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Management of T1 Kidney CancerLaparoscopic Surgery
Karim Touijer, MDKarim Touijer, MD
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Kidney Cancer is a Misnomer!!!Kidney Cancer is a Misnomer!!!
• Kidney cancer = is not a single disease
• Kidney cancer = Compendium of a number of different cancers that originate in the Kidney
• Each have a distinct: - Clinical course - Prognosis - Genetic background
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Clear cell type or Conventional
• Most common (75%) +++
• Aggressive ++
• Accounts for most metastatic cases
• Mutation in VHL gene
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Papillary Type 1
• 15% of kidney cancers
• Multifocal
• Bilateral
• Relatively low risk of Metastases
• Mutation of c-Met proto –oncogene on Chrs 7
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Papillary Type 2
• Aggressive +++
• Metastatic potential
• Mutation of the Fumarate Hydratase gene
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Chromophobe
• 5% of kidney cancers
• Less aggressive than conventional
• Could be associated to the Birt-Hogg-Dube
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Oncocytoma
• Benign• Metastases are rare
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Management of T1 RCC Management of T1 RCC - Ideal Scenario -- Ideal Scenario -
TreatmentTreatment
• Treat accordinglyTreat accordingly
DiagnosisDiagnosis
•Identify the histologic Identify the histologic subtypesubtype
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Management of T1 RCC Management of T1 RCC - Current Status -- Current Status -
Pathology (+++)Pathology (+++)
Specific HistotypeSpecific Histotype•H&EH&E
•ImmunohistochemistryImmunohistochemistry
•Genetic probesGenetic probes
TreatmentTreatment
Renal TumorRenal Tumor
•SurgerySurgery
Diagnosis (-)Diagnosis (-)
Renal TumorRenal Tumor•ImagingImaging
•Needle BiopsyNeedle Biopsy
•G250 scanG250 scan
•Vascular density on Vascular density on USUS
Tyrosine Kinase inhibitors for Tyrosine Kinase inhibitors for metastatic Clear Cell RCCmetastatic Clear Cell RCC
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Surgical Treatment of T1 RCCSurgical Treatment of T1 RCC
• Partial vs. radical NephrectomyPartial vs. radical Nephrectomy
• Laparoscopic vs. Open approachLaparoscopic vs. Open approach
• Investigative therapy
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Partial vs. Radical NephrectomyPartial vs. Radical Nephrectomy
• Whenever possible Partial Nephrectomy should be the preferred treatment.
• Comparable long-term cancer control
• Lesser risks of Chronic renal insufficiency and proteinuria
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Partial vs Radical NephrectomyPartial vs Radical Nephrectomy~ ~ Cancer ControlCancer Control ~ ~
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Partial vs Radical NephrectomyPartial vs Radical Nephrectomy~ ~ Cancer ControlCancer Control ~ ~
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Chronic Kidney DiseaseChronic Kidney Disease
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Chronic Kidney DiseaseChronic Kidney Disease
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Figure 2. Kaplan-Meier survival probabilities by operation typeFigure 2a. Freedom from new onset of GFR<60 Figure 2b. Freedom from new onset of GFR<45
Number at risk:287 134 62 23 11 6204 69 43 20 12
Number at risk:385 187 84 33 13 6262 130 86 56 33 21
ResultsNew Onset of GFR < 60
Solid: Partial Nephrectomy
Dashed: Radica1 Nephrectomy
Median Time to GFR < 60 RN: 18 monthsPN: Was not reached
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Laparoscopic vs OpenLaparoscopic vs Open
No Randomized Trial !?No Randomized Trial !?
• Cancer control
• Morbidity and Convalescence
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Oncologic Outcomes for T1 and T2 Oncologic Outcomes for T1 and T2 DiseaseDisease
LAPLAP
• 5 year cancer-specific survival for T1: 95% - 98%
• 5 year cancer-specific survival for T2: 92%
Portis et al. J Urol. 167:1257, 2002 Ono et al. J Urol. 169: 77, 2003
• Local recurrence rate up to 4.1%
OpenOpen
• 5 year cancer-specific survival for T1: 90%-95%
• 5 year cancer-specific survival for T2: 74%-88%
Tsui et al. J Urol. 163: 1090, 2000 Javidan et al. J urol. 162: 730, 1999
• Local recurrence for T1 and T2 is ~ 4%.
Lee et al. J Urol. 163: 730, 2000 Gogus et al. Urology 61: 926, 200
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Morbidity of Partial NephrectomyLap vs. open
• Review of the recent MSKCC experience
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Patient Characteristics
Open Laparoscopic p-value
n (%) 337 (90) 36 (10)
Age, years, mean (SD) 61 (13) 60 (11) 0.537
Gender Males (%) 204 (60) 27 (75)
Females (%) 133 (40) 9 (25)
Laterality Left 168 (50) 21 58 0.383
Right 169 (50) 15 42 0.289
Incidentally Detected (%) 278 (82) 27 (75) 1.0
Size, cm, mean (SD) 3.0 (1.5) 2.4 (1.0) 0.05
Location (%) Peripheral 161 (48) 18 (50) 0.118
Central 128 (38) 17 (47)
Missing 48 (14) 1 (3)
ASA Score>2 (%) 122 (36) 11 (31) 0.584
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Operative/Postop Data
Open Laparoscopic p-value
n (%) 337 (90) 36 (10)
Clamp (%) 291 (89) 34 (94) 0.559
Clamp Time, min, mean (SD) 38 (18) 37 (18) 0.760
OR Time, min, mean (SD) 162 (49) 249* (83) <0.001
EBL, cc, mean (SD) 403 (378) 343 (398) 0.367
Conversion to Radical nephrectomy (%) 31/390 (8) 3/41 (7) 1.00
Positive Margins (%) 13 (4) 2 (5) 0.138
Length of Stay, days mean (SD) 4.8 (2.4) 3.1 (1.9) <0.001
*Includes time for cystoscopy and stent placement
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Complications
• Laparoscopic group– 10 complications in 8 patients– 22% complication rate
• Open group– 80 complications in 69 patients– 20% complications rate
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Complication MSKCC Grading System
• Grade I: Oral medication or bedrest
• Grade II: IV therapy or thoracostomy tube
• Grade III: Intubation, interventional radiology, endoscopy or reoperation
• Grade IV: Major organ resection or chronic disability
• Grade V: Death
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Complications by Grade
Grade Open Laparoscopic
1 47 13.0% 5 13.9%
2 15 4.2% 1 2.8%
3 10 2.8% 2 5.6%
4 2 0.6% 0 0.0%
5 0 0.0% 0 0.0%
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Conclusions
Priorities in the management of T1 renalPriorities in the management of T1 renal
cell carcinoma are:cell carcinoma are:
1. Identifying the histotype at the time of Diagnosis +++
2. Using a partial nephrectomy as much as possible ++
3. Lap vs. Open: depending on the available skills