New developments in the treatment of kidney cancer
Renal Cell Carcinoma is a tumor that develops as a result of the uncontrolled proliferation of cells in specific areas of the kidney.
It is the third most common neoplasm of the male genitourinary system.
Risk factors for kidney cancer include obesity, arterial hypertension and smoking. Certain other factors have also been implicated, such as the long-term use of antihypertensive medications that act as inhibitors of the converting enzyme of the Renin-Angiotensin-Aldosterone System, although this association has not been fully established.
In addition, the likelihood of developing kidney cancer increases if there is a first-degree relative with a history of kidney cancer.
Symptoms of kidney cancer:
Most kidney tumors remain asymptomatic and are discovered incidentally during ultrasound examinations or CT scans performed for other reasons. Rarely, there may be lower back pain, hematuria and, even more rarely, a palpable mass in the kidney area. Finally, a small number of patients may present with fever of unknown origin, chronic cough or chronic bone pain.
Diagnostic procedure:
If a patient is found to have a kidney tumor, the physician will request a CT scan of the kidneys and chest with intravenous contrast administration.
In cases of allergy to contrast material or suspected extension of the tumor into the renal vein, the physician will recommend an MRI of the kidney with contrast, while if chronic renal failure is also present, the physician may recommend a special examination known as contrast-enhanced ultrasound.
If a patient is scheduled to undergo surgery for the specific tumor, it may also be useful to perform CT angiography so that the surgeon can study in detail the anatomy of the kidney vessels and the vessels surrounding the tumor.
Finally, the physician may also request a renal scintigraphy in order to assess kidney function and the likelihood of renal failure developing after surgery.
Biopsy & Kidney Tumor:
Tumors are generally divided into benign and malignant tumors (cancers). Approximately 85% of kidney tumors detected on imaging examinations are malignant, meaning cancerous. Therefore, when a kidney tumor is identified, surgical removal is generally recommended.
Kidney biopsy is generally not recommended because of the possibility of tumor spread, bleeding and, most importantly, the relatively high rate of false results. It is completely contraindicated in cystic forms of tumors.
In general, kidney biopsy is recommended in solid tumors only if its results are expected to alter the planned treatment approach.
Therefore, kidney biopsy is generally recommended in the following cases:
- when minimally invasive techniques, such as cryotherapy or RF ablation, are being considered for destruction of the tumor
- when renal lymphoma is suspected, in which case the appropriate treatment is chemotherapy rather than nephrectomy, which could further impair kidney function
- when there is strong suspicion of oncocytoma, a benign tumor, especially if it is bilateral, in which case a positive biopsy may allow active surveillance
- in secondary kidney tumors, meaning metastatic tumors
- in patients with multiple metastases, where systemic therapy rather than tumor removal is planned, and who are placed under active surveillance rather than immediate treatment.
Treatment of kidney cancer:
Kidney tumors are generally considered to respond poorly to radiation therapy and chemotherapy. For this reason, when a kidney tumor is detected, the treatment generally recommended is surgery.
If a patient is unable to undergo surgery, other treatments may be proposed, such as cryotherapy or the use of RF radiofrequency ablation on the tumor. However, these treatments can only be applied to specific tumors, for example small tumors located at the periphery of the kidney, and even today, due to their poorer outcomes, they are considered alternatives to surgery and should be used only as such.
In elderly patients with very small tumors, active surveillance may also be recommended, as it has been shown that this option does not affect patient survival or the development of metastases up to the point when surgery is eventually decided upon.
Depending on the location, size and stage of the tumor, as well as the surgeon’s experience, kidney cancer may be treated either with robotic partial nephrectomy or robotic radical (total) nephrectomy.
Kidney cancer can also be treated with laparoscopic surgery. In major centers with experience in kidney cancer treatment, there is a tendency to preserve as much renal parenchyma as possible, directing surgical treatment toward partial nephrectomy, in order to achieve the best possible postoperative kidney function.
In fact, the introduction of robotic surgery, with the advantages it offers, helps make robotic partial nephrectomy possible and allows preservation of the remaining kidney even in very difficult cases.
New technologies offered by Da Vinci robotic systems, such as the use of robotic ultrasound, which helps us intraoperatively identify the boundaries of the tumor, and the use of Firefly technology, allow the surgeon to selectively clamp only the branch of the renal artery that supplies blood to the tumor, thereby minimizing the impact on the blood supply to the kidney and, consequently, on renal function.
The major advantages offered by minimally invasive techniques help ensure minimal bleeding during surgery, faster recovery and return of the patient to normal activities, while the risk of postoperative hernia is significantly reduced compared with open surgery and, finally, the average length of hospital stay is dramatically reduced.
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