Partial Nephrectomy Underused in Patients With Small Renal Tumors

Allison Gandey

February 21, 2008

February 21, 2008 — Patients with small renal tumors can benefit from the preserved kidney function that partial nephrectomy affords, a new study shows. Presenting at the 2008 Genitourinary Cancers Symposium in San Francisco, California, researchers suggested that although removing part of the kidney rather than the whole organ is a more complex procedure with increased complication risks, it might offer important long-term benefits.

"Just as lumpectomy can be less invasive but as effective as mastectomy for treating breast cancer, people with kidney cancer should be aware that partial nephrectomy is not only an option, but may be a better option than radical nephrectomy in many circumstances because it may help preserve kidney function in patients with renal tumors," lead author William Huang, MD, from the New York University School of Medicine, told reporters. "We need to do a better job of educating both patients and physicians about this topic," he added.

Dr. Huang showed that partial nephrectomy is especially underused in the elderly, in women, and in those with pre-existing cerebrovascular disease. He said the reasons for this are unclear, but speculated that surgeons might prefer radical nephrectomy because it is technically less challenging to perform and has a lower risk for complications.

Dr. Huang suggested that surgeons might believe that the procedure is a better option for older patients and those with cerebrovascular disease in the postoperative period. But long term, these patients might have poor kidney function with serious consequences.

Why women are often overlooked for partial nephrectomy is less clear, but Dr. Huang pointed out that preoperative laboratory tests suggest that women have better renal function than they actually do.

Tumors Measuring Less Than 4 cm Generally Good Candidates

Speaking to reporters at a press briefing before the meeting, Dr. Huang said that patients with small renal tumors, those measuring less than 4 cm, are generally good candidates for partial nephrectomy, yet less than one fifth of patients are offered this option.

Another paper, published in the February issue of the Journal of Urology, reports that patients have better overall survival if they have a partial rather than a radical nephrectomy (J Urol. 2008;179:468-471). The retrospective analysis showed that the procedure was most beneficial for patients under 65 years of age undergoing surgery for a small kidney tumor.

As previously reported by Medscape Oncology, lead author R. Houston Thompson, MD, from Memorial Sloan-Kettering Cancer Center in New York, said, "Recent evidence suggests that there is a graded impact on survival based on declining overall kidney function. So as kidney function declines, the risk of heart attacks and heart-related events goes up, and consequently the risk of death from these events goes up."

However, in an editorial published alongside the paper, Steven Campbell, MD, from the Cleveland Clinic in Ohio, suggests that this study "should be considered hypothesis-generating rather than definitive" (J Urol. 2008;179:472-473).

During an interview last month, when the results of the paper were first made public, senior author Michael Blute, MD, said that at the Mayo Clinic, his team treats 95% of patients with small renal tumors with a partial nephrectomy, and he said he feels that this technique should be the standard of care for these patients.

Dr. Blute said that kidney tumors less than 4 cm in size are low risk — about 20% are benign and 60% are slow-growing or indolent. And about a quarter of these patients have unrecognized clinical renal insufficiency and 35% to 40% of patients are at risk for chronic kidney disease. "So in these cases, a radical nephrectomy is overkill," he said, arguing that "these patients should be given the benefit of the doubt."

During an interview with Medscape Oncology, press-conference moderator Howard Sandler, MD, from the University of Michigan Health System in Ann Arbor, said he agrees, "as long as the partial nephrectomy is safe to do."

Dr. Sandler said that partial nephrectomy seems to be gaining popularity. "The authors even demonstrated a change from the beginning of their study to the end, with more partial nephrectomies being done more recently. I don't see this as a big problem."

The researchers examined Surveillance, Epidemiology, and End Results (SEER) data to identify preoperative factors that differed between more than 2500 patients with small renal tumors who had radical nephrectomy and 556 who had partial nephrectomy. The study is reportedly the first to analyze this issue using information from a population-based database rather than data from a single institution.

Investigators found that patients who had partial nephrectomy were more likely to be younger, male, married, and treated later in the study period. A total of 20.5% of men and 22.4% of patients, ages 66 to 69 years, had partial nephrectomy, compared with 16% of women and only 7.1% of patients aged 85 and older.

Dr. Huang and his team recommend education and training to encourage the increased use of partial nephrectomy where appropriate.

The researchers have disclosed no relevant financial relationships.

American Society of Clinical Oncology 2008 Genitourinary Cancers Symposium (GCS): Abstract 366.

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