“I think an important message people need to hear is that it really is a team effort in the operating room,” said Zachary Klaassen, MD, MSc, a urologic oncologist at the Georgia Cancer Center and an assistant professor in the Department of Urology at the Medical College of Georgia at Augusta University. “There may be times when I am operating to remove a kidney cancer and I need the help of a vascular surgeon, or a hepatobiliary surgeon who works with the liver and the gallbladder, or a colorectal surgeon if the colon is displaced or attached to the tumor. And, before we start operating, we get a number of scans and views of the tumor to determine which surgical specialist we are going to need in the room.”
According to the American Cancer Society’s Cancer Facts and Figures 2023 report, more than 81,000 people will be diagnosed with kidney and renal pelvis cancer this year. Of those 81,000, nearly 2,600 patients will live in Georgia and nearly 1,500 will call South Carolina home. Now, not all kidney cancers are the same. This makes the surgical approach very individualized for Klaassen and his colleague Martha K. Terris, MD, F.A.C.S., another urologic oncologist working at the Cancer Center. For some kidney cancers, the tumor is three centimeters or less meaning it can be removed through robotic surgery. Other kidney tumors are slightly larger, around 6-7 centimeters where a laparoscopic approach is necessary to remove the tumor. But larger tumors attached to a kidney can create chaos with other organ systems.
“On the right side of the body we find the liver or inferior vena cava, which is the largest vein in the body connected to our heart,” Klaassen said. “And, on the left side is our spleen, pancreas, and the aorta, which is the largest artery in our body carrying oxygen-rich blood from the heart to other parts of our body. I probably do two to four cases a month where I need at least one other surgical specialist in the operating room with me. These relationships I have built with these other surgeons has definitely led to more favorable outcomes for locally advanced kidney cancer patients.”
In a lot of these cases, Klaassen, his residents, and the surgical team will make the necessary incisions, getting all of the intestines mobilized, getting the kidney ready for operation, and then have their colleagues come in for their section of the surgery. But, there are times when the tumor is attached to the intestines and a colorectal surgeon is called in first. Klaassen refers to this collaboration effort as a planned intraoperative consults where the team of surgeons come in at specific times during the surgery for their part of the process.
“Before we even get to the operating room there’s a lot of imaging scans that we need so we can plan the best approach and process,” Klaassen said. “This includes an MRI and other images to show us the various tissue plains for the kidney, the tumor, and these other organs. All this pre-operation work helps us feel confident we have the right planned intraoperative consult schedule on the day of the surgery.”
According to Klaassen, these relationships and this multidisciplinary approach makes him grateful for partnerships like this because it puts the patient’s experience first.
“I tell my residents that with surgeries like these there is no ego here,” Klaassen said. “You are here to give the patient the best kidney cancer operation possible. And, if there are other structures in danger that could threaten the patient’s life, you need to be responsible and seek assistance. Ultimately, that’s our job as humans, doctors, and surgeons.”
While partnerships are necessary inside the operating room, collaboration is also important with other oncologists who specialize in treating kidney cancer with chemotherapy, immunotherapy, and radiation. At the Georgia Cancer Center, the team follows a clinical trial program that showed doses of pembrolizumab for one year after a patient with advanced kidney cancer removed via surgery saw their risk for the cancer coming back decreased by 30-percent compared to those who did not receive the medication. Before this clinical trial, the standard of care for advanced kidney cancer after surgery was simply observation scans to see if any tumors returned.
“I often talk to the patients with more advanced kidney tumors before surgery to let them know step one is to remove the tumor and their kidney if necessary,” Klaassen said. “After the tumor is removed and analyzed by our pathologist, I let them know they need to be ready to decide if they are willing to undergo the one year of pembrolizumab. If they say they want to do that, my team and I connect them with our medical oncologist to begin therapy if they fit all the criteria.”
Klaassen said around 80-percent of the patients he has who underwent the treatment tolerated the dosage well meaning they could have a 30-percent decreased risk of having their cancer return. For another five to ten percent, they experienced pretty significant side effects and had to stop treatment. While some were able to resume treatment, others moved to getting regular scans to make sure no new tumors formed.
“You really don’t know if you are going to be in that five to ten percent who won’t tolerate the pembrolizumab until you get through three to four doses,” Klaassen said. “But, we are still going to watch and monitor the situation to make sure we catch any new tumors sooner rather than later.”