The discussion was around renal masses that are solid and less than 4cm in size. Surgery gives excellent outcomes, but the question is whether the lesions justify an operation. The AUA guidelines suggest that outcomes are similar with active treatment approaches. Kidney cancer is a heterogeneous disease with up to one-third being benign disease. A biopsy of the small renal mass can help to identify histology and tumor grade. It is best characterized with a needle core biopsy rather than fine needle aspiration. Overall the diagnostic rate is over 80%. He felt that use of a biopsy facilitates use of active surveillance, although the triggers for intervention are not well defined. Growth is most commonly used.
Dr. Jeff Cadeddu argued for ablation. He stated that it is an alternative to surveillance or surgery. It is well established that cryotherapy and ablation have low morbidity. However there is a higher local recurrence rate in ablated tumors. This does depend on size and for tumors <2.5cm, there is a 99% recurrence-free rate at 3 years. However, for 2.5-3.0cm it is 88% and for >3cm it is 78%. The 5-year metastasis-free rate is 95% with ablation. With cryoablation, in 66 patients the eGFR was unchanged, suggesting it is nephron preserving. Regarding costs, ablation technology applied percutaneously is less expensive, about $3,000 less than surgery. Compared to surveillance there is cost of imaging and biopsies, but the analysis has never been done.
Dr. Paul Russo argued for surgery. He stated that surgery is one tool in the armamentarium of treatment options to be integrated with surveillance and ablation. One problem with ablation is the post procedure imaging is non-specific and operating on ablation tumors is tough surgery. Most patients with renal cancer already have intrinsic renal disease. The reason is unclear. He showed data from MSKCC that partial nephrectomy continues to rise while use of radical nephrectomy is declining. Laparoscopic or open partial is fine, depending on the skill level of the surgeon. However, do not perform a radical nephrectomy in a patient who is a candidate for partial nephrectomy, he concluded.
Ablation: Jeff Cadeddu, MD. UT Southwestern
Surgery: Paul Russo, MD. Memorial Sloan-Kettering Cancer Center
Moderated by Michael Jewett, MD at the Society for Basic Urologic Research (SBUR)/Society of Urologic Oncology (SUO) joint meeting during the American Urological Association (AUA) Annual Meeting - May 14 - 19, 2011 - Walter E. Washington Convention Center, Washington, DC USA
Reported for UroToday by Christopher P. Evans, MD, FACS, Professor and Chairman, Department of Urology, University of California, Davis, School of Medicine.
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