Download MBBS Surgery Presentations 50 Renal Cell Carcinoma Lecture Notes

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Epidemiology

? Male predominance (M:F 1.5:1).
? Most common in sixth to eighth decades; peak

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incidence in sixth decade

? Metastatic disease in 30% at diagnosis, and eventually

in 50% (lung, liver, bone, distant LN, adrenal, brain,

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opposite kidney, soft tissue)

? Most sporadic RCCs are unilateral and unifocal

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? Stage at diagnosis is the most important prognostic factor
? Predominant histologic type: adenocarcinoma arising from

tubular epithelium

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? Adenocarcinoma subtypes:

? clear cel (75?85%)
? chromophilic/ papil ary (10?15%)
? chromophobe (5?10%)

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? oncocytic (rare)
? Sarcomatoid (1?6%; poor prognosis)

Papil ary (chromophilic) renal cel carcinoma extending into the col ecting

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system
Risk factors

? Tobacco , urban environmental toxins (cadmium/ asbestos/ petrols),

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obesity, high dietary fat intake, acquired cystic renal disease from renal
failure

? Association with von Hippel-Lindau disease:

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? autosomal dominant
? loss of 3p
? >70% chance developing RCC (almost al clear cel histology) risk of developing

multiple other benign and malignant tumors (retinal angiomas, CNS

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hemangioblastomas, pheochromocytoma , pancreatic cancer)

Pathology

? Round to ovoid

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? Circumscribed by a pseudo capsule of compressed
parenchyma and fibrous tissue

? Nuclear features can be highly variable

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Diagnosis

? Common signs and symptoms:

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? hematuria (80%)
? flank pain (45%)
? flank mass (15%)
? classic triad of prior three only present in 10%

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? normocytic/normochromic anemia, fever, weight loss

? Less common signs and symptoms:

? hepatic dysfunction without mets

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? Polycythemia
? hypercalcemia (occurs in 25% of patients with RCC mets)

Paraneoplastic syndromes in 20% of patients with RCC

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Diagnosis

? Labs: CBC, LFT, BUN/Cr, LDH, urinalysis

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? Imaging:

? CT abdomen
? MRI abdomen if CT suggests IVC involvement

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? Metastatic evaluation:

? Chest X ray
? Bone scan or MRI brain only if clinically indicated

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CT scan shows right renal tumor with perinephric stranding suggesting invasion of

the perinephric fat

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Contrast inferior venacavogram in patient with a right renal tumor shows

involvement of the subdiaphragmatic vena cava

? PET: equivocal findings on conventional imaging

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? Percutaneous renal biopsy or aspiration: limited role

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Staging AJCC 7th Edition

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Prognostic Factors For RCC
Management

Stage I-I I

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Nephrectomy
? Open radical nephrectomy, but laparoscopic gaining

popularity

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? Nephron sparing surgery via partial nephrectomy, if

possible (open or laparoscopic)

? Possible to spare adrenal gland in ~75% cases

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No role for adjuvant chemo/immunotherapy

No widely accepted role for neoadjuvant or adjuvant

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radiotherapy.

Retrospective data suggest possible utility in select

cases:

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? Positive surgical margins

? Local y advanced disease with perinephric fat invasion

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and adrenal invasion (IVC/renal vein extension alone

does not increase local recurrence significantly)

? LN+

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? Unresectable (pre-op RT)
Stage IV

Cytoreductive nephrectomy: improved survival with

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nephrectomy followed by interferon alpha vs.
interferon alpha alone

Systemic therapy

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? Immunotherapy (IL-2, interferon alpha, or combination)

? High dose IL-2 only FDA approved treatment for

? Biologic agents show promise in recent trials

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? Bevacizumab

? Sorafenib or sunitinib

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? Temsirolimus

Consider chemo (gemcitabine ? 5-FU or capecitabine)

Focal pal iation of metastases

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? RT alone

? Metastasectomy

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? Combination of both