Management of T1 Kidney Cancer Laparoscopic Surgery

1. Management of T1 Kidney CancerLaparoscopic Surgery Karim Touijer, MD

2. 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

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

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

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

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

7. Benign Metastases are rare Oncocytoma

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

9. 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

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

11. 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

12. Partial vs Radical Nephrectomy~ Cancer Control ~

13. Partial vs Radical Nephrectomy~ Cancer Control ~

14. Chronic Kidney Disease

15. Chronic Kidney Disease

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

17. Laparoscopic vs OpenNo Randomized Trial !? • Cancer control • Morbidity and Convalescence

18. 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 forT2: 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 Oncologic Outcomes for T1 and T2 Disease

19. Morbidity of Partial NephrectomyLap vs. open • Review of the recent MSKCC experience

20. Patient Characteristics

21. Operative/Postop Data *Includes time for cystoscopy and stent placement

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

23. 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

24. Complications by Grade

25. 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