3. COMPLEX RENAL CYSTS
Bosniak
Class
Radiographic Features Risk of Malig-
nancy
Manage-
ment
I Water density, homogenous, hairline thin wall
No septa, no calcification & no enhancement
None Surveillance
not necessary
II Few hairline thin septa in which “perceived”
enhancement may be present
Fine calcification or short segment of slightly
thickened calcification in wall or septa
No unequivocal enhancement
Minimal Surveillance
not necessary
IIF Hyperdense lesion (≤3cm), well marginated, with no
unequivocal enhancement
Multiple hairline thin septa
No unequivocal enhancement
Hyperdense lesion >3cm or totally intrarenal, with no
enhancement
Minimal
3-5%
5-10%
Periodic
Surveillance
Periodic
Surveillance
III Indeterminate 50% Surgical
excision
IV Clearly malignant lesions 75-90% Surgical
excision
4. (RCC) INCIDENCE
Accounts 2% to 3% of all adult malignancies.
Male to female ratio is 3:2
Presents in elderly population mostly in 6th to 7th
decade
Uncommon in children and accounts for only 2.3
to 6.6% of all renal tumors in children
Majority are sporadic and only 2% to 3% are
familial
Campbell Walsh Urology 10th ed.
7. von Hippel-Lindau Disease, VHL Gene, and
Genetics of Clear Cell Renal Cell Carcinoma
Relatively rare autosomal dominant disorder
Occurs with a frequency of 1 per 36,000 population
RCC develops in about 50% of patients with von Hippel-
Lindau disease
Distinctive for its early age at onset (often in the third,
fourth, or fifth decade of life) and for its bilateral and
multifocal involvement
RCC is the most common cause of mortality in patients
with von Hippel-Lindau disease
VHL gene is a tumor suppressor gene, both alleles of the
VHL gene must be mutated or inactivated for
development of the disease(Knudson`s Hypotheses).
10. Disease
type
Hemangio
-blastoma
RCC Pheochromo
-cytoma
Germline mutation type
1 High High Low Full gene deletions, partial gene deletions,
nonsense mutations, and splice acceptor mutations
2A High Low High Missense mutations in specific areas
2B High High High Partial gene deletions, nonsense mutations, and
missense mutations
2C No No High Missense mutations in other specific areas
Incidence of Major Manifestations of VHL Disease by Mutation Status
11. PATHOLOGY
RCC are round to ovoid and circumscribed by
pseudo-capsule formed by compressed
parenchyma and fibrous tissue.
Most sporadic RCCs are unilateral & unifocal.
Multicentricity is found in 10 to 20% cases, more
commonly associated with papillary histology &
familial RCC.
Predilection for involvement of the venous system
is an unique feature of RCC, found in 10% of
cases.
Campbell Walsh Urology 10th ed.
12. Fuhrman`s Classification System for Nuclear Grade in RCC
GRADE NUCLEAR
SIZE
NUCLEAR OUTLINE NUCLEOLI
1 10mm Round,
Uniform
Absent or inconspicuous
2 15mm Irregular Small (visible at 400x
magnification)
3 20mm Irregular Prominent
4 >20mm Bizarre, often
multilobed
Prominent, heavy
chromatin clumps +nt
Campbell Walsh Urology 10th ed.
13. TYPES OF RCC
Clear cell RCC - 70 to 80%
Papillary RCC - 10 to 15%
Chromophobe RCC - 3 to 5%
Collecting duct carcinoma - <1%
Renal medullary carcinoma - rare
Unclassified RCC - <3%
Sarcomatoid differentiation – 1% to 5% (represents
poorly differentiated regions of other histologic subtypes
so not considered as distinct subtype. Have aggressive
local & metastatic behavior and carries poor prognosis)
Campbell Walsh Urology 10th ed.
14. CLEAR CELL RCC
Well circumscribed, lobulated, hypervascular
tumor with common venous involvement
Chromosome 3 alterations and VHL mutations
are common
Can be associated with von hippel lindau syn.
Originate from proximal convoluted tubule
(PCT)
Responds to immunotherapy but have worse
prognosis compared with papillary or
chromophobe.
Campbell Walsh Urology 10th ed.
15. PAPILLARY RCC
Fleshy tumor with fibrous pseudocapsule and
are muticentric and hypovascular
Commonly found in patients with ESRD and
acquired renal cystic diseases
originate from proximal convoluted tubule
(PCT)
associated with trisomy 7 and 17; loss of Y
Good prognosis
Campbell Walsh Urology 10th ed.
16. CHROMOPHOBE RCC
Well circumscribed with plant cell appearance,
perinuclear halo and nuclear raisins on histology
Hale colloidal iron stain +ve
Can be associated with Birt Hogg Dube syn.
Loss of multiple chromosomes (1,2,6,10,13,17
& 21)
Originate from intercalated cells of collecting
duct, generally good prognosis but sarcomatoid
variants have poor prognosis
Campbell Walsh Urology 10th ed.
17. COLLECTING
DUCT CARCINOMA
Firm, centrally located with infiltrative borders
Originate from collecting duct
Deletions on ch. 1q and monosomy of ch.
6,8,11,18,21 & Y
Poor prognosis but may respond to
chemotherapy
Campbell Walsh Urology 10th ed.
18. RENAL MEDULLARY
CARCINOMA
Associated with sickle cell trait
Highly infiltrative tumor with high grade
nuclei
Extensive hemorrhage & necrosis
Originate from collecting duct
Do not respond to therapy
Poor prognosis
Campbell Walsh Urology 10th ed.
19. CLINICAL PRESENTATION
>50% detected incidently
Local tumor growth- hematuria, flank pain,
abdominal mass (triad) & perirenal hematoma.
Metastasis- persistent cough, bone pain, weight
loss, fever, malaise, cervical lymphadenopathy
& constitutional symptoms.
B/L lower limbs edema due to IVC obstruction
or irreducible varicocele.
Campbell Walsh Urology 10th ed.
21. Continued…
RCC acquired paraneoplastic syndrome requires
surgical excision (nephrectomy/metastasectomy)
or systemic therapy
(chemotherapy/radiotherapy/immunotherapy)
except hypercalcemia which can be managed
medically
(hydration+furosemide/bisphosphonates/corticoste
-roids/calcitonin/indomethacin).
Campbell Walsh Urology 10th ed.
22. Stauffer syndrome
Non metastatic liver dysfunction associated with
RCC characterized by elevated S. ALP(100%),
elevated PT (67%) with elevated S. bilirubin or
transaminases in 20% to 30% cases.
Hepatic metastasis is to be ruled out.
Elevated levels of IL-6 is found to be increased.
Responds to nephrectomy in 60 to 70% cases.
Campbell Walsh Urology 10th ed.
23. STAGING ( according to AJCC 7e, 2010 )
Tx-primary tumor cannot be assessed
T0-no evidence of primary tumor
T1-tumor ≤ 7 cm and confined to kidney
T1a-tumor ≤ 4cm and confined to kidney
T1b-tumor >4cm & ≤ 7 cm and confined to kidney
24. T2-tumor >7cm and confined to kidney
T2a-tumor 7-10cm and confined to kidney
T2b-tumor >10cm and confined to kidney
25. T3-tumor extends into major vein or perinephric tissues
but not adrenal gland and not beyond gerota fascia
T3a-tumor extends into renal vein or segmental branches
or invades perinephric and/or renal sinus fat but not
beyond gerota fascia
T3b-tumor extends in IVC below diaphragm
T3c-tumor extends in IVC above diaphragm and invades
wall of IVC
27. Continued…
Nx – regional LN cannot be assessed
N0 – no regional LN metastasis
N1 – metastasis in regional LN (Hilar, Caval, Interaortocaval, Aortic)
28. Mx – distance metastasis cannot be assessed
M0 – no distance metastasis
M1 – distant metastasis present
STAGE GROUPING
Stage 1- T1N0M0
Stage 2 - T2N0M0
Stage 3 - T1 or T2 N1M0, T3 any N M0
Stage 4 – T4 any N M0, any T any N M1
29. INVESTIGATIONS
Basic workup- Hb, TLC, DLC, ESR, RBS, s.
urea, s. creatinine, s. calcium, LFT, ECG, CXR
(chest X-ray), urine R/M& BP measurement.
USG whole abdomen
CECT abdomen- any renal mass that enhances
with I/V contrast on CT by more than 15 HU
should be considered RCC until proved
otherwise (Hartman et al 2004).
MRI scan- best for evaluation and staging of
IVC thrombosis.
30. Continued….
Renal arteriography, 3D CT or MRI for patients
planned for partial nephrectomy to delineate the
relationship between vascular supply and
collecting system.
PET scan
Useful in monitoring response to therapy in
those with metastatic disease (Hoh et al, 1998).
More accurate than CT in detecting disease
recurrence or progression (Ramdave et al, 2001).
Not useful for staging.
31. Continued….
FNAC-indicated in clinically apparent metastatic
disease, differentiating prim. from metastatic disease
with known prim. of nonrenal origin, radiographically
indeterminate & in Pts. with nonsurgical disease.
Core Needle Biopsy-can accurately diagnose
malignancy in upto 100% of cases >4cm & 95% of cases
<4cm (Wunderlich et al, 2005).
Seeding of the needle tract reported in <0.01% (Volpe et
al,2007).
Accuracy >90%, Sensitivity 70-100% & Specificity 100%
(Volpe et al,2007).
Risk of perinephric bleeding & pneumothorax <1%.
Cystoscopy- If hematuria is the presentation.
33. Localized RCC
Options available are –
Radical nephrectomy (RN)
Nephron Sparing Surgery (NSS)
• Partial nephrectomy (PN)
• Thermal ablative therapies (cryotherapy
and radiofrequency ablation)
Active surveillance
Campbell Walsh Urology 10th ed.
34. Radical nephrectomy (RN)
Gold standard curative procedure for localized
RCC previously but more recently fallen out of
favor for small renal tumors d/t concerns about
CKD & should only be performed when
necessary (Nakada, 2005; Russo & Huang, 2008; Campbell et al, 2009).
Involves removal of I/L kidney with gerota
fascia, I/L adrenal gland, proximal ureter,
regional lymphadenectomy from crus of
diaphragm to aortic bifurcation.
Now routine extended lymphadenectomy is
controversial and performed selectively
(Daneshmand et al, 2005; Leibovich & Blute, 2008).
35. High risk factors for lymphatic involvement are
high grade tumor, sarcomatoid component,
tumor necrosis, size >10 cm, pT3 & pT4 (Blute &
colleagues 2004).
I/L adrenal removal is indicated only when
Radiographic adrenal enlargement is present
RCC extensively involving the kidney
Mass located in upper portion of kidney
adjacent to adrenal (Siemer et al, 2004; Lane et al, 2009).
Local recurrence rate is 2 to 4% depending on
stage, nodal status & histopathological features.
36. Surgical approach is determined by the size,
location and body habitus of the patient.
LAPAROSCOPIC RN
Transperitoneal, retroperitoneal, and hand assisted
Now accepted as standard in patients with <12cm
tumor size, localized RCCs with no local
invasion, limited to or no renal vein involvement,
and manageable lymphadenopathy (Burgess et al, 2007;
Columbo et al, 2008).
Equivalent oncologic outcome, more rapid
recovery and lesser morbidity than open RN (Hemal
et al, 2007; Hollingsworth et al, 2006).
40. Key elements of conventional radical
nephrectomy include early ligation of renal
artery and vein, removal of kidney outside
gerota fascia, removal of I/L adrenal gland,
with complete regional lymphadenect-
omy(O`Malley et al, 2009).
Only early ligation of renal artery remains
an accepted practice now, however it is not
always possible(O`Malley et al, 2009).
41. After dividing subcutaneous tissues with electro-
cautery, ext. oblique, ant. rectus sheath, rectus
abdominis, int. oblique, tr. abdominis, post. rectus
sheath, transversalis fascia are divided.
Peritoneum is opened.
Inspect and palpate the abdominal viscera for
metastases.
Incise the post. parietal peritoneum on the line of
Toldt from comm. iliac art. to hepatic flexure.
Right kidney is approached by taking down hepatic
flexure and reflecting colon medially.
Kocher maneuver may be needed to expose IVC and
aorta.
TRANSABDOMINAL APPROACH
42. Incise the ant. renal fascia on the medial aspect of the
kidney & identify the IVC.
Dissect anteriorly on the IVC, both cranially and
caudally, until the lt. renal vein, rt. renal veins and rt.
gonadal vein are identified.
Palpate the vein & IVC for evidence of tumor
thrombus. Lumbar veins if encountered, should be
ligated.
Identify and dissect the rt. renal artery which is
usually deep & superior to the vein, lateral to IVC.
Two large hemostatic clamps and ligature are used to
ligate and divide the renal artery first and then vein.
Bluntly develop the post. pararenal space.
43. Renal Vascular Pedicle Control
Whole Pedicle Clamp Method
Cut First, Ligate Second Method
Ligate First, Cut second Method
Inferior pole of the kidney is dissected, ureter
identified & ligated. Rt. gonadal vein identified and
retracted medially.
On left side descending and splenic flexure of colon
is mobilized and retracted medially. Unlike on right
side, tributaries of left renal vein (gonadal, lumbar,
adrenal) are ligated. So for identifying left renal
artery, posterior approach is recommended to avoid
inadvertent ligation of SMA.
44. Grasp the kidney with the left hand and pull it caudally
into the wound and working lat. to medial free the kidney
from its cranial attachments.
If adrenalectomy is indicated, remove the gland en bloc
with the kidney, with in the renal fascia.
Control any bleeding vessels and investigate adjacent
organs for signs of injury.
Bubbling in saline irrigation indicates a pneumothorax.
Place a closed suction drain & inject 0.5% bupivacaine
into the incision site and around intercostal nerves.
Straighten the table & lower the kidney bridge for wound
closure.
A slowly absorbable monofilament suture (PDS II) should
be used.
Skin can be closed with staplers or bioadhesives.
45. COMPLICATIONS
Bleeding
Injury to Vasculature of Gut
Injury to Liver and Spleen
Pancreatic Injury
Suprahilar and Retrocrural Lymphadenectomy
Injury to the Duodenum
Infective Complications
Pulmonary Complications
Renal complications
Neurological complications
Incisional complications
46. Post operative surveillance (after radical nephrectomy)
Pathologic
tumor stage
History,
examination
& blood tests
CXR
(chest X-ray)
Abdominal
CT
pT1aN0M0 yearly _ _
pT1b-2bN0M0 yearly yearly _
pT3-T4N0M0 6 mthly 6 mthly for
3yr, then
yearly
at 1yr, then
2 yearly
pTxN1M0 6 mthly for
3yr, then
yearly
4 mthly for
2yr, then
6 mthly
6 mthly for
1yr, then
yearly
Campbell Walsh Urology 10th ed.
47. Nephron Sparing Surgery (NSS)
• Complete local resection of the tumor while leaving
largest possible amount of normal functioning
parenchyma.
• It provides effective long term therapy for patients with
localized RCC and can preserve renal function in the
overwhelming majority ( Nguyen et al, 2008; Novick, 2009).
• Hyperfiltration renal damage (FSGS) is the most
common complication.
• Because proteinuria is the initial manifestation of this
damage so 24-hour urinary protein measurement
should be obtained yearly for screening.
• ACE inhibitors and low protein diet may improve long
term renal functional outcome in these patients.
Campbell Walsh Urology 10th ed.
48. Partial nephrectomy (PN)
Now management of choice for T1 renal masses.
Other indications include—
- B/L RCC
- RCC involving solitary kidney
- U/L carcinoma and threatened opposite kidney
i.e. hydronephrosis, DM, chronic pyelonephritis,
ureteral reflux, renal artery stenosis, calculus ds.
Contraindicated in-
- Cold ischemia time >45min
- <20% of global nephron mass retained
Campbell Walsh Urology 10th ed.
49. Requires preoperatively renal imaging to
delineate relationship of tumor with intra renal
vascular supply and collecting system.
3D CT and MRI is now considered best for
evaluating tumor relationship with collecting
system and vascular supply.
Complications are renal insufficiency, urinary
fistulas and postoperative bleeding.
Local recurrence rate after partial nephrectomy is
1.4 to 10 %.
Campbell Walsh Urology 10th ed.
50. Enucleation for small cortical tumors
Expose the whole kidney excluding palpable tumors
which should be covered with fat.
Administer i/v mannitol & furosemide and control
renal vessels with vessel loop.
55. Pathologic
tumor stage
History,
examination
& blood tests
CXR
(chest X-ray)
Abdominal
CT
pT1aN0M0 yearly _ _
pT1b-2bN0M0 yearly yearly 2 yearly
pT3N0M0 6 mthly for
3yr then
yearly
6 mthly for
3yr then
yearly
6 mthly for
3yr then 2
yearly
Post operative surveillance (after partial nephrectomy)
Campbell Walsh Urology 10th ed.
56. Thermal ablative therapies
Includes renal cryosurgery and radiofrequency
ablation.
Alternative nephron sparing treatment.
Ideal candidates are–
• patients with advanced age or significant
comorbidities but are not the candidates for
conventional surgery
• Local recurrence after previous NSS
• Hereditary RCC with multifocal disease
• Tumors <4cm size
Local recurrence rate is 5 to 20%, higher than
traditional surgeries.
Campbell Walsh Urology 10th ed.
57. Prerequisites for cryoablation are-
Rapid freezing
Gradual thawing
Repetition of freeze-thaw cycle
Target lethal temp. should be -20⁰C at a distance
of 3.1mm inside the leading edge of the ice ball
Complications are-renal fracture, hemorrhage,
adjacent organ injury, ileus, and wound infection.
Central or nodular enhancement within the
tumor bed on extended followup has been
considered diagnostic of local recurrence(Weight et al 2008).
Cryotherapy
Campbell Walsh Urology 10th ed.
58. Experience with RFA is more limited- this
technology is at an earlier state of development
than cryoablation.
One disadvantage of RFA is that the treatment
effect is more difficult to monitor in real time-
there is no true “ice ball” equivalent (Zelkovic and Resnick, 2003).
Treatment is typically based on empirical results
from previous probe alignments and this allows a
fairly predictable target zone of up to 4.0 cm to
be treated in most cases.
Radiofrequency Ablation (RFA)
Campbell Walsh Urology 10th ed.
59. Local control after RFA is difficult to determine owing to a
number of complexities, although most estimate that this
will be 80% to 90% on a longitudinal basis using strict
definitions of local recurrence (Matin and Ahrar, 2009).
Complications are uncommon but have included acute
renal failure, stricture of the ureteropelvic junction,
necrotizing pancreatitis, and lumbar radiculopathy, so
careful and judicious selection of patients is essential (Matin
and Ahrar, 2009).
Other exciting new technologies, such as high-intensity
focused ultrasound (HIFU) and frameless, image-guided
radiosurgical treatments (CyberKnife), are also under
development and may allow extracorporeal treatment of
small renal tumors in the future(Matin and Ahrar, 2009).
60. Active Surveillance (AS)
• Series from several institutions have confirmed that
many small renal masses will grow relatively slowly
(median growth rate 0.28 cm/yr), and there have been
only 4 patients with metastasis in these series (1.2%),
suggesting that this may be a reasonable management
strategy in carefully selected patients who are not
candidates for conventional surgery or thermal ablative
approaches (Chawla et al, 2005, 2006; Crispen and Uzzo, 2006; Rendon and Jewett, 2006; Jewett and
Zuniga, 2008; Campbell et al, 2009).
• These studies suggest that patients with small, solid,
enhancing, well-marginated, homogeneous renal lesions,
who are elderly or poor surgical risks, can safely be
managed with observation and serial renal imaging at 6-
month or 1-year intervals (Chawla et al, 2005; Viterbo et al, 2005; Crispen and Uzzo,
2006; Jewett and Zuniga 2008; Campbell et al, 2009; Chen et al, 2009).
61. • AS is not appropriate for patients with larger (>3 to 4 cm),
poorly marginated, or nonhomogeneous solid renal lesions
(Remzi et al, 2006; Kunkle et al, 2007).
• AS is also not advisable in younger, otherwise healthy
patients with small, solid tumors that have radiographic
characteristics consistent with RCC (Camp- bell et al, 2009).
• Growth rates on observation do not allow differentiation
of benign versus malignant histology (Siu et al, 2007; Crispen et al,
2008).
• Therefore, in this setting, it is more appropriate to consider
treating the tumor by surgical excision or thermal ablation
when it is small, clearly localized, and still amenable to
nephron-sparing approaches (Van Poppel et al, 2007; Campbell et al, 2009;
Chen et al, 2009).
62. Locally advanced RCC
Involvement of venous system occurs in 4% to
10% of RCC.
40 to 70% of patients can be treated with
nephrectomy and thrombectomy.
Multiplaner CT and MRI demonstrate presence
and cephalad extension of tumor thrombus.
Campbell Walsh Urology 10th ed.
63. Continued…
Staging of level of IVC thrombus
1 – Thrombus adjacent to ostia of renal vein
2 – Extending upto lower aspect of the liver
3 – Involving the intrahepatic portion of IVC
4 – Extending in IVC above the diaphragm
64. Level 1
Level 1 thrombi are isolated by satinsky clamp and
readily removed.
65. Level 2
• Level 2 require sequential clamping of caudal IVC,
contralateral renal vasculature, cephalad IVC, occlusion
of lumbar veins. Renal ostia is opened and tumor
thrombus removed.
• If there is invasion of venous wall then venous wall is
resected and reconstruction is done with PTFE or
pericardial graft.
Campbell Walsh Urology 10th ed.
67. Level 3
• Level 3 thrombi requires mobilization of
liver and exposure of intrahepatic IVC and
thrombus is mobilized caudal to hepatic
veins and removed as in level 2.
• Thrombus within 2 cm of hepatic veins and
cephalad generally requires
cardiopulmonary bypass with deep
hypothermic circulatory arrest.
Campbell Walsh Urology 10th ed.
70. Locally invasive RCC
Patients with locally invasive RCC usually present with pain,
generally from invasion of the posterior abdominal wall,
nerve roots, or paraspinous muscles.
Because surgical therapy is the only potentially cura- tive
management for RCC, extended operations with en-bloc
resection of adjacent organs are occasionally indicated.
Complete excision of the tumor, including resection of the
involved bowel, spleen, or abdominal wall muscles, is the
aim of therapy.
If R0 margins are possible then it can be considered for
resection.
Incomplete excision of large tumor or debulking is rarely
indicated.
Campbell Walsh Urology 10th ed.
71. Metastatic RCC
Surgical management includes cytoreductive
surgery, metastasectomy, palliative surgery.
Immunologic approaches
For clear cell RCC– interferons, IL-2, VEGF
antagonists (bevacizumab, sunitinib, sorafinib),
mTOR inhibitors (temsirolimus, everilimus).
Chemotherapy and hormonal therapy has no role in
current management of clear cell RCC.
Systemic therapy for non clear cell RCC– no
standard approach of proven efficacy is present.
Some success is seen with cytotoxic therapy
consisting of carboplatin and gemcitabine.
Campbell Walsh Urology 10th ed.
73. Adjuvant Therapy for RCC
• Isolated local recurrence after radical nephrectomy occurs
in 2% to 4% of patients and a thorough metastatic
evaluation should be pursued if resection is under
consideration.
• Local recurrence after partial nephrectomy is more
common at sites distant from the tumor bed and can be
managed by repeat partial nephrectomy, completion
nephrectomy, ablation, or surveillance.
• Local recurrence after tumor ablation often reflects
incomplete tumor eradication; management options
include repeat ablation, surveillance, or salvage surgery.
• Despite a significant likelihood of recurrence of RCC with
poor risk features, there is no established evidence of a
benefit for adjuvant therapy in patients without evidence of
disease after surgical resection. Campbell Walsh Urology 10th ed.
74. Prognostic Factors
Anatomic Clinical Histologic Molecular
Tumor size Performance status (karnofsky,
ECOG)
Nuclear grade Hypoxia inducible factors
Venous involvement Systemic symptoms (cachexia,
wt. loss >10% of body wt.)
Histologic subtype Costimulatory molecules
Extension into contiguous
organs
Symptomatic vs. incidental
presentation
Presence of sarcomatoid
features
Cell cycle regulators
Adrenal involvement (direct or
metastatic)
Anemia Histologic necrosis Adhesion molecules
Lymph node metastases Hypercalcemia Vascular invasion Other factors
Distant metastases ↑LDH Invasion of perinephric or renal
sinus fat
Metastatic burden of disease ↑ESR Collecting system invasion
↑CRP Surgical margin status
Thrombocytosis
↑ALP
Campbell Walsh Urology 10th ed.
75. 5 Year survival
Findings TNM stage 5 Yr
survival
(%)
Organ confined (overall) T1-2N0M0 70-90
≤4.0 cm T1aN0M0 90-100
>4.0 cm to 7.0 cm T1bN0M0 80-90
>7.0 to 10.0 cm T2aN0M0 65-80
>10.0 cm T2bN0M0 50-70
Invasion of perinephric or renal sinus fat T3aN0M0 50-70
Invasion of renal vein or branches T3aN0M0 40-60
Invasion of IVC below diaphragm T3bN0M0 30-50
Invasion of IVC above the diaphragm or invasion of IC wall T3cN0M0 20-40
Direct adrenal involvement T4N0M0 0-30
Locally advanced (invasion beyond Gerota fascia) T4N0M0 0-20
Lymphatic involvement (Any)TN1M0 0-20
Systemic metastases (Any)T(Any)NM1 0-10
Campbell Walsh Urology 10th ed.
76. Screening
• Patients with End-Stage Renal Disease
Screen only patients with long life expectancy and minimal major comorbidities.
Perform periodic ultrasound examination or CT scan beginning during third year
on dialysis.
• Patients with Known von Hippel-Lindau Syndrome
Obtain biannual abdominal CT or ultrasound study beginning at age 15 to 20
years.
Perform periodic clinical and radiographic screening for nonrenal
manifestations.
• Relatives of Patients with von Hippel-Lindau Syndrome
Obtain genetic analysis.
o If positive, follow screening recommendations for patients with known von
Hippel-Lindau syndrome.
o If negative, less stringent follow-up is required.
• Relatives of Patients with Other Familial Forms of Renal Cell Carcinoma
Obtain periodic ultrasound or CT study and consider genetic analysis.
• Patients with Tuberous Sclerosis
Perform periodic screening with ultrasound examination or CT scan.
• Patients with Autosomal-Dominant Polycystic Kidney Disease
Routine screening is not justified.
Campbell Walsh Urology 10th ed.
