A 42-Year-Old Office Assistant With Chronic Leg and Back Pain

John G. Christensen, Jr, MD

Disclosures

March 05, 2021

Partial nephrectomy is the treatment of choice for T1a (≤4 cm) renal tumors unless anatomically not feasible (eg, hilar invasion). For T1b tumors (4-7 cm), radical nephrectomy is acceptable, but partial nephrectomy should be considered if complete resection can be achieved. Partial nephrectomy may be performed via open, laparoscopic, or robotic-assisted laparoscopic technique. Partial nephrectomy is unfortunately underused, with radical nephrectomy often performed for T1 lesions that are amenable to renal unit-sparing surgery.

Radical nephrectomy is acceptable for T1b (4-7 cm) tumors and is the treatment of choice for T2-4 tumors. However, with T1b tumors that are anatomically amenable to complete excision via partial nephrectomy, no survival or cure benefit is associated with performing radical nephrectomy. With radical nephrectomy instead of partial nephrectomy, the remaining kidney may be prone to hyperfiltration injury over time, and the patient is at risk for total renal loss in the event of trauma or asynchronous de-novo renal cancer. Radical nephrectomy for cytoreduction may improve survival in patients with metastatic disease. Radical nephrectomy can be performed by open or laparoscopic approach.

Active surveillance might be considered with a small asymptomatic renal mass (<4 cm) in elderly patients, those with high surgical risk, and those with limited life expectancy, provided slow growth (or no growth) is documented on serial imaging. A retrospective, single-institution review of 51 patients showed no metastatic spread with a median follow-up of 6 years; only 2 patients required surgical intervention for local progression or symptoms.[6] Periodic follow-up imaging is advised to assess growth rate, with possible intervention if a more aggressive clinical course is evident.[1,2,4] Regardless, active surveillance is not recommended for even very small renal tumors in most patients who are reasonable surgical candidates.

Thermoablation (radiofrequency or cryoablation) is a potentially less-invasive option for elderly or high-risk patients, especially those with tumors <4 cm. Thermoablation can be done as a percutaneous technique, and good long-term results have been obtained in patients with RCCs <4 cm who were poor surgical candidates.[7] Pretreatment tissue pathology confirmation by biopsy is strongly recommended if thermoablation is planned.[1,2,3] However, complete tumor eradication is more difficult to determine, additional treatments may be needed, and a higher rate of local tumor recurrence is associated with ablation techniques compared with surgery. Therefore, at present, thermoablation is not considered a first-line treatment in most patients.[3]

Percutaneous needle biopsy of a renal mass may be considered if the results may affect management.[1,2,4] Traditional concerns for false-negative results or needle tract seeding have been assuaged by new data that indicate that false-negative rates are lower than 1%, and needle tract seeding is actually exceedingly rare. Biopsy is more regularly becoming a part of decision making for small renal masses, particularly with masses <3 cm in elderly or infirm patients who may consider treatment only if cancer is confirmed. At this time, biopsy is not routinely indicated in healthy patients who may not accept the risk for tumor progression with conservative approaches. Likewise, biopsy is not helpful in elderly or infirm patients who may refuse any treatment regardless of biopsy results.

Examples where renal biopsy is recommended and may alter treatment include the following:

  • Suspicion of a metastatic lesion to kidney from another primary source

  • Suspicion of lymphoma

  • Possible abscess (although follow-up imaging alone may suffice)

  • Evaluation of questionable renal cysts in selected cases

  • An elderly or high-risk patient who may consider surgery or thermoablation only if RCC is confirmed

  • A surgical candidate who wishes to consider active surveillance or thermoablation and accepts the possible increased risk for tumor progression by avoiding standard therapy with partial or radical nephrectomy

  • For tissue confirmation prior to thermoablation

In the patient in this case, after the CT scan revealed a 2-cm, solid, enhancing, right renal mass suspicious for RCC, a chest x-ray was obtained, the results of which were negative. No further metastatic evaluation was ordered in the absence of suspicious symptoms or findings and the absence of bony lesions on her MRI and CT. The patient was counseled on further options and elected robotic-assisted laparoscopic right partial nephrectomy, which was performed the following week. She was discharged on postoperative day 2, and recovery was uneventful. Pathology revealed a Fuhrman grade 2/4 clear cell RCC, with negative margins and no sarcomatous elements (pT1aN0M0). Her chronic leg and lower back pain remained unchanged and are felt to be unrelated. Medical investigation into the causes and possible treatment is ongoing.

RCC recurrence occurs in 20%-40% of patients with clinically localized disease following surgery, typically within the first 3-5 years; however, recurrences more than 30 years later have been documented. Periodic follow-up monitoring is therefore recommended. For T1 tumors following partial nephrectomy, a baseline CT scan with and without contrast and chest radiography is planned for 3-6 months postoperatively; CT scanning or ultrasonography plus chest radiography is then planned annually for 3 years, and then as clinically indicated. For larger tumors (T2+), CT scanning and chest radiography are performed at baseline, and then CT scanning or ultrasonography plus chest radiography is performed every 6 months until year 3, then annually until year 5, and then as clinically indicated. Immunotherapy and surgery are available treatments for recurrent RCC.[5]

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