epidemiological data has indicated the increase in detection of kidney tumors in recent years [ 1 , 2 ] . it is probably bound to a better availability of imaging techniques , as the majority of tumors are found incidentally , without any symptoms . despite this , however , some of the detected tumors are larger than 14 cm in diameter . surprisingly , a palpable abdominal mass is not an alarming symptom for some patients and does not force them to seek medical help . other symptoms of classic virchow triad like flank pain and gross hematuria are rare not always present [ 1 , 2 ] . paraneoplastic syndromes i.e. , weight loss , hypertension , pyrexia or anemia are often linked with other conditions . removing a large kidney tumor creates a considerable challenge , even for a skilled urologist . the infiltration of adjacent organs , presence of neoplasmatic thrombus in vena cava , or distant metastases might be found [ 1 , 2 , 3 ] . all of these increase the perioperative risk . on the other hand , only surgical treatment when followed by administration of tk inhibitors work by schrader showed that currently available chemotherapy is not effective as a neoadjuvant treatment used in order to reduce tumor size and stage . the aim of this study is to analyze the result of surgical treatment in patients with very large ( 14 cm ) kidney tumor as well as the perioperative complications on the basis of own experience and literature . between spring 2009 and autumn 2011 , 12 patients with kidney tumor 14 cm were operated in our department . the group consisted of eight men and four women , aged 4680 ( mean 60 ) . bmi was 2138 ( mean 27 ) . on presentation , five out of the 12 patients ( 42% ) suffered from hematuria , weight loss , and malaise . lab tests did not reveal abnormal kidney parameters ( creatinine levels were < 1.3 mg / dl and gfr was > 60 ml / min/1.73 m ) nor low hemoglobin concentration ( < 11 g / dl ) . when done precisely , palpation revealed abdominal mass in all of the patients ( 6/12 left sided , 6/12 right sided ) . echoic tumor mass blurring normal kidney shape ) and confirmed by ct ( 11/12 ) or mr ( 1/12 ) imaging  gross kidney lesions with heterogenous contrast enhancement ( figs . the kidney mass extended into the renal vein . in one patient the kidney cancer thrombus grossly extended into vena cava inferior below the diaphragm . imaging modalities ( ct / mr ) indicted periaortic lymph nodes suspicious for metastases in five patients ( 41.6% ) . in four patients ( 33% ) , . 
  mri scan  transverse section of a tumor ( diameter  12 cm ) . mri scan  crossection through the tumor ( longitudinal length of tumor  16 cm ) . male ) radical nephrectomy including lymphadenectomy and adrenalectomy was performed in all patients due to good performance status facilitating planning of the additional systemic therapy . transperitoneal medial incision was done in 11 patients ( 91.6% ) and extraperitoneal lumbar approach in one patient ( 8.4% ) . mean operation time was 2 h 45 ( 2 h 15  4 h ) and mean blood loss 700 ml ( 3001800 ml ) . blood transfusions were necessary in five patients because of hemoglobin level < 8 g / dl . detailed pathological findings are disclosed in table 2 with the tnm staging system and fuhrman classification . lymph node metastases and tumor thrombus size were correctly assessed in all cases using imaging studies . pathological results in accordance with the 2009 tnm staging system urological and oncological care of all patients treated is continued in the outpatient setting . in the six months after nephrectomy , five patients previously diagnosed with lymph node involvement required systemic therapy because of probable non  radical lymphadenectomy . the most common malignant lesion in the kidney is renal cell carcinoma ( rcc ) , which represents 8590% of all kidney tumors . the remaining 1015% of renal tumors are more rare cancers , unclassified lesions , and some types of benign tumors . among the causes of death in men from cancer , rcc occupies the 7 place . statistically , the number of cases is higher in men than in women by a ratio of 1.5:1 with a peak of incidence between the 6 and 7 decade of life [ 1 , 2 ] . epidemiological data has indicated the increase in detection of kidney tumors in recent years . mainly it is caused due to better availability of imaging techniques , as the majority of tumors are found incidentally without any symptoms . the factors that increase the incidence rate include smoking , obesity , hypertension , and chemical agents . rcc is also present in some genetically determined syndromes such as : von hippel  lindau , birt however , tumor size , location , local advancement , and presence of thrombus in vena cava may cause that some patients may not be qualified for the treatment because of a high risk of complications . from the literature we also know that tumor size is an independent prognostic factor influencing the result of the treatment . in our opinion the currently used diagnostic tools allow for precisely determining the stage of the tumor , which was confirmed in our study group . radiological results in most patients were confirmed by intraoperative examination and pathology results [ 8 , 9 ] . the presence of a very large tumor undoubtedly increases the difficulty of surgery especially in obese patients , which was observed at the time of surgery in patients with bmi greater than 31 . in the literature there are some case report studies suggesting that neoadjuvant chemotherapy with targeted therapy may reduce the stage of the tumor and thus make the surgery easier . however , currently used drugs have proven not to be very effective in larger studies , and this option in poland and other countries is yet neither registered nor recommended . an accurate preoperative diagnosis , proper preparation of the patient and experienced operating team allow the removal of the tumor without serious complications . in our opinion the most suitable surgical approach is a median incision because it allows better control over the vascular pedicle [ 3 , 11 , 12 ] . in experienced hands , operating time , blood loss , and the risk of complications should not be significantly greater than reported for smaller tumors [ 13 , 14 , 15 ] . the qualifications for surgery depend on the presence of infiltrating of adjacent organs , especially liver and spleen , which greatly affect the course of the treatment . it is not directly associated with the tumor size , but undoubtedly is important when planning surgery . the removal of the tumor in such cases is only justified in patients in good condition and with favorable prognostic factors enabling adjuvant treatment with targeted chemotherapy [ 1 , 14 , 16 ] . in our opinion : radical nephrectomy is the method of choice in the treatment of large renal tumors in poland due to healthcare system requirements;there is no scientific proof that neoadjuvant targeted therapy may significantly reduce the stage and size of a tumor;tumor size alone should not affect the qualification of the patient for surgery;currently used imaging modalities enable precise evaluation of clinical stage of the tumor and are basic instruments for surgical planning;the removal of the tumor in disseminated disease is only justified in patients with a condition suile for targeted adjuvant treatment . radical nephrectomy is the method of choice in the treatment of large renal tumors in poland due to healthcare system requirements ; there is no scientific proof that neoadjuvant targeted therapy may significantly reduce the stage and size of a tumor ; tumor size alone should not affect the qualification of the patient for surgery ; currently used imaging modalities enable precise evaluation of clinical stage of the tumor and are basic instruments for surgical planning ; the removal of the tumor in disseminated disease is only justified in patients with a condition suile for targeted adjuvant treatment .
introductiondespite the introduction of better diagnostic tools , very large kidney tumors are still not so rare in our country . 
 the paper presents our experience in the treatment of 12 patients with kidney tumors larger than 14 cm in size.material and methodsbetween spring 2009 and autumn 2011 , radical nephrectomies were performed in 12 patients due to a large kidney tumor ( larger than 14 cm in size ) . 
 symptoms ( hematuria , weight loss , anemia , etc . ) were not present in all the patients , but the kidney tumor was confirmed by imaging studies ( ultrasound , ct , mri ) in all of them.resultsfull recovery was observed with no severe complications in all of the patients treated with radical nephrectomy . 
 pathological staging was correctly established by imaging studies in all of them . 
 after a few months , five of patients ( 41.6% ) required systemic therapy due to lymph node involvement.conclusionspatients with large kidney tumors should be treated in selected medical centers that have experience in the treatment of such cases . 
 radical nephrectomy has to be the method of choice in the treatment of patients with this kind of tumor and its diameter should not disqualify from surgical treatment , which is still the only chance for the patients to be cured , as no adjuvant chemotherapy treatment has proved to be significantly effective .