"Overview of Surgical Issues in the Treatment of Renal Cell Carcinoma"
David Swanson, MD

Dr. David Swanson, MD is Professor of Urology at the U. of Texas MD Anderson Cancer Center, Houston, TX, where he has worked for more than 25 years. He earned his medical degree from the U. of Pennsylvania and trained in general surgery at UCLA-Harbor General Hospital. After serving two years in the US Army Medical Corps (including one year in Vietnam), he completed his urologic residency at the U. of California Davis and a fellowship at MD Anderson. He has published over 100 papers and book chapters.

In describing surgical treatment practiced at MD Anderson, Dr. Swanson indicated that:

1. They do not routinely biopsy. They consider a high risk of false negatives.
2. They do staging before treatment.
3. They utilize helical CT with bolus contrast, which gives better resolution than traditional CT.
4. They utilize Magnetic Resonance Angiography - described as excellent for visualizing IVC thrombus (vena cava involvement)
5. He considers nephrectomy options to be open partial vs. laparoscopic radical.
   
   
   On this final point, I believe he was referring to what is now the current standard at MD Anderson. But I also believe he was recommending that open surgery is not necessary for a radical neph absent any complicating factors. The laparoscopic procedure is here and efficacy is the same, so it is preferred. For a partial he recommends open surgery. I believe this sentiment was echoed by Dr. Wood (also at MDA). For tumors already beyond the kidney borders and into surrounding tissue, I am assuming open surgery would still be in order, likewise vena cava involvement. Dr. Swanson referred to starting surgery as a lap and being able to convert to open surgery if complications resulted or surprises were found.

For patients who have No Evidence of Disease following nephrectomy, he listed the following adjuvant therapy options. He stressed that he felt these therapies should ONLY be practiced in a clinical trial setting.

1. Autolymphocyte Therapy
2. Interferon-alpha + 5-FU
3. Interleukin-2
4. Heat Shock Protein Vaccine
5. Thalidomide

For this group of patients he gave the stage-specific follow up schedule for scans as that published by Levy, et al (and previously cited here on the KIDNEY-ONC list)

For these patients Dr. Swanson talked about the debate about when to remove the kidney. He said since the 1980's, MDA has started IFN-alpha first, then operated on positive responders. He talked about a study by Walther in 1977 at NCI, and said that randomized trials showed delayed progression and improved survival for nephrectomy first vs. biologic treatment only. "The jury is still out."

He gave the following as reasons for surgical excision:

1. Excision of mass [my notes are unclear here as to whether it referred to reduction of tumor mass or harvesting cells for vaccine therapy]
2. Treat localized recurrence
3. Solitary metastasis (as in lungs or brain)

For recurrence in the renal fossa (the kidney bed), Dr. Swanson recommends biological therapy first and then surgery. He said surgery could be palliative to address symptoms without being curative.

Dr. Swanson stressed development of a game plan. Steps:

1. Evaluate patient status and make plan
2. Consider standard and new options
3. Do the Nephrectomy despite presence of mets if:
   1. Clinical trial protocol requires tumor tissue
   2. Patient agrees to follow surgery with biological therapy later
   3. Patient has already had a good response to a biological therapy