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An 84-year-old woman who underwent renal biopsy for a right upper pole enhancing 4.3 cm renal mass is considering her surgical options.
The mass has demonstrated rapid growth kinetics (8 mm growth in six months) and biopsy revealed clear cell renal cell carcinoma with associated necrosis.
The patient enjoys excellent performance status, but has history of TIA, hypertension, rheumatoid arthritis, bradycardia requiring pacemaker, and an open cholecystectomy with concomitant bowel resection (numerous intraperitoneal metallic clips are evident on the CT scan). The patient’s renal function is excellent with a creatinine of 0.8 mg/dL and a calculated GFR (using MDRD) of 73 mL/min/1.73m2.
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Decisions regarding renal surgery in the elderly are complex. The urologist must balance immediate risks of surgery against potential delayed benefits of a nephron-sparing operation.
Risks of partial nephrectomy for moderate and high anatomic complexity renal masses are non-trivial1, while the EORTC 30904 prospective randomized trial of patients with normal contralateral kidney (while admittedly flawed) failed to show an overall survival benefit with partial nephrectomy.2
In fact, significant debate regarding the optimal approach to a patient such as this exists in the literature.3-5 While focal therapy is not an ideal option for this patient,6 previous abdominal surgery should not prohibit a minimally-invasive approach.7
Thus, this elderly individual with a normal contralateral renal unit who is not a candidate for active surveillance because of rapid tumor growth kinetics underwent an uneventful retroperitoneoscopic laparoscopic radical nephrectomy.
Answer: Thoughtful discussion regarding tradeoffs between radical vs. nephron-sparing and laparoscopic vs. open approaches
This case was prepared by Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia.
References
- Simhan J, Smaldone MC, Tsai KJ, et al. Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy. Eur Urol 2011;60:724-730.
- Van Poppel H. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur. Urol 2011;59:543-552.
- Kutikov A, Smaldone MC, Egleston BL, Uzzo RG. Should partial nephrectomy be offered to all patients whenever technically feasible? Eur Urol 2012;61:732-734; discussion 734-735.
- Tan HJ, Norton EC, Ye Z, Hafez KS, et al. Long-term survival following partial vs radical nephrectomy among older patients with early-stage kidney cancer. JAMA 2012;307:1629-1635.
- Smaldone MC, Egleston B, Uzzo RG, Kutikov A. Does partial nephrectomy result in a durable overall survival benefit in the medicare population? J Urol 2012;188:2089-2094.
- Long CJ, Canter DJ, Smaldone MC, et al. Role of tumor location in selecting patients for percutaneous versus surgical cryoablation of renal masses. Can J Urol 2012;19:6417-6422.
- Viterbo R, Greenberg RE, Al-Saleem T, Uzzo RG. Prior abdominal surgery and radiation do not complicate the retroperitoneoscopic approach to the kidney or adrenal gland. J Urol 2005;174:446-450.
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