AUA GUIDELINE: FULL KIDNEY REMOVAL NOT NECESSARY FOR ALL KIDNEY TUMORS
Early-stage renal masses should be treated with nephron-sparing approaches when possible
Radical nephrectomy (complete removal of the affected kidney) is not the best treatment for most small kidney tumors because it puts patients at risk for chronic kidney disease and cardiovascular disease. Nephron-sparing treatments, such as partial nephrectomy, thermal ablation and active surveillance, minimize these risks and are viable options for patients with early-stage kidney tumors, according to a new clinical guideline issued by the American Urological Association (AUA). The guideline was released on Tuesday, April 28, 2009 during the Association’s Annual Scientific Meeting in Chicago.
This is the first time that the AUA has released official guidelines for the management of patients with kidney cancer. This guideline is focused on the management of patients with early-stage renal masses, which has become controversial in the past few years. Guideline Panel Co-Chair Steven C. Campbell, MD, PhD, will present the guideline to the media on April 28, 2009 at 12:30 p.m. in the AUA Press Suite, located at the Hyatt Regency McCormick in Chicago.
Detection of clinical stage 1 (<7.0 cm) renal masses has increased in frequency and is now a common clinical scenario for the practicing urologist. Of these tumors, 20 percent are benign, 60 percent are indolent kidney cancer, and only about 20 percent are potentially aggressive kidney cancer at the time of diagnosis. Kidney cancer is the most lethal of the commonly diagnosed urologic malignancies, but small, clinically confined tumors are very heterogeneous, and most do not require radical nephrectomy.
“There are now several options available for the treatment of early stage kidney cancer,” said Steven Campbell, MD, PhD, co-chair of the panel that developed the Guideline. “Radical nephrectomy is currently greatly overutilized. Whenever possible, it is important to preserve renal function by taking a nephron-sparing approach.”
In preparing the guideline, the Panel assessed the efficacy of the following major treatment modalities:
Partial Nephrectomy: Surgical excision by partial nephrectomy is a reference standard for the management of clinical T1 renal masses, whether for imperative or elective indications, given the importance of preservation of renal function and avoidance of chronic kidney disease. In general, open partial nephrectomy is preferred for complex cases such as hilar tumor location and solitary kidney.
Thermal Ablation: Thermal ablation (cryoablation or radiofrequency ablation), performed either percutaneously or laparoscopically, is an appealing treatment option for the patient at high surgical risk who wants active treatment and accepts the need for long-term radiographic surveillance. Counseling about thermal ablation should include a balanced discussion of the increased risk of local recurrence when compared to surgical excision, the potential need for reintervention, the potential for difficult surgical salvage if tumor progression is found and the substantial limitations of the current thermal ablation literature.
Active Surveillance: Active surveillance is a reasonable option for the management of localized renal masses that should be a primary consideration for patients with decreased life expectancy or extensive comorbidities that would increase the risks of intervention. However, more aggressive or larger tumors (>3 to 4 cm) should be managed in a proactive manner, if possible.
Radical Nephrectomy: Radical nephrectomy is still occasionally required. A laparoscopic approach should be considered because it is associated with a more rapid recovery profile.
The Guideline Panel also addressed the following novel treatment modalities: high-intensity focused ultrasound, radiosurgery, microwave thermotherapy; laser interstitial thermal therapy; and pulsed cavitational ultrasound.
Panel Members included: Steven C. Campbell, MD, PhD, Co-Chair; Arie Belldegrun, MD; Michael L. Blute, MD; George Kuoche Chow, MD; Ithaar H. Derweesh, MD; Jihad H. Kaouk, MD; Raymond J. Leveille, MD; Surena F. Matin, MD; Paul Russo, MD; Robert Guy Uzzo, MD; and the late Andrew C. Novick, MD.
About the American Urological Association: Founded in 1902 and headquartered near Baltimore, Maryland, the American Urological Association is the pre-eminent professional organization for urologists, with more than 16,000 members throughout the world. An educational nonprofit organization, the AUA pursues its mission of fostering the highest standards of urologic care by carrying out a wide variety of programs for members and their patients.