Renal cell carcinoma: presentation, staging, and surgical treatment

The widespread availability of abdominal ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) scanning has increased the diagnosis of incidental renal tumors, which now comprise the vast majority of the new cases diagnosed each year. With the detection of renal tumors at an earlier stage, partial nephrectomy and nephron-sparing surgery have evolved as effective alternatives to radical nephrectomy. The poor prognostic findings of involved regional lymph nodes or ipsilateral adrenal metastases has led to more selective operations on those sites in the face of incidental tumor detection. Technological advances have allowed for the development by committed surgical investigators of techniques of laparoscopic and laparoscopically assisted nephrectomy. Although not widely employed, further improvements in technology may widen the appeal of these approaches to selected renal tumors. Advances in cardiovascular surgical techniques have made resection of renal cell carcinoma (RCC) with tumor thrombi involving the inferior vena cava (IVC) possible, although this approach is still associated with significant perioperative mortality depending on the degree of caval involvement. In highly selected cases, resection of limited metastatic disease is recommended, particularly if the disease-free interval is greater than 12 months and there is a only a single site of metastatic disease. Whether metastectomy is therapeutic or fits within the realm of the often long and unpredictable natural history of RCC is not known. Strategies for follow-up are based primarily on the pathologic stage of the operated tumor. Small incidental tumors have an excellent prognosis and require little in the way of postoperative imaging. As the pathologic stage increases, the likelihood of developing metastatic disease increases, necessitating biannual chest x-ray in addition to history and physical examination. Symptom-directed bone scans and CT scans are effective in identifying most recurrences in patients with large, poorly differentiated tumors. Patients requiring specialized follow-up programs include those treated by partial nephrectomy, and those with end-stage renal disease, acquired cystic disease of the kidney, or von Hippel-Lindau (VHL) disease.