Partial, Radical, Biopsy?

Hubby123

Hi I am writing on behalf of my wife. She is 46.

She was diagnosed with a 6 cm tumor on left kidney. MRI seems to indicate RCC. No indications of spread, and stage 1B as near as can be told with MRI & CT Scan. We have seen two urologic oncologists at 2 different hospitals (both hospitals have stellar reps, one of them is in the top 10 of the country for urologic oncology).

What is frustrating is that the recommended courses of action are very different.

Biopsy

Dr A indicated that no biopsy was needed as at this size there was 80% likelihood it was malignant, and even if it was benign we'd probably want to remove it anyway.

Dr B indicated that she thought a biopsy would not be a bad idea and indicated she was not worried about a biopsy seeding other tumors.

Research seems to indicate something like 1 in 10,000 chance of seeding; not bad odds for seeding but not great odds from a worry perspective (i.e. 1 in 10,000 would have us worried for the rest of her life).

 

Partial vs Full

Dr A said if it were him he'd do a Full nephrectomy, and evaluate on the fly if adrenal gland should also be removed. Robotic procedure.

Dr B said if it were her she's go for partial, Also Robotic procedure.

 

In general both are good with whatever we decide. I guess what we are faced with is 2 competent drs who have different philosophies; Dr A wants to hit it with a sledgehammer, Dr B wants to preserve healthy tissue if possible.

I think my questions to all are:
- Does anyone have any good studies they can point me to as to helping decide on partial vs full? Recurrance possibilities, etc.
- Any ideas on biopsy or no?

Thanks all.

 

Bay Area Guy

Sorry you have to come here.

Sorry you have to come here.  I can’t cite chapter and verse in terms of any studies.  But here are my thoughts.

At 6cm, and an 80% chance of being malignant, why bother with the discomfort of a biopsy when there is a 4 in 5 chance that some or all of the kidney will have to come out anyway?  Also, while tumor seeding is likely not to occur with a biopsy, there’s always the chance of getting tissue that has no malignancy present, while tissue immediately next to it is, in fact, malignant.  When I was diagnosed with a 1.5cm lesion, I asked my sister, a nurse practitioner in a different specialty, but Still conversant in urology, about a biopsy, and she recommended against it on both the seeding and false negative reasons.

As for open versus robotic and full versus partial, I think you go with the method suggested by the surgeon you’re most comfortable with.  

icemantoo

Training and comfort zone

Hubby123,

 

There is no one right or wrong answer. Each Doctor was trained differently and approaches ech case a little different. At 6cm  it is at the upper end of a Partial. Yes there is some recurrance with partials.  No 2 partials are identical because of the size and location of the tumor. In my day 16 years ago there were no partials. The answer lies in which Doctor YOU are most comfortable wither. Others  will chime in with their thoughts.

 

icemantoo

APny

Partials are more complicated

Partials are more complicated so the one recommending radical may not have the expertise. At 6 cm it's pushing the limit of partials but if the other doctor feels it can be done and preserve kidney I'd go for it. It may have to convert to a radical while under surgery but why not give the partial a try? Biopsies are generally not recommended and at that size it'll most likely has to come out regardless of whether it's malignant or benign. All the best to you and your wife.

Shubham

A mass that big causes mass

A tumor that big causes mass effect (puts pressure)on the normal kidney calyces and has to be removed eventually regardless of benign/malignant so biopsy is not useful here imho.also bleeding is a risk associated with biopsy.

As a general rule ,partial nephrectomy is done if 40percent of kidney tissue is normal and can be saved.The decision to go for partial /radical is best made on the surgery table after surgeon directly visualises the tumor.

Partial should be preferred as it is associated with better kidney function in the future .Though there is a risk of incomplete resection of tumor.lymph nodes are also spared in partial nephrectomy and might harbour some tumor cells.

If you go ahead with radical nephrectomy you might want to get a Dtpa renogram done to assess the functioning of the other kidney(rt kidney in your case).this is all the more important if the normal kidney has some other pathology like stone/scar.

At the end remember life with 1 kidney is manageable.

 

Hubby123

Thanks-after more research here is something I posted elsewhere

We have had 2 opinions on [what appears to be*] a 6cm RCC on wife's left kidney, stage 1b. No indications of spread, seems to be wholly contained to kidney. She is 46.

Stanford guy said if it were him he would go full and evaluate adrenal gland removal on the fly (tumor is adjacent to the adrenal gland). Did not advocate for biopsy.

UCSF lady said if it were her she'd probably get a biopsy and try to do partial.

Both doctors are very optimistic for long term results (i.e. live to normal age).

I think this probably relates to different philosphies; Stanford wants to whack it with a sledgehammer and UCSF wants to preserve healthy tissue in a younger patient.

I think after reading a lot we are leaning toward partial with UCSF (both doctors essentially said "we'll do whatever you want" but we are more comfortable with the UCSF doctor, based on a variety of "gut feel" and "UCSF said this and Stanford did not even discuss that" types of issues. UCSF doctor has done 1000 of these.).

Here is my logic on this, if anyone can poke some holes in this please do.

1) We will probably skip the biopsy. While UCSF doctor was not concerned about spreading via biopsy, the studies seem to indicate a 1/10000 chance of seeding. While clinically these are good odds, from a "worry perspective" they are not great. Also Stanford guy said that even if benign we probably want to get rid of it anyway. And at this size and how it presented on the MRI, there is like an 80% chance it IS cancer anyway.

2) If this has been growing for 10 years (both doctors estimated that) then this puts her in the "early onset" class and it seems that this puts her in the area where genetics might be a cause, which would indicate a higher chance of this recurring. 50/50 if it would recur in the other (currently healthy) kidney or what is left of the left kidney. If she has a full and it recurs in the remaining kidney, well, better to have options. In any event we'd have to monitor the crap out of her and both doctors advocated for genetic testing and so on, with later involvement of a medical oncologist, tumor boards, etc.

3) The rate of recurrence for both partial and full seems equivalent, which takes me back to point 2 above.

Any thoughts welcome here.

• I caveat this as there has been no biopsy but based on MRI it does not seem to be oncocytoma (benign), but you can't tell without tissue analysis.

Retcenturion

You have the information

It seems that you have as much information at this point to make a plan. We  didn't have a choice on the procedure. However, we were so comfortable with the surgeon and his experience that made our choice easier. Whatever you choose it sounds like it will be a good option. Good luck and positive thoughts to you and your wife.

icemantoo

My thought

Hubby,

 

Check on your info for no 3 If the recurrance rates are similar are you dealing with the same size tumors. Usually partials are for smaller tumors, 

 

icemantoo

Hubby123

icemantoo said:

My thought

Hubby,

 

Check on your info for no 3 If the recurrance rates are similar are you dealing with the same size tumors. Usually partials are for smaller tumors, 

 

icemantoo

Thanks, think I read

Thanks, think I read somewhere that they are equivalent. Here it is: https://www.urologiconcology.org/article/S1078-1439(17)30063-7/fulltext

I BELIEVE that indicates (and I know I should not rely on one source, we are still fact finding ATM) that while partial carries more procedural risk, oncologically the results appear to be the same between full and partial.

icemantoo

Hubby123 said:

Thanks, think I read

Thanks, think I read somewhere that they are equivalent. Here it is: https://www.urologiconcology.org/article/S1078-1439(17)30063-7/fulltext

I BELIEVE that indicates (and I know I should not rely on one source, we are still fact finding ATM) that while partial carries more procedural risk, oncologically the results appear to be the same between full and partial.

Two differences

Hubby,

 

I read the studies conclusions. It said that complications were more common with a partial and the study was limited to tumors under 4cm. Just food for thought.

 

 

icemantoo

Hubby123

icemantoo said:

Two differences

Hubby,

 

I read the studies conclusions. It said that complications were more common with a partial and the study was limited to tumors under 4cm. Just food for thought.

 

 

icemantoo

I think I read it as tumor is

I think I read it as tumor is greater than or equal to 4cm ("(≥4 cm)"). Now you've got me wondering if I've forgotten all of my algrebra. Understand the complications (bleeding, infection, etc) are more likely.

AnnissaP

I pretty much had the same

I pretty much had the same options you did and definitely went with you "A" choice. I am so glad I did and that was 8 months ago now!!! I wish you guys all the best.

Bay Area Guy

Hubby123 said:

Thanks-after more research here is something I posted elsewhere

We have had 2 opinions on [what appears to be*] a 6cm RCC on wife's left kidney, stage 1b. No indications of spread, seems to be wholly contained to kidney. She is 46.

Stanford guy said if it were him he would go full and evaluate adrenal gland removal on the fly (tumor is adjacent to the adrenal gland). Did not advocate for biopsy.

UCSF lady said if it were her she'd probably get a biopsy and try to do partial.

Both doctors are very optimistic for long term results (i.e. live to normal age).

I think this probably relates to different philosphies; Stanford wants to whack it with a sledgehammer and UCSF wants to preserve healthy tissue in a younger patient.

I think after reading a lot we are leaning toward partial with UCSF (both doctors essentially said "we'll do whatever you want" but we are more comfortable with the UCSF doctor, based on a variety of "gut feel" and "UCSF said this and Stanford did not even discuss that" types of issues. UCSF doctor has done 1000 of these.).

Here is my logic on this, if anyone can poke some holes in this please do.

1) We will probably skip the biopsy. While UCSF doctor was not concerned about spreading via biopsy, the studies seem to indicate a 1/10000 chance of seeding. While clinically these are good odds, from a "worry perspective" they are not great. Also Stanford guy said that even if benign we probably want to get rid of it anyway. And at this size and how it presented on the MRI, there is like an 80% chance it IS cancer anyway.

2) If this has been growing for 10 years (both doctors estimated that) then this puts her in the "early onset" class and it seems that this puts her in the area where genetics might be a cause, which would indicate a higher chance of this recurring. 50/50 if it would recur in the other (currently healthy) kidney or what is left of the left kidney. If she has a full and it recurs in the remaining kidney, well, better to have options. In any event we'd have to monitor the crap out of her and both doctors advocated for genetic testing and so on, with later involvement of a medical oncologist, tumor boards, etc.

3) The rate of recurrence for both partial and full seems equivalent, which takes me back to point 2 above.

Any thoughts welcome here.

• I caveat this as there has been no biopsy but based on MRI it does not seem to be oncocytoma (benign), but you can't tell without tissue analysis.

Who's the Stanford guy?  I

Who's the Stanford guy?  I had Geoffrey Sonn as my surgeon and Dr. H. Gill was my urologic oncologist.

Truth be told, both institutions are great.  I went to Stanford because my choices, based on my insurance company's policies, were Seton Medical Center (I wouldn't send my worst enemy there), CPMC (not bad) or Stanford.  I took about 0.01 seconds to choose Stanford.  If you had thrown UCSF in the mix, it would have made the choice harder since we live about equisidtant between the two hospitals.

In terms of the procedure that will be done, I can't argue with wanting to have a procedure that saves the largest amount of healthy kidney tissue possible.  I chose that route and had a robotic partial. I also think ging with your gut and your comfort level with the surgeon is incredibly important, so I think you're making the right choice.  Your wife will go into the procedure with a lot of confidence in her medical team.

The only possible hole I can poke into your reasoning is that the sledgehammer approach is probably an almost sure thing in terms of getting the entire malignancy out, and then some.  But with the technology available and the fact that they do a pathology screening right in the operating chamber, there should be no reason the finesse approach doesn't have a similar outcome.

 

punster

I'm in a similar boat as your

I'm in a similar boat as your wife - so I'll add my 2 cents. 

I, too, discovered my 4.8cm tumor at age 41 and it is pushing up against the adrenal gland, but not showing signs of invading. 

I too went to the three best hospitals on this coast, and if you look at my post history, you'll see the surgical decisions we debated.

I'm now scheduled for a partial robotic neph next week (8/1), since we decided to save the kidney given my young-ish age. Re: the partial vs the full and the chances of recurrence, a couple of surgeons I've spoken to have indicated the same chances for both for recurrence. IMO, it depends on the skill of the surgeon, not the procedure you're performing. The surgeon we've selected has done over 1500+ nephrectomies, so we're hoping his experience leads the way.

Re: the biopsy, multiple surgeons have said it's not worth it, because it results in false negatives... i.e. the stats we heard were, you'll get a negative result and in 40% of those negative result cases, it will be a positive when pathology is performed. 

APny

Hubby123 said:

I think I read it as tumor is

I think I read it as tumor is greater than or equal to 4cm ("(≥4 cm)"). Now you've got me wondering if I've forgotten all of my algrebra. Understand the complications (bleeding, infection, etc) are more likely.

Nothing wrong with your

Nothing wrong with your algebra. It did say greater or equal to 4 cm.

icemantoo

APny said:

Nothing wrong with your

Nothing wrong with your algebra. It did say greater or equal to 4 cm.

My Algebra was wrong

Sorry

 

 

icemantoo