**5. Surgical treatment of metastastic renal cell carcinoma**

Given the fact that a third of patients who are suffering from a renal cell carcinoma have a synchronous and another third after curative intent therapy have a metachronous metasta‐ sis, the following shows the possibilities and the importance of surgical therapy for meta‐ stastic renal cell carcinoma.

Basically in metastatic renal cell carcinoma a distinction must be made between the sole pal‐ liative and the cytoreductive nephrectomy. Indication criterias for palliative nephrectomy for example are conservative uncontrolled pain or recurrent bleeding. In symptomatic mul‐ timorbid patients with a high surgical risk the possibility of a tumour embolization should be evaluated. Important here is a sufficient analgesic therapy after completion of the proce‐ dure, because severe pain is a common local complication. An impact on the survival rates cannot be seen with surgical procedure nor with tumour embolization. In the era of immu‐ nochemotherapy it was shown that cytoreductive nephrectomy followed by immunochemo‐ therapy opposed to receiving only medical therapy shows significantly better survival rates (7.8 months for interferon vs. 13.6 months for nephrectomy plus interferon) [26]. Whether a nephrectomy in metastatic stage in the post-immunotherapy era is up-to date needs to be evaluated. Results of prospective randomized trials for example CARMENA study ("Clini‐ cal Trial to Assess the Importance of Nephrectomy") are still pending.

imaging diagnostics resulted in an earlier diagnostic of incidentally detected small renal masses therefore an increase of the performance of nephron-sparing procedures. In the meantime partial nephrectomy represents the standard surgical technique in pT1a renal cell carcinomas (size of tumour ≤ 4cm). Over the past years laparoscopic procedures (laparo‐ scopic nephrectomy and laparoscopic partial nephrectomy) showing similar results in con‐ sideration of the oncological outcome compared to open-surgical procedures gained in importance. Long-term results of the rather new technique of robotic nephrectomy and par‐ tial nephrectomy are encouraging but remain to be seen. LESS (Laparoscopic Single Site Sur‐ gery) and NOTES (Natural Orifice Translumenal Endoscopic Surgery) are first steps

Renal Cell Carcinoma: Clinical Surgery http://dx.doi.org/10.5772/53778 83

towards modifying established minimal invasive procedures.

, Stefan Siemer and Stephan Buse

\*Address all correspondence to: carolin.hach@krupp-krankenhaus.de

1 Department of Urology, Alfried Krupp Hospital, Essen, Germany

2 Department of Urology, Saarland University, Homburg/Saar, Germany

ma provides prognostic information. *Urol Oncol*, 7, 135-140.

renal cell carcinoma. *J Urol*, 166, 1611-1623.

tomy for renal cell carcinoma. *J Urol*, 101, 297-301.

[1] Perez-Farinos, N, Lopez-Abente, G, & Pastor-Barriuso, R. (2006). Time trend and ageperiod-cohort effect on kidney cancer mortality in Europe, 1981-2000. *BMC Public*

[2] Lee, C. T, Katz, J, Fearn, P. A, et al. (2002). Mode of presentation of renal cell carcino‐

[3] Pantuck, A. J, Zisman, A, & Belldegrun, A. S. (2001). The changing natural history of

[4] Gupta, K., Miller, J. D., Li, J. Z., et al. (2008). Epidemiologic and socioeconomic bur‐ den of metastatic renal cell carcinoma (mRCC): a literature review. *Cancer Treat Rev*,

[5] Robson, C. J., Churchill, B. M., & Anderson, W. (1969). The results of radical nephrec‐

[6] Hemal, A. K., Kumar, A., Wadhwa, P., et al. (2007). Laparoscopic versus open radical nephrectomy for large tumours; a long-term prospective comparison. *J Urol*, 177,

**Author details**

Carolin Eva Hach\*

**References**

*Health*.

34, 193-205.

862-866.

With regard to the surgical treatment of metastasis themselves this indication must be made primarily in response to the location, size and extent of metastasis findings, the symptoms and the overall situation of the affected patients.

Solitary pulmonary filiae should be checked for resectability. Are there only a few (up to three) localized metastasis, then a nephrectomy plus complete resection of metastasis can lead to a significant survival benefit. Basically patients with synchronous pulmonary meta‐ stasis have a significant worse prognosis than those with a metachronous metastasis. If it is a disseminated metastasis the initiation of a targeted therapy for (long-term) stabilization of the disease should be discussed with the patient. The basis for this inhibition of tumour growth is a modification of growth signaling inside the tumour cell and the (neo)angiogene‐ sis. Currently seven substances (in different indications) are available: tyrosine kinase inhib‐ itors such as sunitinib, sorafenib, pazopanib and axitinib, antibody-based therapies such as bevacizumab plus interferon-alpha and mTOR ("mamillian target of Rapamycin") inhibitors as temsirolimus and everolimus. The use of drugs in the adjuvant setting with advanced re‐ nal cell carcinoma with a high risk of disease progression is currently being evaluated in clinical trials.

In case of hepatic filiae with a median survival rate of 6-18 months the indication for resec‐ tion in case of a solitary metastasis with a diameter <5 cm should be evaluated if liver func‐ tion is intact. It is essential to inform the patient about this procedure`s high morbidity. For non-resectable liver metastasis it is possible to perform a CT-guided percutaneous radiofre‐ quency induced thermal ablation (RITA).

In the detection of brain metastasis a surgical approach is to be discussed especially with the onset of neurological symptoms. The indication for resection of metastasis through stereo‐ tactic radiosurgery (GammaKnife, CyberKnife) or radiation therapy is to be weighed indi‐ vidually. When limited in size and number of brain metastasis very good results can be achieved in this case with regard to the local control of metastasis.

An indication for surgery in bone metastasis may present neurological deficits in a myelon compression, pain, and fracture risk in instability of the bone. However survival time exten‐ sions are described in an osseous metastasis only in individual cases.

Metachronous adrenal metastasis without evidence of further metastasis should be surgical‐ ly removed.
