Download MBBS Surgery Presentations 50 Renal Cell Carcinoma Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 50 Renal Cell Carcinoma PPT-Powerpoint Presentations and lecture notes

Renal Cel Carcinoma

Dept. of Surgery

Epidemiology

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

incidence in sixth decade

? Metastatic disease in 30% at diagnosis, and eventually

in 50% (lung, liver, bone, distant LN, adrenal, brain,
opposite kidney, soft tissue)

? Most sporadic RCCs are unilateral and unifocal


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

tubular epithelium

? Adenocarcinoma subtypes:

? clear cel (75?85%)
? chromophilic/ papil ary (10?15%)
? chromophobe (5?10%)
? oncocytic (rare)
? Sarcomatoid (1?6%; poor prognosis)

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

system
Risk factors

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

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

? Association with von Hippel-Lindau disease:

? 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
hemangioblastomas, pheochromocytoma , pancreatic cancer)

Pathology

? Round to ovoid

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

? Nuclear features can be highly variable


Diagnosis

? Common signs and symptoms:

? hematuria (80%)
? flank pain (45%)
? flank mass (15%)
? classic triad of prior three only present in 10%
? normocytic/normochromic anemia, fever, weight loss

? Less common signs and symptoms:

? hepatic dysfunction without mets
? Polycythemia
? hypercalcemia (occurs in 25% of patients with RCC mets)

Paraneoplastic syndromes in 20% of patients with RCC


Diagnosis

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

? Imaging:

? CT abdomen
? MRI abdomen if CT suggests IVC involvement

? Metastatic evaluation:

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

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

the perinephric fat


Contrast inferior venacavogram in patient with a right renal tumor shows

involvement of the subdiaphragmatic vena cava

? PET: equivocal findings on conventional imaging

? Percutaneous renal biopsy or aspiration: limited role




Staging AJCC 7th Edition




Prognostic Factors For RCC
Management

Stage I-I I
Nephrectomy
? Open radical nephrectomy, but laparoscopic gaining

popularity

? Nephron sparing surgery via partial nephrectomy, if

possible (open or laparoscopic)

? Possible to spare adrenal gland in ~75% cases

No role for adjuvant chemo/immunotherapy

No widely accepted role for neoadjuvant or adjuvant

radiotherapy.

Retrospective data suggest possible utility in select

cases:

? Positive surgical margins

? Local y advanced disease with perinephric fat invasion

and adrenal invasion (IVC/renal vein extension alone

does not increase local recurrence significantly)

? LN+

? Unresectable (pre-op RT)
Stage IV

Cytoreductive nephrectomy: improved survival with
nephrectomy followed by interferon alpha vs.
interferon alpha alone

Systemic therapy

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

? High dose IL-2 only FDA approved treatment for

? Biologic agents show promise in recent trials

? Bevacizumab

? Sorafenib or sunitinib

? Temsirolimus

Consider chemo (gemcitabine ? 5-FU or capecitabine)

Focal pal iation of metastases

? RT alone

? Metastasectomy

? Combination of both