ROLE OF SURGERY in

RCC

 Inspite of our understanding about RCC, surgery

remains the major for curative treatment of this
disease, with the objective of surgical theraphy is to
remove all tumor with adequate surgical margin.
Unfortunately, our ability to salvage patients with
advanced disease remains limited. The primary factor
that limits the widespread implementation of
early screening for RCC is the relatively low

 A journal by Laurent Zini and colleagues showed us a

population based comparison of survival after
nephrectomy versus non surgical treatment in 16 years
surveillance. Relative to nephrectomy, NSM appears to
undermine the overall and cancer-specific survival of
patients with small renal masses by as much as 9.4%,
at 5 years. So nephrectomy should be considered as a
standard of care in young and healthy patients

 Thats why, Robson and colleagues in 1969 made

RN as gold standard in curative intent for RCC.
Several studies demonstrate 5-year survival rates
of 70% to 90% for organ-confined disease and
document a 15% to 20% reduction in survival
associated with invasion of the perinephric fat
(Kontak and Campbell, 2003; Leibovich et al, 2005a;
Lane and Kattan, 2008).
The perceptive about renal masses have changed in last
decades. Previously, all presumed and managed
aggressively especially T1/T2 tumor. Now we recognize
multiple management strategies, such as partial

 Nephron-sparing surgery has became important

curative intent at localiced tumor especially in
imperative indication such as bilateral tumors, tumor in
solitary kidney, or patient at high risk of future renal
failure, because a functioning renal remnant of at
least 20% of one kidney is necessary to avoid
end-stage renal failure, although this presumes
good functional status of the remaining
parenchyma. Local recurrence after PN for
imperative indications has ranged from 3% to 5%,
hinges to hilar tumor location, the need to minimize
the amount of excised functional parenchyma, tumor
multifocality, or other complexities (Uzzo and Novick,

 Many resources have shown almost equally

effective curative treatment between radical and
nephron sparing surgery in localized RCC. It was
proved in journals by Campbell an collegues that show
local recurrence in the remnant kidney after PN
for RCC has been reported in 1.4% to 10% of
patients, and the main risk factor is advanced T
stage (Campbell and Novick, 1994; Lane and Gill, 2007;
Krambeck et al, 2008). Local recurrence of RCC after
radical nephrectomy is occurring in 2% to 4%.

 Another journal by Laurent Zini showed survival rate

between patients treated partial dan radical
nephrectomy have small difference. That the survival
rate differences of partial versus radical was 3.4 %

 Journal by Dash and collegues also showed small

differences in patients treated with partial and radical
nephrectomy in disease-free survival ratio 0,22 without
statistically significant.

PALIATIF INTENTION
Incomplete excision of a large primary tumor, or
debulking, is rarely indicated.
Initially, the rationale for nephrectomy included
palliation for severe bleeding, pain, and
paraneoplastic symptoms

DeKernion et al, 1978 only 12% of patients who

underwent incomplete excision of locally extensive
tumor were alive at 1 year .
Karellas and colleagues (2009) similarly poor results
in patients with positive margins at the time of
nephrectomy for stage pT4 RCC.

Cytoreductive Nephrectomy: is it a
option in patients with renal cancer?
Curative surgery almost impossible in disseminated disease, that
make the role of surgery in a patient with metastases has been
disputed
FOR

AGAINST

Treatment/prevention of tumour
complication (haematuria,
bleeding,
flank pain)

Treatment alternatives available

(embolization/irradiation)

Spontaneous regression of
metastases

Useless (wast of time)

Remove source of new metastases

Dangerous (perioperative
morbidity/mortality)

Reduction of tumour burden

No survival benefit ever confirmed

Remove trap for trafficking

lymphocytes

May compromise immune system

Interferon alfa Monotherapy or Interferon

alfa with Cytoreductive Nephrectomy:
Metastatic Renal Cell Carcinoma