Active Surveillance (“Active Waiting”).
- There are neither objective criteria for selecting adequate patients nor a uniform definition for active surveillance.
- In patients with high comorbidity (serious concomitant diseases) and/or limited life expectancy, the small renal tumor (diameter ≤ 4 cm) can be monitored.In old age, tumors grow very slowly and tend not to metastasize. In such cases, needle biopsy (form of tissue sampling (biopsy)) should be performed primarily to. Despite radiological malignancy criteria, 20-30 % are benign tumors, so that surgery can be omitted. Approximately 60% are indolent (slow-growing) and 20% are aggressive carcinomas with higher metastatic potential. If tumor cells are detected, regular monitoring of the tumor is performed (renal sonography/ultrasound of the kidneys or even computed tomography, CT). Surgery should only be performed if the tumor is growing disproportionately fast and the risk of metastasis is increasing. This approach leads to the fact that surgery is avoided primarily, if necessary, or if necessary in the later course.
For cure, surgical resection should be performed in localized renal cell carcinoma. 1st order in renal cell carcinoma
- Partial kidney resection or partial nephrectomy (surgical removal of part of the kidney) possibly also a radiofrequency ablation (destruction of the tumor by intense heat) – especially for small tumors in stage I (T1 to max. 4 cm)Partial kidney resection is the therapeutic gold standard for localized renal cell carcinoma.
- Radical nephrectomy (complete removal of the affected kidney).
- Laparoscopic tumor nephrectomy (removal of the “tumor-bearing” kidney) – up to stage: T3, M0; also considered a standard procedureNote: In laparoscopic nephrectomy, intraoperative blood loss is less and inpatient stay is shorter than with open surgery.
- Radical tumor nephrectomy – for unfavorable tumor localization (tumor location) and extensive tumors, if necessary with lymphadenectomy (lymph node removal).
- Tumor-specific survival with total nephrectomy was described as 95.12% (laparoscopy) and 94.36% (open surgery), respectively.
- Adjuvant lymphadenectomy (lymph node removal):
- Systematic or extended lymphadenectomy during surgical therapy for renal cell carcinoma should not be performed if imaging and intraoperative findings are unremarkable.
- In patients with enlarged lymph nodes, lymphadenectomy may be performed for local staging and control (consensus-based recommendation; EC).
- Adrenalectomy (surgical removal of the adrenal gland) should not be performed if imaging and intraoperative findings are unremarkable.
- Renal tumor removal should be R0 resection (removal of the tumor in healthy tissue; no tumor tissue is detectable in the resection margin on histopathology).
Further notes
- Patients who underwent radical or partial nephrectomy for T1-2Nx/N0M0 renal cell carcinoma (RCC) between 1970 and 2010 were analyzed: For RCC with a maximum diameter of 3 cm, the rates of progression-free and cancer-specific 10-year survival were 93-95% and 97-99%, respectively; beyond this threshold, these rates were 91% and 95%, respectively.
- Partial renal resection or partial nephrectomy (surgical removal of part of the kidney; nephron-sparing approach) for localized renal cell carcinoma (T1a tumor) has reduced progression to stage 3 chronic kidney disease.
- The state of the tumor pseudocapsule after renal surgery provides information about the likely course of the disease (esp. in patients with localized renal cell carcinoma); rate of progression-free survival (…) over eight years in relation to a pseudocapsule:
- Grade 0: completely intact. (85 %)
- Grade I: collapse without breakthrough (81%).
- Grade II: completely breached (63%)
- Absence of pseudocapsule (43%)
In case of metastasis
- A comprehensive analysis of findings from the U.S. National Cancer Database demonstrated that patients with metastatic renal cell carcinoma who received “targeted therapy” (immunotherapy) lived longer if they also underwent cytoreductive nephrectomy (cytoreductive, i.e., removal of a majority of tumor masses (lowering tumor burden) to target; nephrectomy: surgical removal of a kidney). Median overall survival was consistently significantly longer in the group with surgery at the first, second, third, and later years: compared with the group of patients without surgery:
- 1st year: 62.7% vs. 34.7
- 2nd year: 39.1% vs. 17.1
- 3rd year and later: 27.7% vs. 9.8
- Cytoreductive nephrectomy in the metastatic stage is a treatment option in patients in good general health.
- Even in metastatic renal cell carcinoma (hypernephroma), a cure is possible in principle; in such cases, tumor extirpation is performed first and metastases (daughter tumors) are removed in a second operation (metasectomy).
- Requirements for metastasectomy (surgical removal of metastases):
- The primary tumor should be under control.
- Further extrathoracic (outside the chest) metastasis after interdisciplinary consultation.
- Metastases must be completely resectable (surgically removable, with prospect of cure or improvement).
- The general and functional surgical risk must be acceptable.
- Resectable pulmonary metastases should be resected with systematic lymph node dissection because of frequent lymphogenic metastasis.
- A phase III trial demonstrated noninferiority of sunitinib (tyrosine kinase inhibitor; 50 mg/d in cycles for four weeks followed by 14-day breaks) alone in patients with metastatic clear cell renal cell carcinoma and a moderate to poor prognosis: Median survival was 18.4 months in the group without and 13.9 months in the group with nephrectomy.
