Renal Cell Carcinoma: Controversies in care
“The only thing that is permanent in surgery is change,” remarked Prof. Alexandre Mottrie (BE), launching the first debate in Sunday morning’s packed plenary on renal cell carcinoma (RCC).
He was arguing that the benefits of new technologies, including robotic-assisted partial nephrectomy (RAPN), are unlimited compared to classical surgery, which he said results in too many complications. In his view, RAPN spares more healthy tissue, avoids large painful incisions, and gives good oncological and functional outcomes.
However Mottrie admitted although robots do not cause problems, the people behind them can. He therefore emphasised the need for proficiency-based, standardised, and quality-assured education, and congratulated the EAU on certifying the first training programme in robotics, by ERUS.
In counter-argument, Prof. Markus Kuczyk (DE) said RAPN results in decreased patient satisfaction and in low-volume centres often leads to transfusions, positive margins, and conversions to open surgery. In these centres, doctors experienced in open surgery should stick with this or send patients to expert centres.
In the second debate, moderator Prof. Peter Mulders (NL) presented the case of a small renal mass in a 42-year-old woman with a BMI of 31. Three experts then discussed her treatment.
Prof. Charles Karim Bensalah (FR) felt PN was the primary option, with fewer complications and a comparable survival rate. PN can actually improve outcomes in obese patients and the only potential obstacle would be toxic fat, which can be surmounted with good training and ultrasound identification of the tumour margin. He noted support from the EAU Guidelines (2019), which recommend offering PN to patients with P1 tumours (strong level of evidence).
Dr. Umberto Capitanio (IT) favoured local tumour ablation (cryoablation, radiofrequency, microwaves, or irreversible electroporation), especially in a patient at high risk of PN complications. However, in view of the weaker evidence, he said more research was needed.
Dr. Antonio Finelli (CA) suggested active surveillance (AS) rather than potentially unnecessary surgery. He noted that 80-90% of <4cm masses grow at only 0.22cm per year on average and that it’s not uncommon for <1cm tumours to disappear. In addition, as obesity is a risk for RCC, de novo tumours might develop after initial surgery. He therefore advocated AS (except in young and healthy patients with >4cm tumours) intervening only when the opportunity for cure exists and the risk of progression has been appreciated.
In conclusion, the experts agreed that in this particular case, all modalities were valid, depending on biopsy results and discussion with the patient. As Mulders said, any treatment decision must be based on all factors known about the patient, the physician, the facility and new research.