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Management of Renal Cell Carcinoma with Coexistent Renal Artery Disease
0022-534 7 /93/1503-0808$03.00/0
Vol. 150, 808-813, September 1993 Printed in U. S.A.
THE JOURNAL OF UROLOGY Copyright © 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
MANAGEMENT OF RENAL CELL CARCINOMA WITH COEXISTENT RENAL ARTERY DISEASE STEVEN C. CAMPBELL, ANDREW C. NOVICK,* STEVAN B. STREEM
AND
ERIC A. KLEIN
From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT
Coexistence of renal cell carcinoma and renal artery disease is an unusual and challenging problem. From 1969 to 1991, 34 patients presented with localized renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma. These patients represented 4 categories: 1) a solitary kidney with renal cell carcinoma and renal artery disease (5), 2) bilateral renal cell carcinoma and coexistent renal artery disease (5), 3) unilateral renal cell carcinoma and contralateral renal artery disease (13), and 4) unilateral renal cell carcinoma and bilateral renal artery disease ( 1 1 ) . Atherosclerosis was the most common cause of renal artery disease (30) , followed by medial fibroplasia (2) , renal artery aneurysm (1) and arteriovenous malformation ( 1 ) . A total of 23 patients (68 % ) presented with azotemia (serum creatinine 1.5 mg./dl. or more) and 11 (32 % ) presented with hypertension. All patients underwent complete surgical excision of renal cell carcinoma. A nephron sparing operation was performed preferentially (30 patients) and bilateral renal cancer operations were staged. Eight patients underwent simultaneous partial (6) or radical (2) nephrectomy and surgical renal revascularization. There were no operative deaths. Postoperatively, preservation of renal function was achieved in 33 patients and 1 required chronic dialysis. At mean followup of 47 months 23 patients ( 68 % ) were alive with no evidence of malignancy and 2 were alive with recurrent renal cell carcinoma. Three patients died of metastatic renal cell carcinoma, while 6 died of unrelated causes. All of the latter 6 patients were free of renal cell carcinoma at death. Nephron sparing surgery combined occasionally with renal arterial reconstruction can yield gratifying results in this complex patient population. KEY WORDS:
carcinoma, renal cell; kidney neoplasms; renal artery
It is uncommon for renal cell carcinoma and renal artery disease to be found in the same patient. When renal cell carcinoma and renal artery disease coexist in the same kidney, with a normal contralateral kidney, radical nephrectomy is the treatment of choice. Involvement of all functioning parenchyma by these 2 conditions poses a more challenging therapeutic dilemma. In such patients renal function may be compromised by vascular disease and efforts to achieve maximal tumor control must be balanced with the need to preserve renal parenchyma. The potential risks and benefits of renal revas cularization must also be considered in this high risk patient population. Review of the literature reveals only isolated case reports addressing the management of this interesting clinical problem. In 1974 Kaufman et al reported a case of renal artery stenosis and renal cell carcinoma in a solitary kidney that was successfully treated by simultaneous partial nephrectomy and aortorenal bypass. 1 Dean et al reported on 2 patients with ipsilateral renal artery disease and renal cell carcinoma who underwent extracorporeal renal surgery but no long-term fol lowup was provided. 2 A previous report from our institution described the performance of nephron sparing surgery in 9 patients with renal artery disease and renal cell carcinoma but specific details were not provided. 3 There is a clear need to define appropriate principles and guidelines for the manage ment of these patients. We present our experience in the management of patients with coexistent renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma. Accepted for publication March 19, 1993. * Requests for reprints: Department of Urology, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44195.
MATERIALS AND METHODS
From January 1969 to June 1991 , 34 patients presented with coexistent localized renal cell carcinoma and renal artery dis ease affecting all of the functioning renal parenchyma. Patients with ipsilateral renal cell carcinoma and renal artery disease and an entirely normal contralateral kidney were excluded from this review. This series includes 20 men and 14 women ranging from 42 to 85 years old (mean age 67 years) . These patients represented 4 categories: 1) an anatomically solitary kidney involved with renal cell carcinoma and renal artery disease (5), 2) synchronous bilateral renal cell carcinoma and coexistent renal artery disease (5), 3) unilateral renal cell carcinoma and contralateral renal artery disease (13), and 4) unilateral renal cell carcinoma and bilateral renal artery disease ( 1 1 ) . All patients i n this study had localized and histopathologi cally proved renal cell carcinoma. Tumor stage was determined according to the tumor, nodes and metastasis system. 4 The pathological tumor stage was Tl to T2 in 25 patients, T3A in 5, T3B in 2 and T3C in 2. Patients with bilateral synchronous or asynchronous renal cell carcinoma were assigned the stage of the most advanced tumor in either kidney. The local extent of renal cell carcinoma was estimated from the radiographic and operative reports, and was classified as extensive if excision required removal of more than 70% of the kidney, moderate if 30 to 70% was excised and minimal if less than 30% was excised. All patients had angiographically proved renal artery disease. The cause of renal artery disease was atherosclerosis in 30 patients, medial fibroplasia in 2, a renal artery aneurysm in 1 and an arteriovenous malformation in 1 . Renal artery stenosis was classified as mild (less than 30% ) , moderate (30 to 75% ) o r high grade (more than 75 % ) . · Of the patients 16 (47 % ) presented with symptoms related
808
809
RENAL CELL CARCI N O MA WITH C O EXISTENT RENAL ARTERY DISEASE
to renal cell carcinoma, such as hematuria (8) , flank discomfort (6) or both conditions (2) . Nine patients (26%) presented with findings suggestive of renal artery stenosis, such as hyperten sion or azotemia. In 9 patients (26%) there were no symptoms of either renal cell carcinoma or renal artery disease and these conditions were discovered incidentally during evaluation for an unrelated problem. The preoperative serum creatinine level was less than 1.5 mg./dl. in 11 patients, 1.5 to 2.0 mg./dl. in 14 and 2.0 mg./dl. or more in 9. All patients were evaluated at regular intervals postopera tively with blood pressure and serum creatinine measurements, chest radiography, excretory urography, and either abdominal ultrasonography or computerized tomography. Postoperative clinical data were obtained by review of the medical records and, when necessary, by contacting surviving patients or their local physicians. Complete followup was obtained in all but 2 patients who were lost to followup at 8 and 12 years postoper atively. Patient followup in this series ranged from 6 to 144 months (mean 47) . RESULTS
Solitary kidney with renal cell carcinoma and renal artery disease. Five patients presented with renal cell carcinoma and
renal artery disease affecting an anatomically solitary kidney (table 1 ) . All 5 patients had undergone previous contralateral nephrectomy for renal cell carcinoma (3) or benign disease (2) and all were managed with nephron sparing excision of the malignancy to obviate the need for dialysis. Patient 1 with severe atherosclerotic renal artery stenosis also underwent si multaneous surgical renal revascularization for control of hy pertension and preservation of renal function. Atherosclerotic renal artery stenosis was of only mild or moderate severity in the remaining 4 patients and, thus, it was not treated. Postop erative renal function was well preserved in all patients in this group. Three patients were tumor-free, while 2 were alive with recurrent malignancy. The latter 2 patients had bilateral asyn chronous renal cell carcinoma, including patient 1 with von Hippel-Lindau's disease. Bilateral renal cell carcinoma and coexistent renal artery disease. A total of 5 patients presented with bilateral synchro
nous renal cell carcinoma and either unilateral (3) or bilateral (2) renal artery disease (table 2) . All 5 patients underwent complete excision of the renal malignancy. Bilateral partial nephrectomy was performed in 1 patient, while 4 underwent unilateral partial nephrectomy. A contralateral radical ne phrectomy was required in the latter patients due to locally extensive renal cell carcinoma. Bilateral renal operations were staged in all of these patients. No patient in this group underwent surgical renal revascu larization f o r a variety of reasons. In patients 6 and 7 partial nephrectomy was performed in a kidney with no renal artery disease. In patients 8 and 10 partial nephrectomy was per formed in a kidney involved with only moderate renal artery stenosis. In patient 9 the only salvageable parenchyma was the right upper pole, which was supplied by a normal accessory artery. The dominant right renal artery was involved with marked stenosis but did not supply the tumor-free portion of the kidney. TABLE 1.
Pt. No.
Postoperative preservation of renal function was achieved in all patients in this group. Two patients were tumor-free, while 2 ultimately died of metastatic renal cell carcinoma, 1 of whom (patient 10) had presented with renal cell carcinoma involving the inferior vena cava. One patient in this group died of a myocardial infarction with no evidence of malignancy at death. Unilateral renal cell carcinoma and contralateral renal artery disease. A total of 13 patients presented with unilateral renal
cell carcinoma and contralateral renal artery disease (table 3). Ten patients underwent nephron sparing surgical excision of the renal malignancy, of whom patient 12 underwent simulta neous contralateral surgical renal revascularization due to se vere renal artery stenosis and associated hypertension. Surgical renal revascularization was not performed in the remaining 9 patients treated with partial nephrectomy, since they either underwent minimal renal resections (fig. 1) or had clinically insignificant contralateral renal artery disease (mild to mod erate stenosis or a small asymptomatic aneurysm). The remaining 3 patients in this group required radical nephrectomy for removal of locally extensive renal cell carci noma. Patient 11 underwent simultaneous contralateral sur gical renal revascularization due to severe atherosclerotic renal artery stenosis (fig. 2) . Patient 18 had an asymptomatic arte riovenous malformation in the contralateral kidney, which did not require treatment. Patient 14 had high grade contralateral atherosclerotic renal artery stenosis but was considered at increased risk for surgical renal revascularization due to inter current medical conditions. Postoperative renal function was preserved in all patients in this group. Of the patients 7 were free of malignancy, 1 died of metastatic renal cell carcinoma and 5 remained tumor-free but died of unrelated causes. Unilateral renal cell carcinoma and bilateral renal artery disease. A total of 11 patients presented with unilateral renal
cell carcinoma and bilateral renal artery disease (table 4) . Five patients in this group underwent surgical renal revasculariza tion due to high grade renal artery stenosis and associated hypertension. Preservation of renal function was an additional concern in those with advanced atherosclerotic renal artery stenosis. Patient 27 underwent simultaneous radical nephrec tomy and contralateral surgical renal revascularization. Four patients underwent simultaneous partial nephrectomy and sur gical renal revascularization of the contralateral (1) or ipsilat eral (3) kidney. Of the latter patients 1 (patient 24) subse quently also underwent contralateral surgical renal revascular ization. Six patients from this group underwent nephron sparing excision of the renal malignancy without surgical renal revas cularization. Surgical renal revascularization was not per formed in these patients for 1 or more reasons, including a small tumor requiring minimal renal resection, functionally insignificant (mild or moderate) renal artery stenosis, good overall renal function and/or absence of associated hyperten sion (fig. 3) . All patients in this group were free of malignancy. Postoperative renal function was preserved in 10 patients. Patient 25 had progressive renal insufficiency several months postoperatively and is currently being maintained on chronic dialysis. This patient had a preoperative serum creatinine level of 3.1 mg./dl. and underwent excision of two-thirds of 1 kidney.
Patients with solitary kidney containing renal cell carcinoma and renal artery disease
Renal Artery Disease Cause/Severity
Renal Cell Ca Stage/Extent
Operation
2 3
Atherosclerosis/moderate Atherosclerosis/mild
T2/minimal T2/moderate
Partial nephrectomy, aortorenal bypass Partial nephrectomy Partial nephrectomy
4 5
Atherosclerosis/moderate Atherosclerosis/mild
T2/moderate T2/moderate
Partial nephrectomy Partial nephrectomy
1
Atherosclerosis/high grade
Tl/minimal
Serum Creatinine (mg.fell.) Preop./Postop. 2.3/2.0
1.2/1.4 1.6/2.2
1.7/1.7 2.2/2.3
Outcome (mos.) Alive with local tumor recurrence ( 144) Tumor-free ( 18) Alive with metastatic renal call Ca ( 45) Tumor-free (31) Tumor-free (42)
810
RENAL CELL CARCINOMA WITH COEXISTENT RENAL ARTERY DISEASE TABLE 2. Patients with bilateral renal cell carcinoma and coexistent renal artery disease Renal Artery Disease Cause/Severity
Renal Cell Ca Stage/Extent
6
Atherosclerosis/It. high grade
Lt. T3A/extensive, rt. T2/moderate
7
Atherosclerosis/It. moderate
8
Atherosclerosis/bilat. moderate
Lt. T2/minimal, rt. T3A/moderate Rt. T2/minimal, It. T2/extensive
9
Atherosclerosis/ rt. high grade, It. moderate
Rt. T2/moderate, It. T2/extensive
Atherosclerosis/It. moderate
Rt. T3C/extensive, It. Tl/minimal
Pt. No.
10
Operation Rt. partial nephrectomy, It. radical nephrectomy Bilat. partial nephrectomy Rt. partial nephrectomy, It. radical nephrectomy Rt. partial nephrectomy, It. radical nephrectomy Rt. radical nephrectomy,* It. partial nephrectomy
Serum Creatinine (mg./dl.) Preop./Postop.
Outcome (mos.)
2.5/2.2
Tumor-free (26)
1.0/1.4
Died of heart attack, tumor-free (6) Tumor-free (70)
1.7/2.3 1.9/4.4
Died of metastatic renal cell Ca (32)
1.8/1.5
Died of metastatic renal cell Ca (96)
* With vena caval thrombectomy.
TABLE Pt. No. 11 12 13 14 15 16 17 18 19 20 21 22 23
3. Patients with unilateral renal cell carcinoma and contralateral renal artery disease
Renal Artery Disease Cause/Severity (side)
Renal Cell Ca Stage/Extent (side)
Serum Creatinine (mg./dl.) Preop./Postop. 1.6/1.2
Outcome (mos.) Died of metastatic renal cell Ca ( 108) Died of sepsis, tumor-free (12 ) Died of prostate cancer, free of renal cell Ca (49) Died of emphysema, tumor-free (48) Tumor-free (58)
T2/minimal (It. )
Rt. radical nephrectomy, It. aortorenal b yp ass Rt. partial nephrectomy, It. splenorenal byp ass Lt. partial nephrectomy
2.7/3.3
T3B/extensive (It.)
Lt. radical nephrectomy
1.1/1.4
T2/moderate (It.)
Lt. partial nephrectomy
2.6/2.4
Tl/minimal (It.)
Lt. partial nephrectomy
2.2/2.6
T2/minimal (It. )
Lt. partial nephrectomy
1.5/1.7
Died of heart attack, tumor-free (8) Tumor-free (63)
T3C/extensive (It.)
0.8/1.0
Tumor-free (53)
T2/moderate (It.)
Lt. radical nephrectomy and inferior vena caval thrombectomy Lt. partial nephrectomy
1 .8/2.4
Tumor-free ( 1 1 3 )
T2/minimal (rt.) T2/minimal (It.)
Rt. partial nephrectomy Lt. partial nephrectomy
1.9/1.7 1.2/1.0
T2/moderate (It.)
Lt. partial nephrectomy
1.4/1.2
Tumor-free (34) Died of emphysema, tumor-free (48) Tumor-free (69)
T2/minimal (rt.)
Rt. partial nephrectomy
1.7/1.7
Tumor-free (39)
Atherosclerosis/high grade (It.) Atherosclerosis/high grade (It.) Atherosclerosis/high grade (rt.)
T3A/extensive (rt. )
Atherosclerosis/high grade (rt.) Atherosclerosis/moderate (rt.) Atherosclerosis/high grade (rt.) Atherosclerosis/high grade (rt.) Arteriovenous malformation/(rt.) Renal artery aneurysm/ (rt.) Atherosclerosis/mild (It.) Atherosclerosis/high grade (rt.) Atherosclerosis/moderate (rt.) Atherosclerosis/high grade (It.)
Operation
T2/moderate (rt.)
1.2/1.5
A) .,,J
l
FIG. 1. Patient 23. A, left renal arteriogram shows high grade stenosis from atherosclerotic plaque with intramural dissection. B, right renal arteriogram demonstrates hypervascular malignancy. Patient underwent right partial nephrectomy.
811
RENAL C E L L CARCI N O M A WITH C O EXISTENT RENAL ARTERY D I S EASE
control was improved in all 8 patients who underwent surgical renal revascularization. None of the remaining patients had severe hypertension. Postoperative followup in this series ranged from 6 to 144 months (mean 47). Of the patients 23 are currently tumor-free, while 6 died of unrelated causes with no evidence of malignancy at death. Postoperative local tumor recurrence was noted in 2 of 30 patients treated with nephron sparing surgery (patients 1 and 9) for an incidence of 6. 7%. Of 5 patients who had recurrent renal cell carcinoma postoperatively 3 died and 2 remain alive. DISCUSSION
FIG. 2. Patient 1 1 . Abdominal aortogram reveals extensive right renal malignancy and high grade left renal artery stenosis. Patient underwent right radical nephrectomy and left aortorenal bypass.
Despite a technically satisfactory splenorenal bypass, progres sive renal failure developed from advanced nephrosclerosis. Overall results. All patients underwent surgical excision of localized renal cell carcinoma. A nephron sparing operation was performed in 30 patients, while 4 underwent radical ne phrectomy. Eight patients underwent surgical renal vascular reconstruction in conjunction with either partial (6) or radical (2) nephrectomy. All revascularizations were technically suc cessful as determined by postoperative isotope renography or arteriography. There were no operative deaths in this series. Four patients required temporary dialysis postoperatively for acute renal failure that resolved, including 1 of the patients who underwent surgical renal revascularization. Postoperatively, preservation of renal function was achieved in 33 of 34 patients. The pre operative serum creatinine level in these patients ranged from 0.8 to 3.1 mg./dl. (mean 1.7) and the postoperative level ranged from 0.8 to 4.4 mg./dl. (mean 1.9). Postoperative blood pressure
The management of patients with coexistent localized renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma presents a challenging clinical problem. Several treatment goals must be balanced, including complete tumor excision, preservation of renal function and treatment of associated hypertension. Toward this end a variety of factors must be considered including the size of the tumor, technical feasibility of a nephron sparing cancer operation, specific type and severity of renal artery disease, amount of parenchyma affected by renal artery disease, technical feasibil ity of surgical renal revascularization, merits of simultaneous versus staged renal operations, presence and severity of hyper tension, level of overall renal function and general medical condition of the patient. No single approach can be uniformly applied to these patients and treatment must be individualized taking into account all of the aforementioned considerations. In our series atherosclerosis was the cause of renal artery disease in 30 of 34 patients. Since arteriography is no longer performed routinely during the evaluation of patients with suspected or proved renal cell carcinoma, it is appropriate to emphasize the clinical setting in which atherosclerosis-renal artery disease is most likely to be found. This situation com prises patients with evidence of generalized atherosclerosis, a decrease in the size of 1 or both kidneys, a serum creatinine level of more than 1.5 mg./dl. and hypertension of any magni tude. In patients who manifest all of these features angiographic screening for atherosclerosis-renal artery disease is specifically indicated. 5 In most patients with renal cell carcinoma and renal artery disease it is appropriate to consider the use of nephron sparing surgery for renal cell carcinoma on the basis of a solitary kidney, bilateral synchronous renal cell carcinoma, contralateral renal involvement with significant renal artery disease or concurrent
TABLE 4. Patients with unilateral renal cell carcinoma and bilateral renal artery disease
Pt. No.
Renal Artery Disease Cause/Severity
Renal Cell Ca Stage/Extent (side)
Tl/minimal (rt.)
Rt. partial nephrectomy
1.2/1.8
Tumor-free ( 55)
T3/minimal (rt.)
Rt. partial nephrectomy
1 .1/1.4
Tumor-free (7)
T2/moderate (rt.)
Rt. partial nephrectomy
1.5/1.6
Tumor-free (8)
T2/moderate (It.)
Lt. partial nephrectomy
1.8/2.3
Tumor-free (8)
T2/moderate (It.)
Lt. partial nephrectomy
1.0/0.8
Tumor-free (76)
T2/minimal (lt.)
25
Atherosclerosis/It. high grade, rt. moderate Medial fibroplasia/bilat. high grade Atherosclerosis/bilat. high grade Atherosclerosis/bilat. high grade Atherosclerosis/It. moderate, rt. high grade Atherosclerosis/It. high grade, rt. mild Atherosclerosis/It. moderate, rt. mild Atherosclerosis/It. moderate, rt. high grade Atherosclerosis/It. moderate, rt. high grade Medial fibroplasia/bilat. moderate
T2/moderate (rt.)
28 29 30 31 32 33 34
Outcome (mos.)
Tl/minimal (It.)
Atherosclerosis/bilat. high grade
27
Serum Creatinine (mg./d!.) Preop./Postop.
Lt. partial nephrectomy and aortorenal byp ass, rt. aortorenal byp ass Rt. partial nephrectomy, lt. splenorenal byp ass Rt. partial nephrectomy, rt. aortorenal byp ass Rt. radical nephrectomy, It. splenorenal b yp ass Rt. partial nephrectomy, rt. hepatorenal byp ass Lt. partial nephrectomy
24
26
Operation
T2/moderate (rt.) T2/moderate (rt.) Tl/minimal (rt.)
1.9/2.6
Tumor-free (108)
3. 1/dialysis
Tumor-free (23)
0.9/1.0
Tumor-free (13)
3.0/3.0
Tumor-free (14)
2.2/2.0
Tumor-free ( 18)
1.9/2.3
Tumor-free (57)
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RENAL CELL CARCINOMA WITH COEXISTENT RENAL ARTERY DISEASE
FIG. 3. Patient 30. A, abdominal aortogram shows high grade left renal artery stenosis and mild right renal artery stenosis. B, computerized tomography reveals small solid right renal malignancy. Patient underwent right partial nephrectomy.
renal insufficiency. These are accepted indications for nephron sparing surgery to treat localized low stage renal cell carcinoma and there are several reports of excellent clinical results with this approach. 3 • -8 In our series nephron sparing excision of renal cell carcinoma was performed in 30 of 34 patients for 1 of the aforementioned reasons. The remaining 4 patients under went radical nephrectomy for removal of locally extensive renal cell carcinoma that was not technically amenable to conserva tive excision. The need to perform adjunctive surgical renal revasculari zation in these patients is determined by the specific type, location, extent and severity of renal artery disease. The major clinical considerations are the presence and severity of associ ated hypertension, and the risk of ischemic renal failure from progressive vascular disease. Atherosclerosis was the cause of renal artery disease in 30 of 34 patients (88%) in this series. Progressive renal arterial obstruction with loss of renal function occurs commonly with this disease, particularly when the af fected renal artery is involved with high grade (more than 75%) stenosis. 9- 11 Therefore, if a significant amount of renal paren chyma is affected by this type of high grade stenosis surgical renal revascularization is indicated to preserve renal func tion. 5 • 12, 13 Severe associated hypertension comprises an addi tional indication for surgical renal revascularization when the blood pressure cannot be adequately controlled with medical treatment. 1 4 In our series surgical renal revascularization was performed for these indications in 7 patients with atheroscle rotic renal artery disease simultaneous with either partial (5) or radical (2) nephrectomy. These patients had ostial athero sclerotic lesions that were not amenable to treatment with percutaneous transluminal angioplasty. 1 5 In 2 patients from this series the cause of renal artery disease was medial fibroplasia. While this type of vascular disease can cause renin-mediated hypertension, it does not pose a signifi cant threat to overall renal function. 9 One patient underwent surgical renal revascularization for medial fibroplasia causing significant hypertension, while 1 with medial fibroplasia had only moderate renal artery stenosis that did not require treat ment. Surgical treatment for renal artery disease was also not necessary in 1 patient with an asymptomatic arteriovenous malformation and 1 patient with a small renal artery aneurysm. All of our patients underwent complete surgical excision of renal cell carcinoma, including 8 who also underwent simulta neous renal vascular reconstruction. The performance of si multaneous surgical tenal revascularization was well tolerated with no increased morbidity and all revascularization opera tions were technically successful. One of the revascularized patients had end stage renal failure postoperatively due to 6
progressive nephrosclerosis. Postoperative blood pressure con trol was improved in all 8 patients undergoing surgical renal revascularization. Overall, stable postoperative preservation of renal function was achieved in 33 of 34 patients (97%). The predominant use of nephron sparing surgery to treat renal cell carcinoma in these patients also yielded satisfactory results with respect to control of the malignancy. Postoperative recurrent renal cell carcinoma developed in only 4 of 30 patients (13.3%), including 2 (6.7%) with local tumor recurrence in the operated kidney. These results mirror our wider experience with nephron sparing surgery for treatment of localized renal cell carcinoma. 3 • 7 In the overall series of 34 patients 23 (68%) are tumor-free (mean followup 44 months), while 6 (17%) died of unrelated causes (mean followup 29 months) with no evidence of malig nancy at death. Three patients died of metastatic renal cell carcinoma (mean survival 79 months), while 2 are alive with recurrent renal cell carcinoma (mean followup 95 months). In summary, these results indicate that nephron sparing surgery in conjunction with selective renal arterial reconstruc tion can provide effective therapy for patients with renal cell carcinoma and renal artery disease affecting all of the function ing renal parenchyma. Multiple factors must be weighed when determining the optimal approach for each individual patient. The data presented are encouraging and suggest that cancer free survival with preservation of renal function can be achieved in most patients. REFERENCES 1. Kaufman, J. J., Marks, L. S. and Smith, R. B.: Stenosis of the renal artery and coexistent lesions. Surg., Gynec. & Obst., 139: 59, 1974. 2. Dean, R. H., Meacham, P. W. and Weaver, F. A.: Ex vivo renal artery reconstructions: indications and techniques. J. Vase. Surg., 4: 546, 1986. 3. Novick, A. C., Streem, S., Montie, J. E., Pontes, J. E., Siegel, S., Montague, D. K. and Goormastic, M.: Conservative surgery for renal cell carcinoma: a single-center experience with 100 pa tients. J. Urol., 1 4 1 : 835, 1989. 4. Hermanek, P. and Sobin, L. H.: TNM Classification of Malignant Tumours, 4th ed. New York: Springer-Verlag, pp. 146-148, 1987. 5. Novick, A. C.: Selection of patients with atherosclerosis for renal reconstruction to preserve renal function. World J. Urol., 7: 98, 1989. 6. Novick, A. C.: Partial nephrectomy for renal cell carcinoma. Urol. Clin. N. Amer., 14: 419, 1987. 7. Novick, A. C.: The role of renal-sparing surgery for renal cell carcinoma. Sem. Urol., 10: 12, 1992. 8. Morgan, W. R. and Zinke, H.: Progression and survival after renal-
RENAL CELL CARCINOMA WITH C O EXISTENT RENAL ARTERY DISEASE
9. 10. 11.
12.
conserving surgery fo r renal cell carcinoma: experience i n 104 patients and extended followup. J. Urol., 1 44: 852, 1990. Schreiber, M. J., Pohl, M. A. and Novick, A. C.: The natural history of atherosclerotic and fibrous renal artery disease. Urol. Clin. N. Amer., 1 1 : 383, 1984. Meaney, T. F., Dustan, H . P. and McCormack, L. J.: Natural history of renal arterial disease. Radiology, 9 1 : 881 , 1968. Dean, R. H., Kieffer, R. W., Smith, B. M., Oates, J. A., Nadeau, J. H. J., Hollifield, J. W. and DuPont, W. D.: Renovascular hyper tension: anatomic and renal function changes during drug ther apy. Arch. Surg., 1 1 6 : 1408, 198 1 . Libertino, J. A., Bosco, P. J., Ying, C . Y . , Breslin, D. J., Woods, B.
813
0., Tsapatsaris, N. P. and Swinton, N. W., Jr.: Renal revascu larization to preserve and restore renal function. J. Urol., 1 4 7 : 1485, 1992. 13. Novick, A. C., Pohl, M. A., Schreiber, M. J., Gifford, R. W., Jr. and Vidt, D . G.: Revascularization for preservation of renal function in patients with atherosclerotic renovascular disease. J. Urol., 129: 907, 1983. 14. Novick, A. C.: Surgical correction of renovascular hyp ertension. Surg. Clin. N. Amer. , 68: 1007, 1988. 15. Flechner, S. M.: Percutaneous transluminal dilation. A realistic appraisal in patients with stenosing lesions of the renal artery. Urol. Clin. N. Amer. , 1 1 : 515, 1984.
Vol. 150, 808-813, September 1993 Printed in U. S.A.
THE JOURNAL OF UROLOGY Copyright © 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
MANAGEMENT OF RENAL CELL CARCINOMA WITH COEXISTENT RENAL ARTERY DISEASE STEVEN C. CAMPBELL, ANDREW C. NOVICK,* STEVAN B. STREEM
AND
ERIC A. KLEIN
From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT
Coexistence of renal cell carcinoma and renal artery disease is an unusual and challenging problem. From 1969 to 1991, 34 patients presented with localized renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma. These patients represented 4 categories: 1) a solitary kidney with renal cell carcinoma and renal artery disease (5), 2) bilateral renal cell carcinoma and coexistent renal artery disease (5), 3) unilateral renal cell carcinoma and contralateral renal artery disease (13), and 4) unilateral renal cell carcinoma and bilateral renal artery disease ( 1 1 ) . Atherosclerosis was the most common cause of renal artery disease (30) , followed by medial fibroplasia (2) , renal artery aneurysm (1) and arteriovenous malformation ( 1 ) . A total of 23 patients (68 % ) presented with azotemia (serum creatinine 1.5 mg./dl. or more) and 11 (32 % ) presented with hypertension. All patients underwent complete surgical excision of renal cell carcinoma. A nephron sparing operation was performed preferentially (30 patients) and bilateral renal cancer operations were staged. Eight patients underwent simultaneous partial (6) or radical (2) nephrectomy and surgical renal revascularization. There were no operative deaths. Postoperatively, preservation of renal function was achieved in 33 patients and 1 required chronic dialysis. At mean followup of 47 months 23 patients ( 68 % ) were alive with no evidence of malignancy and 2 were alive with recurrent renal cell carcinoma. Three patients died of metastatic renal cell carcinoma, while 6 died of unrelated causes. All of the latter 6 patients were free of renal cell carcinoma at death. Nephron sparing surgery combined occasionally with renal arterial reconstruction can yield gratifying results in this complex patient population. KEY WORDS:
carcinoma, renal cell; kidney neoplasms; renal artery
It is uncommon for renal cell carcinoma and renal artery disease to be found in the same patient. When renal cell carcinoma and renal artery disease coexist in the same kidney, with a normal contralateral kidney, radical nephrectomy is the treatment of choice. Involvement of all functioning parenchyma by these 2 conditions poses a more challenging therapeutic dilemma. In such patients renal function may be compromised by vascular disease and efforts to achieve maximal tumor control must be balanced with the need to preserve renal parenchyma. The potential risks and benefits of renal revas cularization must also be considered in this high risk patient population. Review of the literature reveals only isolated case reports addressing the management of this interesting clinical problem. In 1974 Kaufman et al reported a case of renal artery stenosis and renal cell carcinoma in a solitary kidney that was successfully treated by simultaneous partial nephrectomy and aortorenal bypass. 1 Dean et al reported on 2 patients with ipsilateral renal artery disease and renal cell carcinoma who underwent extracorporeal renal surgery but no long-term fol lowup was provided. 2 A previous report from our institution described the performance of nephron sparing surgery in 9 patients with renal artery disease and renal cell carcinoma but specific details were not provided. 3 There is a clear need to define appropriate principles and guidelines for the manage ment of these patients. We present our experience in the management of patients with coexistent renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma. Accepted for publication March 19, 1993. * Requests for reprints: Department of Urology, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44195.
MATERIALS AND METHODS
From January 1969 to June 1991 , 34 patients presented with coexistent localized renal cell carcinoma and renal artery dis ease affecting all of the functioning renal parenchyma. Patients with ipsilateral renal cell carcinoma and renal artery disease and an entirely normal contralateral kidney were excluded from this review. This series includes 20 men and 14 women ranging from 42 to 85 years old (mean age 67 years) . These patients represented 4 categories: 1) an anatomically solitary kidney involved with renal cell carcinoma and renal artery disease (5), 2) synchronous bilateral renal cell carcinoma and coexistent renal artery disease (5), 3) unilateral renal cell carcinoma and contralateral renal artery disease (13), and 4) unilateral renal cell carcinoma and bilateral renal artery disease ( 1 1 ) . All patients i n this study had localized and histopathologi cally proved renal cell carcinoma. Tumor stage was determined according to the tumor, nodes and metastasis system. 4 The pathological tumor stage was Tl to T2 in 25 patients, T3A in 5, T3B in 2 and T3C in 2. Patients with bilateral synchronous or asynchronous renal cell carcinoma were assigned the stage of the most advanced tumor in either kidney. The local extent of renal cell carcinoma was estimated from the radiographic and operative reports, and was classified as extensive if excision required removal of more than 70% of the kidney, moderate if 30 to 70% was excised and minimal if less than 30% was excised. All patients had angiographically proved renal artery disease. The cause of renal artery disease was atherosclerosis in 30 patients, medial fibroplasia in 2, a renal artery aneurysm in 1 and an arteriovenous malformation in 1 . Renal artery stenosis was classified as mild (less than 30% ) , moderate (30 to 75% ) o r high grade (more than 75 % ) . · Of the patients 16 (47 % ) presented with symptoms related
808
809
RENAL CELL CARCI N O MA WITH C O EXISTENT RENAL ARTERY DISEASE
to renal cell carcinoma, such as hematuria (8) , flank discomfort (6) or both conditions (2) . Nine patients (26%) presented with findings suggestive of renal artery stenosis, such as hyperten sion or azotemia. In 9 patients (26%) there were no symptoms of either renal cell carcinoma or renal artery disease and these conditions were discovered incidentally during evaluation for an unrelated problem. The preoperative serum creatinine level was less than 1.5 mg./dl. in 11 patients, 1.5 to 2.0 mg./dl. in 14 and 2.0 mg./dl. or more in 9. All patients were evaluated at regular intervals postopera tively with blood pressure and serum creatinine measurements, chest radiography, excretory urography, and either abdominal ultrasonography or computerized tomography. Postoperative clinical data were obtained by review of the medical records and, when necessary, by contacting surviving patients or their local physicians. Complete followup was obtained in all but 2 patients who were lost to followup at 8 and 12 years postoper atively. Patient followup in this series ranged from 6 to 144 months (mean 47) . RESULTS
Solitary kidney with renal cell carcinoma and renal artery disease. Five patients presented with renal cell carcinoma and
renal artery disease affecting an anatomically solitary kidney (table 1 ) . All 5 patients had undergone previous contralateral nephrectomy for renal cell carcinoma (3) or benign disease (2) and all were managed with nephron sparing excision of the malignancy to obviate the need for dialysis. Patient 1 with severe atherosclerotic renal artery stenosis also underwent si multaneous surgical renal revascularization for control of hy pertension and preservation of renal function. Atherosclerotic renal artery stenosis was of only mild or moderate severity in the remaining 4 patients and, thus, it was not treated. Postop erative renal function was well preserved in all patients in this group. Three patients were tumor-free, while 2 were alive with recurrent malignancy. The latter 2 patients had bilateral asyn chronous renal cell carcinoma, including patient 1 with von Hippel-Lindau's disease. Bilateral renal cell carcinoma and coexistent renal artery disease. A total of 5 patients presented with bilateral synchro
nous renal cell carcinoma and either unilateral (3) or bilateral (2) renal artery disease (table 2) . All 5 patients underwent complete excision of the renal malignancy. Bilateral partial nephrectomy was performed in 1 patient, while 4 underwent unilateral partial nephrectomy. A contralateral radical ne phrectomy was required in the latter patients due to locally extensive renal cell carcinoma. Bilateral renal operations were staged in all of these patients. No patient in this group underwent surgical renal revascu larization f o r a variety of reasons. In patients 6 and 7 partial nephrectomy was performed in a kidney with no renal artery disease. In patients 8 and 10 partial nephrectomy was per formed in a kidney involved with only moderate renal artery stenosis. In patient 9 the only salvageable parenchyma was the right upper pole, which was supplied by a normal accessory artery. The dominant right renal artery was involved with marked stenosis but did not supply the tumor-free portion of the kidney. TABLE 1.
Pt. No.
Postoperative preservation of renal function was achieved in all patients in this group. Two patients were tumor-free, while 2 ultimately died of metastatic renal cell carcinoma, 1 of whom (patient 10) had presented with renal cell carcinoma involving the inferior vena cava. One patient in this group died of a myocardial infarction with no evidence of malignancy at death. Unilateral renal cell carcinoma and contralateral renal artery disease. A total of 13 patients presented with unilateral renal
cell carcinoma and contralateral renal artery disease (table 3). Ten patients underwent nephron sparing surgical excision of the renal malignancy, of whom patient 12 underwent simulta neous contralateral surgical renal revascularization due to se vere renal artery stenosis and associated hypertension. Surgical renal revascularization was not performed in the remaining 9 patients treated with partial nephrectomy, since they either underwent minimal renal resections (fig. 1) or had clinically insignificant contralateral renal artery disease (mild to mod erate stenosis or a small asymptomatic aneurysm). The remaining 3 patients in this group required radical nephrectomy for removal of locally extensive renal cell carci noma. Patient 11 underwent simultaneous contralateral sur gical renal revascularization due to severe atherosclerotic renal artery stenosis (fig. 2) . Patient 18 had an asymptomatic arte riovenous malformation in the contralateral kidney, which did not require treatment. Patient 14 had high grade contralateral atherosclerotic renal artery stenosis but was considered at increased risk for surgical renal revascularization due to inter current medical conditions. Postoperative renal function was preserved in all patients in this group. Of the patients 7 were free of malignancy, 1 died of metastatic renal cell carcinoma and 5 remained tumor-free but died of unrelated causes. Unilateral renal cell carcinoma and bilateral renal artery disease. A total of 11 patients presented with unilateral renal
cell carcinoma and bilateral renal artery disease (table 4) . Five patients in this group underwent surgical renal revasculariza tion due to high grade renal artery stenosis and associated hypertension. Preservation of renal function was an additional concern in those with advanced atherosclerotic renal artery stenosis. Patient 27 underwent simultaneous radical nephrec tomy and contralateral surgical renal revascularization. Four patients underwent simultaneous partial nephrectomy and sur gical renal revascularization of the contralateral (1) or ipsilat eral (3) kidney. Of the latter patients 1 (patient 24) subse quently also underwent contralateral surgical renal revascular ization. Six patients from this group underwent nephron sparing excision of the renal malignancy without surgical renal revas cularization. Surgical renal revascularization was not per formed in these patients for 1 or more reasons, including a small tumor requiring minimal renal resection, functionally insignificant (mild or moderate) renal artery stenosis, good overall renal function and/or absence of associated hyperten sion (fig. 3) . All patients in this group were free of malignancy. Postoperative renal function was preserved in 10 patients. Patient 25 had progressive renal insufficiency several months postoperatively and is currently being maintained on chronic dialysis. This patient had a preoperative serum creatinine level of 3.1 mg./dl. and underwent excision of two-thirds of 1 kidney.
Patients with solitary kidney containing renal cell carcinoma and renal artery disease
Renal Artery Disease Cause/Severity
Renal Cell Ca Stage/Extent
Operation
2 3
Atherosclerosis/moderate Atherosclerosis/mild
T2/minimal T2/moderate
Partial nephrectomy, aortorenal bypass Partial nephrectomy Partial nephrectomy
4 5
Atherosclerosis/moderate Atherosclerosis/mild
T2/moderate T2/moderate
Partial nephrectomy Partial nephrectomy
1
Atherosclerosis/high grade
Tl/minimal
Serum Creatinine (mg.fell.) Preop./Postop. 2.3/2.0
1.2/1.4 1.6/2.2
1.7/1.7 2.2/2.3
Outcome (mos.) Alive with local tumor recurrence ( 144) Tumor-free ( 18) Alive with metastatic renal call Ca ( 45) Tumor-free (31) Tumor-free (42)
810
RENAL CELL CARCINOMA WITH COEXISTENT RENAL ARTERY DISEASE TABLE 2. Patients with bilateral renal cell carcinoma and coexistent renal artery disease Renal Artery Disease Cause/Severity
Renal Cell Ca Stage/Extent
6
Atherosclerosis/It. high grade
Lt. T3A/extensive, rt. T2/moderate
7
Atherosclerosis/It. moderate
8
Atherosclerosis/bilat. moderate
Lt. T2/minimal, rt. T3A/moderate Rt. T2/minimal, It. T2/extensive
9
Atherosclerosis/ rt. high grade, It. moderate
Rt. T2/moderate, It. T2/extensive
Atherosclerosis/It. moderate
Rt. T3C/extensive, It. Tl/minimal
Pt. No.
10
Operation Rt. partial nephrectomy, It. radical nephrectomy Bilat. partial nephrectomy Rt. partial nephrectomy, It. radical nephrectomy Rt. partial nephrectomy, It. radical nephrectomy Rt. radical nephrectomy,* It. partial nephrectomy
Serum Creatinine (mg./dl.) Preop./Postop.
Outcome (mos.)
2.5/2.2
Tumor-free (26)
1.0/1.4
Died of heart attack, tumor-free (6) Tumor-free (70)
1.7/2.3 1.9/4.4
Died of metastatic renal cell Ca (32)
1.8/1.5
Died of metastatic renal cell Ca (96)
* With vena caval thrombectomy.
TABLE Pt. No. 11 12 13 14 15 16 17 18 19 20 21 22 23
3. Patients with unilateral renal cell carcinoma and contralateral renal artery disease
Renal Artery Disease Cause/Severity (side)
Renal Cell Ca Stage/Extent (side)
Serum Creatinine (mg./dl.) Preop./Postop. 1.6/1.2
Outcome (mos.) Died of metastatic renal cell Ca ( 108) Died of sepsis, tumor-free (12 ) Died of prostate cancer, free of renal cell Ca (49) Died of emphysema, tumor-free (48) Tumor-free (58)
T2/minimal (It. )
Rt. radical nephrectomy, It. aortorenal b yp ass Rt. partial nephrectomy, It. splenorenal byp ass Lt. partial nephrectomy
2.7/3.3
T3B/extensive (It.)
Lt. radical nephrectomy
1.1/1.4
T2/moderate (It.)
Lt. partial nephrectomy
2.6/2.4
Tl/minimal (It.)
Lt. partial nephrectomy
2.2/2.6
T2/minimal (It. )
Lt. partial nephrectomy
1.5/1.7
Died of heart attack, tumor-free (8) Tumor-free (63)
T3C/extensive (It.)
0.8/1.0
Tumor-free (53)
T2/moderate (It.)
Lt. radical nephrectomy and inferior vena caval thrombectomy Lt. partial nephrectomy
1 .8/2.4
Tumor-free ( 1 1 3 )
T2/minimal (rt.) T2/minimal (It.)
Rt. partial nephrectomy Lt. partial nephrectomy
1.9/1.7 1.2/1.0
T2/moderate (It.)
Lt. partial nephrectomy
1.4/1.2
Tumor-free (34) Died of emphysema, tumor-free (48) Tumor-free (69)
T2/minimal (rt.)
Rt. partial nephrectomy
1.7/1.7
Tumor-free (39)
Atherosclerosis/high grade (It.) Atherosclerosis/high grade (It.) Atherosclerosis/high grade (rt.)
T3A/extensive (rt. )
Atherosclerosis/high grade (rt.) Atherosclerosis/moderate (rt.) Atherosclerosis/high grade (rt.) Atherosclerosis/high grade (rt.) Arteriovenous malformation/(rt.) Renal artery aneurysm/ (rt.) Atherosclerosis/mild (It.) Atherosclerosis/high grade (rt.) Atherosclerosis/moderate (rt.) Atherosclerosis/high grade (It.)
Operation
T2/moderate (rt.)
1.2/1.5
A) .,,J
l
FIG. 1. Patient 23. A, left renal arteriogram shows high grade stenosis from atherosclerotic plaque with intramural dissection. B, right renal arteriogram demonstrates hypervascular malignancy. Patient underwent right partial nephrectomy.
811
RENAL C E L L CARCI N O M A WITH C O EXISTENT RENAL ARTERY D I S EASE
control was improved in all 8 patients who underwent surgical renal revascularization. None of the remaining patients had severe hypertension. Postoperative followup in this series ranged from 6 to 144 months (mean 47). Of the patients 23 are currently tumor-free, while 6 died of unrelated causes with no evidence of malignancy at death. Postoperative local tumor recurrence was noted in 2 of 30 patients treated with nephron sparing surgery (patients 1 and 9) for an incidence of 6. 7%. Of 5 patients who had recurrent renal cell carcinoma postoperatively 3 died and 2 remain alive. DISCUSSION
FIG. 2. Patient 1 1 . Abdominal aortogram reveals extensive right renal malignancy and high grade left renal artery stenosis. Patient underwent right radical nephrectomy and left aortorenal bypass.
Despite a technically satisfactory splenorenal bypass, progres sive renal failure developed from advanced nephrosclerosis. Overall results. All patients underwent surgical excision of localized renal cell carcinoma. A nephron sparing operation was performed in 30 patients, while 4 underwent radical ne phrectomy. Eight patients underwent surgical renal vascular reconstruction in conjunction with either partial (6) or radical (2) nephrectomy. All revascularizations were technically suc cessful as determined by postoperative isotope renography or arteriography. There were no operative deaths in this series. Four patients required temporary dialysis postoperatively for acute renal failure that resolved, including 1 of the patients who underwent surgical renal revascularization. Postoperatively, preservation of renal function was achieved in 33 of 34 patients. The pre operative serum creatinine level in these patients ranged from 0.8 to 3.1 mg./dl. (mean 1.7) and the postoperative level ranged from 0.8 to 4.4 mg./dl. (mean 1.9). Postoperative blood pressure
The management of patients with coexistent localized renal cell carcinoma and renal artery disease affecting all of the functioning renal parenchyma presents a challenging clinical problem. Several treatment goals must be balanced, including complete tumor excision, preservation of renal function and treatment of associated hypertension. Toward this end a variety of factors must be considered including the size of the tumor, technical feasibility of a nephron sparing cancer operation, specific type and severity of renal artery disease, amount of parenchyma affected by renal artery disease, technical feasibil ity of surgical renal revascularization, merits of simultaneous versus staged renal operations, presence and severity of hyper tension, level of overall renal function and general medical condition of the patient. No single approach can be uniformly applied to these patients and treatment must be individualized taking into account all of the aforementioned considerations. In our series atherosclerosis was the cause of renal artery disease in 30 of 34 patients. Since arteriography is no longer performed routinely during the evaluation of patients with suspected or proved renal cell carcinoma, it is appropriate to emphasize the clinical setting in which atherosclerosis-renal artery disease is most likely to be found. This situation com prises patients with evidence of generalized atherosclerosis, a decrease in the size of 1 or both kidneys, a serum creatinine level of more than 1.5 mg./dl. and hypertension of any magni tude. In patients who manifest all of these features angiographic screening for atherosclerosis-renal artery disease is specifically indicated. 5 In most patients with renal cell carcinoma and renal artery disease it is appropriate to consider the use of nephron sparing surgery for renal cell carcinoma on the basis of a solitary kidney, bilateral synchronous renal cell carcinoma, contralateral renal involvement with significant renal artery disease or concurrent
TABLE 4. Patients with unilateral renal cell carcinoma and bilateral renal artery disease
Pt. No.
Renal Artery Disease Cause/Severity
Renal Cell Ca Stage/Extent (side)
Tl/minimal (rt.)
Rt. partial nephrectomy
1.2/1.8
Tumor-free ( 55)
T3/minimal (rt.)
Rt. partial nephrectomy
1 .1/1.4
Tumor-free (7)
T2/moderate (rt.)
Rt. partial nephrectomy
1.5/1.6
Tumor-free (8)
T2/moderate (It.)
Lt. partial nephrectomy
1.8/2.3
Tumor-free (8)
T2/moderate (It.)
Lt. partial nephrectomy
1.0/0.8
Tumor-free (76)
T2/minimal (lt.)
25
Atherosclerosis/It. high grade, rt. moderate Medial fibroplasia/bilat. high grade Atherosclerosis/bilat. high grade Atherosclerosis/bilat. high grade Atherosclerosis/It. moderate, rt. high grade Atherosclerosis/It. high grade, rt. mild Atherosclerosis/It. moderate, rt. mild Atherosclerosis/It. moderate, rt. high grade Atherosclerosis/It. moderate, rt. high grade Medial fibroplasia/bilat. moderate
T2/moderate (rt.)
28 29 30 31 32 33 34
Outcome (mos.)
Tl/minimal (It.)
Atherosclerosis/bilat. high grade
27
Serum Creatinine (mg./d!.) Preop./Postop.
Lt. partial nephrectomy and aortorenal byp ass, rt. aortorenal byp ass Rt. partial nephrectomy, lt. splenorenal byp ass Rt. partial nephrectomy, rt. aortorenal byp ass Rt. radical nephrectomy, It. splenorenal b yp ass Rt. partial nephrectomy, rt. hepatorenal byp ass Lt. partial nephrectomy
24
26
Operation
T2/moderate (rt.) T2/moderate (rt.) Tl/minimal (rt.)
1.9/2.6
Tumor-free (108)
3. 1/dialysis
Tumor-free (23)
0.9/1.0
Tumor-free (13)
3.0/3.0
Tumor-free (14)
2.2/2.0
Tumor-free ( 18)
1.9/2.3
Tumor-free (57)
812
RENAL CELL CARCINOMA WITH COEXISTENT RENAL ARTERY DISEASE
FIG. 3. Patient 30. A, abdominal aortogram shows high grade left renal artery stenosis and mild right renal artery stenosis. B, computerized tomography reveals small solid right renal malignancy. Patient underwent right partial nephrectomy.
renal insufficiency. These are accepted indications for nephron sparing surgery to treat localized low stage renal cell carcinoma and there are several reports of excellent clinical results with this approach. 3 • -8 In our series nephron sparing excision of renal cell carcinoma was performed in 30 of 34 patients for 1 of the aforementioned reasons. The remaining 4 patients under went radical nephrectomy for removal of locally extensive renal cell carcinoma that was not technically amenable to conserva tive excision. The need to perform adjunctive surgical renal revasculari zation in these patients is determined by the specific type, location, extent and severity of renal artery disease. The major clinical considerations are the presence and severity of associ ated hypertension, and the risk of ischemic renal failure from progressive vascular disease. Atherosclerosis was the cause of renal artery disease in 30 of 34 patients (88%) in this series. Progressive renal arterial obstruction with loss of renal function occurs commonly with this disease, particularly when the af fected renal artery is involved with high grade (more than 75%) stenosis. 9- 11 Therefore, if a significant amount of renal paren chyma is affected by this type of high grade stenosis surgical renal revascularization is indicated to preserve renal func tion. 5 • 12, 13 Severe associated hypertension comprises an addi tional indication for surgical renal revascularization when the blood pressure cannot be adequately controlled with medical treatment. 1 4 In our series surgical renal revascularization was performed for these indications in 7 patients with atheroscle rotic renal artery disease simultaneous with either partial (5) or radical (2) nephrectomy. These patients had ostial athero sclerotic lesions that were not amenable to treatment with percutaneous transluminal angioplasty. 1 5 In 2 patients from this series the cause of renal artery disease was medial fibroplasia. While this type of vascular disease can cause renin-mediated hypertension, it does not pose a signifi cant threat to overall renal function. 9 One patient underwent surgical renal revascularization for medial fibroplasia causing significant hypertension, while 1 with medial fibroplasia had only moderate renal artery stenosis that did not require treat ment. Surgical treatment for renal artery disease was also not necessary in 1 patient with an asymptomatic arteriovenous malformation and 1 patient with a small renal artery aneurysm. All of our patients underwent complete surgical excision of renal cell carcinoma, including 8 who also underwent simulta neous renal vascular reconstruction. The performance of si multaneous surgical tenal revascularization was well tolerated with no increased morbidity and all revascularization opera tions were technically successful. One of the revascularized patients had end stage renal failure postoperatively due to 6
progressive nephrosclerosis. Postoperative blood pressure con trol was improved in all 8 patients undergoing surgical renal revascularization. Overall, stable postoperative preservation of renal function was achieved in 33 of 34 patients (97%). The predominant use of nephron sparing surgery to treat renal cell carcinoma in these patients also yielded satisfactory results with respect to control of the malignancy. Postoperative recurrent renal cell carcinoma developed in only 4 of 30 patients (13.3%), including 2 (6.7%) with local tumor recurrence in the operated kidney. These results mirror our wider experience with nephron sparing surgery for treatment of localized renal cell carcinoma. 3 • 7 In the overall series of 34 patients 23 (68%) are tumor-free (mean followup 44 months), while 6 (17%) died of unrelated causes (mean followup 29 months) with no evidence of malig nancy at death. Three patients died of metastatic renal cell carcinoma (mean survival 79 months), while 2 are alive with recurrent renal cell carcinoma (mean followup 95 months). In summary, these results indicate that nephron sparing surgery in conjunction with selective renal arterial reconstruc tion can provide effective therapy for patients with renal cell carcinoma and renal artery disease affecting all of the function ing renal parenchyma. Multiple factors must be weighed when determining the optimal approach for each individual patient. The data presented are encouraging and suggest that cancer free survival with preservation of renal function can be achieved in most patients. REFERENCES 1. Kaufman, J. J., Marks, L. S. and Smith, R. B.: Stenosis of the renal artery and coexistent lesions. Surg., Gynec. & Obst., 139: 59, 1974. 2. Dean, R. H., Meacham, P. W. and Weaver, F. A.: Ex vivo renal artery reconstructions: indications and techniques. J. Vase. Surg., 4: 546, 1986. 3. Novick, A. C., Streem, S., Montie, J. E., Pontes, J. E., Siegel, S., Montague, D. K. and Goormastic, M.: Conservative surgery for renal cell carcinoma: a single-center experience with 100 pa tients. J. Urol., 1 4 1 : 835, 1989. 4. Hermanek, P. and Sobin, L. H.: TNM Classification of Malignant Tumours, 4th ed. New York: Springer-Verlag, pp. 146-148, 1987. 5. Novick, A. C.: Selection of patients with atherosclerosis for renal reconstruction to preserve renal function. World J. Urol., 7: 98, 1989. 6. Novick, A. C.: Partial nephrectomy for renal cell carcinoma. Urol. Clin. N. Amer., 14: 419, 1987. 7. Novick, A. C.: The role of renal-sparing surgery for renal cell carcinoma. Sem. Urol., 10: 12, 1992. 8. Morgan, W. R. and Zinke, H.: Progression and survival after renal-
RENAL CELL CARCINOMA WITH C O EXISTENT RENAL ARTERY DISEASE
9. 10. 11.
12.
conserving surgery fo r renal cell carcinoma: experience i n 104 patients and extended followup. J. Urol., 1 44: 852, 1990. Schreiber, M. J., Pohl, M. A. and Novick, A. C.: The natural history of atherosclerotic and fibrous renal artery disease. Urol. Clin. N. Amer., 1 1 : 383, 1984. Meaney, T. F., Dustan, H . P. and McCormack, L. J.: Natural history of renal arterial disease. Radiology, 9 1 : 881 , 1968. Dean, R. H., Kieffer, R. W., Smith, B. M., Oates, J. A., Nadeau, J. H. J., Hollifield, J. W. and DuPont, W. D.: Renovascular hyper tension: anatomic and renal function changes during drug ther apy. Arch. Surg., 1 1 6 : 1408, 198 1 . Libertino, J. A., Bosco, P. J., Ying, C . Y . , Breslin, D. J., Woods, B.
813
0., Tsapatsaris, N. P. and Swinton, N. W., Jr.: Renal revascu larization to preserve and restore renal function. J. Urol., 1 4 7 : 1485, 1992. 13. Novick, A. C., Pohl, M. A., Schreiber, M. J., Gifford, R. W., Jr. and Vidt, D . G.: Revascularization for preservation of renal function in patients with atherosclerotic renovascular disease. J. Urol., 129: 907, 1983. 14. Novick, A. C.: Surgical correction of renovascular hyp ertension. Surg. Clin. N. Amer. , 68: 1007, 1988. 15. Flechner, S. M.: Percutaneous transluminal dilation. A realistic appraisal in patients with stenosing lesions of the renal artery. Urol. Clin. N. Amer. , 1 1 : 515, 1984.