Aug. 11, 2023
Navigating the Complexities of Renal Tumors with Dr. Mark Lloyd
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Ready to peel back the layers of the medical universe and step into the world of renal cancer? We've got your ticket right here! Joined by urological surgeon, Dr Mark Lloyd, we journey into the intricacies of renal cancer.
In a riveting discussion with our host Dr Gavin Nimon (Adelaide Orthopaedic Surgeon), Dr Lloyd unveils the subgroups of renal cancer, the genetic marvel of the von Hippel Lindau gene, and targeted treatment, such as Sunitinib. Further, we familiarize ourselves with the TNM staging system, a crucial tool in determining the most beneficial treatment method for the patient.
As we dissect the treatment landscape for renal carcinoma, we encounter robotic surgery, whose precision goes beyond the grasp of the human hand. We tackle minimally invasive techniques like laparoscopic nephrectomy and robotic partial nephrectomy, used widely for treating renal tumors. Weighing in on focal therapy, an alternative route to surgical intervention, we discuss its effectiveness in small renal tumors and the types of tumors suitable for thermal treatments. So gear up for a roller coaster ride through the world of renal cancer!
Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.
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Transcript
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You may not be aware, but cancer of the kidney, or renal cancer, is in the top 10 cancers that affect men and women, with twice the incidence of men, or one in 50 chance of a lifelong risk of developing it.
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If diagnosed early, it'd be quite curable.
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Today we're going to learn more on Aussie Med Ed.
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Good day and welcome to , the Australian Medical Education podcast, a program born during COVID times to emulate the general chit, chat and banter around the hospital with the idea of educating the medical, student and GP alike.
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I'm Gavin Nimon, an orthopedic surgeon based in Adelaide, and it's my pleasure to bring to you.
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And today we're joined by Dr Mark Lloyd, a urological surgeon with 20 years of experience.
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He's a graduate from the University of Adelaide and a member of the Royal Australasian College of Surgeons and the Urological Society of Australasia.
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He's a senior lecturer with the University of Adelaide and his interests are kidney and bladder health, men's health and prostate disorders.
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He's going to talk to us about renal cancers and how they're diagnosed and treated.
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I'd like to start by acknowledging the traditional owners of the land on which this podcast has been the Kaurna people, and pay my respect to the elders, both past, present and emerging.
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Well, it's my pleasure now to introduce Dr Mark Lloyd, a friend and colleague from the Queen Elizabeth Hospital in Adelaide.
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He's a specialist in renal carcinoma and he's going to give us some insight about this particular condition.
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Welcome, Mark.
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Thanks, Gavin.
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Thanks for asking me to talk today about renal tumors and renal carcinoma in particular.
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It's a particular interest of mine.
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I'm a surgeon and I perform surgery on renal tumors on a regular basis.
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I'm very pleased to answer any questions that you have about renal tumors and the presentation and treatment of them.
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Thanks, Gavin.
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Yes, great to have you on board.
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Perhaps you can outline why renal cancer is important and what the subgroups there are of renal cancer.
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So renal cancers comprise about 5% of adult malignancies, so they are a common malignancy.
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So we do need to know about them because of the frequency of their occurrence.
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So really they can be divided into primary malignancies of the kidney and secondary malignancies of the kidney.
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Now secondary malignancies of the kidney are fortunately quite rare.
00:02:06.147 --> 00:02:10.454
So we're mostly dealing with primary malignancies of the kidney.
00:02:11.020 --> 00:02:18.979
Now the vast majority are renal carcinoma, which is a primary kidney cancer, and most of them are to clear cell carcinomas.
00:02:18.979 --> 00:02:21.979
And you might wonder why they're called clear cell carcinomas.
00:02:21.979 --> 00:02:36.616
That's because the staining on histology, when they perform a stain on the cells, are washed out and so appear clear or see-through on the histology of the H&E stain.
00:02:36.616 --> 00:02:40.025
So that is about 80% of renal tumors.
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Are these clear cell carcinomas, which is a primary tumor of the kidney?
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There are some variants of this and that includes papillary renal cell carcinoma, which comprises about 10% of renal malignancies, and this is more aggressive than the typical clear cell, and also chromophobic carcinoma, which also has a typical appearance on H&E staining, and this comprises about 5% of tumors and has a low malignant potential.
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So those are the three different types of renal cell carcinomas.
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Now there are in the differential diagnosis a number of different diagnoses which can be responsible for a mass in the kidney, and those can include other types of tumors, such as lymphoma, which may occur in an elderly person, or a Wilms tumor, which is seen in children and usually under the age of five years.
00:03:36.969 --> 00:04:01.000
There are other benign conditions which can occur, which include benign tumor, which is called an angiomyalipoma, which is composed of, as the name suggests, blood vessels, muscle cells and fat and has a typical appearance on a CT scan, and an oncocytoma, which is a type of benign renal tumor which is very slow growing.
00:04:01.540 --> 00:04:05.909
Well, that's a nice simple classification system, but how do these renal cancers present?
00:04:05.909 --> 00:04:07.913
What's the most common way they present to you?
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We were taught back in medical student days that someone would appear with a classic sign of pain in the loin, a mass in the abdomen and blood in urine.
00:04:19.980 --> 00:04:27.894
But the fact is that most of these tumors these days are referred with an incidental finding on an ultrasound.
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So it used to be that these tumors were diagnosed when the situation was quite advanced.
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But now we've been increasingly being referred tumors which are really quite small, with early detection on ultrasound, which is great because it means they're more easy for us to treat.
00:04:43.841 --> 00:04:51.168
And if you're were suspecting a renal cancer, is an ultrasound the best way of investigating for one, perhaps for someone who has blood in the urine or you're concerned about a renal mass.
00:04:52.180 --> 00:04:56.807
An ultrasound is pretty good but may miss some small renal masses.
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An MRI or a CT scan will have a very good sensitivity for detecting renal masses.
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The key thing here is to make sure that someone who has hematuria that is, blood in the urine has a proper investigation not only of the kidneys but also of the bladder to exclude a carcinoma.
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So we would suggest that everyone who has blood in the urine undergoes at least an ultrasound or preferably, if there is visible blood in the urine, a contrast CT scan of the urinary tract.
00:05:29.120 --> 00:05:35.980
And Mark, t he fact that these cancers are picked up, incidentally, to my mind might suggest that they're a bit more slow growing than the average type of cancer we're worried about.
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Is that the case?
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Yes, that's exactly right.
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So a typical renal tumor has a growth rate of between 1 and 3 millimetres per year.
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So this is a slow growing tumor and it's thought that many renal tumors which are detected have been there for many years prior to detection and in fact it takes quite a bit of growth for a renal tumor to become symptomatic in terms of either pain or blood in the urine.
00:06:02.595 --> 00:06:11.690
So these tumors, especially in elderly patients, there is a role for surveillance, which is conservative management of a renal tumor.
00:06:11.690 --> 00:06:18.980
If the patient is not fit for surgery, then that is an appropriate treatment choice for those patients.
00:06:19.622 --> 00:06:25.980
Now, obviously back pain is quite common, but what aspects of back pain will make you a bit more concerned to investigate for renal cancer?
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Sure?
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So I think with the history, if someone has central back pain that's more likely to be related to the spine.
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If anyone has symptoms of loin pain, then that is more suggestive of a renal abnormality.
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It's difficult, on history too, tell those two things apart to be honest.
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So I think if someone has back pain, if they have look, if they have risk factors for a renal tumour, so those risk factors for arenal tumour would be age, smoking and male gender.
00:07:03.290 --> 00:07:09.672
Those significant risk factors should be taken into account and a previous history of cancer.
00:07:09.805 --> 00:07:15.454
So any other cancer in any other system increases the risk of cancer in the urinary tract.
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So I think if patients have those risk factors and there is some suspicion that back pain could be malignant, then they should have an ultrasound or a CT scan.
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And the other thing of course to remember in the elderly patient would be prostate cancer, which has a predisposition to bony metastases that can also present with back pain.
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So I think if there's doubt and there's concern about the possibility of a renal malignancy, a urine test to exclude e-maturia should be done and in men with possible prostate malignancy a PSA test should be obtained to screen for those conditions and if there is concern, then a CT scan of the abdomen will help with that diagnosis.
00:08:00.384 --> 00:08:08.632
And putting it into perspective what would be the chance, or how often have you seen someone who presented with a simple back pain to an orthopedic surgeon then be identified as having a renal cancer?
00:08:09.564 --> 00:08:25.336
It's not common but I have seen actually more likely, I have seen patients with kidney stones who've presented with back pain that in the younger age group that is a more common finding and again, those patients usually also would have blood in the urine.
00:08:25.336 --> 00:08:36.413
So look, I don't think this is a common finding and I know that the guidelines for back pain in the primary healthcare setting suggests that imaging is not a routine.
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So I think that if a GP is seeing a patient with back pain, they should be concerned.
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If the patient has risk factors or family history of malignancy, those patients should be the ones that should be screened.
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And obviously, if the patient does have imaging for their spine and no specific cause is found, then you would go on to investigate other organ systems.
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And do all renal cancers have blood in the urine?
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Or if you have a negative dipstick, does that exclude renal cancer as a cause?
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You can still get it.
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A dipstick testing for blood in the urine is commonly done as a screening medical test and it's commonly done by insurance companies prior to taking out occupational health insurance.
00:09:18.216 --> 00:09:29.190
So we do get patients referred with microscopic hematuria but in those younger patients, the vast majority of those patients investigations prove negative.
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So in fact up to 10% of the population, sometimes higher than that, can have incidental microscopic hematuria.
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So microscopic hematuria has poor specificity for an abnormality of the urine retract because of the common false positives associated with blood in the urine.
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But I think screening is a different situation to investigating someone with symptoms.
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If someone has symptoms and they have a positive urine dipstick, then the chance of an underlying abnormality is much higher, obviously, than if you're screening an asymptomatic patient.
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You've touched upon the risk factors.
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Are there any other risk factors apart from male and smoking and age that you've mentioned as well?
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There are.
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So we know that renal carcinomas are increasing in incidents and this is related to hypertension and obesity and chronic kidney disease.
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So these conditions are increasing in the community and they're known to increase the risk of renal carcinoma.
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So smoking also increases the risk two to two and a half times, and the male-female ratio is two to one.
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Patients with diabetes also get chronic kidney disease and this increases the risk of renal carcinoma in terms of the chronic kidney disease, and those patients with end-stage renal failure also have a higher risk of renal carcinoma.
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So those patients have actually gone on to have had renal failure and had a renal transplant.
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Do they have a higher risk of developing cancer in that transplant as well, or is that just purely the renal disease itself?
00:11:06.405 --> 00:11:12.975
It's the renal disease and the immunosuppression that goes along with the treatment of the renal transplant.
00:11:12.975 --> 00:11:18.210
So the risk of the carcinoma is in the native kidneys, the failing kidneys.
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The transplanted kidney is always a very healthy kidney, so this has a very low risk of a renal tumor.
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Gee, that's unfortunate.
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Then you mean the kidney that's caused the requirement for the transplant is also the one that goes on to get cancer.
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Do they think about removing that kidney at the time of surgery to prevent this?
00:11:38.284 --> 00:11:40.493
Yeah, look, that's a great question, gavin.
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And look in decades ago, when I first trained, patients had their what they call their native kidneys that is, the failing kidneys removed prior to transplantation and the thought was, they're not so much to prevent the tumors, but it was thought that the native kidneys produced chemical messengers that led to kidney disease and hypertension, and they found those conditions the hypertension associated with failing kidneys difficult to treat.
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Now, with new drugs, they're well able to treat that, but the issue now is that the kidneys are left behind, so they actually undergo regular ultrasound.
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Of course, if the patient then presents with a mass in the failing kidney, then they have to have a nephrectomy, but the incidence is not so high as to justify patients having a prophylactic nephrectomy.
00:12:36.705 --> 00:12:38.873
And what's thought to be the cause of renal carcinoma.
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What's the pathogenesis of it?
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Does it lead to scarring or generalized inflammation, particularly in these scenarios, or does it occur de novo?
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It is thought in that situation of those particular patients to be scarring and chronic infection which leads to the development of a renal carcinoma.
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But that is just a small number of the overall patients who develop renal carcinoma.
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So 80% of renal carcinomas are spontaneous and sporadic.
00:13:06.899 --> 00:13:16.534
And they've done a lot of research on the genetics of renal carcinomas and they found a gene called the von Hippel Lindau gene.
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Now von Hippel Lindau is a syndrome which is associated with increased risk of renal carcinoma and this syndrome was associated with an abnormality in chromosome three called the von Hippel Lindau gene.
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Now that was investigated and the discovery of that gene allowed the development of an antibody which targeted the cytokine called vascular endothelial growth factor which was produced by this gene.
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So this was one of the first treatments using targeted treatments towards a cytokine produced by Tumour, and that drug which was developed was called Sunitinib and Sunitinib was the first drug really that we had available to treat patients with metastatic renal carcinoma.
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Prior to that there was very little treatment for patients with metastatic renal carcinoma Hemotherapy, most chemotherapy drugs being ineffective to treat renal carcinoma.
00:14:20.725 --> 00:14:21.825
Excellent Look.
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You mentioned earlier on a Wilms Tumour, which is a tumor that occurs under the age of five.
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Perhaps you can explain to us what a Wilms Tumour actually is, and is this genus associated with a Wilms Tumour?
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Is this what causes it?
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I have to first say I'm not a pediatric urologist so I don't actually see patients with Wilms Tuma.
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I'm an adult urologist.
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But Wilms Tuma is a tumor which is developed in the third to fourth year of life.
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It presents with abdominal pain and hematuria in a young child.
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It is usually unilateral.
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It's associated with a defect in chromosome one.
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It's a different genetic abnormality compared to the adult renal carcinomas.
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Its management is normally surgical with nephrectomy.
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It has a good prognosis when it's picked up early and it has an entirely different genetic abnormality compared to the tumors that develop in the adult.
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The Tumor with Wilms Tumour is often picked up when the tumor is quite big.
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It's picked up as an abdominal mass and those patients that have a large tumor may need to go on and have chemotherapy treatment.
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But the prognosis has improved markedly over the last decade in terms of treatment of Wilms Tumour.
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Yeah, so it's usually rare to have a development of a tumour in the other kidney, which is very fortunate.
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But, as I said, I'm not an expert in Wilm's tumour because that's a pediatric condition.
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Yeah, it's a genetic disorder that affects only one kidney.
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That's really unusual, isn't it?
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Yeah, that's right.
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But the surgical treatment would be quite similar to an adult with renal cancer.
00:16:07.076 --> 00:16:10.405
Now, once you've made the diagnosis of renal cancer, what's the next step?
00:16:10.405 --> 00:16:13.443
Do you go on to stage the condition and how do you actually stage it?
00:16:14.056 --> 00:16:15.120
Yeah, that's a great question.
00:16:15.120 --> 00:16:21.528
We perform staging essentially based on the CT scan, which would be our standard investigation.
00:16:21.528 --> 00:16:27.547
So CT scanning enables us to tell exactly what the stage of the tumour is.
00:16:27.547 --> 00:16:38.725
If the CT scan at least just of the urinary tract, you will also do a CT scan of the chest to exclude a metastasis in the lungs.
00:16:38.725 --> 00:16:43.365
So to do the staging we'll use the TNM staging system.
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So we have a T1 tumour which is between 4 and 7 centimetres in size and that's confined to the kidney.
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We have a T2 tumour which is 7 to 10 centimetres, a larger tumour.
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When the tumour becomes larger and pushes into the fat, the perinephoric fat around the kidney, that is classified as a stage T3 tumour.
00:17:06.344 --> 00:17:22.964
Now the renal cartilomas are interesting in that they can invade blood vessels and in terms of renal tumour, this can spread into the renal vein and also into the vena caver, the main vein in the leading blood to the heart.
00:17:22.964 --> 00:17:37.227
Now stage T3B involves a tumour into the vena caver below the diaphragm, and it can go above the diaphragm, even into the atria and the heart stage T3C.
00:17:37.227 --> 00:17:41.644
So you can actually have cardiac involvement of a renal carcinoma.
00:17:42.795 --> 00:17:50.885
Stage T4 is where the tumour invades surrounding organs and then we have the N stage, which is the nodal stage.
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There can be stage 1 for one node, stage 2 for more than one node, and then the M or N stage, which is either 0 for no metastases or 1 for detectable metastases.
00:18:04.508 --> 00:18:08.325
So that's the staging system that we use.
00:18:09.076 --> 00:18:10.338
A number of nodes assessed.
00:18:10.338 --> 00:18:16.182
Is that based upon the CT or MRI or based upon the decision of the nodes and histological diagnosis?
00:18:16.634 --> 00:18:19.222
The staging is a radiological staging system.
00:18:19.222 --> 00:18:32.916
There is a pathological staging system which is used the following removal of the kidney, and that pathological stage may change depending on what pathologist finds In terms of lymph nodes.
00:18:32.916 --> 00:18:42.224
There is been no evidence that excision of lymph nodes associated with a renal carcinoma may have an improvement in prognosis.
00:18:42.224 --> 00:18:51.286
The lymph nodes are usually removed along with the kidney, but we don't normally go searching for lymph nodes when the kidney is removed.
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Usually the tissue alongside the vena cava or the aorta are removed along with the kidney and then the lymph nodes are analysed at that time Regional lymph nodes if they're involved they're close to the kidney will be removed, but if they're more distant and away from the kidney, those mean that the patient will need some adjuvant treatment.
00:19:11.082 --> 00:19:15.605
Adjuvant treatment is treatment with another modality after the surgery.
00:19:16.175 --> 00:19:19.384
Okay, so those patients will then go on to have chemotherapy and other treatment.
00:19:19.384 --> 00:19:28.842
Going back to when the patients are first and issue referred to you, I presume they're presented an MDT or multidisciplinary team and discussed in that process who makes up the members of that team.
00:19:29.355 --> 00:19:51.645
Yeah, the patient would be referred, we would see them in the clinic setting, we would arrange the necessary radiological tests and then we would present their findings at a multidisciplinary team meeting which includes a pathologist, a radiologist and an oncologist, and often a radiation oncologist as well.
00:19:51.645 --> 00:20:04.028
So these are a multidisciplinary team approach, but the treatment of renal carcinoma is primarily a surgical treatment, provided that the disease is surgically receptive.
00:20:04.455 --> 00:20:05.740
Now we're in sudden cancers.
00:20:05.740 --> 00:20:08.272
Chemotherapy is undertaken prior to surgery.
00:20:08.272 --> 00:20:12.185
Is that ever required in renal cancer as well, depending on the stage of the condition?
00:20:12.736 --> 00:20:13.840
Yeah, that's a great question.
00:20:13.840 --> 00:20:25.085
So, in terms of the treatment, first the staging I mentioned that the stage T1 was the 4 to 7 centimetre tumours and the stage 2 is the 7 to 10 centimetres.
00:20:25.085 --> 00:20:40.863
Both two staging systems are used because stage T1 is usually amenable to removal of the tumour without whole kidney, and that's called a partial nephrectomy or a partial removal of the kidney with the tumour in it.
00:20:40.863 --> 00:20:55.788
The stage T2, which is the 7 to 10 centimetres, as the tumour becomes larger it invades more of the kidney and so the recommended treatment is a total, or we call a radical, nephrectomy.
00:20:55.788 --> 00:21:02.779
That would also be done if the tumour is invading into the fat where the kidney is removed with the surrounding fat.
00:21:02.779 --> 00:21:26.123
Obviously, if the tumour is involving the main blood vessels, renal vein or the inferior vena cava, then we usually call on our vascular surgeons to help us with that, and the tumour can still be cured even in that situation, as the tumour can be removed from within the vena cava at the time of surgery.
00:21:26.494 --> 00:21:33.804
And in that scenario, do they actually remove the vena cava and use a graft to replace it, or do they actually just remove the endothelial wall and leave it to revascularise?
00:21:34.894 --> 00:21:38.221
Luckily, normally the tumours don't invade the vascular wall.
00:21:38.221 --> 00:21:51.664
They are more a projection of a tongue of tumour into the renal vein or the vena cava, and so these tumours can be removed without having to remove the wall of the vena cava.
00:21:51.664 --> 00:22:02.865
It seems that the tumours can exist within the lumen of the vessel without actually invading the vessel itself, so normally the blood vessel or the vein can be closed primarily.
00:22:03.376 --> 00:22:11.881
Now, Mark, if the treatment of renal cancers predominantly surgery, in effect removing part of the kidney, is there anything you need to do prior to surgery to assess that it's actually safe to proceed?
00:22:12.355 --> 00:22:24.423
Part of the assessment of the patient, we would assess their kidney function, because if we're removing a kidney, clearly we need to be sure that the other kidney is functioning properly Before the surgery and after the surgery.
00:22:24.503 --> 00:22:37.635
We'll be monitoring kidney function quite closely to make sure that the other kidney is working well, monitoring urine output, monitoring serum, creatinine and electrolytes postoperatively and an optimising renal function.
00:22:37.635 --> 00:23:07.367
That can involve checking the patient's medications and may involve involvement of a renal physician if there is renal impairment, and optimising their drugs and avoiding any drugs which are nephrotoxic, that is, drugs that can reduce kidney function, which can include non-steroidal anti-inflammatory drugs, some antibiotics and a range of other drugs which we need to make sure that the patients avoid to optimise their kidney function.
00:23:07.935 --> 00:23:11.665
Okay, so once you've made the decision to perform a surgery, how has it actually performed?
00:23:11.665 --> 00:23:16.315
I understand the kidney sits in the retroperitoneum, ie behind the peritoneal cavity.
00:23:16.315 --> 00:23:20.605
Do you go through the peritoneum or do you actually go through the loin and just behind the muscles?
00:23:21.375 --> 00:23:31.003
So, Gavin, the nephrectomy is classically performed with an incision in the through the loin, which is a retroperitoneal approach, as you point out.
00:23:31.003 --> 00:23:44.426
I'll just explain that the peritoneum is an abdominal cavity which contains the intra-abdominal organs, such as the bowel, stomach and other intra-abdominal contents.
00:23:44.426 --> 00:24:07.586
The peritoneum is a thin layer which lines the abdominal cavity and, you're right, the kidneys, the ureters and the bladder lie behind the peritoneum, so the approach to the kidney can be through the side, which involves not entering the peritoneal cavity but entering the retroperitoneal area and removing the kidney that way.
00:24:07.586 --> 00:24:14.656
So this was the classic way of performing nephrectomy is through the side, with a retroperitoneal approach.
00:24:14.656 --> 00:24:31.503
In particular cases, an intra-peritoneal approach is taken, and this is particularly for larger tumours and those with vascular involvement, because the intra-peritoneal approach allows for a better approach to the major vessels which can be involved.
00:24:32.346 --> 00:24:36.616
Of late, minimally invasive techniques became used.
00:24:36.616 --> 00:24:48.912
Laparoscopic nephrectomy was developed 20 years ago and is a very effective technique for removing renal tumors which are confined to the kidney.
00:24:48.912 --> 00:25:09.056
This was followed by robotic approaches allowing on-dome, minimal invasive techniques to be employed, and particularly effective in the situation of a partial nephrectomy, where a partial nephrectomy can be performed with reconstruction of the renal defect via a minimally interventional technique.
00:25:09.056 --> 00:25:20.074
This partial nephrectomy, performed robotically, would be the mainstay of treatment for small renal tumors in patients who are suitable for surgery.
00:25:20.074 --> 00:25:31.095
The open surgery is now reserved for those patients who are either not suitable for minimally invasive techniques or who have larger tumors which require an open approach.
00:25:31.946 --> 00:25:38.404
Okay, and one thing I didn't quite realise until I spoke to Dan Spurnett about prostate cancer was that the actual surgeon is not scrubbed.
00:25:38.404 --> 00:25:45.440
He actually just operates the machine, while the assistant and the scrub nurse sets up the equipment on the patient, and they remain scrubbed.
00:25:45.440 --> 00:25:46.404
Yes, that's right.
00:25:46.565 --> 00:25:50.557
So this shows that robotic surgery is truly a team approach.
00:25:50.557 --> 00:25:57.005
We need to understand that the robot it's not an intelligent robot, it's what's called a master and slave robot.
00:25:57.005 --> 00:26:04.090
So the robot will only perform what the surgeon is indicating for it to do with the movements of his hands.
00:26:04.090 --> 00:26:07.414
Those are mirrored by the robotic instruments within the patient.
00:26:07.414 --> 00:26:21.657
So it's really important that the two people who are scrubbed with the patient, who is the assistant that is often a second surgeon and the scrub nurse, are well trained and familiar with robotic techniques.
00:26:21.657 --> 00:26:31.317
And there is a long learning curve to robotic surgery, both for the surgeon and also for the assistant surgeon and the scrub nurse.
00:26:31.317 --> 00:26:35.019
That takes a long time to learn how to work as a team together.
00:26:35.401 --> 00:26:36.184
It's truly amazing.
00:26:36.184 --> 00:26:37.984
I've put my head in to see some of it being done.
00:26:37.984 --> 00:26:39.270
It's really impressive.
00:26:40.053 --> 00:26:41.005
It is impressive and it's great.
00:26:41.005 --> 00:26:48.135
We've got the technology available to be able to treat patients with minimal side effects and minimal morbidity and great results.
00:26:48.689 --> 00:26:57.790
And just pointing out to the listener, it gives the surgeon an extra pair of hands effectively and also a way to maneuver the hands in a way that the person normally can't move the hands as a normal human being.
00:26:57.790 --> 00:26:58.713
Is that correct?
00:26:58.894 --> 00:26:59.797
That's exactly right.
00:26:59.797 --> 00:27:09.698
So the robotic arms can move in a 360 degree direction, so that they can actually move in ways that are beyond what the human hand can achieve.
00:27:09.698 --> 00:27:26.116
This means the only limitations actually are the skill of the operator and the extent that he can move his hands and wrists so that, together with better lighting and better magnification, allows us to perform major surgery but also micro surgery.
00:27:26.116 --> 00:27:37.834
The DaVinci surgical platform that we use was actually designed originally for vascular surgery and cardiac surgery, so the potentials for it are almost limitless.
00:27:38.846 --> 00:27:48.632
And, as an extra benefit, I believe the actual person observing a procedure, such as a medical student, can actually see what's going on, rather than struggling to look over someone's shoulder or actually not be able to see into the surgical field.
00:27:49.105 --> 00:27:54.593
That's exactly right, so they can see all of the surgery that's being performed and exactly how it's being performed.
00:27:54.593 --> 00:28:01.355
And, if we have, when the surgeon is performing the surgery, he looks through a console which allows 3D vision.
00:28:01.355 --> 00:28:18.133
If there is a second console, which often there is in several hospitals, then the learning students are able to see the surgery in 3D, which vastly improves the ability to recognize structures and understand what surgery is being performed.
00:28:19.086 --> 00:28:19.869
Truly amazing.
00:28:19.869 --> 00:28:23.535
Are there any other options apart from surgery for treating renal carcinoma?
00:28:24.026 --> 00:28:25.131
So that's a great question.
00:28:25.131 --> 00:28:48.056
For small renal tumours, we know that they are slow growing and in this situation, particularly for older patients who are wishing to avoid surgery, we can choose a modality of treatment called focal therapy, where the tumour is essentially treated with energy to destroy the tumour in situ without requiring surgery.
00:28:48.056 --> 00:28:54.133
These treatments can involve application of heat or cold and are called thermal ablation techniques.
00:28:54.133 --> 00:29:12.854
We can use radiofrequency ablation, cryoablation with freezing the tumour, or microwave energy to destroy the tumour in situ, and these are great techniques, particularly for elderly patients, patients who are wishing to avoid surgery and patients who are of older age.
00:29:13.464 --> 00:29:26.693
So what you're saying is, in treating the renal carcinoma rather than excising it, you apply thermal treatment, either cold or heat, either through ultrasound or through a probe, to actually destroy the renal carcinoma in situ.
00:29:26.693 --> 00:29:27.407
Is that correct?
00:29:28.244 --> 00:29:39.875
Yeah, that's absolutely correct and the follow-up data for these treatments show very effective control of the tumour, with the follow-up data five to ten years remaining very good.
00:29:39.875 --> 00:29:48.474
So this is a very promising treatment and has minimal side effects and is an exciting new area for treatment of renal carcinoma.
00:29:49.346 --> 00:29:56.048
Now, does that involve actually stinging a probe into the kidney itself, or is it actually done purely through the skin and radiation through the skin?
00:29:57.411 --> 00:30:03.462
So these techniques always involve an application of a probe into the kidney.
00:30:03.462 --> 00:30:18.029
Initially this was done with keyhole surgery, but now these techniques can be done percutaneously in the X-ray department, allowing treatment of a renal tumor essentially on an outpatient basis, without any incision.
00:30:18.029 --> 00:30:20.938
They are still a percutaneous treatment.
00:30:20.938 --> 00:30:24.618
The risks are small related to this treatment.
00:30:24.618 --> 00:30:28.840
This allows the patient to have even outpatient treatment of a small renal tumor.
00:30:28.840 --> 00:30:39.901
We recommend that tumors less than 2 centimetres are most appropriate for these treatments and usually we will have done a biopsy prior to confirm the diagnosis.
00:30:40.250 --> 00:30:42.857
So a stage T1 was 4 to 7 centimetres.
00:30:42.857 --> 00:30:45.056
Is this like a stage zero or something?
00:30:45.056 --> 00:30:45.296
Is it?
00:30:46.190 --> 00:30:50.461
This is still a stage T1, but a small T1 tumor.
00:30:50.461 --> 00:31:13.019
The reason for applying this technique for these small tumors is that we know the small tumors are well treated with this thermal technology and the larger tumors we may will not be able to treat them all at one setting, and there's also a higher recurrence rate for the larger tumors with this focal therapy.
00:31:13.019 --> 00:31:19.873
So we're only treating those patients in this way who have the best prognosis and wish to avoid surgery.
00:31:20.576 --> 00:31:20.977
Excellent.
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