Surgery

Resection of all the tumour is the only potentially curative modality and should be offered to patients without metastases who are fit for surgery. In patients with limited metastatic disease who are fit, nephrectomy may be indicated to control local symptoms. There are documented cases of regression of metastases following nephrectomy. However, this is extremely rare and nephrectomy cannot be justified on this basis in patients who are frail or have extensive metastatic disease. Partial nephrectomy is occasionally performed for localized tumours or in patients without a second kidney.

Surgery for metastases is occasionally indicated for isolated metastases that occur after a long disease-free interval or, rarely, at presentation in young, fit patients. Although supported by anecdotal evidence, randomized data are lacking.

Although surgery is the cornerstone of management of localized disease, some patients are unfit for nephrectomy. Tumour emboliza-tion (infarction) may provide some symptom control but can itself

Table 22.1 The Robson staging system

Stage

Description

% of cases

5-year survival

I

Confined to the kidney

20-40%

50-60%

II

Extends into peri-renal fat but confined to Gerota's fascia

4-20%

27-60%

III

Involvement of renal vein or IVC or lymph node involvement

10-42%

20-50%

IV

Involvement of adjacent organs or metastatic disease

11-49%

0-18%

cause considerable morbidity. Adjuvant therapy has not been proven to offer a survival benefit. Cytotoxic chemotherapies, endocrine therapy, radiotherapy, and interferon have been tested. There is current interest in testing more complex biological therapies in this setting, but no positive studies have yet been reported.

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