Wednesday, September 26, 2012

Renal Cell Carcinoma - A Reappraisal part 7


Treatment Modalities

The treatment options for RCC are surgery, radiation therapy (palliative), targeted therapy (bevacizumab, sumitinib, sorafenib, everolimus, temsirolimus), biological therapy (immunotherapy), and combinations of these (Campbell & Lane, 2012). Surgical resection can be curative in patients who present with localized RCC. Unfortunately, most RCCs are asymptomatic for most of their natural history. Therefore, the diagnosis is frequently made when the disease has progressed locally to the extent where it cannot be resected or has already metastasized.
Historically, radical nephrectomy (removal of kidney, ipsilateral adrenal gland, and Gerota's fascia) was advocated for the surgical treatment of RCC. Nephronsparing surgery was indicated for those with a solitary kidney, those at risk for inheritable forms of RCC (such as VHL), or patients with baseline or at risk for renal insufficiency (such as with diabetes mellitus). However, the current trend is to consider nephron-sparing surgical procedures when the lesion is amenable.
The role of adrenalectomy at the time of nephrectomy has also been questioned. In a review of 351 patients who underwent radical nephrectomy from 1998 to 2008, Tsui et al. (2000) concluded that adrenal involvement is not likely with localized early stage RCC, and thus, adrenalectomy is not necessary, particularly when the CT scan is negative. In patients with large and upper pole tumors, the risk of adrenal involvement is greater, and ipsilateral adrenalectomy should be performed; all 10 patients with ipsilateral adrenal metastases in the aforementioned review had upper pole tumors (8) and/or large renal masses (2) (Tsui et al., 2000).
For patients with Stage I or Stage II disease, surgery is usually curative. Surgical options include either a radical or partial nephrectomy for T1 (≤ 7 cm) lesions. Recently, there has been a paradigm shift in the treatment of such tumors from radical nephrectomies to more nephronsparing approaches. Numerous studies have shown that patients who have small tumors (< 4 cm) with a healthy contralateral kidney treated with partial nephrectomy will have much higher likelihood of maintaining an acceptable glomerular filtration rate (GFR) over 45 ml/minute when compared to radical nephrectomy patients (36% vs. 5%) (Huang et al., 2006). Survival was better for patients undergoing partial nephrectomy compared to patients treated with radical nephrectomy (85% vs. 78%) for tumors between 4 to 7 cm (p = 0.01). This increased survival is likely attributable to better renal function in patients with partial nephrectomy (Weight et al., 2010).
Other nephron-sparing approaches, such as radiofrequency ablation, cryoablation, and even active surveillance, may be acceptable alternatives to radical nephrectomy for carefully selected patients who are compliant with regular follow-up visits. For patients with Stage III (> 7 cm) primary lesions, however, radical nephrectomy is the standard of care. Guidelines developed by an AUA panel exist for the management of the clinical Stage 1 renal mass (AUA, 2009).
Laparoscopic nephrectomy, hand-assisted laparoscopic nephrec tomy, and robotic-assisted nephrectomy are less invasive procedures than the traditional open radical nephrectomy and are reasonable alternatives to open radical nephrectomy in T1 and T2 tumors. These procedures incur less morbidity, and are associated with less blood loss and a shorter recovery time (Burgess et al., 2007). Disadvantages include higher costs along with the technically demanding aspect of these procedures. Partial nephrectomy is traditionally performed in an open fashion. However, in an attempt to decrease the associated morbidity, this surgery is increasingly being performed laparoscopically or with robotic-assisted laparoscopy by skilled surgeons.
Patients faced with treatment choices regarding management of RCC look to the urologist and urology staff for guidance in selecting the most appropriate treatment. The patient and his or her family may have questions after the initial office visit that can often be addressed in a timely fashion by a knowledgeable nurse. This often decreases the patient's anxiety and allows the patient to further understand recommendations made by the urologist. Informed choice is important, and nursing staff play a critical role in ensuring that the patient understands the information being presented and the risks and benefits of the treatment selected.

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