As a general rule, kidney tumors are considered surgical problems. Radiation and traditional methods of chemotherapy do not work for these cancers. Immunotherapy, and more recently, tyrosine kinase inhibition have been explored with some success for patients with disseminated disease.
Most kidney tumors may be approached using minimally invasive methods such as laparoscopy or robotics. The type of operation chosen is dependent upon a variety of factors:
About half of all kidney tumors discovered are 4cm or less - almost all of these tumors may be treated by partial nephrectomy [and yet only 12% of kidney tumors are treated by partial nephrectomy nation wide]. Few surgeons have the demonstrated skill to perform robotic and straight-stick laparoscopic partial nephrectomy. Make certain that you see a surgeon, like Dr. Kaynan, who is facile in all the treatment options such that you may be recommended without bias to the best choice for you!
Radical Nephrectomy (Open / Laparoscopic / Robotic)
This entails total removal of the kidney. It's used primarily for large kidney tumors. The open approach is preferred for the biggest tumors, and tumors with advanced local features such as invasion into the main vein of the kidney. Most people can live just fine with only one kidney.
Partial Nephrectomy (Open / Laparoscopic / Robotic)
Patients with smaller kidney tumors (4 cm or less), poor kidney function, tumor in a solitary kidney, or bilateral kidney tumors are candidates for partial nephrectomy. While there is a slightly higher chance of local tumor recurrence with partial nephrectomy, the chance of long-term survival from cancer is the same whether treatment is by total nephrectomy or partial nephrectomy. Overall kidney function is better preserved by partial nephrectomy, however.
This surgery is much more complex than total nephrectomy because once the tumor is removed from the kidney, the kidney must be reconstructed so that it does not bleed or leak urine. The kidney has a rich blood supply, and the main vessels to the kidney often must be temporarily clamped in order to remove the tumor without excessive blood loss. During open surgery, the kidney is typically iced down in order to reduce the energy requirements of the kidney while the vessels are clamped. This safely extends the working time allowed to remove the tumor and reconstruct the kidney. The specimen is checked by a pathologist during surgery to ascertain that the margins are clear of tumor.
Radical Nephroureterectomy (Open / Laparoscopic / Robotic)
This surgery is directed at patients with tumors involving the urothelial lining of the inner kidney or ureter (transitional cell cancers) and entails total removal of the kidney, ureter and cuff of bladder. This may be done using open, laparoscopic or robotic methods, depending upon the specifics of the case. The benefits of laparoscopy over open surgery are the same as for radical nephrectomy (see above). Dr. Kaynan prefers a combined approach of cystoscopic incision of the bladder cuff (ie, transurethrally), followed by hand-assisted laparoscopic kidney removal. In Dr. Kaynan's experience, as in radical nephrectomy, the robot adds nothing to the quality of the outcome.
Cryotherapy and Radiofrequency Ablation
These are energy ablation techniques which may be done laparoscopically or percutaneously (passing a needle through the skin to the kidney). In cryotherapy, the tumor is frozen. In radiofrequency ablation, the tumor is heated. Both methods are considered minimally invasive. However, they have demonstrably higher rates of recurrence compared to partial or total nephrectomy. These methods are generally reserved for small tumors (3 cm or less) in patients who ought not risk partial or total nephrectomy.
IL-2 and alpha-interferon are cytokine agents which stimulate the immune system to fight kidney cancer cells. Until recently, these agents had been typically used for patients with demonstrable spread of kidney cancer. Surgical removal of the kidney has been recommended, even in the setting of known tumor spread, as a means of "debulking" cancer from the body - this improves the effectiveness of immunotherapy. The side effects from IL-2 can be quite drastic and may not be administered to patients who are particularly weak.
Sunitinib (a Tyrosine Kinase Inhibitor) is the new treatment of choice for patients with disseminated kidney cancer. It indirectly suppresses blood vessel formation, which kidney cancer cells need in order to grow and flourish. Preliminary studies have shown that Sunitinib is significantly more effective than immunotherapy to improve survival. It is also much better tolerated than immunotherapy. Surgical removal of the kidney is often recommended, even in the setting of known tumor spread as a means of "debulking" cancer from the body, though there is not yet enough data to substantiate this as in immunotherapy. Research protocols are available at the Carol G. Simon Cancer Center for patients at risk who wish to enroll. Ask Dr. Kaynan about this.