Kuliah RCC.ppt

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)


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


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


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)


• 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)


• 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


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)

Kuliah RCC.ppt

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