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RCCRCC
± 3% of all adult malignancies± 3% of all adult malignancies M / F: 3 / 2M / F: 3 / 2 Typically in 6th and 7th decade of life, uncommon Typically in 6th and 7th decade of life, uncommon
in childhoodin childhood Renal cell carcinoma arise from the renal Renal cell carcinoma arise from the renal
epithelium and account for about 85 percent of epithelium and account for about 85 percent of renal cancers.renal cancers.
A quarter of the patients present with advanced A quarter of the patients present with advanced disease, including locally invasive or metastatic disease, including locally invasive or metastatic renal-cell carcinoma (mRCC).renal-cell carcinoma (mRCC).
A third of the patients who undergo resection of A third of the patients who undergo resection of localized disease will have a recurrence.localized disease will have a recurrence.
Renal Cell CarcinomaRenal Cell Carcinoma
Incidental findings on USGIncidental findings on USG Symptoms:Symptoms: - Hematuria- Hematuria - Flank pain- Flank pain - Abdominal/flank mass - Abdominal/flank mass Others: Varicocelle / Lower extremity Others: Varicocelle / Lower extremity
OedemaOedema Para-neoplastiPara-neoplasticc symptoms: symptoms:
Increased LED / LDH / Ca+Increased LED / LDH / Ca+ UnexplainUnexplaineded fever fever
Renal cell carcinoma:Renal cell carcinoma: Clinical presentation Clinical presentation
Incidence of Systemic Syndromes Associated withIncidence of Systemic Syndromes Associated with Renal Cell Carcinoma (percentage)Renal Cell Carcinoma (percentage)
Elevated erythrocyte sedimentation rate 55.6 Elevated erythrocyte sedimentation rate 55.6 Hypertension 37.5 Hypertension 37.5 Anemia 36.3 Anemia 36.3 Cachexia, weight loss 34.5 Cachexia, weight loss 34.5 Pyrexia 17.2 Pyrexia 17.2 Abnormal liver function 14.4 Abnormal liver function 14.4 Hypercalcemia 4.9 Hypercalcemia 4.9 Polycythemia 3.5 Polycythemia 3.5 Neuromyopathy 3.2 Neuromyopathy 3.2 Amyloidosis 2.0Amyloidosis 2.0
Clinical presentationClinical presentation
Renal cell carcinoma:Renal cell carcinoma:
Initial workupInitial workup
• CBC, metabolic panel (ESR, LDH, Ca+ )CBC, metabolic panel (ESR, LDH, Ca+ )• UrinalysisUrinalysis• Abdominal/pelvic Abdominal/pelvic ultrasound ultrasound / CT or MRI with or without / CT or MRI with or without
contrast depending on renal functioncontrast depending on renal function• Chest imagingChest imaging• Bone scan, if clinically indicatedBone scan, if clinically indicated• Brain MRI, if clinically indicatedBrain MRI, if clinically indicated• If urothelial carcinoma suspected, consider urine If urothelial carcinoma suspected, consider urine
cytology, URS or cytology, URS or retrograde pyelographyretrograde pyelography• Consider needle biopsy, if clinically indicatedConsider needle biopsy, if clinically indicated• (NCCN Asia 2009)(NCCN Asia 2009)
Renal cell carcinoma:Renal cell carcinoma:
Imaging modalitiesImaging modalities USGUSG : 32.5% (as first imaging): 32.5% (as first imaging) CT ScanCT Scan : 95.0%: 95.0%
Renal Cell CarcinomaRenal Cell Carcinoma::
Staging Overview and Five-Year Survival for Renal CancerStaging Overview and Five-Year Survival for Renal Cancer
Renal cell carcinoma:Renal cell carcinoma:
Renal cell carcinoma:Renal cell carcinoma:
Staging: TNMStaging: TNM
SurgerySurgery
• Currative intent (radical or nephron-sparing)Currative intent (radical or nephron-sparing)• Palliative intent (to avoid pain / prevent gross Palliative intent (to avoid pain / prevent gross
hematuria)hematuria)• Metastasectomy (for single metastasis lesion Metastasectomy (for single metastasis lesion
in the lung or liver)in the lung or liver)
Grading: FuhrmanGrading: FuhrmanHistopathological type / sub-typeHistopathological type / sub-type
SubtypeSubtype IncidencIncidencee
Genetic AlterationsGenetic Alterations Clinical FeaturesClinical Features
Clear cell / Clear cell / conventionalconventional
70-80%70-80% Loss of VHL geneLoss of VHL geneDeletion of chromosome 3Deletion of chromosome 3
Garden-variety RCCGarden-variety RCCHypervascularHypervascular
PapillaryPapillary 10-15%10-15% Activation of MET proto-Activation of MET proto-oncogeneoncogeneTrisomy chromosome 7 & Trisomy chromosome 7 & 1717
Increased incidence Increased incidence of multicentricityof multicentricityOften hypovascularOften hypovascular
ChromophobiChromophobicc
4-5%4-5% Not definedNot defined Not definedNot defined
Collecting Collecting ductduct
< 1%< 1% Not definedNot defined Poor prognosisPoor prognosis
Medullary cellMedullary cell < 1%< 1% Not definedNot defined Poor prognosisPoor prognosis
OncocytomaOncocytoma 3-7%3-7% Loss of chromosome 1 & YLoss of chromosome 1 & Y BenignBenign
Classification of Classification of Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma:Renal cell carcinoma:
Principles of surgeryPrinciples of surgery
• Radical nephrectomyRadical nephrectomy• oror• Nephron-sparing surgery may be indicated in Nephron-sparing surgery may be indicated in
selected patients: selected patients:
• - Multiple primary (absolute)- Multiple primary (absolute)• - Uninephric state (absolute)- Uninephric state (absolute)• - Renal insufficiency (relative)- Renal insufficiency (relative)• - Selected patients with small - Selected patients with small
unilateral tumor & healthy contra lateral unilateral tumor & healthy contra lateral kidney (elective)kidney (elective)
Renal cell carcinoma:Renal cell carcinoma:
• Principles of surgery (con’t)Principles of surgery (con’t)
Lymph node dissection is optionalLymph node dissection is optional
Adrenal gland may be left if uninvolved Adrenal gland may be left if uninvolved and tumor is not high risk, on the basis of size and tumor is not high risk, on the basis of size and location (e.g.: mid or lower pole tumor)and location (e.g.: mid or lower pole tumor)
Renal cell carcinoma:Renal cell carcinoma:
• Local recurrence or progression after radical / Local recurrence or progression after radical / nephron-sparing surgery for localized RCC:nephron-sparing surgery for localized RCC:
• Local recurrenceLocal recurrence• Contra lateral kidneyContra lateral kidney• Metastasis: Lung, Liver, Bone, or BrainMetastasis: Lung, Liver, Bone, or Brain
• Follow up after radical / nephron-sparing surgery for Follow up after radical / nephron-sparing surgery for localized RCC:localized RCC:
• Based on tumor stage (Campbell-Walsh Urology 2007)Based on tumor stage (Campbell-Walsh Urology 2007)
StageStage History, History, Examination, & Examination, & Blood testBlood test
Chest Chest RadiographRadiograph
Abdominal CTAbdominal CT
T1T1 YearlyYearly -- --
T2T2 YearlyYearly YearlyYearly Every 2 yearsEvery 2 years
T3T3 Every 6 months for 3 Every 6 months for 3 years, then yearlyyears, then yearly
Every 6 Every 6 months for 3 months for 3 years, then years, then yearlyyearly
At 1 year, At 1 year, then every 2 then every 2 yearsyears
Renal cell carcinoma:Renal cell carcinoma:
RCC is approximately 2-3% of adult cancerRCC is approximately 2-3% of adult cancer mRCC is diagnosed in 20-30% of new patients mRCC is diagnosed in 20-30% of new patients
and about one third of those who underwent and about one third of those who underwent radical nephrectomy for localized tumor will radical nephrectomy for localized tumor will develop metastasesdevelop metastases
Site of metastasis: lung, liver, bone, brainSite of metastasis: lung, liver, bone, brainTreatmentTreatment: : - - Solitary lesionSolitary lesion in the lung (& liver) could be in the lung (& liver) could be managed by surgery followed by systemicmanaged by surgery followed by systemic therapytherapy - - Multiple lesionsMultiple lesions should be managed by should be managed by systemic therapysystemic therapy
Metastatic Renal Cell Carcinoma (mRCC)Metastatic Renal Cell Carcinoma (mRCC)