Management of T1 Kidney Cancer Laparoscopic Surgery Karim Touijer, MD

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

Clear cell type or Conventional Most common (75%) +++ Aggressive ++ Accounts for most metastatic cases Mutation in VHL gene

Papillary Type 1 15% of kidney cancers Multifocal Bilateral Relatively low risk of Metastases Mutation of c-Met proto –oncogene on Chrs 7

Papillary Type 2 Aggressive +++ Metastatic potential Mutation of the Fumarate Hydratase gene

Chromophobe 5% of kidney cancers Less aggressive than conventional Could be associated to the Birt-Hogg-Dube

Oncocytoma Benign Metastases are rare

Management of T1 RCC - Ideal Scenario - Diagnosis Identify the histologic subtype Treatment Treat accordingly

Management of T1 RCC - Current Status - Diagnosis (-) Renal Tumor Imaging Needle Biopsy G250 scan Vascular density on US Treatment Renal Tumor Surgery Pathology (+++) Specific Histotype H&E Immunohistochemistry Genetic probes Tyrosine Kinase inhibitors for metastatic Clear Cell RCC

Surgical Treatment of T1 RCC Partial vs. radical Nephrectomy Laparoscopic vs. Open approach Investigative therapy

Partial 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

Partial vs Radical Nephrectomy ~ Cancer Control ~

Partial vs Radical Nephrectomy ~ Cancer Control ~

Chronic Kidney Disease

Chronic Kidney Disease

Results New Onset of GFR < 60 Median Time to GFR < 60 RN: 18 months PN: Was not reached Solid: Partial Nephrectomy Dashed: Radica1 Nephrectomy

Laparoscopic vs Open No Randomized Trial !? Cancer control Morbidity and Convalescence

Oncologic Outcomes for T1 and T2 Disease LAP 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% Open 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

Morbidity of Partial Nephrectomy Lap vs. open Review of the recent MSKCC experience

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 15 42 0.289 Incidentally Detected (%) 278 (82) 1.0 Size, cm, mean (SD) 3.0 (1.5) 2.4 (1.0) 0.05 Location (%) Peripheral 161 (48) 18 0.118 Central 128 (38) 17 (47) Missing 48 (14) 1 (3) ASA Score>2 (%) 122 (36) 11 (31) 0.584

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 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) *Includes time for cystoscopy and stent placement

Complications Laparoscopic group Open group 10 complications in 8 patients 22% complication rate Open group 80 complications in 69 patients 20% complications rate

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

Complications by Grade Open Laparoscopic 1 47 13.0% 5 13.9% 2 15 4.2% 2.8% 3 10 5.6% 4 0.6% 0.0%

Priorities in the management of T1 renal Conclusions Priorities in the management of T1 renal cell carcinoma are: Identifying the histotype at the time of Diagnosis +++ Using a partial nephrectomy as much as possible ++ Lap vs. Open: depending on the available skills