Renal oncocytoma medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Homa Najafi, M.D.[2]

Overview

The mainstay of therapy for renal oncocytoma is surgery.

Medical Therapy

The mainstay of therapy for renal oncocytoma is surgery.

The standard of treatment for oncocytomas is surgical extirpation. The continuing debate concerns the extent of surgery necessary for this tumor whose natural history follows a benign and usually slow-growing course despite the occasional presence of apparently invasive features such as lymphovascular and renal capsular involvement.1,4,26 Since CRCC has become widely recognized, only one biopsy-proven case of metastatic oncocytoma has been reported in the English data.1 The patient had an oncocytic liver lesion with stable disease at 58 months with expectant management only, suggesting that oncocytomas retain their benign nature even in the presence of multiorgan involvement.The excellent prognosis associated with this tumor seems to indicate that minimally extensive and invasive ablative techniques such as partial nephrectomy, cryotherapy,54 or radiofrequency55 may be adequate for the removal of the tumor while sparing unaffected renal parenchyma. However, a few concerns have been raised. The coexistence of RCC and oncocytoma is not uncommon and is seen in 10% to 32% of patients with oncocytoma. 10,11 Dechet et al.11 looked at 14 cases of coexistent RCC and oncocytoma and found that all the RCC and oncocytoma tumors (1.0 to 12.0 cm) except for one (0.3 cm) were detectable by preoperative studies or intraoperative inspection of the kidney. The same study found that 5 of 6 patients with recurrent oncocytoma had recurrence on the contralateral kidney.11 These findings seem to suggest that nephron-sparing surgery should be attempted only after thorough intraoperative inspection by open or laparoscopic techniques for the presence of additional lesions. The surprisingly high occurrence of coexistent oncocytoma and RCC brings into question whether various reports of patients dying of metastatic oncocytoma1,5 may have, in fact, been cases of the coexistent disease with the patients actually dying of metastatic RCC. Until more accurate methods of distinguishing oncocytoma from RCC and of ruling out the presence of coexistent tumors are available, it is unlikely that patients can forego surgery altogether.

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: 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. Whether the patient has a RCC or a renal oncocytoma, radical nephrectomy will be the treatment of choice, and agonizing over the possible presence of a renal oncocytoma is not very practical or rewarding. Whether to employ laparoscopic techniques to extract a particular renal mass remains controversial. Although laparoscopic radical nephrectomy has proven its merits from an oncologic perspective [43], and has begun to move from academic centers into the general medical community, laparoscopic partial nephrectomy has not yet made this transition. Obtaining adequate hemostasis in the bed of resection remains a challenge for the surgeon, and ongoing investigators are working to identify the optimal means of achieving this goal. At the present time the authors’ preference is to prioritize the objective of nephron-sparing over the reduction in morbidity provided by the laparoscopic approach. Cryotherapy, radiofrequency ablation, and other minimally invasive techniques for extirpating renal tumors are still in their infancy and their respective roles for the treatment of oncocytoma remains to be determined.

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.

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR

The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

• Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
• Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
• Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
• Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Disease Name

• 1 Stage 1 - Name of stage
  • 1.1 Specific Organ system involved 1
    • 1.1.1 Adult
      • Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days (Contraindications/specific instructions)
      • Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
      • Preferred regimen (3): drug name 500 mg q12h for 14-21 days
      • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
      • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
      • Alternative regimen (3): drug name 500 mg PO q6h for 14–21 days
    • 1.1.2 Pediatric
      • 1.1.2.1 (Specific population e.g. children < 8 years of age)
        • Preferred regimen (1): drug name 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
        • Preferred regimen (2): drug name 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
        • Alternative regimen (1): drug name10 mg/kg PO q6h (maximum, 500 mg per day)
        • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
        • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
      • 1.1.2.2 (Specific population e.g. 'children < 8 years of age')
        • Preferred regimen (1): drug name 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
        • Alternative regimen (1): drug name 10 mg/kg PO q6h (maximum, 500 mg per day)
        • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
        • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
  • 1.2 Specific Organ system involved 2
    • 1.2.1 Adult
      • Preferred regimen (1): drug name 500 mg PO q8h
    • 1.2.2 Pediatric
      • Preferred regimen (1): drug name 50 mg/kg/day PO q8h (maximum, 500 mg per dose)

• 2 Stage 2 - Name of stage
  • 2.1 Specific Organ system involved 1

    Note (1):

    Note (2):

    Note (3):

    • 2.1.1 Adult
      • Parenteral regimen
        • Preferred regimen (1): drug name 2 g IV q24h for 14 (14–21) days
        • Alternative regimen (1): drug name 2 g IV q8h for 14 (14–21) days
        • Alternative regimen (2): drug name 18–24 MU/day IV q4h for 14 (14–21) days
      • Oral regimen
        • Preferred regimen (1): drug name 500 mg PO q8h for 14 (14–21) days
        • Preferred regimen (2): drug name 100 mg PO q12h for 14 (14–21) days
        • Preferred regimen (3): drug name 500 mg PO q12h for 14 (14–21) days
        • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
        • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
        • Alternative regimen (3):drug name 500 mg PO q6h for 14–21 days
    • 2.1.2 Pediatric
      • Parenteral regimen
        • Preferred regimen (1): drug name 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
        • Alternative regimen (1): drug name 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
        • Alternative regimen (2): drug name 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '(Contraindications/specific instructions)'
      • Oral regimen
        • Preferred regimen (1): drug name 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
        • Preferred regimen (2): drug name (for children aged ≥ 8 years) 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
        • Preferred regimen (3): drug name 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
        • Alternative regimen (1): drug name 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
        • Alternative regimen (2): drug name 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
        • Alternative regimen (3): drug name 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
  • 2.2 'Other Organ system involved 2'

    Note (1):

    Note (2):

    Note (3):

    • 2.2.1 Adult
      • Parenteral regimen
        • Preferred regimen (1): drug name 2 g IV q24h for 14 (14–21) days
        • Alternative regimen (1): drug name 2 g IV q8h for 14 (14–21) days
        • Alternative regimen (2): drug name 18–24 MU/day IV q4h for 14 (14–21) days
      • Oral regimen
        • Preferred regimen (1): drug name 500 mg PO q8h for 14 (14–21) days
        • Preferred regimen (2): drug name 100 mg PO q12h for 14 (14–21) days
        • Preferred regimen (3): drug name 500 mg PO q12h for 14 (14–21) days
        • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
        • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
        • Alternative regimen (3):drug name 500 mg PO q6h for 14–21 days
    • 2.2.2 Pediatric
      • Parenteral regimen
        • Preferred regimen (1): drug name 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
        • Alternative regimen (1): drug name 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
        • Alternative regimen (2): drug name 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
      • Oral regimen
        • Preferred regimen (1): drug name 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
        • Preferred regimen (2): drug name 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
        • Preferred regimen (3): drug name 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
        • Alternative regimen (1): drug name 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
        • Alternative regimen (2): drug name 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
        • Alternative regimen (3): drug name 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)