RENAL CELL CARCINOMA , ETIOLOGY , PATHOGENESIS, CLINICAL FETURE , MANAGMENT

1. RENAL CELL CARCINOMA
PRAHLAD
VISHNU
SHRAWAN
MODERATOR-DR GURUPRASAD RAI

2. NAME- Mr X
AGE- 55 YEARS
SEX- MALE
ADDRESS- MANGALORE
OCCUPATION- FACTORY WORKER
PRESENTING COMPLAINTS
 HEMATURIA
 LOIN PAIN
 MASS IN LOIN
INSPECTION LOIN MASS
PALPATION MOBILE,NODULAR,
HARD,MOVES WITH
RESPIRATION
PERCUSSION DULL RENAL ANGLE

9. PATHOLOGY
GROSS– UNILATERAL, UPPER POLE,
LARGE ,GOLDEN YELLOW ,CIRCUMSCRIBED
CUT SECTION - AREA OF NECROSIS,CYSTIC CHANGE,
FOCI OF HAEMORRHAGE,THROMBUS

10. CLEAR CELL TYPE
INCIDENCE – 70%
GENETICS – SPORADICS & FAMILIAL
HISTOLOGY – CLEAR CYTOPLASM
WELL DIFFERENTIATED
INCIDENCE – 15%
GENETICS -SPORADICS & FAMILIAL
HISTOLOGY – PAPILLARY PATTERN
PSAMMOMA BODIES
PAPILLARY TYPE

11. TYPE INCIDENCE GENETICS HISTOLOGY
GRANULAR CELL
TYPE
8% SPORADIC
&
FAMILIAL
ABUNDANT
ACIDOPHILIC
CYTOPLASM
MARKED ATYPIA
CROMOPHOBE TYPE 5% MULTIPLE
CROMOSOMES
LOSS,
HYPODIPLOIDY
•MIXTURE PALE
CLEAR CELL WITH
PERINUCLEAR HALO
•GRANULAR CELL
SARCOMATOID TYPE 1.5%
-------
WHORLS OF
ATYPICAL
ANAPLASTIC
SPINDLE CELLS
COLLECTING DUCT
TYPE
0.5 TUBULAR &
PAPILLARY PATTERN

12. LYMPHATIC
SPREAD
PROLIFERATIVE TROMBUS
EXTENDS INTO IVC
CANNON BALL SECONDARIES
IN LUNG
VARICOCELE DUE TO
BLOCKED LEFT RENAL VEIN
BRAIN,BONE
HILAR & PARA AORTIC
LYMPHNODE
PERINEPHRIC PAD OF FAT,CALYCES
RENAL PELVIS

13. CLINICAL FEATURES

15. Renal cell carcinoma
(investigations, staging, treatment
and prognosis).

16. Investigations
1. Urine :- RBCs
2. IVU:- Shows mass lesion and irregular filling defect
3. U/S abdomen:- size, extension, lymph node, status of renal vein, spread to liver.
4. Ct scan:- Confirmatory
status of renal vein and ivc
lymph node status and tumour extension
5. CECT: Early lesions, function, spread and venous status.
6. Renal angiogram:- to access the vascularity.
Seldinger’s technique via transfemoral.
Pharmaco angiogram- tumour blush
Also therapeutic embolisation.
7. MRI/MR ANGIOGRAM:- Tumour thrombus in IVC
8. Chest x-ray:- cannon ball mets
9. Ct chest:-
10. Bone scan.
11. Peripheral smear, serum calcium, haematocrit and ESR

18. A, Magnetic resonance scan
of kidneys without
administration of
gadolinium suggests
anterior right renal mass.
B, After intravenous
administration of
gadolinium-labeled
diethylene-triamine-penta-
acetic acid, MRI shows
enhancement of this mass
indicative of malignancy.

20. Tissue Diagnosis
• Tissue diagnosis obtained from nephrectomy or
biopsy
Papillary (chromophilic) renal cell
carcinoma extending into the
collecting system with histological
findings

21. AJCC (AMERICAN JOINT COMMITTEE
ON CANCER STAGING): TNM STAGING
• TX:- PRIMARY TUMOUR CAN NOT BE ASSESSED
• T0:- NO PRIMARY TUMOUR.
• T1: <7CM limited to kidney
T1a: 0-4CM, T1b: 4-7cm
• T2: >7CM, limited to kidney.
• T3: T3a:- extends to adrenals, perinephric fat
(not gerota’s fascia).
T3b: entends into renal vein or IVC below
diaphragm.
T3c: extends into IVC above diaphragm.
• T4: invades Gerota’s fascia and extends beyond.

22. • N0:- no lymph nodes
• N1:- spread to single region of lymph nodes.
• N2:- spread to more than a group of lymph
nodes.
• M0:- no blood spread.
• M1:- distant spread, lungs 75%, soft tissue,
bones, liver, cns and skin

23. • Stage 1:- T1 N0 M0
• Stage 2:- T2 N0 M0
• Stage 3:- T1 or T2 N1 M0
T3 N0 or N1 M0
• Stage 4:- T4 anyN M0
AnyT anyN M1

24. Robson-Flock and Kadesky staging.

25. TREATMENT
SURGERY IS TREATMENT OF CHOICE!
1. Radical nephrectomy:-
• Structures removed?
• Approach:-Transperitoneal (common),
Others are retroperitoneal, Nagamatsu,
thoraco-abdominal and posterior
vertical.
• Position:- lateral

26. • Procedure: laporotomy
colon mobilised medially
vessels are identified, dissected and ligated (transfixation and
three ligatures proximally using silk or non absorbable sutures).
renal vein always first, why.? Problem?
preoperative renal artery embolisation can be done, why?, How?.
• IVC extension: Oblique vascular clamp placed, open, remove
tumour thrombus, suture.
• Supradiaphragmatic venacaval extension:- cardio- pulmonary
bypass.

27. Laparoscopic Radical Nephrectomy Hand-Assisted Laparoscopic
Radical Nephrectomy

28. 2. Large fixed tumours:- palliative nephrectomy or debulking is
adviced, why?
3. Bilateral RCC: Bilateral partial nephrectomy is
done.
Renal artery is temporarily ocluded using
vascular clamps and kidney cooled, why?
Resected specimen send for frozen section
biopsy.
retained partial capsule is sutured after heamostasis
arterial clamp released.

29. A. Localized disease:
• Partial Nephrectomy(nephron-sparing surgery, NSS )
--polar tumor
--tumor size<4cm
--bilateral RCC
Laparoscopic NSS

30. Localized disease:
• Percutaneous/Laparoscopic Radiofrequency
Ablation or Cryoablation

31. • NO ROLE FOR RADIOTHERAPY!!!

32. • Chemotherapy: Vinblastine and progesterone
• Interferons and interleukins.
• Antiangiogenic drugs like endostatin and
angiostatin under trial.
• Humanised monoclonal antibodies like
bevacizumab under trial.
• Laporoscopic approach becoming popular.
Difference?

33. Prognosis
Factors:- 1. tumour size >4cm
2. entension into renal vein
3. presence of secondaries
4. local extension
5. hypercalcaemia and stauffer’s
syndrome.
5 years survival: stage 1 and 2 is 65%
stage 3 is 40%
stage 4 is 10%

34. THANK YOU