Members of the Department of Urology have well-established programs to deliver state-of-the-art surgical innovations to patients with early and advanced renal cancers. The following techniques aim to maximize the probability of cure, preserve the largest amount of functional renal tissue, accelerate recovery, and return to normal daily function, while maintaining the best possible quality of life.
Active Surveillance of Small Renal Masses (SRM) Program
Through the use of state-of-the-art imaging technologies such as multi-parametric MRI, researchers in the Urology Department in collaboration with researchers in Radiology have developed novel protocols to closely monitor select patients with SRM and avoid unnecessary surgeries.
Tissue Ablation Program
We have developed the first and largest kidney tumor ablation program in Texas. UT Southwestern urologic surgeons and interventional radiologists first introduced radiofrequency ablation (RFA) of kidney tumors in 2000 and are recognized world leaders in this approach. RFA and similar approaches allow the delivery of different energy modalities to completely destroy small stage I renal tumors. This offers an alternative to surgery with significantly less risk and shorter recovery times. UT Southwestern faculty have pioneered new ablation methods using irreversible electroporation. The incorporation of the Nanoknife, a new electrical technology to the kill cancer cells, expands the number of patients eligible for tumor ablation at UT Southwestern.
Minimally Invasive Nephron Sparing
UT Southwestern has one of the largest robotic kidney cancer surgery programs in Texas, and performs more than a quarter of all robotic kidney cancer surgeries in North Texas. Our surgeons have perfected the use of robotic techniques for minimally invasive partial nephrectomies, which, while completely removing the tumor, minimize the effects on renal function. Urologists at UT Southwestern were the first in the United States to perform laparoendoscopic single-site surgery (LESS), which allows the removal of kidney tumors laparoscopically and robotically through a small 1-2 inch incision in the umbilicus, resulting in less pain, shorter recovery times, and better cosmetic results.
Multi-Specialty Management of Advanced Renal Tumors
Up to 10 percent of renal tumors invade into blood vessels and can extend into major venous structures, sometimes all the way to the heart. Removing such advanced tumors is fraught with complications and risks. Urologic surgeons at UT Southwestern, in close collaboration with cardiovascular surgeons and cardiac anesthesiologists, have established and perfected techniques which have allowed effective removal of such tumors with a significant decrease in perioperative complications. With the establishment of a dedicated multi-specialty surgical team and the use of vascular bypass and deep hypothermic circulatory arrest techniques, UT Southwestern surgeons have reduced the risk of peri-operative mortality and major complications by 60 percent.
Physicians and physicists within the Department of Radiation Oncology at UT Southwestern are recognized worldwide as leaders in advanced radiation treatment techniques. A particularly robust specialty of our radiation oncology team is stereotactic ablative radiotherapy (SABR) – also known as stereotactic body radiation therapy (SBRT). SABR is a relatively new, non-invasive treatment in which high-dose radiation beams enter the body through multiple angles intersecting on the kidney tumor or metastasis. Brain metastases are often treated in this manner at the Annette Simmons Stereotactic Treatment Center.
Evaluating SBRT for the Management of SRM
We are one of the few centers investigating stereotactic radiation therapy for treatment of small renal cancers (see clinical trials).
Pioneering Treatment of Tumor Thrombi
In May 2015, UT Southwestern radiation oncologists reported, for the first time ever, the deployment of SABR for the treatment of a deadly complication of kidney cancer. In approximately one quarter to one third of patients, kidney cancer invades directly into the venous system, where it crawls sometimes all the way into the heart. These extensions, referred to as tumor thrombi, start in the renal vein, progress to the inferior vena cava and occasionally reach the right atrium. The primary treatment is surgery, but the tumor thrombus can recur and in some patients it is not surgically removable. UT Southwestern radiation oncologists have pioneered the use of SABR for the treatment of these thrombi using state-of-the-art linear accelerators (TrueBeam and Vero) and recently reported their success in two patients (Hannan et al., Cancer Biol Ther 2015). Their study shows that SABR may be a treatment option for advanced tumor thrombi. This approach, which remains experimental, is being systematically evaluated in a clinical trial.
CyberKnife: Image-Guided Robotic Radiosurgery
The CyberKnife uses a linear accelerator mounted on a robotic arm. At the Annette Simmons Stereotactic Treatment Center in Zale Lipshy University Hospital, both radiosurgery and radiotherapy with CyberKnife are performed on an outpatient basis.
At the Moncrief Radiation Oncology clinic, stereotactic radiosurgery is performed using the next-generation Elekta Agility linear accelerator with multifunctional intelligent beam shaping. This advanced machine offers integrated digital control of leaves and leaf guides, combined with unique Rubicon optical leaf positioning for accurate beam shaping. Coupled with extremely low-leaf transmission of less than 0.5 percent, Agility enhances treatment delivery while reducing integral dose.
UT Southwestern Medical Center was the first institution in North America to install Vero, an advanced system for delivering noninvasive radiation treatment to cancer patients. The Vero system integrates many state-of-the-art radiation therapy capabilities into one machine and is designed to locate tumors and meticulously direct radiation precisely where it is needed. The Vero machine also incorporates several different types of imaging technologies, including X-ray, CT, and fluoroscopy, which allow clinicians to locate and track tumors, even when the patient’s body moves. Unique to the Vero is a gamboled linear accelerator head that can move in multiple directions.
The versatile TrueBeam system from Varian is designed to address complex clinical cases. TrueBeam integrates respiratory gating, real-time tracking, and imaging with treatment delivery. This integration allows using the latest techniques, including SABR/SBRT and RapidArc.
Gamma Knife: Precise, Noninvasive Radiosurgery
The Gamma Knife uses beams of highly focused gamma rays to treat tumors or other abnormalities in the brain. It remains the most precise tool available and is used to treat brain metastases.
The Department of Radiology provides a full range of support for diagnostic imaging and image-guided interventional procedures for patients with kidney cancer. Innovative imaging techniques and image-guided interventional procedures are incorporated into clinical practice on an ongoing basis.
Magnetic Resonance Imaging (MRI)
3Tesla and 7Tesla MRI scanners in the Department of Radiology and Advanced Imaging Research Center are being used to optimize image acquisition. The Kidney Cancer Imaging program, supported in part by a grant from the National Cancer Institute, pioneers novel techniques for the study of tumor heterogeneity as well as angiogenesis (i.e. formation of new blood vessels) in kidney tumors.
UT Southwestern features the latest molecular imaging technologies including Single-photon emission computed tomography (SPECT-CT) and positron emission tomography (PET-CT). A cyclotron, installed in July of 2014, provides access to novel short-lived positron-emitting isotopes suitable for innovative PET-CT imaging protocols for kidney cancer.
Interventional Radiology offers unique and technically advanced solutions for the management of kidney cancer including trans-arterial embolization to reduce spontaneous bleeding and selective arterial embolization for localization and treatment of bleeding following partial nephrectomy.
Genitourinary pathology, with seven subspecialized urological pathologists, plays a critical role in the clinical management of patients with kidney cancer. This team of pathologists provides diagnoses of the specific subtype of kidney cancer. Each year, our subspecialized pathologists interpret more than 500 renal surgical and cytology specimens, including rare and complex cases. Additionally, our urological pathologists provide consultation services for in-house and referral cases.
Recent discoveries by UT Southwestern investigators have led to a novel classification of clear cell renal cell carcinoma (ccRCC), the most common type of kidney cancer in adults. Payal Kapur, M.D., developed the first immunohistochemistry test for molecular phenotyping of renal tumors based on mutated tumor suppressor genes. Analyses by Dr. Kapur of over 1,400 cases from Mayo Clinic have confirmed and extended previous discoveries by UT Southwestern investigators that ccRCC can be subclassified based on the expression of the proteins BAP1 (BRCA1 associated protein 1) and PBRM1 (Polybromo 1) into 4 different subtypes.
These subtypes are: BAP1-deficient tumors, PBRM1-deficient tumors, tumors deficient for both proteins, and tumors deficient for neither. These four different tumor types exhibit different biology and outcomes. A more accurate diagnosis will help patients understand better the risk of tumor recurrence. These findings set the foundation for the first molecular genetic classification of renal cancer and pave the way for subtype-specific treatments.
Patients often are intrigued to see what their tumor looks like under a microscope. These images show and identify different types of kidney cancer tumors.