TEACHING MBBS CLASS PURPOSE

1. RENAL CELL CARCINOMA

2. • Also known as hypernephroma, internist
tumour, gravitz tumour.
Incidence-
• RCC represents 2% of overall cancer incidence
and mortality.
• 85% of primary malignant tumour
• M:F-2:1
• Commonly occurs in 6th decade of life

3. Etiology
• Environmental exposure
• RCC occurs in 2 forms-
-inheritated
-sporadic
• 2 other forms of hereditary RCC
-von-hippel lindau disease
-papillary RCC
• Higher in dialysis pt.

4. Pathology
• Clear cell type-25%
• Granular cell type-25%
• Mixed type-rest%

5. Clear cell RCC
• <5% multicentric or
bilateral
• 50% stage I & II at
presentation
• <5% stage IV
• Organ involvement with
metastases
– 40% bone
– 22% adrenals
– 15% brain
– 14% kidney

6. Papillary RCC
• 70% stage I
• More commonly
bilateral and
multifocal

7. Spread
• Local
• Blood
• Lymphatic

8. Staging :The Robson staging system
– Stage I - Tumor confined within renal parenchyma
– Stage II - Tumor invading perinephric fat but still
contained within the Gerota fascia
– Stage III - Tumor invading the renal vein or inferior
vena cava (A), or regional lymph-node
involvement (B), or both (C)
– Stage IV - Tumor invading adjacent viscera
(excluding ipsilateral adrenal) or distant
metastases

9. Staging :TNM
– Primary tumor (T)
• TX - Primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• T1 - Tumor 7 cm or smaller in greatest dimension, limited to the
kidney
• T2 - Tumor larger than 7 cm in greatest dimension, limited to the
kidney
• T3 - Tumor extends into major veins or invades adrenal gland or
perinephric tissues but not beyond the Gerota fascia
• T3a - Tumor invades adrenal gland or perinephric tissues but not
beyond the Gerota fascia
• T3b - Tumor grossly extends into the renal vein(s) or vena cava
below the diaphragm
• T3c - Tumor grossly extends into the renal vein(s) or vena cava
above the diaphragm
• T4 - Tumor invading beyond the Gerota fascia

10. – Regional lymph nodes (N) - Laterality does not
affect the N classification
• NX - Regional lymph nodes cannot be assessed
• N0 - No regional lymph node metastasis
• N1 - Metastasis in a single regional lymph node
• N2 - Metastasis in more than 1 regional lymph node
– Distant metastasis (M)
• MX - Distant metastasis cannot be assessed
• M0 - No distant metastasis
• M1 - Distant metastasis

11. Staging and Prognosis
Cohen HT, McGovern FJ. NEJM. 2005;353:2477.

12. • AJCC stages
– AJCC stage I - T1, N0, M0
– AJCC stage II - T2, N0, M0
– AJCC stage III - T1-2, N1, M0 or T3a-c, N0-1, M0
– AJCC stage IV - T4; or any T, N2, M0; or any T, any
N, M1

13. C/F
• M:F-2:1
• Hematuria
• Lt sided varicocele
• Triad –pain,hematuria,mass
• Atypical presentation-25%
• Persistent pyrexia with no evidence of infection
• Constitutional symptoms

14. PARANEOPLASTIC SYNDROME
• Polycythemia
• 20% hypercalcemia
• 40% HTN
• Stauffers syndrome
• Biological active products-
-ACTH-cushing syndrome
-enteroglucagon-protein enteropathy
-prolactin-galactorrhoea
-insulin-hypoglycemia
-gonadotrophin-gynaecomastia and decrease libido

15. Investigation :
• USG abdomen
• IVP
• CECT abdomen
• Renal angiography
• MRI
• CXR
• FNAC

16. • Complete blood count
• Urine examination
• KUB x-rays

17. • Anemia occurs in 30% of RCC
• Anemia is not secondary to blood loss or hemolysis
and is normochromic.
• Gross hematuria is seen upto 60%
• ESR
• Calcium level
• LFT
• detectable calcification or is large enough to distort
the normal renal contour.

18. • IVP used alone75% accurate.
• Calcification overlying the renal shadow is an
important finding.
• USG –non invasive, inexpensive, able to
delineate a renal mass seen on IVU. Approx
98% accurate.
• Extension of tumor thrombus into IVC can also
be determined.

19. • CECT abdomen
– Diagnosis
– Staging
– Renal Angiography

20. • More sensitive than US / IVU
• Typical finding of a mass that becomes enhanced
with the use of IV contrast.
• Amputation of a portion of the collecting
system,presence of calcification, poorly defined
interface between renal parenchyma and lesion.
• Method of staging by visualizing renal hilum,
perinphric space, renal vein, IVC, adrenals, regional
LN, adjacent organs.

21. Typical renal cell carcinoma. CT scan obtained before contrast
enhancement

22. Typical renal cell carcinoma. Contrast-enhanced CT

23. Treatment
• Localised disease-surgical removal
• Radical nephrectomy is primary treatment
• Pre-operative renal artery embolisation can be
used as adjuvant therapy to facilitate radical
nephrectomy.
• Radiation therapy
• Different approach-midline ,thoraco
abdominal,classsical lumbar incision

24. • Partial nephrectomy
• Laparoscopic nephrectomy

25. Partial nephrectomy

26. Partial nephrectomy performed
Intraoperative View Specimen
(Renal Cell Carcinoma)
Fisse

27. Indications for
nephron-sparing surgery (NSS)
• Absolute
– nephrectomy would render patient anephric
– bilat tumours, solitary kidney, familial RCC
• Relative
– Future threat to contralateral kidney
• Elective
– Small, exophytic, polar location
– Benign disease

28. Disseminated disease
• About 30%pt present with disseminated RCC
• Radical nephrectomy _as a palliative
treatment
• Radiation therapy
• Hormonal therapy
• Biologic response modifiers

29. Prognostic factors
• 5-year survival
• By stage
– T1 - 80%-100%
– T2-3a – 60%
– T3b – 15-20%
– T4 – 0-20%

31. Bosniak classification of renal masses is as follows:
class I includes simple cysts;
class II, minimally complicated but overwhelmingly
benign masses with thin septa, hyperattenuation, or
small amounts of mural or septal calcification;
class III, moderately complicated masses with mural
nodularity, thick septa, or irregular or thick
calcifications that often require surgical exploration;
class IV, significantly complicated and generally
malignant masses with thick and irregular enhancing
regions and definite solid components.