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Renal Masses
DJ22-534 7 /85/1332-0251$02.GO/O 'TH2 jouRr;t,.I., CF UROLOGY
Ccpy:l'ight © 1985 by The V-/illiams & V/ilkins Co.
Editorial RENAL MASSES Extension of renal cell carcinoma into the inferior vena cava the confirmation of the presence of oncocytes by fine needle does not necessarily portend an unfavorable outcome, provided aspiration of the mass. However, the authors were properly the tumor can be excised completely and there are no regional skeptical about the findings and approached the tumor with or distant metastases. The methods to remove vena caval uncertainty as to its identity, convinced of its true nature only thrombi successfully have been devised and refined during the when "after generous sampling, neoplastic cells were not idenlast several decades. 1 A limited vena caval tumor thrombus tified". As pointed out by Lieber and associates,2 well differextending to a point below the hepatic veins presents little entiated renal carcinomas may contain foci of oncocytoma technical difficulty, and such thrombi seldom occlude the vena mixed with true malignant tissue. The authors imply that in cava completely. However, thrombi extending above the hepatic the present state of our lack of understanding of the natural veins pose a difficult surgical challenge, with success measured history of oncocytomas the management is unclear, suggesting by the degree of morbidity, extent of relief of symptoms and that more aggressive treatment would have been appropriate had the patient not had tuberous sclerosis. This philosophy r.emoval of all malignant tissue. The article in this issue by Marshall and Reitz (page 266) accurately presents the current state of the art in the manageaddresses some of the technical points necessary to achieve ment of oncocytomas. However, conservative resection of small these goals and introduces a valuable adjunct in the surgical tumors, even of small malignant tumors, is an emerging philosmanagement of these patients. The use of a pericardial patch ophy, the efficacy of which is unproved but the rationale of for segmental construction of the wall of the vena cava is a which is reflected in the successful conservative excision of method that should be in every urologist's armamentarium. renal carcinomas in the solitary kidney. 3 Although the hypothThe authors rightly note that compromising the lumen of the esis remains largely untested, one wonders whether the patient inferior vena cava 50 per cent or greater presents a high risk of would not still have been best served with partial resection of vena caval thrombosis with its complications of chronic edema the lesion, regardless of its histological nature. and potential pulmonary emboli. Partial venacavectomy is posThe emergence of interventional uroradiology and the prosible using this method of reconstruction and may be important fusion of methods for renal artery cannulation and embolizain patients with invasion of the vena cava by tumor, in the tion has spawned widespread enthusiasm for preoperative renal absence of sufficient collateral venous circulation. However, angioinfarction. Occlusion of the renal artery has been advodirect invasion is not a common occurrence and thrombectomy cated for 2 major purposes: to facilitate radical nephrectomy usually is sufficient to remove all tumor. Extensive invasion of and as an adjunct to nephrectomy in patients with metastatic the vena cava requires venacavectomy, and complete replace- disease for the purpose of achieving a systemic effect. The ment of the entire circumference of the vena cava with pericar- article by Christensen and associates (page 191) addresses the dium, although postulated by the authors, has not been proved issue of whether embolization influences the morbidity of radto be feasible. Therefore, the method has limited application ical nephrectomy. The limitations of angioinfarction are unbut, nonetheless, represents a valuable innovation in selected derscored by the fact that 19 per cent of the tumors were not patients, successfully embolized. Furthermore, the post-infarction synThe paper Srinivas and associates (page 263) addresses drome was manifested to greater or lesser degree in all patients. another important clinical problem related to the management Although there were no mortalities, deaths have been reported of renal masses. Perhaps the most important message in their in other series. 4 · 5 The authors were unable to find any advancase report is the necessity for conservative excision of renal tage in terms of operating time or blood loss attributable to masses in patients with tuberous sclerosis owing to the known routine preoperative embolization, generally performed 1 propensity for bilateral tumor development. Their fascinating before surgery, The basis for comparison was a historical concase also reminds us that tumors other than angiomyolipomas trol group that did not have preoperative angioinfarction and, occur in the kidneys of patients with tuberous sclerosis and the therefore, results are difficult to compare. diagnosis cannot be presumed. Their patient exemplifies the Routine preoperative infarction, although practiced at some problems encountered in making a preoperative diagnosis of institutions, is generally believed to be unnecessary and imthe nature of a renal mass with the various diagnostic methods poses a real although slight added risk to the patient and added currently available. The pyelogram clearly was not diagnostic cost. In this study the procedure was performed at the time of and the computerized tomography (CT) scan, although it elim- routine angiography. Since CT and perhaps magnetic resonance inated the probability of angiomyolipoma due to the absence of imaging are largely replacing angiography in most centers, fat, did not indicate the true malignant potential of the lesion. angioinfarction becomes especially burdensome. Most uroloIn addition, the angiogram failed to show the typical "spoke gists would agree with the final assessment of the authors, that wheel" pattern supposedly diagnostic of renal oncocytoma. is this method confers no distinct advantage and is probably Clearly, even in a cost-containment environment we must still best restricted to patients with large renal carcinomas containdepend on a multitude of tests in certain cases, each of which ing profuse collateral venous circulation. Although the intent provides a kernel of diagnostic information, the sum of which of the paper was not to explore the potential systemic effects of angioinfarction, the authors were unable to notice any difbrings us as close as possible to a preoperative diagnosis. An unusual aspect of the report by Srinivas and associates is ference in survival between the control group and the infarcted 251
252 group. The efficacy of infarction in metastatic disease has not been demonstrated clearly and this study supports the impression that "responses" may simply be secondary to natural history factors or to tumor burden. 6 After nearly a decade of enthusiasm the role of angioinfarction for any purpose seems to be diminishing rapidly. These 3 papers, although focused on varied aspects of renal masses, reflect the fact that surgical excision is still the only effective management for renal tumors. While searching for systemic agents, we must continue to refine our methods of diagnosis and surgical treatment, and each of these authors has contributed another important step in the direction of more effective management of renal neoplasms. Jean B. deKernion Division of Urology UCLA Medical Center 10833 Le Conte Avenue Los Angeles, California 90024
REFERENCES
1. Klein, F. A., Smith, M. J. V. and Greenfield, L. J.: Extracorporeal circulation for renal cell carcinoma with supradiaphragmatic vena caval thrombi. J. Urol., 131: 880, 1984. 2. Lieber, M. M., Tomera, K. M. and Farrow, G. M.: Renal oncocytoma. J. Urol., 125: 481, 1981. 3. Topley, M., Novick, A. C. and Montie, J. E.: Long-term results following partial nephrectomy for localized renal adenocarcinoma ..J. Urol., 131: 1050, 1984. 4. Teasdale,.C., Kirk, D., Jeans, W. D., Penry, J.B., Tribe, C. T. and Slade, N.: Arterial embolisation in renal carcinoma: a useful . procedure? Brit. J. Urol., 54: 616, 1982. 5. WaHace, S., Chuang, V. P., Swanson, D., Bracken, B., Hersh, E. M., Ayala, A. and Johnson, D.: Embolization of renal carcinoma. Radiology, 138: 563, 1981. 6. Swanson, D. A., Johnson, D. E., von Eschenbach, A. C., Chuang, V. P. and Wallace, S.: Angioinfarction plus nephrectomy for metastatic renal cell carcinoma-an update. J. Urol., 130: 449, 1983.
Ccpy:l'ight © 1985 by The V-/illiams & V/ilkins Co.
Editorial RENAL MASSES Extension of renal cell carcinoma into the inferior vena cava the confirmation of the presence of oncocytes by fine needle does not necessarily portend an unfavorable outcome, provided aspiration of the mass. However, the authors were properly the tumor can be excised completely and there are no regional skeptical about the findings and approached the tumor with or distant metastases. The methods to remove vena caval uncertainty as to its identity, convinced of its true nature only thrombi successfully have been devised and refined during the when "after generous sampling, neoplastic cells were not idenlast several decades. 1 A limited vena caval tumor thrombus tified". As pointed out by Lieber and associates,2 well differextending to a point below the hepatic veins presents little entiated renal carcinomas may contain foci of oncocytoma technical difficulty, and such thrombi seldom occlude the vena mixed with true malignant tissue. The authors imply that in cava completely. However, thrombi extending above the hepatic the present state of our lack of understanding of the natural veins pose a difficult surgical challenge, with success measured history of oncocytomas the management is unclear, suggesting by the degree of morbidity, extent of relief of symptoms and that more aggressive treatment would have been appropriate had the patient not had tuberous sclerosis. This philosophy r.emoval of all malignant tissue. The article in this issue by Marshall and Reitz (page 266) accurately presents the current state of the art in the manageaddresses some of the technical points necessary to achieve ment of oncocytomas. However, conservative resection of small these goals and introduces a valuable adjunct in the surgical tumors, even of small malignant tumors, is an emerging philosmanagement of these patients. The use of a pericardial patch ophy, the efficacy of which is unproved but the rationale of for segmental construction of the wall of the vena cava is a which is reflected in the successful conservative excision of method that should be in every urologist's armamentarium. renal carcinomas in the solitary kidney. 3 Although the hypothThe authors rightly note that compromising the lumen of the esis remains largely untested, one wonders whether the patient inferior vena cava 50 per cent or greater presents a high risk of would not still have been best served with partial resection of vena caval thrombosis with its complications of chronic edema the lesion, regardless of its histological nature. and potential pulmonary emboli. Partial venacavectomy is posThe emergence of interventional uroradiology and the prosible using this method of reconstruction and may be important fusion of methods for renal artery cannulation and embolizain patients with invasion of the vena cava by tumor, in the tion has spawned widespread enthusiasm for preoperative renal absence of sufficient collateral venous circulation. However, angioinfarction. Occlusion of the renal artery has been advodirect invasion is not a common occurrence and thrombectomy cated for 2 major purposes: to facilitate radical nephrectomy usually is sufficient to remove all tumor. Extensive invasion of and as an adjunct to nephrectomy in patients with metastatic the vena cava requires venacavectomy, and complete replace- disease for the purpose of achieving a systemic effect. The ment of the entire circumference of the vena cava with pericar- article by Christensen and associates (page 191) addresses the dium, although postulated by the authors, has not been proved issue of whether embolization influences the morbidity of radto be feasible. Therefore, the method has limited application ical nephrectomy. The limitations of angioinfarction are unbut, nonetheless, represents a valuable innovation in selected derscored by the fact that 19 per cent of the tumors were not patients, successfully embolized. Furthermore, the post-infarction synThe paper Srinivas and associates (page 263) addresses drome was manifested to greater or lesser degree in all patients. another important clinical problem related to the management Although there were no mortalities, deaths have been reported of renal masses. Perhaps the most important message in their in other series. 4 · 5 The authors were unable to find any advancase report is the necessity for conservative excision of renal tage in terms of operating time or blood loss attributable to masses in patients with tuberous sclerosis owing to the known routine preoperative embolization, generally performed 1 propensity for bilateral tumor development. Their fascinating before surgery, The basis for comparison was a historical concase also reminds us that tumors other than angiomyolipomas trol group that did not have preoperative angioinfarction and, occur in the kidneys of patients with tuberous sclerosis and the therefore, results are difficult to compare. diagnosis cannot be presumed. Their patient exemplifies the Routine preoperative infarction, although practiced at some problems encountered in making a preoperative diagnosis of institutions, is generally believed to be unnecessary and imthe nature of a renal mass with the various diagnostic methods poses a real although slight added risk to the patient and added currently available. The pyelogram clearly was not diagnostic cost. In this study the procedure was performed at the time of and the computerized tomography (CT) scan, although it elim- routine angiography. Since CT and perhaps magnetic resonance inated the probability of angiomyolipoma due to the absence of imaging are largely replacing angiography in most centers, fat, did not indicate the true malignant potential of the lesion. angioinfarction becomes especially burdensome. Most uroloIn addition, the angiogram failed to show the typical "spoke gists would agree with the final assessment of the authors, that wheel" pattern supposedly diagnostic of renal oncocytoma. is this method confers no distinct advantage and is probably Clearly, even in a cost-containment environment we must still best restricted to patients with large renal carcinomas containdepend on a multitude of tests in certain cases, each of which ing profuse collateral venous circulation. Although the intent provides a kernel of diagnostic information, the sum of which of the paper was not to explore the potential systemic effects of angioinfarction, the authors were unable to notice any difbrings us as close as possible to a preoperative diagnosis. An unusual aspect of the report by Srinivas and associates is ference in survival between the control group and the infarcted 251
252 group. The efficacy of infarction in metastatic disease has not been demonstrated clearly and this study supports the impression that "responses" may simply be secondary to natural history factors or to tumor burden. 6 After nearly a decade of enthusiasm the role of angioinfarction for any purpose seems to be diminishing rapidly. These 3 papers, although focused on varied aspects of renal masses, reflect the fact that surgical excision is still the only effective management for renal tumors. While searching for systemic agents, we must continue to refine our methods of diagnosis and surgical treatment, and each of these authors has contributed another important step in the direction of more effective management of renal neoplasms. Jean B. deKernion Division of Urology UCLA Medical Center 10833 Le Conte Avenue Los Angeles, California 90024
REFERENCES
1. Klein, F. A., Smith, M. J. V. and Greenfield, L. J.: Extracorporeal circulation for renal cell carcinoma with supradiaphragmatic vena caval thrombi. J. Urol., 131: 880, 1984. 2. Lieber, M. M., Tomera, K. M. and Farrow, G. M.: Renal oncocytoma. J. Urol., 125: 481, 1981. 3. Topley, M., Novick, A. C. and Montie, J. E.: Long-term results following partial nephrectomy for localized renal adenocarcinoma ..J. Urol., 131: 1050, 1984. 4. Teasdale,.C., Kirk, D., Jeans, W. D., Penry, J.B., Tribe, C. T. and Slade, N.: Arterial embolisation in renal carcinoma: a useful . procedure? Brit. J. Urol., 54: 616, 1982. 5. WaHace, S., Chuang, V. P., Swanson, D., Bracken, B., Hersh, E. M., Ayala, A. and Johnson, D.: Embolization of renal carcinoma. Radiology, 138: 563, 1981. 6. Swanson, D. A., Johnson, D. E., von Eschenbach, A. C., Chuang, V. P. and Wallace, S.: Angioinfarction plus nephrectomy for metastatic renal cell carcinoma-an update. J. Urol., 130: 449, 1983.