomy

Conclusions

• LRN has been performed for > 10 years
• Oncologic outcomes equivalent

Oncologic outcomes equivalent

• Diminished morbidity

I di i di

• Indications are expanding
• Caution in selecting patients

LRN LRN

• Standard of care for T2 RCC in the

Standard of care for T2 RCC in the absence of imperative indications for NSS NSS

• Caution:

– Large hilar tumour – Hilar adenopathy – > 12 cm – Multiple parasitic vessels p p

LAPAROSCOPIC PARTIAL LAPAROSCOPIC PARTIAL LAPAROSCOPIC PARTIAL LAPAROSCOPIC PARTIAL NEPHRECTOMY NEPHRECTOMY

Laparoscopic Partial Nephrectomy p p p y

L i i l h i 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

Laparoscopic Partial Nephrectomy p p p y RETROSPECTIVE COMPARISON

J Urol 170:64 J Urol 170:64-

• 8, July 2003

8, July 2003

Laparoscopy vs. Open (n=200) Laparoscopy vs. Open (n=200)

• 33% had > 1 complication
• Overall 18% had a urologic complication

Overall 18% had a urologic complication

• Hemorrhage – 9.5% (3.5, 2, and 4%)

i l k 4 %

• Urine leak – 4.5%
• Open conversion – 1%
• Reoperation – 2%

Oncologic Outcomes

• N = 100
• Mean tumour size – 3.1 cm

Mean tumour size 3.1 cm

• Mean WIT – 27 minutes

2 iti i ( t RCC)

• 2 positive margins (oncocytoma, RCC)
• Median f/u – 42 months

– 86 % survival, 100% cancer specific survival

Laparoscopic Partial Laparoscopic Partial Nephrectomy

Laparoscopic Partial Nephrectomy Laparoscopic Partial Nephrectomy

• The most demanding laparoscopic procedure
• Potential for hemorrhage

g

• Time pressure of warm ischemia
• Requires complete comfort with lap
• Requires complete comfort with lap
• Must master suturing angles
• Set-up is critical
• Requires efficient intracorporeal suturing

Laparoscopic Partial Nephrectom Laparoscopic Partial Nephrectomy

• Initially LPN was applied to:

Small tumours – Small tumours – Solid tumours E h ti t – Exophytic tumours – In the setting of two kidneys

Expanding the Application of i i l h Laparoscopic Partial Nephrectomy

Laparoscopic Heminephrectomy for Tumor

Finelli et al. Urol 2005

Laparoscopic Partial Nephrectomy for Laparoscopic Partial Nephrectomy for Centrally Located Renal Tumors

Frank et al J Urol 2006 Frank et al. J Urol 2006

Laparoscopic Partial Nephrectomy for p p p y Hilar Tumors

Gill et al., J Urol 2005

Laparoscopic Partial Nephrectomy in Solitary Kidney Solitary Kidney

Gill et al. J Urol 2006

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

CRYOABLATION CRYOABLATION CRYOABLATION CRYOABLATION

Renal Cryoablation Renal Cryoablation

Resurgence of visceral cryosurgery: Resurgence of visceral cryosurgery:

• Improved cryo delivery systems: N Argon
• Improved cryo-delivery systems: N2, Argon
• Superior intraoperative (ultrasound/MRI)
• Superior intraoperative (ultrasound/MRI)

and postoperative (MRI) imaging systems

LAPAROSCOPIC RENAL CRYOABLATION CRYOABLATION

CLEVELAND CLINIC EXPERIENCE

• Total No. Cases: 150+
• 56 patients (60 tumors) completed min. 3 yrs f/u
• Mean patient age:

65 years

• Mean tumor size:

2 3 cm

• Mean tumor size:

2.3 cm

• No. Solitary kidneys:

11 (20%)

Laparoscopic Renal Cryoablation

FOLLOW UP FOLLOW-UP

RADIOLOGIC

MRI

RADIOLOGIC

MRI

RADIOLOGIC :

MRI

• day 1

th 3

RADIOLOGIC :

MRI

• day 1

th 3

• month 3
• month 6
• month 12
• month 3
• month 6
• month 12
• month 12
• annual MRI , CXR
• month 12
• annual MRI , CXR

HISTOLOGY:

CT guided needle biopsy: month 6

HISTOLOGY:

CT guided needle biopsy: month 6 CT guided needle biopsy: month 6 CT guided needle biopsy: month 6

Laparoscopic Renal Cyoablation

RADIOLOGIC FOLLOW UP

Lesion Size on MRI

RADIOLOGIC FOLLOW-UP

% Reduction % Reduction Actual size Actual size

• Day 1

Day 1

• 3.6 cm

3.6 cm

• Month 3

Month 3 26% 26% 2.8 cm 2.8 cm

• Month 6

Month 6 39% 39% 2.3 cm 2.3 cm

• Month 12

Month 12 56% 56% 1.7 cm 1.7 cm

• Month 24

Month 24 69% 69% 1.2 cm 1.2 cm

• Month 36

Month 36 75% 75% 0.9 cm 0.9 cm 17 (38%) cryolesions undetectable at 3rd year MRI 17 (38%) cryolesions undetectable at 3rd year MRI 17 (38%) cryolesions undetectable at 3rd year MRI 17 (38%) cryolesions undetectable at 3rd year MRI

Laparoscopic Renal Cryoablation

P t ti MRI I i

Preoperative Preoperative Preoperative Preoperative

Post-operative MRI Imaging

Preoperative Preoperative Preoperative Preoperative 24 hours post 24 hours post-

• op
• p

24 hours post 24 hours post-

• op
• p

3 months post 3 months post-

• op
• p

3 months post 3 months post-

• op
• p

LAPAROSCOPIC RENAL CRYOABLATION CRYOABLATION

FOLLOW-UP BIOPSY (n=56)

• 39 patients (70%) had a CT - guided core
• 39 patients (70%) had a CT - guided core

needle biopsy 6 months postoperatively

• 2 positive biopsies (RCC Radical nx)

LAPAROSCOPIC RENAL CRYOABLATION CRYOABLATION

Summary Summary

• 56 Patients with minimum 3 year followup
• 56 Patients with minimum 3 year followup
• Renal cryolesions decreased in size by 75%
• Renal cryolesions decreased in size by 75%
• Completely disappeared in 38%
• Completely disappeared in 38%

LAPAROSCOPIC RENAL CRYOABLATION

Summary Summary

• Locally persistent / recurrent cancer 3.6%
• Overall survival 89%
• Cancer-specific survival 100%

Summary of Cryoablation

Reference N Age Tumor Biopsy Approach Follow-up Failure (%) Complications R d i 7 63 2 2 71% RCC L /O 14 2 0 (0) l i th b

Summary of Cryoablation

Rodriquez Urol 2000 7 63 2.2 71% RCC (29% -ve) Lap/Open 14.2 0 (0) pelvic thrombus CVA Shingleton J Urol 2001 20 58 3.0 NA MRI 9.1 1 (5) abscess Nadler J Urol 2003 15 69 2.2 67% RCC (13% -ve) Lap 15 1 (6.7) resp failure ileus Lee 20 NA NA 55% RCC Lap 14.2 1 (5) pancreatic injury Urol 2003 (25% -ve) p ( ) p j y Cestari J Urol 2004 37 64 2.6 78% RCC (5% -ve) Lap 20.5 1 (2.7) UPJO renal # Gill J Urol 2005 56 65 2.3 64% RCC (36% -ve) Lap 36 2 (3.6) nil Lawatsch J Urol 2006 59 62 2.5 63% RCC (10% ve) Lap 26.8 2 (3.4)

• pen conversion,

nephrectomy, MI

J Urol 2006 (10% -ve) TOTAL 230 8 (3.5)

RADIOFREQUENCY ABLATION RADIOFREQUENCY ABLATION Q (RFA) (RFA)

Impedance and Power Monitoring

RF Ablation with Infusion RF Ablation with Infusion

A T T A A T

A = Active electrode

T

T = Passive Temperature probes = Infusion conduction

RFA

• Outpatient procedure

Outpatient procedure

• IV sedation and local

anesthetic

• CT guidance
• Radiologist +/-

Radiologist +/ Urologist present

Clinical RFA Concerns Clinical RFA- Concerns

• Michaels et al, J Urol 168:2406, 2002

Residual viable cells seen in all 20 tumors undergoing i l h f RFA

• pen partial nephrectomy after RFA
• Rendon et al J Urol 167:1592:2002**
• 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

• 7 Institutions (616 patients)
• Residual or recurrent disease

– RFA – 13.4% – Cryoablation – 3.9%

• 70% were detected in first 3 months
• 70% were detected in first 3 months
• Salvage ablation – 4.2% failure

Summary of RFA

Reference N Age Tumor Biopsy Approach Follow-up Failure (%) Complications Rendon J Urol 2002 10 NA 2.4 NA

• pen, US,

CT NA 8 (80) liver infarct Michaels 15 NA 2.4 90% RCC

• pen, US

NA 4 (27) thermal injury J Urol 2002 calyceal leaks Matlaga J Urol 2002 10 NA 3.2 100% RCC

• pen, US

NA 2 (20) Roy-Choudury 8 73 3.0 NA US, CT 17.1 1 (12) renal infarcts AJR 2003 psoas injury Mayo-Smith AJR 2003 32 76 2.6 44% RCC (44% -ve) US, CT 9 2 (6) hematomas probe site met Hwang 17 38 2.3 NA lap, US, 12.7 1 (6) UPJO J Urol 2004 CT Lewin Rad 2004 10 70 2.3 67% RCC (11% -ve) MRI 25 0 (0) hematomas Zagoria 22 70 3.5 75% RCC CT 7 2 (9) pneumothorax g AJR 2004 (15% -ve) ( ) p hematoma Varkarakis J Urol 05 46 64 NA 57% RCC (34% -ve) CT 27.5 3 (7) aspiration/death 16 minor Gervais 85 70 3.2 90% RCC US, CT 27.6 8 (9) hemorrhages AJR 2005 85 3 90% CC US, C 6 8 (9) e

• ages

ureter stricture TOTAL 254 23 (9)

Epidemiology Epidemiology

I i i id f RCC ld id

• Increasing incidence of RCC worldwide

with only modest increase in mortality.

6 3 t 9 1 100 000 f 1975 t 1995 – 6.3 to 9.1 per 100,000 from 1975 to 1995

O t 30 i i t ti

• Over past 30 yrs., increase in asymptomatic

cases from 10% to 57%.

• Usually smaller, low stage and low grade.

Localized RCC – TNM (2002) ( )

Natural History of SRMs

J Urol, 175:425, 2006

• 10 reports (9 institutions)
• 6 – 40 patients (mean 25/series)

6 40 patients (mean 25/series)

• Mean followup: 30 months (25 – 39 months)

i 2 6

• Means tumor size: 2.6 cm
• Mean growth rate: 0.28 cm/year
• Path available in 46%, confirmed RCC in 92%

Natural History of Small Renal Tumors

Year (n )

• Prosp. or

Retro. Growth rate Follow up (months) Remarks Bosniak 1995 40 R 0.36cm/yr No mets Takebayas hi et al 2000 17 P 0.7- 17.34 cm3 25 median 65% <1yr doubling Rendon et 2000 13 P 1 32cm/yr Rendon et al 2000 13 P 1.32cm/yr Oda 2001/ 2003 16 R 0.10- 1.35 cm/ yr PI/AI ratio Yamada 2002 17 R 26-157 median 100% 10 yr survival Volpe et al 2004 32 P 0.005- 0.2 / 27.9 No

i

cm/yr

progression

Kassouf 2004 24 R 0.49cm/ yr 24 & 31.6 median No mets Kato 2004 18 R 0 42cm/ yr 22 5 AI & Kato 2004 18 R 0.42cm/ yr 22.5 median AI & grade

Meta-analysis – Natural History

C bi d Combined

Rationale for Active Surveillance

• Most tumors now diagnosed at < 3 - 4 cm

at o a e o ct ve Su ve a ce

Most tumors now diagnosed at < 3 - 4 cm

• 20 - 40% are benign

20 - 40% are benign

• Most small tumors grow slowly

Most small tumors grow slowly

• Good treatment results are therefore biased by

Good treatment results are therefore biased by benign tumours and the “benign” behaviour of small tumors small tumors

Conclusions Conclusions

• Surgery is the cornerstone of management in

RCC RCC

• Localized tumours, especially T1a, carry an

excellent prognosis regardless of treatment used

• The majority renal tumours can be managed

with minimally invasive techniques y q

• Larger and advanced tumours require

conventional surgery as described by Robson conventional surgery as described by Robson

Acknowledgements Acknowledgements

CCF

PMH

• Inderbir Gill, MD
• Andrew Novick, MD

PMH

• Neil Fleshner, MD
• Michael Jewett MD

d ew Nov c , Michael Jewett, MD

• Michael Robinette, MD
• John Trachtenberg
• John Trachtenberg,

MD