Jan 17, 2019
Due to advances in imaging scans, kidney cancer often is detected by chance and early in the disease process. Dr. Ross Krasnow discusses minimally invasive robotic surgery and other treatment options for localized kidney cancer.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re talking to Dr. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.
Dr. Krasnow: It’s great to be here.
Host: Today we’re talking about management options for localized kidney cancer and, in particular, the minimally invasive surgery options available to some patients. Dr. Krasnow, what do you mean when you say localized kidney cancer?
Dr. Krasnow: So, localized kidney cancer is cancer that originates from the kidney but is confined to within the kidney or the fat surrounding the kidney or adjacent structures surrounding the kidney. It can also be in some of the lymph nodes, but it has not yet spread to far away lymph nodes and other organs that are not directly touching the kidney.
Host: How common is kidney cancer, in general, and then how common is localized kidney cancer?
Dr. Krasnow: So, kidney cancer is the seventh most common cancer generally, in men and in women. When it presents, most of the time it is localized at the time of presentation. And that’s really because of a stage migration that’s occurred over the years. The kidney lies in the back of the body, and as you can imagine, before we had advanced imaging, it was only picked up when it became symptomatic and at that point it was very large, it would cause pain, it would cause blood in the urine, and it had often already spread at the time of presentation. Now there’s been a stage migration and what that means is often it is picked up incidentally. A patient has imaging such as an ultrasound or a cat scan for another purpose. They have gallstones, they have vague pain, they have indigestion. And they end up getting some sort of imaging and that imaging just happens to show a small renal mass. More and more we’re picking this up when it’s asymptomatic and confined to the kidney, and it’s easier to treat.
Host: So, an individual could come in thinking that maybe they’re just having some back pain and they get an MRI for example, and it turns out that it’s cancer. What is somebody’s reaction to something like that?
Dr. Krasnow: Just to be clear, often when they get that MRI for back pain, the pain is not even related to the cancer; it’s completely unrelated. I think most patients, when they learn that they have a renal mass, are very nervous. And I hope that when I see them and talk to them I can reassure them that they’re going to be fine, most all of the time. Especially when these tumors are small. They’re very easy to manage and very rarely life-threatening until they get to a certain size or demonstrate evidence of spread.
Host: So, does kidney cancer tend to strike certain individuals or certain demographics of people more often than others?
Dr. Krasnow: It’s actually quite sporadic. There’s a slightly increased risk in patients who are smokers, patients who are obese and have diabetes. Certainly, there’s an increased risk in more unusual patient populations such as those with certain genetic predispositions or those on dialysis. But I would say, for the most part, the vast majority of patients I see it in, it‘s completely sporadic.
Host: So, if an individual is diagnosed with a localized kidney cancer - so that fairly contained cancer - what types of treatment might a doctor recommend? Um, you know, traditionally they talk about active surveillance, they talk about radiofrequency. Can you talk about those common types a little bit, and then some of those minimally invasive options?
Dr. Krasnow: When I first see a patient that comes to me with a renal mass, I’m actually reluctant to call it a cancer right away. And that’s because one third, one out of three patients with a small renal mass less than, say, three or four cm, don’t actually have cancer. They just have a growth on the kidney. The other two thirds of those patients do have a cancer, but it actually tends to not be very aggressive, and these cancers are not very aggressive until they’re over, say, three or four centimeters. Once I frame it like that, patients are immediately reassured. And then I talk about some of the management options. Active surveillance is a great option for certain patients. Even renal masses less than three cm have almost no metastatic potential. And that ultimately is what we worry about, not actually having a tumor on the kidney but having a tumor on the kidney that has the potential to spread. Knowing that allows us to offer active surveillance for patients. That means that we watch the mass every, say, three to six months for some time, maybe extend that out to every year, and if the tumor doesn’t seem to be growing, we may not need to treat them at all. This is a really great option for patients who are older, have a lot of other medical problems, or, for whatever reason, are reluctant to have surgery. Maybe they have just one kidney, and were very concerned about preserving their kidney function. When the tumors are over three or four cm, I do tend to recommend some form of treatment, although that’s not always the case. And, of course, it’s not realistic to watch tumors in patients who are very young. You’re not going to watch a tumor in a thirty-year-old for forty years.
So, when we talk about the treatment options, again, there are many. One is often we don’t even have to biopsy these masses but sometimes we do biopsy them to confirm that they’re a cancer. The treatment options from the least invasive to the most invasive, would be having our colleagues in radiology simply put a needle in it, and through that needle they can burn or freeze the mass. That is called radiofrequency ablation when you burn it or cryoablation when you freeze it. Again, that’s a great option for patients who are older, have some other medical problems. It’s also a great option for tumors that are small and in a location where the damage from freezing it or burning it would be confined to just the cancer and not damage other structures that are nearby. The long-term results of cryoablation and radiofrequency ablation are not as clear. The short-term results show very good efficacy, maybe just a little bit less than radical surgery—but not by much. There are certainly situations where ablative techniques are not appropriate. If the tumor is large, is in the middle of the kidney close to blood vessels, close to adjacent organs such as the pancreas, the duodenum, the liver, if it’s close to where the urine collects in the kidney - those techniques aren’t controlled enough. So, at that point, we do recommend radical surgery. Also, patients who want the most effective treatment, the gold standard, we recommend radical surgery. Most often for a small renal mass that is a partial nephrectomy. So, that’s removing the part of the kidney that has the cancer in it while leaving the rest of the healthy kidney behind. In the past, we did too many radical nephrectomies. That’s when we remove the whole kidney for small renal masses. It was really unnecessary. While effective as a cancer therapy, it hurt patients in terms of their renal function, and we really concentrate on maximizing and preserving renal function now.
Host: When you have those treatments such as radiofrequency or cryoablation, those very focused and targeted type therapies, do you also have to undergo chemo or radiation, or any other subsequent treatment?
Dr. Krasnow: It actually is one of the few cancers that doesn’t respond well to chemotherapy at all. And agents for the management of kidney cancer tend to work on the immune system. They also tend to be reserved for patients with metastatic disease or disease that’s already spread. Radiotherapy is ok for kidney cancer. The problem is that it damages the rest of the kidney. So, for localized kidney cancer, chemotherapy and radiotherapy are not…are not needed and they’re not great options.
Host: So, what about something like immunotherapy? That’s…that’s becoming more and more common for so many types of cancers. Could you talk about that a little?
Dr. Krasnow: Yes. So, immunotherapy for kidney cancer has made a lot of waves lately as second line therapy for patients with metastatic disease who have failed first line therapy. There are investigational studies looking at it for localized kidney cancer. Those would be patients who have a very large mass that may not be able to be treated surgically, and you may consider giving them some sort of therapy before surgery to see if you can shrink it to the point where surgery is a viable option. The other space that it’s being looked at is in patients with high-risk localized cancer, so they had surgery but the tumor appeared very aggressive, and the risk of recurrence is high. In that…those are patients you may consider giving an agent such as an immunotherapy agent right after surgery, even if they don’t have evidence of metastatic disease. Those two settings are completely investigational right now and are not the standard of care.
Host: Let’s go back and talk about those surgical options. So, could you elaborate a little bit further on partial nephrectomy?
Dr. Krasnow: So, partial nephrectomy is when we remove the part of the kidney that just has the cancer in it, leaving the rest of the healthy kidney behind. This is in order to preserve renal function and also to maximize cancer control, arguably better than the ablative techniques, such as cryoablation and radiofrequency ablation. The great progress that we’ve made in partial nephrectomy is that we’re now able to do it in a minimally invasive fashion, specifically using robotic laparoscopy. This allows us to make small keyhole incisions, get to the kidney, remove the part of the kidney that has the cancer in it using excellent visualization that the robotic optics provides for us, and then reconstruct the kidney afterwards, to close up all the vessels, and to close up where the urine drains out, in order to achieve a good outcome for the patient. And we can now approach the kidney from the front or from the back, which is helpful for patients who have a tumor in the back of the kidney or for patients who have had prior abdominal surgery where the abdominal cavity may be very scarred and adhesed. Both of these techniques are also extremely good for patients with obesity, because otherwise an open incision would be very large, painful, and lead to a longer recovery.
Host: So, when you’re talking keyhole incisions, about what size is that? Could you give a visual?
Dr. Krasnow: The incisions are between half and one centimeter.
Host: And how does that work when you’re going in through such a small incision - how are you able to remove part of an organ?
Dr. Krasnow: So, we have a camera that has 3-dimensional vision. When we’re doing the surgery, we can actually get depth perception. And, the instruments we place are wristed, so we get more dexterity than we would otherwise through what we would call straight laparoscopy. The last option for localized cancer, when we can’t spare the kidney, we do have to often remove the whole kidney, and maybe remove some of the lymph nodes around the kidney, and we’ve also made advances in minimally invasive techniques for more advanced localized kidney cancer. When kidney cancer that’s localized is very advanced, it can even extend into big vessels within the body, and traditionally that type of surgery would be approached open in order to perform a vascular operation where you’re not only removing the kidney, but you’re removing tumor that’s within blood vessels. This can now be done oftentimes using the robotic platform as well. So, whereas patients would be staying in the hospital for a week or two after surgery with a prolonged convalescence, they can go home in a day or two with very little blood loss.
Host: So, when you approach a patient who you’ve determined needs surgery for their kidney cancer and you say, “We’re gonna offer you this robotic treatment method,” what’s their reaction, or what questions do they usually have?
Dr. Krasnow: Most patients are just interested in how long they’re going to be in the hospital for and how long it’s going to take them to recover. And also, they want a treatment option that’s going to offer the best chance at cure. And I tell them that the robotic partial nephrectomy or a minimally invasive radical nephrectomy is the best way to achieve cure but also provides them to have a fairly rapid recovery.
Host: What does that recovery time look like in comparison to that traditional open surgery?
Dr. Krasnow: So, the traditional open surgery, in order to get to the kidney, we would have to make a very large incision in the front or the side of the patient, have to go through many layers of muscle, and sew that back together. Patients after were extremely sore, they would have difficulty walking and breathing afterwards because of the soreness. Also, during the surgery there was an increased risk for blood loss and other complications. Because we’re making small keyhole incisions, the patients have very controllable pain after surgery. They can restart their diet much earlier, the next day really. Most patients can go home one or two days after surgery compared to staying in the hospital for a week or longer, and they can get back to work much quicker.
Host: What sort of, uh, restrictions at home or restrictions at work would an individual have after that minimally invasive surgery?
Dr. Krasnow: So, after surgery, actually the day after surgery, we want them up walking, moving around, sitting, eating, trying to get back to as much normal functioning as possible. The only thing I ask the patients not to do for a few weeks after surgery is to avoid really heavy straining, heavy lifting, running, strenuous exercise, swimming - things like that, but for the most part they can go about their day when they get home.
Host: What are some of those other benefits for the patients or for their caregivers to minimally invasive surgery?
Dr. Krasnow: For some people, cosmesis matters. And the small incisions are much more cosmetically pleasing than the large incisions we made in the past. So, for certain patients who are looking to go swimming that summer and want to wear a swimsuit, you can hardly ever tell that they had surgery. I think that technology is even going to get better.
Host: Thanks for joining us today, Dr. Krasnow.
Dr. Krasnow: Thank you so much for having me.
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