Bilateral syncronous renal cancer: therapeutic strategies and “extreme kidney surgery”
Renal cancer represents 3% of all cancers and in 1-2% of cases it is bilateral. Bilateral outset may be a sign of the presence of genetic syndromes predisposing to this cancer, such as Von Hippel-Lindau syndrome, Cowden syndrome, family renal carcinoma syndrome, Birth-Hogg-Dubè syndrome, renal hereditary papillary carcinoma syndrome, Tuberous Sclerosis (1).
Today, the treatment of bilateral renal cancers is a challenge that aims to cure oncologic disease while preserving renal function as much as possible, using nephron-sparing techniques and non-surgical ablation (thermoablation, cryotherapy, radiofrequency), to "extreme kidney surgery" (2,3,4,5). We report our experience in the surgical treatment of 2 patients who have come to our attention with synchronous bilateral renal cancers, in light of recent articles published in the literature.
Materials and Methods
Between July and September 2017 we treated 2 patients with synchronous bilateral renal cancers. Patient M.R., age 51, was affected by left kidney cancer measuring 14 cm in diameter and by right kidney cancer measuring 9 cm in diameter, with suspected pulmonary metastasis. We have chosen to treat cancers in two times: in order to avoid dialysis, first enucleoresection of right renal tumor was performed (without warm ischemia time and controlled hypotension) and then, after approximately one month, left radical nephrectomy was performed. The second Patient, P.G. was affected by left kidney cancer measuring 8,5 x 7 cm in diameter and by two right kidney cancers measuring 3 cm and 5,7 cm in diameter (in addition to multiple cysts). Again, the treatment was performed in two times, to minimize the risk of impaired renal function. We started with enucleoresection of left kidney cancer, a single neoplasm with lower risk of intra and post-operative bleeding (without warm ischemia time and controlled hypotension). After 1 month, we proceeded with the enucleoresection of the double right renal cancers (again without warm ischemia time and controlled hypotension).
Histological examinations in the first patient revealed clear cell carcinoma pT2a (enucleoresection of right renal carcinoma) and clear cell carcinoma pT2b (left radical nephrectomy). In the second patient histological examinations revealed papillary renal carcinoma type I, pT2a (enucleoresection of single left kidney cancer) and papillary renal carcinoma type I on both right kidney cancers treated by enucleoresection, pT1a the smallest and pT1b the largest. None of two patients needed to be treated with intra or postoperative blood transfusion. None of the two patients required postoperative dialysis. The patient subjected to enucleoresection of right kidney cancer and left radical nephrectomy showed a moderate renal function impairment. We currently have a very limited oncological follow-up for both patients.
The occurrence of synchronous bilateral renal cancer is rare, but not exceptional. The main goal of treatment is certainly the radical cure for oncologic disease, but another important target is preservation of renal function to avoid dialysis (6). Recent retrospective works about treatment of patients with synchronous bilateral renal cancer exist, but there are no clear guidelines on the type of intervention to be performed and the timing of the interventions themselves in case of two-times interventions.
In case of bilateral renal cancer, treatment planning should take into account size, number and location of the tumours as well as the patient's performance status. If enucleoresection of tumour lesions is executable, nephron-sparing surgery should be considered as a valid therapeutic option even in case of voluminous cancers, in order to avoid postoperative renal function impairment requiring definitive dialysis. If two times treatment is planned, it is advisable to perform conservative surgery on the "best" kidney first, ensuring an adequate post-operative recovery period before treating the contralateral kidney, without delaying too much second intervention. In case of cancers deriving from suspected hereditary syndromes, patients should be advised to have a oncological genetic examination with personalized follow-up. It would be appropriate to create guidelines for treatment of these types of cancer, in order to ensure more standardized and effective treatment.
1) Inherited renal carcinomas.
Kawashima A, Young SW, Takahashi N, King BF, Atwell TD.
Abdom Radiol (NY). 2016 Jun;41(6):1066-78. doi: 10.1007/s00261-016-0743-6.
2) A Combination Therapy of Partial Nephrectomy and Cryoablation Achieved Good Cancer Control and Renal Function in Bilateral Synchronous Renal Cell Carcinoma.
Takamoto A, Araki M, Wada K, Sugimoto M, Kobayashi Y, Sasaki K, Watanabe T, Nasu Y.
Acta Med Okayama. 2017 Apr;71(2):187-190. doi: 10.18926/AMO/54989.
3) Hereditary Kidney Cancer Syndromes and Surgical Management of the Small Renal Mass.
Nguyen KA, Syed JS, Shuch B.
Urol Clin North Am. 2017 May;44(2):155-167. doi: 10.1016/j.ucl.2016.12.002. Epub 2017 Mar 14.
4) Surgical strategy of bilateral synchronous sporadic renal cell carcinoma-experience of a Chinese university hospital.
Hu XY, Xu L, Guo JM, Wang H.
World J Surg Oncol. 2017 Feb 28;15(1):53. doi: 10.1186/s12957-016-1071-6.
5) Bilateral Synchronous Sporadic Renal Cell Carcinoma: Retroperitoneoscopic Strategies and Intermediate Outcomes of 60 Patients.
Wang B, Gong H, Zhang X, Li H, Ma X, Song E, Gao J, Dong J.
PLoS One. 2016 May 2;11(5):e0154578. doi: 10.1371/journal.pone.0154578. eCollection 2016.
6) Bilateral renal cancers: oncological and functional outcomes.
Berczi C, Thomas B, Bacso Z, Flasko T.
Int Urol Nephrol. 2016 Oct;48(10):1617-22. doi: 10.1007/s11255-016-1354-4. Epub 2016 Jul 5.