Ask Dr. Wagner
What happens to the tumor after it is removed?
The tumor is placed in a laparoscopic bag, removed from the patient, and sent to our renal cancer pathology team. There, they evaluate the tumor to determine what category it falls into (in terms of what type of kidney cancer it is), or if it is even cancer at all! Then the pathologists evaluate the tumor to see what grade it is, which they determine by looking at the cells under a microscope and determining how chaotic the cells look. The more chaotic the cells, the higher the grade level, which ranges from 1-4. They also determine the stage of the tumor, which is determined by the size of the tumor, as well as the degree to which the tumor is invading the surrounding tissue just outside the kidney.
What is laparoscopy?
Laparoscopy is a surgical approach to abdominal surgery where, instead of making a large incision and forcing the surgeon’s hands inside of the patient, we make several small incisions about one centimeter each. Then we place a camera and long thin instruments through these incisions, and we use those instruments to perform the operation. In our case, we perform kidney surgery and remove either the entire kidney or parts of the kidney with these instruments.
Is there a benefit to choosing a laparoscopic procedure over an open surgery procedure?
With laparoscopy, the incisions are smaller and the trauma to the patient is much less. Thus they have far less pain and return to normal activities in 3-4 weeks instead of 8-12 weeks, which is common after open kidney surgery. It is important for patients to realize that in experienced hands, the surgery on the inside of them is the same, thus the cure rate for cancer is the same in both procedures, but we’re able to spare patients a lot of the post-operative pain and recovery time that was common for open surgery.
Could you explain the differences between a partial, radical, and debulking nephrectomy?
Sure. A partial nephrectomy is the removal of part of the kidney. It is usually performed on tumors that are smaller or located towards the edge of the kidney, so that we are able to save most of the kidney but remove tumor. Radical nephrectomies are performed on larger tumors or in the middle of kidney, and require removal of the entire kidney and surrounding fatty tissue. Sometimes the adrenal gland (which sites on top of each kidney) or lymph nodes in the region must be removed as well. Debulking radical nephrectomy is the removal of entire kidney and tumor in patients who have metastatic disease – cancer that’s already spread to other parts of the body. And we perform that to help patients respond better to systemic therapies after surgery.
How will I be followed after a nephrectomy?
The way we follow patients after a nephrectomy depends on the grade and the stage of their tumor. Those patients with small tumors that are low grade are typically followed on a yearly basis with X-rays or CT scans taken of their chest and abdomen. Those patients with more aggressive disease require closer follow up to make sure that the disease does not spread. For such patients, we sometimes see them as often as 3 months, with appropriate scans and blood work.
Why are adjacent organs to the kidney sometimes removed during a nephrectomy?
If the kidney tumor is invading or starting to encroach on adjacent organs, then often we’ll remove those organs because they can be involved by the cancer. For the most part, the most common organ we remove is the adrenal gland during the surgery, but others can be affected like bowel, liver, or even pancreas.
What is radiofrequency ablation (RFA)?
RFA is a less invasive technique of killing cancer cells and small tumors. In very selected patients whose tumors are smaller than 3 cm, we can place a probe through the patient’s skin into the tumor, and this probe allows us to deliver enough heat to the tumor to kill the cancer cells. The advantages of this are that the patients don’t require general anesthesia and they can usually be discharged and go home the same day with less pain than surgery. A disadvantage is that, since it’s a relatively new technique, we don’t have long term data showing that its cure rate is equivalent to surgery. Another disadvantage is that we’re not able to fully stage and grade the tumor with this approach since it is destroyed without going to pathology for analysis.
I’ve been hearing a lot about Cyberknife therapy. Could you explain that a little more?
Cyberknife is the newest technology that we are using for patients, and it allows us to ablate tumors without any anesthesia or invasive procedures. This is called extra corporeal ablation. Currently, we’re using Cyberknife on patients with smaller tumors who, for one reason or another, are unfit for surgery or RFA. We were the first center in New England, and one of the only centers in the country, to use this modality to treat kidney tumors. We found that there have been little or no side effects from this. We also take a needle biopsy on all Cyberknife patients so that we can look at all the cells and stage it. Ultimately, we can verify that you have cancer, but we don’t get a full sense of pathological information. For example, we can identify that a tumor is clear cell renal cancer, but not that it is Grade 4 clear cell renal cancer.
How often do you perform these types of surgeries?
During a 2 year fellowship in laparoscopic and robotic urologic surgery at Johns Hopkins Hospital, I performed hundreds of kidney surgeries and therefore the vast majority of kidney cancer surgery I perform here at BIDMC is performed via the laparoscopic approach. This includes partial, radical, and debulking nephrectomies, even for very aggressive tumors. In those patients for whom we perform minimally invasive surgery, they benefit from quicker recover time, less pain, and more time to start other systemic treatments than other traditional surgeries. Currently I am performing 3-4 major kidney cancer surgeries per week.
How does BIDMC stand apart from other centers offering similar treatment options?
I believe that we stand apart particularly because of our multidisciplinary approach to kidney tumors. Patients are cared for by a team of doctors and nurses, not just a surgeon. Our team meets weekly to discuss important patient issues and therefore patients really do benefit from that team approach. Furthermore, we treat patients like we would want our familiy to be treated, with respect, kindess, and patience. Regarding surgical advances, we are able to offer the most recent advances in minimally invasive surgery as well as advanced techniques for partial nephrectomy, performed by fellowship-trained experts in kidney surgery. Our breadth and volume of kidney surgery performed here at BIDMC I believe is second to none. Another factor that I think makes us unique is that we combine cutting edge surgery options with cutting edge systemic therapy for patients with metastatic disease, including our tumor vaccine trial, and HD IL2 trials, among others.
Are there any other novel surgical techniques on the horizon?
Other innovative techniques we are exploring include the Cyberknife radioablation of tumors, robotic-assisted laparoscopic surgery, and single-port-laparoscopic surgery. Although these are still considered experimental for kidney cancer, we are constantly studying ways to decrease pain and shorten recovery after surgery. We continue to conduct studies that evaluate quality of life following all types of kidney surgery. The goals of this effort are to further diminish post operative pain and to improve patients’ ability to resume their normal activities after surgery.
