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| {{CMG}}; {{AE}}{{Homa}} {{SC}} | | {{CMG}}; {{AE}}{{Homa}} {{SC}} |
| ==Overview== | | ==Overview== |
| [[Surgery]] is the mainstay of treatment for renal oncocytoma. | | [[Surgery]] is the mainstay of treatment for renal oncocytoma. Although the nature of renal oncocytoma is [[benign]] and the [[prognosis]] is excellent, since the definite [[diagnosis]] can not be obtained before [[Operation (mathematics)|operation]], [[surgical resection]] is a choice of treatment. Best option for [[surgery]] differs based on the [[mass]] characteristics, [[partial nephrectomy]] is done in [[polar]] [[lesions]] smaller than 4 cm in a normal contralateral [[kidney]] while, large [[solid]] [[renal]] [[mass]]<nowiki/>es which destroy most part of [[renal]] [[tissue]] or [[patients]] who have not candidate for nephron-sparing [[surgery]] are reserved for total [[nephrectomy]]. |
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| ==Surgery== | | ==Surgery== |
| [[Surgery]] is the mainstay of treatment for renal oncocytoma. | | [[Surgery]] is the mainstay of treatment for renal oncocytoma. Although the nature of renal oncocytoma is [[benign]] and the [[prognosis]] is excellent, since the definite [[diagnosis]] can not be obtained before [[Operation (mathematics)|operation]], [[surgical resection]] is a choice of treatment.<ref>{{Cite journal |
| * [[Nephrectomy]]:
| | | author = [[I. S. Gill]], [[A. C. Novick]], [[A. M. Meraney]], [[R. N. Chen]], [[M. G. Hobart]], [[G. T. Sung]], [[J. Hale]], [[D. K. Schweizer]] & [[E. M. Remer]] |
| | | | title = Laparoscopic renal cryoablation in 32 patients |
| centrally located and larger tumors need to be evaluated on a case-by-case basis. The availability of intraoperative frozen section to assess adequacy of the margins of resection is crucial to this strategy. Nevertheless, as one might imagine, nephrectomy has been a particularly good treatment for renal oncocytomas. This strategy must be remembered for the patient with a large solid renal mass that destroys most of the kidney, and who has no strong or absolute indication for nephron-sparing surgery.
| | | journal = [[Urology]] |
| :* Nephrectomy is performed with the patient under [[general anesthesia]]. A kidney can be removed through an open incision or [[laparoscopic surgery]].
| | | volume = 56 |
| :* For the open procedure, the surgeon makes an incision in the side of the [[abdomen]] to reach the kidney. Depending on circumstances, the incision can also be made midline. The [[ureter]] and [[blood vessels]] are disconnected, and the [[kidney]] is then removed.
| | | issue = 5 |
| :* The laparoscopic approach utilizes three or four small (5–10 mm) cuts in the abdominal and flank area. The kidney is completely detached inside the body and then placed in a bag.<ref>{{cite journal |doi=10.1016/S0022-5347(01)62049-4 |title=Complete Renal Embolization As an Alternative to Nephrectomy |year=1999 |last1=Hom |first1=David |last2=Eiley |first2=David |last3=Lumerman |first3=Jeffrey H. |last4=Siegel |first4=David N. |last5=Goldfischer |first5=Evan R. |last6=Smith |first6=Arthur D. |journal=The Journal of Urology |volume=161 |pages=24–7 |pmid=10037359 |issue=1}}</ref><ref>{{cite journal |pmid=10851826 |year=2000 |last1=Crotty |first1=KL |last2=MacAluso Jr |first2=JN |title=Partial colectomy required for resection of renal cell carcinoma: A case report and review of treatment options for locally advanced disease |volume=152 |issue=3 |pages=119–23 |journal=The Journal of the Louisiana State Medical Society}}</ref>
| | | pages = 748–753 |
| | | | year = 2000 |
| * [[Partial nephrectomy]]:
| | | month = November |
| * Therapy When faced with the patient with a renal mass and a normal contralateral kidney, our approach has been, when technically feasible, to attempt partial nephrectomy [42••]. Polar lesions smaller than 4 cm in size can routinely be managed with this approach
| | | pmid = 11068292 |
| :* Partial nephrectomy is performed with a patient under general anesthesia as well. A partial nephrectomy can be performed through an [[open surgery|open]], [[laparoscopic surgery|laparoscopic]], or robotic surgery approach. The patient is typically placed on the operating room bed lying on the side opposite the kidney tumor.
| | }}</ref> |
| :* The goal of the procedure is to remove the kidney tumor along with a thin rim of normal kidney tissue. In order to safely remove the kidney tumor, the blood flow to the kidney is often temporarily blocked off. The tumor is then cut out and the surgeon must sew the remaining kidney back together.<ref name="eighteen">{{cite journal |doi=10.1016/j.juro.2007.03.038 |title=Comparison of 1,800 Laparoscopic and Open Partial Nephrectomies for Single Renal Tumors |year=2007 |last1=Gill |first1=Inderbir S. |last2=Kavoussi |first2=Louis R. |last3=Lane |first3=Brian R. |last4=Blute |first4=Michael L. |last5=Babineau |first5=Denise |last6=Colombo Jr |first6=J. Roberto |last7=Frank |first7=Igor |last8=Permpongkosol |first8=Sompol |last9=Weight |first9=Christopher J. |last10=Kaouk |first10=Jihad H. |last11=Kattan |first11=Michael W. |last12=Novick |first12=Andrew C. |journal=The Journal of Urology |volume=178 |pages=41–6 |pmid=17574056 |issue=1}}</ref>
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| ==Overview==
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| The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
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| The feasibility of surgery depends on the stage of [malignancy] at diagnosis.OR
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| Surgery is the mainstay of treatment for [disease or malignancy].
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| **
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| ==Surgery==
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| *Surgery is the mainstay of treatment for renal oncocytoma. Although the nature of renal oncocytoma is benign and the prognosis is excellent, since the definite diagnosis is not been obtained pre-operatively, surgical resection is a choice of treatment.
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| *
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| *
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| *since the definite diagnosis can not be obtained before operation and the renal oncocytoma can occure along with RCC which is seen in 10 to 32% of patients with renal oncocytoma the extent of surgery
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| Although renal oncocytomas are benign lesions and metastases are extremely uncommon 6,13, as they cannot be confidently pre-operatively distinguished from renal cell carcinomas, they are surgically resected.
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| Large solid renal mass lesions which are identified in the setting of an anatomically and functionally normal contralateral kidney do not present much of a therapeutic dilemma. The identification of an 8 or 10 cm solid renal mass lesion occurring in the hilum of a kidney with a normal contralateral kidney, whether it has typical features of a renal oncocytoma by CT scanning or angiographic examination, should not provoke much difficulty in selecting a total or radical nephrectomy as a suitable treatment option. Conversely, the presence of a solid renal mass lesion in a functionally or anatomically solitary kidney should not be the cause of that much therapeutic turmoil since every effort at parenchymal preservation would be carried out in this setting. Whether a renal cell carcinoma or a renal oncocytoma was present, with a good capsule demonstrated by preoperative CT scanning, tumor enucleation with frozen section control of the margins would seem appropriate in this particular setting. A much more difficult situation for therapeutic decisions is occasioned by the much more common clinical circumstance, that is where a relatively small, for example 3 cm, solid renal mass lesion is detected in a kidney when ultrasound examination or CT scanning of the abdomen is performed for some nonrenal symptom. Even with a contralateral normal kidney, it does not now seem necessary to perform a radical nephrectomy for a small suitably located solid renal mass which can be treated by partial nephrectomy or perhaps in some cases tumor enucleation. Many small incidentally discovered solid renal masses will be renal oncocytomas and many will be renal cell carcinomas. If such tumors are less than approximately 4 cm in diameter, well encapsulated and suitably located peripherally on the parenchyma or upper or lower pole and there is no evidence of multifocal tumor involvement by preoperative imaging techniques or intraoperative inspection of the kidney, then serious consideration of partial nephrectomy in the treatment of these tumors must be given. Reflex radical nephrectomy for every kidney containing a solid mass lesion is probably outdated in 1987. The urologic surgeon should not expect to receive kudos for performing a technically excellent radical nephrectomy in a young patient with a well encapsulated 2 cm renal oncocytoma or renal cell carcinoma located on the lower pole of the kidney. There is no immediate expectation now for a preoperative imaging test that will allow preoperative distinction between renal oncocytoma and renal cell carcinoma. Moreover, it seems unlikely that preoperative aspiration needle biopsy will allow differential diagnosis between renal oncocytoma and renal cell carcinoma since many renal cell carcinomas contain granular cells which may be difficult to distinguish from those found in renal oncocytomas. Needle tract seeding and hemorrhage also are a concern in the preoperative needling of solid renal mass lesions. Even the latest technological advances, such as DNA ploidy analysis, probably cannot separate renal oncocytomas from renal cell carcinomas even if applied systematically on a preoperative basis. Urologic surgeons and other physicians must care for renal mass lesion patients for whom a preoperative definitive diagnosis is not yet possible.At the very least, urologic surgeons must take into account the existence of the renal oncocytoma syndrome when they approach any patient with a solid renal mass for clinical decision making. If radical nephrectomy is contemplated, patients and their families should be informed that the tumor removed most likely is a renal cell carcinoma but may be a renal oncocytoma which has demonstrated a low degree of malignant potential and is considered by some to be a benign tumor. If the clinical circumstances suggest that partial nephrectomy or tumor enucleation is desirable, the rationale for this decision with either a presumed renal oncocytoma or a small renal cell carcinoma in the setting of a contralateral normal kidney should be thoroughly discussed with the patient and his family. Renal oncocytomas certainly do exist as a distinctive clinicopathologic entity. The observational and deductive genius of Drs. Klein and Valensi in describing and defining this specific syndrome is now amply confirmed. Urologists, radiologists, pathologists, and others involved in the care of patients with renal tumors must take this new knowledge into account in their clinical practices. Future efforts to allow preoperative and intraoperative diagnosis of renal oncocytoma must be avidly pursued as well.
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| The standard of treatment for oncocytomas is
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| surgical extirpation. The continuing debate concerns
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| the extent of surgery necessary for this tumor
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| whose natural history follows a benign and usually
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| slow-growing course despite the occasional presence
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| of apparently invasive features such as lymphovascular
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| and renal capsular involvement.1,4,26
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| Since CRCC has become widely recognized, only
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| one biopsy-proven case of metastatic oncocytoma
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| has been reported in the English data.1 The patient
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| had an oncocytic liver lesion with stable disease at
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| 58 months with expectant management only, suggesting
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| that oncocytomas retain their benign nature
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| even in the presence of multiorgan involvement.
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| The excellent prognosis associated with this tumor
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| seems to indicate that minimally extensive
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| and invasive ablative techniques such as partial nephrectomy,
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| cryotherapy,54 or radiofrequency55
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| may be adequate for the removal of the tumor
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| while sparing unaffected renal parenchyma. However,
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| a few concerns have been raised. The coexistence
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| of RCC and oncocytoma is not uncommon
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| and is seen in 10% to 32% of patients with oncocytoma.
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| 10,11 Dechet et al.11 looked at 14 cases of coexistent
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| RCC and oncocytoma and found that all
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| the RCC and oncocytoma tumors (1.0 to 12.0 cm)
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| except for one (0.3 cm) were detectable by preoperative
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| studies or intraoperative inspection of the
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| kidney. The same study found that 5 of 6 patients
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| with recurrent oncocytoma had recurrence on the
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| contralateral kidney.11 These findings seem to suggest
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| that nephron-sparing surgery should be attempted
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| only after thorough intraoperative inspection
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| by open or laparoscopic techniques for the
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| presence of additional lesions. The surprisingly
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| high occurrence of coexistent oncocytoma and
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| RCC brings into question whether various reports
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| of patients dying of metastatic oncocytoma1,5 may
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| have, in fact, been cases of coexistent disease with
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| the patients actually dying of metastatic RCC. Until
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| more accurate methods of distinguishing oncocytoma
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| from RCC and of ruling out the presence of
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| coexistent tumors are available, it is unlikely that
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| patients can forego surgery altogether.
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| When faced with the patient with a renal mass and a
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| normal contralateral kidney, our approach has been, when
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| technically feasible, to attempt partial nephrectomy
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| [42••]. Polar lesions smaller than 4 cm in size can | |
| routinely be managed with this approach: centrally located
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| and larger tumors need to be evaluated on a case-by-case
| |
| basis. The availability of intraoperative frozen section to
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| assess adequacy of the margins of resection is crucial to this
| |
| strategy. Nevertheless, as one might imagine, nephrectomy
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| has been a particularly good treatment for renal oncocytomas. This strategy must be remembered for the patient
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| with a large solid renal mass that destroys most of the
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| kidney, and who has no strong or absolute indication for
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| nephron-sparing surgery. Whether the patient has a RCC or
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| a renal oncocytoma, radical nephrectomy will be the treatment of choice, and agonizing over the possible presence
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| of a renal oncocytoma is not very practical or rewarding.
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| Whether to employ laparoscopic techniques to extract
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| a particular renal mass remains controversial. Although
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| laparoscopic radical nephrectomy has proven its merits
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| from an oncologic perspective [43], and has begun to
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| move from academic centers into the general medical
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| community, laparoscopic partial nephrectomy has not yet
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| made this transition. Obtaining adequate hemostasis in
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| the bed of resection remains a challenge for the surgeon,
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| and ongoing investigators are working to identify the
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| optimal means of achieving this goal. At the present time
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| the authors’ preference is to prioritize the objective of
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| nephron-sparing over the reduction in morbidity provided
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| by the laparoscopic approach.
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| Cryotherapy, radiofrequency ablation, and other
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| minimally invasive techniques for extirpating renal tumors
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| are still in their infancy and their respective roles for the
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| treatment of oncocytoma remains to be determined.
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| Most patients with oncocytomas are treated with
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| radical nephrectomy. Partial nephrectomy, enucleation or
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| wegde resection may be performed (Morra and Das,
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| 1993; Perez-Ordoñez et al.,
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| ==Contraindications==
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| | There are some debate in choosing the best option of [[surgery]] for these [[patients]], although the recommendations are:<ref>{{Cite journal |
| | | author = [[Stephen M. Schatz]] & [[Michael M. Lieber]] |
| | | title = Update on oncocytoma |
| | | journal = [[Current urology reports]] |
| | | volume = 4 |
| | | issue = 1 |
| | | pages = 30–35 |
| | | year = 2003 |
| | | month = February |
| | | pmid = 12537936 |
| | }}</ref><ref>{{Cite journal |
| | | author = [[D. Y. Chan]], [[J. A. Cadeddu]], [[T. W. Jarrett]], [[F. F. Marshall]] & [[L. R. Kavoussi]] |
| | | title = Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma |
| | | journal = [[The Journal of urology]] |
| | | volume = 166 |
| | | issue = 6 |
| | | pages = 2095–2099 |
| | | year = 2001 |
| | | month = December |
| | | pmid = 11696714 |
| | }}</ref><ref>{{Cite journal |
| | | author = [[W. K. Lau]], [[M. L. Blute]], [[A. L. Weaver]], [[V. E. Torres]] & [[H. Zincke]] |
| | | title = Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney |
| | | journal = [[Mayo Clinic proceedings]] |
| | | volume = 75 |
| | | issue = 12 |
| | | pages = 1236–1242 |
| | | year = 2000 |
| | | month = December |
| | | pmid = 11126830 |
| | }}</ref> |
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| | #[[Partial nephrectomy]]: |
| | #*In a normal [[contralateral]] [[kidney]] |
| | #*[[Polar]] lesions smaller than 4 cm in size |
| | #[[Nephrectomy]]: |
| | #*Large [[solid]] [[renal]] [[mass]]<nowiki/>es which destroys most part of the [[renal]] [[tissue]] |
| | #*The patient who has not candidate for nephron-sparing [[surgery]] |
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| ==References== | | ==References== |
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| [[Category:Oncology]] | | [[Category:Oncology]] |
| [[Category:Nephrology]] | | [[Category:Nephrology]] |
| [[Category:Surgery]] | | [[Category:Surgery]] |
| [[Category: Primary care]]
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