078IC - Diagnosis and Management of Localized, Locally Advanced and Advanced Kidney Cancer

Kidney cancer is not a single disease; it is made up of several different types of cancer, each with a different histology, a different clinical course, responding differently to therapy and caused by different genes. After completing this course, attendees be able to describe the different types of kidney cancer and the genes that cause each. They will learn how to identify the different types of inherited versus sporadic forms of kidney cancer. They will differentiate between indolent and slow growing tumors, such as clear cell renal cell carcinoma (RCC), type 1 papillary RCC and chromophobe RCC, and more aggressive tumors, such as type 2 papillary RCC and TFE3 RCC which can infiltrate into the renal parenchyma and have a propensity to spread when the tumors are small. Attendees will apply this knowledge to decide between active surveillance and surgical intervention, and when to utilize renal tumor biopsy. Attendees will integrate knowledge of tumor biology to choose between minimally invasive surgical enucleation techniques for indolent cancers versus open surgical approach with wide margins for aggressive forms of RCC.

Attendees will learn how to perform open and minimally invasive partial nephrectomy. Laparoscopic and robotic port placement will be reviewed as well as the role of retroperitoneal surgery in the management of posterior renal tumors. Critical surgical techniques such as hilar exposure and recommendations about when and how to clamp the hilum, appropriate warm and cold ischemia guidelines and the use kidney cooling will be reviewed. The critical role of intraoperative ultrasound in patients undergoing open as well as minimally invasive partial nephrectomy will be discussed. New surgical techniques for stopping bleeding and safely closing the renal cortex after removal of multiple renal tumors will be discussed. Surgical approaches for reoperative surgery in patients with recurrent, multiple renal tumors will be reviewed. The critical role of intraoperative resuscitation of patients who have undergone significant blood loss will also be discussed.

Attendees will learn approaches for management of patients with large renal tumors involving the renal vein and vena cava, how to safely get exposure and management of vascular structures, and when to involve vascular surgery and potentially cardiopulmonary bypass in tumors that extend above the portal vein. Discussion of when to perform lymph node removal and the surgical techniques for ipsilateral, aorto-caval and contralateral nodal dissection will be conducted.

There have been significant advances in the systemic therapeutic approaches with targeted therapies and immunotherapies for patients with locally advanced and advanced forms of renal cell carcinoma. The most recent immunotherapy and targeted therapies will be discussed for patients with both clear and non-clear cell RCC, including agents such as nivolumab, ipilimumab, cabozantinib and pazopanib in combination and as single agents. The role of surgery in patients with advanced RCC with the primary kidney tumor in place will be discussed, i.e., when to recommend cytoreductive nephrectomy and when to recommend immediate systemic therapy. Recent findings in the role of adjuvant or neo-adjuvant therapy in patients with locally advanced RCC will be discussed.