DCF NewsLETTERVol. 15 No. 166 • AUGUST 2012 • PRICE `1.50 PER COPY

Dear Friends,

Happy Independence DayLaparoscopic surgery including laparoscopically assisted surgery is fast emerging as an alternative to open surgery for cancer patients. The decision is made after proper evaluation of case and an informed consent between the patient and the surgeon. Availability of onco-surgeon trained in advanced laparoscopic surgery is the key for successful outcome. Several studies have shown that the outcomes of laparoscopic oncosurgery are comparable with that of open surgery. Few advantages of laparoscopic oncosurgery are:✦ Better access and visualization✦ Less blood loss✦ Less pain and scarring✦ Faster recovery✦ Lesser risk of infection✦ Lesser medications✦ Short hospital stay✦ Quicker return to work✦ Quick recoveryWe have started entire spectrum of advanced laparoscopic oncosurgical procedures at Dharamshila Hospital. Few of the procedures done till date laparoscopically / laparoscopic assisted are:✦ Whipple’s procedure for periampullary carcinoma✦ Wertheim’s hysterectomy for carcinoma cervix ✦ Laparoscopic assisted abdomino-perineal resection ✦ Radical cholecystomy ✦ Total radical gasterectomy for GE junction tumor.We are also planning a workshop on Laparoscopic cancer surgery in November for a group of 100 surgeons at our hospital. The details of the workshop will be intimated to our surgeon friends very shortly. To get register yourself for this workshop, please write us at contact@dhrc.inWe look forward for your support in developing this specialty to greater heights.

Dr. S. KhannaExecutive Director

Stereotactic irradiation involves the delivery of a very high dose of X-ray treatment precisely focused on a target within the brain. The use of SRS allows delivery of a very high target dose with signifi cantly lower dose to normal brain tissue in the immediately surrounding region. The result is an enhanced ability to control intracranial disease coupled with a reduction in the risk of side effects from radiation therapy.

SUCCESSFUL TREATMENT OF TRIGEMINAL NEURALGIA WITH LINEAR ACCELERATOR BASED IMAGE GUIDED STEREOTACTIC RADIO-SURGERY

Stereotactic radiosurgery (SRS) is one of the least invasive treatments for trigeminal neuralgia (TN). To date, most reports have been about Cobalt-based treatments (i.e., Gamma Knife) with limited data on image-guided stereotactic linear accelerator treatments. We describe our initial experience of using Elekta Synergy stereotactic radiosurgery system for the radiosurgical treatment of TN. Thin cuts MRI images of 1 mm thickness were acquired and fused with the simulation CT of the patient. The trigeminal nerve root received a single dose

Vol. 15 No. 166 • AUGUST 2012

of 80 Gy. The adjacent Brainstem received less than 10% of the total dose to the target i.e. less than 8 Gy). The patient reported 90% pain relief post procedure and stopped taking carbamazepine. Vomiting was seen as a side effect for the next 3 days and controlled with steroids and antiemetics. No other complication was reported.

We conclude that LA based Stereotactic radiosurgery using the Elekta Synergy is a safe and effective treatment for TN.

This information is important as more centers are obtaining image-guided stereotactic-based linear accelerators capab le o f pe r fo rm ing radiosurgery.

Dr. Hari Mohan AgrawalMD (Radiation Oncology)

Consultant - Department of Radiation Oncology

NE PHRON-SPARING SURGERY FOR PAPILLARY RENAL CELL CARCINOMA IN HORSESHOE KIDNEY: A CASE REPORT

INTRODUCTIONHorseshoe kidney is perhaps the most frequent variation of kidney fusion. It occurs in 0.25% of the population and was described for the fi rst time in 1521 by Jacopo Berengario da Carpi. It consists of two kidneys joined at their lower poles by parenchymatous or fi brous tissue called isthmus. It is more frequent in men with a 2:1 male/female ratio.1,2 It occurs in the embryo between the 4th and 6th weeks of gestation after the ureteral yolk has entered into the renal blastema. This usually occurs before rotation and the renal pelvises are facing forward. The cause has not been completely identifi ed but it has been suggested that alterations in the position of the umbilical or com-mon iliac artery is responsible, altering the ascent and rotation of the kidneys which end up being situated in the lower part of the abdomen. The position of the superior mesenteric artery has also been implicated. The calyces are normal in number but atypical in orientation and their blood supply varies widely.1,3

The exact incidence of carcinoma in horseshoe kidney has not been described in literature but the observation has been made that it is higher - approximately 3 to 4 times greater than that of the rest of the population. Survival in patients with this type of tumor is related to stage and histopathological grade.4 Knowledge of preoperative neoplastic localization, extent, and vasculature is indispensible as part of the management approach to horseshoe kidney tumors so that complete resection of the tumor can be carried out without unnecessarily removing functional tissue. Angiography or helical computed tomography (CT) angiography is essential for planning surgical approach due to the great variability of blood vessels.5 We recently managed a case of papillary renal cell carcinoma in a horse-shoe kidney by performing a nephron-sparing resection of part of the left renal moiety at our hospital.

CASE REPORTA fi fty-seven old female patient presented to our hospital with complaints of occasional left sided fl ank pain for 1 year. The general physical examination revealed pallor. Examination of the abdomen was unremarkable. Patient’s routine hematological and biochemical investigations revealed anemia (Hb-6.7 gm %) and microscopic hematuria. CECT abdomen shows mass lesion

Fig. 1 Heterogenous mass upper pole of left moiety of horse-shoe kidney

After mobilization of the left colon, meticulous dissection was performed to clearly demonstrate the vascular anatomy at the left hilum. The isthmus was confi rmed to have an independent arterial and venous supply. The pelvis was extra-renal and only the upper calyx was draining the tumour-bearing area. This calyx was divided and then the vessels to the upper part of left moiety were dealt with. A distinct line of demarcation appeared above the junction of left moiety and the isthmus and the renal tissue was divided along this line using harmonic scalpel (Figs 3, 4). The tumour-bearing renal tissue with >2cm free margin, the left adrenal and the para-aortic lymph nodes were then removed in standard fashion. After ensuring haemostasis and integrity of pelvi-calyceal system on the cut-surface of the residual kidney, the procedure was completed. The patient had an

Fig. 2 Formatted view showing absence of pelvicalyceal and vascular pattern in upper pole on left side. Note the independent artery running across transverse pedicle of lumbar vertebra and supplying the isthmus

7.5 cm diameter with heterogeneous morphology and mixed Hounsfi eld values in the upper pole of the left moiety of a horse shoe kidney (Fig.1, 2).

The kidney was lower placed (malascended) than normal. Reconstruction of the vascular anatomy revealed a separate artery supplying the isthmus. (Fig 2)

With a preoperative diagnosis of a carcinoma in the horseshoe kidney, the patient was taken for surgery following conventional preparation, including pre-operative blood transfusions. The kidney was approached through midline abdominal incision, and revealed a tumor (7×7cm) localized to the upper pole of left moiety of the horse shoe kidney.

Vol. 15 No. 166 • AUGUST 2012

malformation remain asymptomatic. Clinical manifestations become apparent as a consequence of hydronephrosis, lithiasis, infection, or less frequently, tumor.1,6 The most common symptom that refl ects these conditions is vague abdominal pain that may radiate to the lower lumbar region. Different abnormalities are associated with horseshoe kidney but carcinoma has been reported in only 123 patients.7 Forty-seven percent of these cases correspond to clear cell carcinoma, 28% to urothelial carcinoma, 20% to Wilms’ tumor, and 5% to sarcomas.8 Survival from these tumors is related to the pathology and stage of the tumor at diagnosis, and not the renal anomaly.9

The surgical approach is guided more by individual preference than by necessity. The transperitoneal approach through a subcostal incision or midline incision allows early ligation of the renal artery and vein before tumor manipulation. This is an essential technical consideration in the management of renal carcinoma. We preferred the midline approach here as the horse-shoe kidney was low-lying due to incomplete ascent in this case.

Preoperative imaging is crucial in planning the surgery in a case of horseshoe kidney. Magnetic resonance angiography (MRA), magnetic resonance venography (MRV), and CT angiography have been advocated for imaging vascular anatomy. Angiographic examination for the specifi c tumor blood supply is able to reduce the intraoperative vascular injury, and reduce the need for blood transfusions postoperatively.10 The surgeon should however be prepared for unexpected vascular anatomy, despite impressions gained from preoperative imaging. It is our intuition that imaging for venous involvement may be less accurate in fused kidneys due to smaller caliber renal veins and variable venous anatomy. Formatted images obtained on modern CT machines have eliminated the requirement of separate angiographic examination. We could demonstrate independent arterial supply to the isthmus preoperatively. Meticulous and careful dissection at the hilum to demonstrate individual branches and intelligent use of vascular clamps facilitated a nephron-sparing, oncological safe surgery.

In general, the isthmus lies anterior to the aorta and vena cava, and receives a branch from the main renal artery. The division of

the isthmus may be essential in resecting renal cell cancer from a horseshoe kidney, not only to achieve complete oncological clerance, but also to normalize the course of the ureters if considered essential. In our case we achieved complete tumor clearance with adequate margins without isthemustectomy, and were able to preserve additional renal parenchyma.

Papillary renal cell carcinoma in the horseshoe kidney is not common. Diagnosis of the disease is not diffi cult; however, saving the maximum residual renal function can be challenging. In our view, accurate preoperative assessment of renal function is necessary. The choice of surgical incision and the scrupulous attention to detail during surgery aids in retention of maximal functional renal tissue.

REFERENCES1. Glenn JF. Analysis of 51 patients with horseshoe kidney. N Eng J Med

1959;261:684-687. 2. Jones L, Reeves M, Wingo S. Malignant tumor in a horseshoe kidney. Urol

J 2007;4(1),46-48.3. Hohenfellner M. Tumor in the horseshoe kidney: clinical implications and

review of embryogenesis. J Urol 1992;147(4):1098-1102.4. Vázquez S, Calahorra-Rodríguez A. Patología tumoral en el riñón en her-

radura. Actas Urol Esp 1994;18:764-767. 5. Arce Y, Trias I, Santaularia JM, Antonio Rosales. Aplicación clínica de las

actuales clasifi caciones del cáncer renal. Actas Urol Esp 2006;30:372-385.6. Boatman DL, Cornell SH, Kölln CP. The arterial supply of horseshoe kidney.

Am J Roentgenol Radium Ther Nucl Med 1971;113(3):447- 451.7. Blackard CE, Mellinger GT. Cancer in a horseshoe kidney. A report of two

cases. Arch Surg 1968;97(4):616-27.8. Otero García JM, Maldonado Alcaráz E, López Samano VA. Carcinoma

de células claras en riñón en herradura. Descripción de un caso y revisión de la literatura. Gac Med Mex 2005;141(4);305-307.

9. Murphy DM, Zincke H. Transitional cell carcinoma in the horseshoe kidney: report of 3 cases and review of the literature. Br J Urol 1982;54:484–487.

10. Wilhelm L, Albrecht L, Kirsch M, et al. Preoperative application of selective angiographic embolization in the treatment of focal nodular hyperplasia. Surg Laparosc Endosc Percutan Tech 2006;16:177–181.

Prof (Dr.) Sharan Choudhri Senior Consultant & HOD – Surgical Oncology

Dr. Gyanendra S. Mittal DNB Resident – Surgical Oncology

Fig. 3 (Left) Note the clear line of demarcation after division of arterial supply and sparing the isthmus.

Fig. 4 (Right) Complete division of upper pole and adjacent area achieving tumour-free margin >2cm.

uneventful post-operative course and was discharged on the fourth postoperative day.

The histopathology examination revealed a papillary renal cell carcinoma, Fuhrman nuclear grade 3. There was no metastasis in the removed para-aortic nodes. The resection margin, renal vein and ureter were free of the tumor.

DISCUSSIONThe horseshoe kidney is probably the most common of all renal fusion anomalies. The anomaly consists of two distinct renal masses lying vertically on either side of the midline and connected at their respective lower poles by a parenchymatous or fi brous isthmus that crosses the midplane of the body. Almost a third of patients presenting with this congenital

Vol.

15 N

o. 1

66 •

AU

GU

ST 2

012