Introduction
Cytoreductive nephrectomy (CN) is a surgery to remove a kidney with cancer when the cancer has already spread to other parts of the body. This might sound strange – why remove the kidney if cancer has spread elsewhere? Yet research shows this surgery helps many patients live longer when combined with other treatments.
This guide explains who needs this surgery, its benefits and risks, and how it fits with modern cancer treatments.
What is Cytoreductive Nephrectomy?
Cytoreductive nephrectomy means removing a kidney that contains cancer when the cancer has already spread beyond the kidney. “Cytoreductive” comes from “cyto” (cell) and “reduction,” meaning the surgery aims to reduce the total amount of cancer in the body.
Unlike standard kidney removal for cancer that’s just in the kidney, this surgery happens when cancer has already spread to places like the lungs, liver, bones, or brain.
How Treatment Has Changed Over Time
The role of this surgery has changed a lot over the years:
- Before 1990s: Doctors mainly did the surgery to relieve symptoms like pain and bleeding.
- 1990s-2005: Studies showed patients lived longer when surgery was followed by immune treatments, making it standard care.
- 2005-2015: New targeted drug therapies raised questions about whether the surgery was still needed.
- 2015-present: Modern immunotherapies have again changed how we think about this surgery and when to use it.
Who Should Have This Surgery?
Not everyone with kidney cancer that has spread needs this surgery. Doctors consider many factors:
Good Candidates Include:
- Patients in good overall health
- Those with limited spread of cancer
- People with clear cell kidney cancer (the most common type)
- Patients with symptoms from the kidney tumor
- Those likely to benefit from drug treatments after surgery
- Younger patients with positive outlook factors
- Patients whose spread cancer might also be removable
Surgery May Not Help:
- People in poor health
- Those with extensive or fast-growing cancer
- Patients with high-risk primary tumors (like those growing into heart vessels)
- People with serious other health problems
- Those with very poor outlook (expected survival less than a year)
- Patients with rare types of kidney cancer that don’t respond well to treatment
How Doctors Choose the Right Patients
Doctors use scoring systems to help decide who will benefit most from surgery:
IMDC Risk Factors
- Poor performance status
- Less than a year from diagnosis to treatment
- Low hemoglobin
- High calcium
- High neutrophil count
- High platelet count
Patients with none of these factors do best with surgery. Those with 3 or more factors may not benefit.
MSKCC Risk Factors
- Poor performance status
- Less than a year from diagnosis to treatment
- Low hemoglobin
- High LDH levels
- High calcium
These scores help guide treatment decisions based on each patient’s unique situation.
Surgical Approaches
Surgeons can remove the kidney using different methods:
Open Surgery
- Through the abdomen: Gives great access, especially for large tumors
- Through the back: Better for tumors in the back of the kidney
- Combined chest and abdomen: For very large tumors at the top of the kidney
Minimally Invasive Options
- Laparoscopic: Uses small incisions, less pain, faster recovery
- Robot-assisted: Offers better vision and precision
- Hand-assisted: Combines benefits of open and laparoscopic methods
The choice depends on tumor size, surgeon skill, and patient factors. Open surgery is often needed for advanced tumors.
What Gets Removed
- The entire kidney and surrounding fat
- Sometimes nearby lymph nodes
- Tumor growth in blood vessels when present
- Occasionally parts of nearby organs if cancer has grown into them
When to Do the Surgery
The timing of surgery is still debated:
Immediate Surgery
- Traditional approach based on older studies
- May work best for patients with small amounts of spread
- Confirms the exact cancer type
- Prevents problems from the kidney tumor during drug treatment
Delayed Surgery (After Drug Treatment)
- Growing evidence supports this approach for some patients
- Shows how well the cancer responds to drugs
- Avoids surgery in patients whose cancer grows quickly
- May improve patient’s condition before surgery
Recent studies suggest starting with drug therapy and doing surgery later may be better for many patients.
Key Research Studies
Several important studies have shaped treatment:
SWOG 8949 and EORTC 30947 (1990s)
These studies showed patients lived about 6 months longer when they had surgery plus immune therapy compared to immune therapy alone.
CARMENA Trial (2018)
This study found that for intermediate and high-risk patients, the drug sunitinib alone worked as well as (or better than) surgery followed by sunitinib.
SURTIME Trial (2019)
This small study suggested starting with drug therapy and doing surgery later might improve survival.
KEYNOTE-564 (2021)
While not directly testing CN, this study showed immunotherapy after kidney removal improved outcomes for high-risk patients.
Benefits of the Surgery
Cytoreductive nephrectomy offers several potential benefits:
Reduces Cancer Amount
- Removes the main tumor mass
- May help other treatments work better
- Gets rid of a source of growth factors that feed cancer
Controls Symptoms
- Relieves pain and bleeding
- Addresses related health problems like high calcium or blood pressure
- Improves quality of life for patients with symptoms
Immune System Benefits
- May reduce factors that suppress the immune system
- Could enhance response to immunotherapy
- Removes a source of signals that can tire out immune cells
Diagnostic Value
- Provides complete tissue analysis
- Allows for genetic testing of the tumor
- May guide choice of targeted drugs
Risks and Complications
Like any major surgery, this procedure has risks:
During or Right After Surgery
- Bleeding requiring blood transfusion (5-20%)
- Infections (wound, pneumonia, urinary): 5-10%
- Blood clots: 2-5%
- Heart problems: 2-8%
- Breathing problems: 5-15%
Specific Surgical Risks
- Damage to nearby organs: 1-3%
- Lung damage requiring chest tube: 2-5%
- Leakage of lymph fluid: less than 1%
- Kidney failure requiring dialysis: 1-5%
Long-term Risks
- Worsening kidney function
- Hernia development
- Ongoing pain
- Slow wound healing in patients on cancer drugs
Death Risk
- 30-day mortality: 1-5%, higher in less healthy patients
Surgery in the Age of Immunotherapy
Modern immune treatments have changed kidney cancer care:
Current Immune Treatments
- PD-1 blockers (nivolumab, pembrolizumab)
- PD-L1 blockers (avelumab)
- CTLA-4 blockers (ipilimumab)
- Combination approaches
Impact on Surgery Decisions
- Immune therapy responses differ from older targeted drugs
- Delayed responses complicate assessment
- Potential for complete remissions raises questions about need for surgery
- Immune-related side effects may affect surgical recovery
Ongoing Research
Limited data exists on surgery with modern immune combinations. Studies like PROBE and NORDIC-SUN aim to answer these questions.
Team Approach
Managing advanced kidney cancer requires teamwork:
The Care Team
- Urologic surgeons
- Medical oncologists
- Radiation doctors
- Interventional radiologists
- Pathologists
- Kidney specialists
- Palliative care experts
Decision Process
- Complete imaging (CT, MRI, bone scan)
- Tissue diagnosis when possible
- Risk assessment using proven models
- Surgery evaluation
- Review of drug therapy options
- Discussion of targeted treatments for spread
- Patient preferences and goals
Alternatives to Surgery
When surgery isn’t possible or appropriate:
Embolization
- Blocking blood flow to control bleeding
- Useful for severe bleeding in the urine
- Sometimes helps make later surgery easier
Radiation
- Effective for pain control
- May help control bleeding
- Usually given in short courses
Ablation Techniques
- Radiofrequency ablation, cryoablation, or microwave ablation
- Better for small tumors than large ones
- Often used for patients who can’t have surgery
Drug Therapy Alone
- First choice for poor surgical candidates
- Appropriate for high-risk patients with few symptoms
- Can help identify patients who might benefit from delayed surgery
Future Directions
The field continues to evolve:
Ongoing Clinical Trials
- PROBE trial: Testing surgery with immunotherapy
- NORDIC-SUN: Studying delayed surgery after immunotherapy
- CYTOSHRINK: Looking at immune therapy before surgery
New Biomarkers
- PD-L1 expression
- Tumor mutation burden
- Gene patterns
- Circulating tumor DNA
- Immune cell patterns
Novel Treatments
- PARP inhibitors for selected patients
- New immune combinations
- HIF-2α blockers
- Metabolic approaches
- Personalized vaccines
Patient Perspectives and Quality of Life
Beyond survival, patient experience matters:
Quality of Life Concerns
- Impact on physical function
- Pain control
- Return to normal activities
- Body image
- Financial burden
Patient Support
- Shared decision tools
- Patient-reported outcomes
- Setting realistic expectations
- Survivorship planning
- Palliative care when needed
FAQs
Q: Will I need dialysis after this surgery? A: Most patients with a normal second kidney maintain good function without dialysis. Your doctor will check your kidney function before surgery.
Q: How long is recovery? A: It varies by surgical approach and individual factors. Open surgery typically requires 6-8 weeks for full recovery. Minimally invasive approaches may allow return to normal activities in 3-4 weeks.
Q: Can this surgery cure my cancer? A: Surgery alone cannot cure cancer that has spread. However, combined with effective drug therapy, some patients achieve long-term control or occasionally complete remission.
Q: How is this different from standard kidney removal? A: While the technique may be similar, this surgery happens when cancer has already spread. It often involves larger tumors and is part of a broader treatment plan rather than a cure.
Q: When might this surgery not be recommended? A: It may not help patients in poor health, those with extensive spread, limited life expectancy, or when surgery risks outweigh benefits.
Q: How soon after surgery can drug therapy start? A: Typically 4-6 weeks after surgery, allowing for proper healing. This timeline may vary based on your recovery and planned treatment.
Conclusion
Cytoreductive nephrectomy remains important for many patients with advanced kidney cancer. However, its role has become more nuanced with effective drug therapies.
The decision should be personalized based on patient health, tumor factors, and treatment goals. The best approach involves careful selection through team evaluation, consideration of timing with drug therapy, and integration into a complete treatment plan.
As immune and targeted therapies advance, the role of surgery will likely continue to evolve. Ongoing research will help refine patient selection and treatment timing.