Follow-up of patients
treated for renal cancer
Grégory Lenczner, Samuel Merran,
Paris - France
CCC

Chromophobe C

Papillary C

CCC

Chromophobe C

Papillary C
Renal cancer
•  Treatment : Surgery
- Nephrectomy
- Radical nephrectomy
- Nephron spearing surgery
•  Imprevisible evoluti...
Follow-up frequency
Good prognosis
pT1 V0 N0 M0
grade 1 2
Anual follow-up
•  Blood tests
•  Chest-Abomen-Pelvis
CT

Interm...
Follow-up frequency
Bad prognosis (pT4, V+ et N2, M1) 
Follow-up every 6 month (5 years)
Blood tests
CAP CT
After 5 years ...
Follow-up frequency after
nephron spearing surgery
•  Blood tests and CAP CT during the 6
monthes following surgery as a b...
Results in follow-up after
treatment
Metastasis
•  50% of metastasis occurs during the
two first years
•  80% winthin 3 to...
Results in follow-up after
treatment
Metastasis
•  Lung (66 à 80%)
•  Bone (24 à 49%)
•  Liver (10 à 26%)
•  Brain (8 à 13...
Results in follow-up after
treatment
Metastasis
•  Controlateral kidney
•  Thyroid
•  Prostate, Ovairies
•  Gal bladder , ...
Back ground (1/2)
•  The wide use of CT and MR and US
allowed to discover unsuspected solid
renal
•  The masses are both s...
Back ground(2/2)
•  The « Gold Standard » surgical treatment for renal
cancer used to be nephrectomy or radical nephrectom...
Nephrectomy versus
nephron spearing surgery
•  Survival prognosis : no difference between the
two surgical tecnics
•  Comp...
Usual appearence after NSS
•  One or multiples of the following may be
present :
-Cortical wedge
-Rotation of the kidney
-...
Usual appearence after NSS

A

B

C

CT before (A) and (B) after injection : solid mass on the the anterior face of the ri...
Usual appearence after NSS

A
A Pre op CT : 15 mm mass of
the lateral aspect of the right
kidney

B
B Post op CT : lateral...
A Pre op CT without injection : mass of
the superior pole of the left

A

B Pre op CT after injection the wall of
this cys...
C Pre op MR (T1) the cystic mass is
hypointense

C

D Pre op MR (T2) : the cystic mass is
hyperintense and the wall is thi...
A

B

C

CT coronal reconstructions after NSC before injection (A) arterial phase
(B) delayed phase (C) Wedge scar in plac...
Post op Axial MR image T2 FS
(D) coronal MR images after
Gadolinium injection (E and F)

Wedge scar in place of the renal ...
A

C

B

Axial CT images before injection (A)
arterial phase (B) delayed phase (C)
post NSS. Infiltration of the
retroperi...
Surgical clips
- The use of surgical clips during NSS
generates artifacts on follow-up
imaging
- Because of the artifacts ...
A

D

B

C
Pitfalls and pseudo
angiomyolipomas
- Pseudo surgical scar
- Pseudo AML
Not surgical scar

A

C

B

D

Embryological
incomplete fusion
A

B

C

D

E

Post op MR the surgical site is
filled by the retroperitoneal fat
and looks like an AML

F

G
A

B
Resorbable hemostatic material
in the site of tumorectomy
•  To avoid post op bleeding the surgeon
fills the site of tumor...
A

D

B

C
A

C

B
Peri renal fluid collections
- Hematoma :
* sub capsular
* peri renal
- Urinoma
- Lymphocele
Sub capsular hematoma

A

B
A

B

C

The peri renal collection contains
contrast media on the delayed phase :
fistula of the renal cavities in the per...
Peri renal fluid collection
The delayed scans do not demonstrate
contrast media in the collection
A fine needle aspiration...
Infectious complications
- Acute pyelonepritis
- Renal abcess
a

b

c
A

B
Vascular complications
- Localised ischmia and renal atrophy
- Faulse aneurism
A

B

C

D
A

B

B

C
A

B

Post op CT

C
A

B

C

CT imageswithout injection (A) arterial phase (B) delayed
pahse (C) : small solid hypervascular of the lower thir...
A

B

Post op follow-up : Arterial phase (A) tubular phase (B) : A
faulse aneurism is detected in the site of tumorectomy
A

B

C

Selective left renal angiography (A) : confirmation of the
faulse aneurism treated with endo vascular coils Saggi...
A

B

C
Post embolisation control :
Coils are visible at the
inferior pole of the kidney
and the faulse aneurysme is
no longer enh...
Local recurrence
A

C

B
A

C

B
CONCLUSION
•  Cross sectional imaging detect small renal
solide mass as incidental findings
•  NSS replace radical nephrec...
Urology gynecology suivi kr g lenczner
Urology gynecology suivi kr g lenczner
Urology gynecology suivi kr g lenczner
Urology gynecology suivi kr g lenczner
Urology gynecology suivi kr g lenczner
Urology gynecology suivi kr g lenczner
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Urology gynecology suivi kr g lenczner

  1. 1. Follow-up of patients treated for renal cancer Grégory Lenczner, Samuel Merran, Paris - France
  2. 2. CCC Chromophobe C Papillary C CCC Chromophobe C Papillary C
  3. 3. Renal cancer •  Treatment : Surgery - Nephrectomy - Radical nephrectomy - Nephron spearing surgery •  Imprevisible evolution •  Regular follow-up
  4. 4. Follow-up frequency Good prognosis pT1 V0 N0 M0 grade 1 2 Anual follow-up •  Blood tests •  Chest-Abomen-Pelvis CT Intermediary prognosis pT2-3, V+ ou N1, M0 grade 3 Control every 6 months during 3 years •  Blood tests •  Chest-Abomen-Pelvis CT Anual follow-up for the 2 following years
  5. 5. Follow-up frequency Bad prognosis (pT4, V+ et N2, M1)  Follow-up every 6 month (5 years) Blood tests CAP CT After 5 years one follow-up a year
  6. 6. Follow-up frequency after nephron spearing surgery •  Blood tests and CAP CT during the 6 monthes following surgery as a base line CAP CT one time a year •  Doppler ultrasound in the week after surgery
  7. 7. Results in follow-up after treatment Metastasis •  50% of metastasis occurs during the two first years •  80% winthin 3 to 5 years after treatment •  5% can occur 10 years after treatment
  8. 8. Results in follow-up after treatment Metastasis •  Lung (66 à 80%) •  Bone (24 à 49%) •  Liver (10 à 26%) •  Brain (8 à 13%) •  Adrenal (8 à 11%) •  Skin (2 à 13%)
  9. 9. Results in follow-up after treatment Metastasis •  Controlateral kidney •  Thyroid •  Prostate, Ovairies •  Gal bladder , Pancreas •  Sinuses •  Controlateral adrenal gland
  10. 10. Back ground (1/2) •  The wide use of CT and MR and US allowed to discover unsuspected solid renal •  The masses are both smaller and with a lower Fuhrman grade W.-H. Chow, S. S. Devesa, J. L. Warren, and J. F. Fraumeni Jr Rising incidence of renal cell cancer in the United States, Journal of the American Medical Association, 1999. 281, 1628–1631
  11. 11. Back ground(2/2) •  The « Gold Standard » surgical treatment for renal cancer used to be nephrectomy or radical nephrectomy •  During the ten past years nephron spearing surgery becomes the treatment of renal solid masses. Piper C, et Al. Organ-preserving renal tumor surgery for renal cell carcinoma >/= T1b : opertive technique, complications and oncological control. Urologe A 2011  Ezzat Ael H, et Al. Nephron sparing surgery for renal tumors J Egypt Natl Cancer Inst, 2011 23 : 61-6
  12. 12. Nephrectomy versus nephron spearing surgery •  Survival prognosis : no difference between the two surgical tecnics •  Complications : More complications are describe with nephron spearing surgery (NSS) * Ross FC, et Al Functional analysis of elective nephron-sparing sugery vs radical nephrectomy for renal tumors larger than 4 cm. Urology 2012, 79 : 607-14 **Van Poppel H et Al. A prospective randomized EORCT intergroup phase 3 study comparing the complications of elective nephron sparing surgery and radical nephrectomy for low stage RCC European Association of Urology
  13. 13. Usual appearence after NSS •  One or multiples of the following may be present : -Cortical wedge -Rotation of the kidney -Infiltration of the retoperitoneal fat -Decrease of the retrorenal fat -Infiltration of the posterior abdominal wall
  14. 14. Usual appearence after NSS A B C CT before (A) and (B) after injection : solid mass on the the anterior face of the right kidney. (C) post operative follow-up the tumorectomy scar is visible as a cortical wedge
  15. 15. Usual appearence after NSS A A Pre op CT : 15 mm mass of the lateral aspect of the right kidney B B Post op CT : lateral rotation latérale of the right kidney, cortical wedge and important reduction of the retro renal fat. Infiltration of the peri renal fat and the posterior abdominal wall C C Post op CT : : the tumorectomy scar was filled with retroperitoneal fat Infiltration of the peri renal fat and the posterior abdominal wall
  16. 16. A Pre op CT without injection : mass of the superior pole of the left A B Pre op CT after injection the wall of this cystic mass is thick and enhances (Uniloculat type III uniloculaire of Bosniak classification) B
  17. 17. C Pre op MR (T1) the cystic mass is hypointense C D Pre op MR (T2) : the cystic mass is hyperintense and the wall is thick D
  18. 18. A B C CT coronal reconstructions after NSC before injection (A) arterial phase (B) delayed phase (C) Wedge scar in place of the renal mass Infiltration of the peri renal fat
  19. 19. Post op Axial MR image T2 FS (D) coronal MR images after Gadolinium injection (E and F) Wedge scar in place of the renal mass Infiltration of the peri renal fat and thickening of perirenal fascia D E F
  20. 20. A C B Axial CT images before injection (A) arterial phase (B) delayed phase (C) post NSS. Infiltration of the retroperitoneal, modification (thickening) of the posterior abdominal wall, infiltration of the sub cutaneous fat
  21. 21. Surgical clips - The use of surgical clips during NSS generates artifacts on follow-up imaging - Because of the artifacts the analysis of the adjacent renal parenchyma may be difficult
  22. 22. A D B C
  23. 23. Pitfalls and pseudo angiomyolipomas - Pseudo surgical scar - Pseudo AML
  24. 24. Not surgical scar A C B D Embryological incomplete fusion
  25. 25. A B C D E Post op MR the surgical site is filled by the retroperitoneal fat and looks like an AML F G
  26. 26. A B
  27. 27. Resorbable hemostatic material in the site of tumorectomy •  To avoid post op bleeding the surgeon fills the site of tumorectomy with resorbable hemostatic material. •  This material can simulate a renal mass on post op follow-up imaging
  28. 28. A D B C
  29. 29. A C B
  30. 30. Peri renal fluid collections - Hematoma : * sub capsular * peri renal - Urinoma - Lymphocele
  31. 31. Sub capsular hematoma A B
  32. 32. A B C The peri renal collection contains contrast media on the delayed phase : fistula of the renal cavities in the peri renal space D
  33. 33. Peri renal fluid collection The delayed scans do not demonstrate contrast media in the collection A fine needle aspiration find lymph.
  34. 34. Infectious complications - Acute pyelonepritis - Renal abcess
  35. 35. a b c
  36. 36. A B
  37. 37. Vascular complications - Localised ischmia and renal atrophy - Faulse aneurism
  38. 38. A B C D
  39. 39. A B B C
  40. 40. A B Post op CT C
  41. 41. A B C CT imageswithout injection (A) arterial phase (B) delayed pahse (C) : small solid hypervascular of the lower third of the left kidney
  42. 42. A B Post op follow-up : Arterial phase (A) tubular phase (B) : A faulse aneurism is detected in the site of tumorectomy
  43. 43. A B C Selective left renal angiography (A) : confirmation of the faulse aneurism treated with endo vascular coils Saggital and coronal CT reconstructions post embolization the fauls aneurysm is no longer enhancing
  44. 44. A B C
  45. 45. Post embolisation control : Coils are visible at the inferior pole of the kidney and the faulse aneurysme is no longer enhancing
  46. 46. Local recurrence
  47. 47. A C B
  48. 48. A C B
  49. 49. CONCLUSION •  Cross sectional imaging detect small renal solide mass as incidental findings •  NSS replace radical nephrectomy •  Usual aspects on post operative imaging have to be recognized by radiologists to avoid faulse diagnosis •  The different complications must also be recognized to treat them either surgically of by inteventional radiology
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