Genitourinary Cancer – 14
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for important points related to kidney cancer: 1. Many presenting now as incidental finding on a sonography done for some other reason. Results are excellent when treated at this stage. 2. Patients do not always present with classical symptoms of blood in urine or pain in abdomen. May present with other nonspecific symptoms. 3. Known risk factors include tobacco smoking, obesity. Kidney stones are NOT a risk factor. 4. Majority are histologically Renal Cell Carcinoma. Most patients with localized disease, in operable stage, do not need a biopsy. Partial or complete removal of kidney can be done without biopsy.
Can you tell us more about treatment?
Answer: Kidney cancer has excellent results in early stages, especially stage 1. Most of the time these are detected incidentally, as discussed last time. Surgery is curative in over 90% of these cases. In fact, results are so good that now most of these patients are treated by partial nephrectomy (removing part of kidney) rather than complete kidney removal. For decades, radical nephrectomy (removing whole kidney) has been the standard of care. Even today, only specialized centers practice partial nephrectomy. Partial nephrectomy has been shown to provide equivalent risk of cancer free survival, as radical surgery. However, partial surgery provides better kidney function in long term and less cardiovascular mortality. THIS IS IMPORTANT for our readers to know, since more and more patients now undergo sonography for various reasons, and thus small incidental tumors are detected more frequently. Large majority of these patients do not need complete kidney removal.
Stage 2, 3 tumors also have fairly good results with good surgery. Today, with improvement in surgical techniques and availability of good cardiovascular surgical teams, even patients with tumor extending in vena cava or atrium can be resected. Mortality of this procedure is higher, but at least it provides a fairly good chance of cure, compared to no surgery.
Routine lymph node dissection is not indicated. However, those with obvious enlarged nodes should have lymph nodes removed.
Que: What are the advances in surgery? Now that we have laparoscopic and robotic surgery available in our region, how much improvement in survival is seen with these techniques?
Ans: Good point. Yes these techniques are available, with some advantages. Unfortunately, they do NOT improve survival, compared with standard open surgery technique. That means it does not cure more patients, or does not prolong life more than what the open surgery provides. It is same. New techniques allow shorter hospital stay and a smaller incision. In fact, readers should know that it is more important to find a good, experienced surgeon, than a hospital who offers new techniques. Experience with new techniques is also critical, as improper use of these minimally invasive surgical techniques can actually lead to shorter life or less cure. This has been seen in multiple cancers, most recently published in October 2018 NEJM for cervix cancer. Two good studies showed less cure, less survival with laparoscopic or robotic surgery. NEJM is one of the top journals in world.
Thus it is important not to jump to a new technique of minimally invasive surgery, especially when it comes to cancer. For most other cancers too, these new techniques have been shown at best to be equivalent in survival, but not better. Again IMPORTANT FOR OUR READERS, as new techniques cost significantly more, frequently two to three times more than the standard open surgery.
Que: Can you comment on the role of observation for very small tumors?
Ans: Good question. Since a number of tumors are detected incidentally, frequently we come across cases where tumor is very small, such as about 1 cm or smaller. In general, these patients should also be operated with a partial nephrectomy. However if patient is very old or has serious comorbidities that make surgery high risk, observation is an option, with close monitoring by serial imaging. Some experts offer cryoablation or radiofrequency ablation to these patients. Also, it is important to remember that all small tumors are not malignant.
Que: What is the role of chemotherapy or other adjuvant therapy after surgery?
Ans: A number of studies have been done using interferon alpha, interleukin, and more recently sunitnib, sorafenib, pazopanib in this setting. Unfortunately, so far there is no good data to recommend any option strongly, even in high risk patients. One study, S-TRAC, with adjuvant sunitinib showed improvement in disease free survival but not overall survival. But another study, ASSURE, using same drug did not show even DFS improvement. Hence it remains controversial at best. It is also very expensive, and frequently not so well tolerated for such a long course. Chemotherapy in general is not too effective in kidney cancer. November 11th 2018.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org