Editing CUA: Surgical Management of RCC (2014) (section)

===== '''Treatment options''' =====

* '''Stage T1aN0M0'''
** '''Partial nephrectomy recommended. This can be done via open/laparoscopic/robotic procedures.'''
*** '''EORTC 30904 was a multi-national trial randomizing 541 patients with tumours <5cm suspicious for RCC (and normal contralateral kidney) to RN vs. PN. Primary outcome was OS and CSS was a secondary outcome. In the intention to treat analysis, RN was associated with significant improvement in OS but not difference in CSS (only 2% of patients died of cancer). In the subgroup analysis of patients with RCC, associated for OS was extinguished. Cardiovascular deaths were less common in the RN group. RN favorable in terms of lower perioperative morbidity, while PN provided better renal functional outcomes.''' Numerous shortcomings of this study (such as premature study closure, trial designed as non-inferiority design but OS significance is based on superiority, patient comorbidity imbalances, cross-over, low statistical power, variable surgical technique and parenchymal sparing) have rendered its interpretation problematic.
*** While the impact of a positive surgical margin on subsequent disease outcome has not definitively been shown to adversely affect survival outcomes, a negative surgical margin is always the goal of any nephron-sparing procedure.
** '''Pure or robot-assisted laparoscopic partial nephrectomy with experienced surgeons (transperitoneal or retroperitoneal).'''
** '''Consider laparoscopic radical nephrectomy for tumours not amenable to partial nephrectomy.'''
** '''Consider probe ablation by radiofrequency (RFA) or cryotherapy in patients with high surgical risk. A biopsy should be obtained before or at the time of ablation.'''
*** Despite the lack of long-term recurrence and survival data, radiofrequency ablation (RFA) or cryotherapy performed either percutaneously under image guidance or laparoscopically, is a viable management option in patients with tumours less than 3 cm in diameter, with infrequent complications; they do, however, have a slightly higher risk of local recurrence compared to PN. Currently, patients considered for ablative approaches are those with severe medical comorbidities precluding surgical extirpation, or in patients with multiple bilateral lesions, possibly due to underlying genetic predispositions (Birt-Hogg-Dubé syndrome, Von Hippel-Lindau disease).
** '''Consider active surveillance in the elderly or infirm'''
*** The long-term safety of initial active surveillance with delayed treatment for progression is not yet established. However, it is an alternative for managing SRMs that are asymptomatic and characteristic of RCC on imaging in the elderly and/or comorbid. It is not yet recommended for the young and fit.
*** Patients must be counselled on the potential of systemic (1.1%) or local progression (12%) merits
*** Follow-up must include serial imaging
* '''Stage T1bN0M0'''
** '''PN (open/laparoscopic/robotic) in cases where technically feasible'''
** '''Laparoscopic RN should be offered if a PN is not feasible'''
** '''Open RN if laparoscopic surgery not possible.'''
** '''Ablative modalities are not recommended for these tumours due to the high rate of incomplete ablation in lesions greater than 4 cm'''
* '''Stage T2N0M0'''
** '''RN – open/laparoscopic/robotic'''
** '''PN – open/laparoscopic/robotic'''
*** '''The role of extended PN for tumours greater than 7 cm is controversial, and the consideration of such highly selected cases should be limited to experienced surgeons'''
* '''Stage T3'''
** '''Patients with tumours greater than 7 cm should raise suspicion of involvement of peri-renal tissues, such as Gerota’s fascia or renal sinus fat'''
** '''RN – open, laparoscopic or robotic assisted'''
*** '''Resection of vascular thrombus when applicable (usually open)'''
*** '''Resection of all gross disease including hilar or retroperitoneal extension'''
** '''PN may be attempted in highly selected cases by experienced surgeons'''
* '''IVC and renal vein thrombus'''
** '''In the presence or absence of distant metastases, tumour thrombus should be resected if technically feasible in appropriately selected patients'''
** '''It is recommended that these operations be performed in a centre with experience and with an availability of a multidisciplinary team as these complex procedures have significant risk of morbidity and mortality.'''
** '''Tumour thrombectomy with cytoreductive nephrectomy in the metastatic setting should be considered for all patients secondary to the poor outcome associated with untreated intravascular disease.'''