Rcc

Radical NephrectomyRadical Nephrectomy
Renal Cell CarcinomaRenal Cell Carcinoma

HistoryHistory
The first radical nephrectomy removedThe first radical nephrectomy removed
through Thoracoabdominal incisionthrough Thoracoabdominal incision
Mortensen (1948)

Robson 1960s, popularized RadicalRobson 1960s, popularized Radical
nephrectomynephrectomy
Perifascial resection of the kidneyPerifascial resection of the kidney
Perirenal fatPerirenal fat
Regional LNRegional LN
Adrenal glandAdrenal gland
Robson CJ. Radical nephrectomy for renal cell carcinoma. J Urol 1963;
89:37.
Robson CJ. Radical nephrectomy for renal cell carcinoma. J Urol 1963;
89:37.
HistoryHistory

HistoryHistory
Robson 1960s, Radical nephrectomyRobson 1960s, Radical nephrectomy
Large abdominal or transthoracic incisionsLarge abdominal or transthoracic incisions
Standard approach to the renal tumors forStandard approach to the renal tumors for
the next 20 yearsthe next 20 years
Skinner DG, Colvin RB, Vermillion CD, et al. Diagnosis and management of renal cell carcinoma: a
clinical and pathological study of 309 cases. Cancer 1971;28:1165â€“1177.
Patel NP, Lavengood RW. Renal cell carcinoma: natural history and results of treatment. J Urol
1978;119:722.
Skinner DG, Colvin RB, Vermillion CD, et al. Diagnosis and management of renal cell carcinoma: a
clinical and pathological study of 309 cases. Cancer 1971;28:1165â€“1177.
Patel NP, Lavengood RW. Renal cell carcinoma: natural history and results of treatment. J Urol
1978;119:722.

Contemporary Perspective InContemporary Perspective In
Radical NephrectomyRadical Nephrectomy

Radical nephrectomyRadical nephrectomy
 Patients selectionPatients selection
 Comprehensive counselingComprehensive counseling
 Surgical aspectsSurgical aspects
 ComplicationsComplications
 Oncologic outcomesOncologic outcomes

Patient selectionPatient selection
MSKCCMSKCC
 large and centrally localized tumors that havelarge and centrally localized tumors that have
effectively replaced most of the normal renaleffectively replaced most of the normal renal
parenchymaparenchyma
 large tumors associated with regionallarge tumors associated with regional
adenopathy (of benign or malignant etiology)adenopathy (of benign or malignant etiology)
Flanigan RC, Salmon SE, Blumenstein BA, et al. Nephrectomy followed by interferon alfa-2b compared
with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 2001;23:1655â€“1659.
Flanigan RC, Salmon SE, Blumenstein BA, et al. Nephrectomy followed by interferon alfa-2b compared
with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 2001;23:1655â€“1659.

 inferior vena cava (IVC) or right atrial extensioninferior vena cava (IVC) or right atrial extension
 metastatic disease referred by medical oncologymetastatic disease referred by medical oncology
for cytoreductive nephrectomy before thefor cytoreductive nephrectomy before the
initiation of systemic therapy.initiation of systemic therapy.
 partial nephrectomy are asked to also signpartial nephrectomy are asked to also sign
consent for radical nephrectomy if observedconsent for radical nephrectomy if observed
operative findings or technical problems ariseoperative findings or technical problems arise
making partial nephrectomy unsafe or unwise.making partial nephrectomy unsafe or unwise.

RCC with ipsilateral adrenalRCC with ipsilateral adrenal
involvementinvolvement

Comprehensive counselingComprehensive counseling
 Informed Consent: topics covered in this process include aInformed Consent: topics covered in this process include a
description of the procedure including:description of the procedure including:
 the suspected diagnosisthe suspected diagnosis
 the need for removing the affected kidney, surroundingthe need for removing the affected kidney, surrounding
tissues, and ipsilateral adrenal gland if requiredtissues, and ipsilateral adrenal gland if required
 the alternatives to the intended procedure such asthe alternatives to the intended procedure such as
cryoablation, partial nephrectomy, or laparoscopic RNcryoablation, partial nephrectomy, or laparoscopic RN
 the potential complications of the operation includingthe potential complications of the operation including
 the need for long-term medical follow-up after surgerythe need for long-term medical follow-up after surgery

PreparationPreparation
 routine serum chemistriesroutine serum chemistries
 coagulation profile,coagulation profile,
 cross matchcross match
 chest x-ray are obtainedchest x-ray are obtained

 Preferred imagingPreferred imaging
 Dedicated renal computed tomography (CT)Dedicated renal computed tomography (CT)
 In most cases, this single examination can be used toIn most cases, this single examination can be used to
detect and stagedetect and stage RCC and to provideRCC and to provide
information forinformation for surgical planningsurgical planning withoutwithout
additional imagingadditional imaging

 In the few patients in whom the CT findings areIn the few patients in whom the CT findings are
equivocal, MRI or doppler U/S can be usefulequivocal, MRI or doppler U/S can be useful
 Angiography is rarely used in the workup ofAngiography is rarely used in the workup of
RCCRCC

CTCT
 Dedicated renal CTDedicated renal CT
 Thin section 2.5-5 mm helical imaging of theThin section 2.5-5 mm helical imaging of the
kidneys before IV contrast, followed bykidneys before IV contrast, followed by
coticomedullary (arterial at 40 second),coticomedullary (arterial at 40 second),
nephrographic (at 90 second) and urographicnephrographic (at 90 second) and urographic
(delayed at 7 minute)(delayed at 7 minute)

 Historically, enhancement was consideredHistorically, enhancement was considered
present if the attenuation of the lesion increasedpresent if the attenuation of the lesion increased
by more than 10 HU from baselineby more than 10 HU from baseline
 However, with recent advances in CT hardware,However, with recent advances in CT hardware,
this definition may need to be changed to 15-20this definition may need to be changed to 15-20
HUHU
CTCT

On initial nonenhanced CT scans, RCCs may appear as:On initial nonenhanced CT scans, RCCs may appear as:
hyperattenuatinghyperattenuating
isoattenuatingisoattenuating
Hypoattenuating relative to the remainder of the kidney.Hypoattenuating relative to the remainder of the kidney.
CalcificationsCalcifications
amorphous and internal, although rimlike calcificationsamorphous and internal, although rimlike calcifications
can also be present.can also be present.
CTCT

 On contrast-enhanced CT scans, RCC is usuallyOn contrast-enhanced CT scans, RCC is usually
solid, and decreased attenuation suggestive ofsolid, and decreased attenuation suggestive of
necrosis is often present.necrosis is often present.
 Sometimes RCC is a predominantly cystic mass,Sometimes RCC is a predominantly cystic mass,
with thick septa and wall nodularity.with thick septa and wall nodularity.
 RCC may also appear as a completely solid andRCC may also appear as a completely solid and
highly enhancing masshighly enhancing mass

 Degree of confidence in the imagingDegree of confidence in the imaging
 If a solitary mass isIf a solitary mass is enhancingenhancing, the degree of, the degree of
confidence in diagnosing RCC is high.confidence in diagnosing RCC is high.
 When masses are multiple, metastatic disease andWhen masses are multiple, metastatic disease and
lymphomalymphoma must be considered, especially if themust be considered, especially if the
patient has a history of a primary malignancy.patient has a history of a primary malignancy.
 When a mass is predominantlyWhen a mass is predominantly cysticcystic, the, the
confidence level decreases. In these patients, US mayconfidence level decreases. In these patients, US may
be useful.be useful.
CTCT

 False-positive results for CTFalse-positive results for CT
 Pseudoenhancement of small masses (cysts)Pseudoenhancement of small masses (cysts)
 Bosniak type 2 cystsBosniak type 2 cysts
 Thin septa, hyperattenuation, or small amounts of muralThin septa, hyperattenuation, or small amounts of mural
or septal calcificationsor septal calcifications
 Bosniak type 3 cystsBosniak type 3 cysts
 Mural nodularity, thick septa, or irregular or thickMural nodularity, thick septa, or irregular or thick
calcifications that often require surgical explorationcalcifications that often require surgical exploration
 Oncocytomas (indistinguishable from RCC on CT)Oncocytomas (indistinguishable from RCC on CT)
 Angiomyolipomas that do not contain visible fatAngiomyolipomas that do not contain visible fat
CTCT

CTCT
 False-negative results for CTFalse-negative results for CT
 If the attenuation is not carefully measured beforeIf the attenuation is not carefully measured before
and after IV contrastand after IV contrast
 If cystic masses are not carefully examined for septaIf cystic masses are not carefully examined for septa
or nodularityor nodularity
 If enhancement of a lesion is missed (i.e. lack ofIf enhancement of a lesion is missed (i.e. lack of
enhancement at the time of scanning)enhancement at the time of scanning)
 If the mass is too small for adequate characterizationIf the mass is too small for adequate characterization

Renal Cell Carcinoma
Non contrast CT

Contrast CT show LT renal cyst with Bosnik IV

 Renal cell carcinoma. Dedicated renal CT scan obtained before contrastRenal cell carcinoma. Dedicated renal CT scan obtained before contrast
enhancement. Right kidney has an attenuation measurement of 45.7 HUenhancement. Right kidney has an attenuation measurement of 45.7 HU

 Renal cell carcinoma. Contrast-enhanced dedicated renal CT scan with anRenal cell carcinoma. Contrast-enhanced dedicated renal CT scan with an
attenuation measurement of 101.7 HUattenuation measurement of 101.7 HU

SURGICAL ASPECTSSURGICAL ASPECTS

TechniquesTechniques
 Whats meant by radical nephrectomyWhats meant by radical nephrectomy
 Open surgeryOpen surgery
 LaparoscopyLaparoscopy
 Robotic surgeryRobotic surgery

Open surgeryOpen surgery
RNRN
 How to choose theHow to choose the
incision?incision?
 surgeon's preferencesurgeon's preference
 patient's body habituspatient's body habitus
 tumor size & sitetumor size & site
 Other pathology [IVCOther pathology [IVC
thrombus]thrombus]
 What are the types ofWhat are the types of
incisions?incisions?
 Supracostal flank incisionSupracostal flank incision
 transperitoneal midlinetransperitoneal midline
 transperitoneal subcostaltransperitoneal subcostal
incisionincision
 ThoracoabdominalThoracoabdominal
incisionincision

Radical Nephrectomy Patient in theRadical Nephrectomy Patient in the
Operating RoomOperating Room

Other ClinicalOther Clinical
SituationsSituations

LocallyLocally
Advanced Renal Cell CarcinomaAdvanced Renal Cell Carcinoma
 RCC with perinephric fat involvementRCC with perinephric fat involvement
 RCC with ipsilateral adrenal involvementRCC with ipsilateral adrenal involvement
 RCC with venous tumor thrombusRCC with venous tumor thrombus
 RCC with direct invasion of adjacent organsRCC with direct invasion of adjacent organs

RCC with perinephric fatRCC with perinephric fat
involvementinvolvement
 Modern nephrectomy series demonstrate thatModern nephrectomy series demonstrate that
approximately 20 to 30% of RCC are found toapproximately 20 to 30% of RCC are found to
extend into the perinephric fatextend into the perinephric fat
 Regardless of surgical approach, RN remains theRegardless of surgical approach, RN remains the
treatment of choice for RCC extending into thetreatment of choice for RCC extending into the
perinephric fat.perinephric fat.

RCC WITH IPSILATERAL ADRENALRCC WITH IPSILATERAL ADRENAL
INVOLVEMENTINVOLVEMENT
 DespiteDespite poor cancer specific outcomespoor cancer specific outcomes associatedassociated
with ipsilateral adrenal involvement by RCC, a smallwith ipsilateral adrenal involvement by RCC, a small
but significant proportion of patients can expect abut significant proportion of patients can expect a
durable cure following complete surgical resection.durable cure following complete surgical resection.
 As such, patients with preoperative orAs such, patients with preoperative or
intraoperative evidence of adrenal involvement, asintraoperative evidence of adrenal involvement, as
well as patients with features of LARCC shouldwell as patients with features of LARCC should
undergo nephrectomy with concomitant en blocundergo nephrectomy with concomitant en bloc
adrenalectomyadrenalectomy..

RCC WITH VENOUS TUMORRCC WITH VENOUS TUMOR
THROMBUSTHROMBUS
 The incidence of venous tumor extension inThe incidence of venous tumor extension in
patients with RCC is reported to be between 4patients with RCC is reported to be between 4
and 10%.and 10%.
 In up to 25% of patients, the tumor extendsIn up to 25% of patients, the tumor extends
above the confluence of the hepatic veins and inabove the confluence of the hepatic veins and in
approximately 5%, the thrombi are supra-approximately 5%, the thrombi are supra-
diaphragmatic or intracardialdiaphragmatic or intracardial

Inferior vena caval tumorsInferior vena caval tumors

RCC WITH DIRECT INVASION OFRCC WITH DIRECT INVASION OF
ADJACENT ORGANSADJACENT ORGANS
 Tumor invasion beyond Gerota’s fascia into adjacentTumor invasion beyond Gerota’s fascia into adjacent
organs (pT4), without concomitant metastatic disease,organs (pT4), without concomitant metastatic disease,
is ais a relatively unusualrelatively unusual
 Large retrospective series report a 5 to 15% incidenceLarge retrospective series report a 5 to 15% incidence
of pT4 RCC.4,33of pT4 RCC.4,33
 aggressive surgical resection with en bloc removal of allaggressive surgical resection with en bloc removal of all
affected organs in patients with adjacent organaffected organs in patients with adjacent organ
involvement by RCC.involvement by RCC.

SURGICALSURGICAL
COMPLICATIONSCOMPLICATIONS

 Following radical nephrectomy there areFollowing radical nephrectomy there are
reported complication rates of between 13reported complication rates of between 13
and 20 per centand 20 per cent
(Swanson and Borges 1983).(Swanson and Borges 1983).

Laparoscopic RadicalLaparoscopic Radical
NephrectomyNephrectomy
 The introduction of laparoscopic nephrectomyThe introduction of laparoscopic nephrectomy
for the treatment of localized RCC by Claymanfor the treatment of localized RCC by Clayman
and colleagues in 1991 revolutionized renaland colleagues in 1991 revolutionized renal
surgery for renal tumors.surgery for renal tumors.
Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case
report. J Urol 1991;146:278–82.

 Recently, longer follow-up data has validatedRecently, longer follow-up data has validated
early observations, with local recurrence ratesearly observations, with local recurrence rates
and survival data similar to that of traditionaland survival data similar to that of traditional
open surgery.open surgery.

 several series have reported 5-year disease free andseveral series have reported 5-year disease free and
actuarial survival for patients with stage T1-actuarial survival for patients with stage T1-
2N0M0, ranging from 91 to 95% and 81 to 95%,2N0M0, ranging from 91 to 95% and 81 to 95%,
respectivelyrespectively
 Concerns about tumor spillage, particularly withConcerns about tumor spillage, particularly with
morcellation and the risk of port site recurrencemorcellation and the risk of port site recurrence
were shown to be unfounded as rates are equivalentwere shown to be unfounded as rates are equivalent
with open surgery.with open surgery.
 There have been only nine reported cases ofThere have been only nine reported cases of
port site metastases following laparoscopicport site metastases following laparoscopic
nephrectomy with an overall reported incidencenephrectomy with an overall reported incidence

 Sudies comparing laparoscopic partialSudies comparing laparoscopic partial
nephrectomy and open partial nephrectomynephrectomy and open partial nephrectomy
show:show:
 Blood loss was lower in laparoscopic groupBlood loss was lower in laparoscopic group
 No difference in postoperative morbidity inNo difference in postoperative morbidity in
both groupboth group
 Operative time and warm ischamia was lower inOperative time and warm ischamia was lower in
open group (Gill et al, 2007)open group (Gill et al, 2007)

 Most common primary renal malignant neoplasm inMost common primary renal malignant neoplasm in
adultsadults
 90% of renal tumours90% of renal tumours
 2% of all adult malignancies2% of all adult malignancies
 More common in men (1.6 to 1)More common in men (1.6 to 1)
 Incidence peaks in patients 55-84 years oldIncidence peaks in patients 55-84 years old
 Approximately 5,800 new cases in Canada in 2009Approximately 5,800 new cases in Canada in 2009
 Approximately 1,300 deaths in Canada in 2009Approximately 1,300 deaths in Canada in 2009

 20% of cases present with metastatic disease20% of cases present with metastatic disease
 2% of cases present with simultaneous bilateral2% of cases present with simultaneous bilateral
diseasedisease
 Most cases are found in early stages incidentallyMost cases are found in early stages incidentally
due to widespread use of medical imaging indue to widespread use of medical imaging in
generalgeneral
 ““Incidentaloma”Incidentaloma”

 Risk factors:Risk factors:
 MaleMale
 SmokingSmoking
 CadmiumCadmium
 BenzeneBenzene
 TrichloroethyleneTrichloroethylene
 Asbestos exposureAsbestos exposure
 Elevated body mass indexElevated body mass index
 Chronic dialysisChronic dialysis
 Genetic syndromes (familial RCC, hereditary papillary RCC,Genetic syndromes (familial RCC, hereditary papillary RCC,
von Hippel-Lindau syndrome and tuberous sclerosis)von Hippel-Lindau syndrome and tuberous sclerosis)

 RCC’s arise from the tubular epithelium and areRCC’s arise from the tubular epithelium and are
based in the renal cortexbased in the renal cortex
 Pathologic subtypes:Pathologic subtypes:
 Clear cellClear cell
 PapillaryPapillary
 Granular cellGranular cell
 Chromophobe cellChromophobe cell
 SarcomatoidSarcomatoid

 Clear cell carcinomaClear cell carcinoma

 Bilateral RCC’s are more common in von HippelBilateral RCC’s are more common in von Hippel
Lindau syndrome, tuberous sclerosis and chronicLindau syndrome, tuberous sclerosis and chronic
dialysisdialysis

 Spread may occur by direct local invasion ofSpread may occur by direct local invasion of
adjacent structuresadjacent structures
 Adrenal glandsAdrenal glands
 LiverLiver
 SpleenSpleen
 ColonColon
 PancreasPancreas

 Local regional lymph node metastases are alsoLocal regional lymph node metastases are also
commoncommon
 Renal vein or IVC thrombus may occurRenal vein or IVC thrombus may occur
 Distant metastasesDistant metastases
 Lungs (most common)Lungs (most common)
 LiverLiver
 BoneBone
 Adrenal glandAdrenal gland
 Contralateral kidneyContralateral kidney

 Primary tumor (T)Primary tumor (T)
 TX - Primary tumor cannot be assessedTX - Primary tumor cannot be assessed
 T0 - No evidence of primary tumorT0 - No evidence of primary tumor
 T1 - Tumor 7 cm or smaller in greatest dimension, limited to the kidneyT1 - Tumor 7 cm or smaller in greatest dimension, limited to the kidney
 T2 - Tumor larger than 7 cm in greatest dimension, limited to the kidneyT2 - 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 notT3 - Tumor extends into major veins or invades adrenal gland or perinephric tissues but not
beyond the Gerota fasciabeyond the Gerota fascia
 T3a - Tumor invades adrenal gland or perinephric tissues but not beyond the Gerota fasciaT3a - 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 diaphragmT3b - 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 diaphragmT3c - Tumor grossly extends into the renal vein(s) or vena cava above the diaphragm
 T4 - Tumor invading beyond the Gerota fasciaT4 - Tumor invading beyond the Gerota fascia
 Regional lymph nodes (N) - Laterality does not affect the N classificationRegional lymph nodes (N) - Laterality does not affect the N classification
 NX - Regional lymph nodes cannot be assessedNX - Regional lymph nodes cannot be assessed
 N0 - No regional lymph node metastasisN0 - No regional lymph node metastasis
 N1 - Metastasis in a single regional lymph nodeN1 - Metastasis in a single regional lymph node
 N2 - Metastasis in more than 1 regional lymph nodeN2 - Metastasis in more than 1 regional lymph node
 Distant metastasis (M)Distant metastasis (M)
 MX - Distant metastasis cannot be assessedMX - Distant metastasis cannot be assessed
 M0 - No distant metastasisM0 - No distant metastasis
 M1 - Distant metastasisM1 - Distant metastasis

 TNM staging systemTNM staging system
 Stage IStage I
 7cm or less and confined to the kidney7cm or less and confined to the kidney
 Stage IIStage II
 >7cm but still organ confined>7cm but still organ confined
 Stage IIIStage III
 Extend into the renal vein or vena cava, involve theExtend into the renal vein or vena cava, involve the
ipsilateral adrenal gland and/or perinephric fat, or haveipsilateral adrenal gland and/or perinephric fat, or have
spread to one local lymph nodespread to one local lymph node
 Stage IVStage IV
 Extend beyond Gerota’s fascia, to more than one localExtend beyond Gerota’s fascia, to more than one local
node or have distant metastasesnode or have distant metastases

 PrognosisPrognosis
 Dependent on stageDependent on stage
 Survial after surgical resectionSurvial after surgical resection
 T1 (<7cm)T1 (<7cm)
 5yr5yr 95%95%
 10yr10yr 91%91%
 T2 (>7cm)T2 (>7cm)
 5yr5yr 80%80%
 10yr10yr 70%70%
 T3T3 5 yr5 yr 59%59%
 T4T4 5 yr5 yr 20%20%
 Suvival for unresectable RCC is <20% at 5 yearsSuvival for unresectable RCC is <20% at 5 years

 PresentationPresentation
 Incidental finding on imaging (‘incidentaloma”)Incidental finding on imaging (‘incidentaloma”)
 HematuriaHematuria
 Flank painFlank pain
 Flank massFlank mass
 Fever, nausea, anorexia, malaise, night sweats andFever, nausea, anorexia, malaise, night sweats and
weight lossweight loss

 Large renal cell carcinoma (U/S)Large renal cell carcinoma (U/S)
 For the workup in RCC, US is used primarily to differentiateFor the workup in RCC, US is used primarily to differentiate
solid masses from simple cystssolid masses from simple cysts

 Large renal cell carcinoma (contrast enhanced CT)Large renal cell carcinoma (contrast enhanced CT)

 Small renal cell carcinoma (contrast enhanced CT)Small renal cell carcinoma (contrast enhanced CT)

 Limitations of imaging techniques (CT)Limitations of imaging techniques (CT)
 Pseudoenhancement of masses smaller than 8-Pseudoenhancement of masses smaller than 8-
10mm may be a problem for CT10mm may be a problem for CT
 U/S may help in characterizing some of these asU/S may help in characterizing some of these as
cystscysts
 If contrast cannot be given then CT is a poor choiceIf contrast cannot be given then CT is a poor choice
so MRI may be more helpfulso MRI may be more helpful

 Limitations of imaging techniques (U/S)Limitations of imaging techniques (U/S)
 Incomplete staging (bones, lungs and regional nodes)Incomplete staging (bones, lungs and regional nodes)
 Difficult to detect small non-contour deformingDifficult to detect small non-contour deforming
massesmasses
 Large patients may not be good candidates for U/SLarge patients may not be good candidates for U/S
because of technical difficulties in obtaining goodbecause of technical difficulties in obtaining good
quality images of the kidneysquality images of the kidneys

 Limitations of imaging techniques (MRI)Limitations of imaging techniques (MRI)
 Patient cooperation because MRI is more sensitivePatient cooperation because MRI is more sensitive
to motion artifact than CTto motion artifact than CT
 MRI is more expensive and less readily available thanMRI is more expensive and less readily available than
CTCT
 Patients with pacemakers, medical implants andPatients with pacemakers, medical implants and
severe claustrophobia are excludedsevere claustrophobia are excluded
 BenefitBenefit
 No radiation exposureNo radiation exposure

 Differntial diagnosisDifferntial diagnosis
 OncocytomaOncocytoma
 Other problems to be consideredOther problems to be considered
 AngiomyolipomaAngiomyolipoma
 Collecting duct carcinomaCollecting duct carcinoma
 Hemorrhagic cystHemorrhagic cyst
 Infected cystInfected cyst
 LymphomaLymphoma
 Metastatic diseaseMetastatic disease
 Renal abscessRenal abscess
 Transitional cell carcinomaTransitional cell carcinoma

 Typical renal cell carcinoma. CT scan obtained before contrastTypical renal cell carcinoma. CT scan obtained before contrast
enhancement has an attenuation measurement of 33.9 HUenhancement has an attenuation measurement of 33.9 HU

 Typical renal cell carcinoma. Contrast-enhanced CT scan has anTypical renal cell carcinoma. Contrast-enhanced CT scan has an

 Multifocal renal cell carcinoma in a patient with Von Hippel-Multifocal renal cell carcinoma in a patient with Von Hippel-
Lindau disease. Contrast-enhanced CT scanLindau disease. Contrast-enhanced CT scan

 Multifocal renal cell carcinoma in a patient with Von Hippel Lindau disease.Multifocal renal cell carcinoma in a patient with Von Hippel Lindau disease.
Patient had already undergone a right nephrectomy. Contrast-enhanced CT scanPatient had already undergone a right nephrectomy. Contrast-enhanced CT scan

 Multifocal renal cell carcinoma in patient presenting with palpableMultifocal renal cell carcinoma in patient presenting with palpable
mass. Nonenhanced CT scanmass. Nonenhanced CT scan

 Cystic renal cell carcinoma. Nonenhanced CT scan with anCystic renal cell carcinoma. Nonenhanced CT scan with an

 Cystic renal cell carcinoma. Contrast-enhanced CT scan with anCystic renal cell carcinoma. Contrast-enhanced CT scan with an

 MRIMRI
 Findings are similar to those of CTFindings are similar to those of CT
 Numeric criteria for enhancement are not definedNumeric criteria for enhancement are not defined
for MRI as they are for CT, but MRI signal intensityfor MRI as they are for CT, but MRI signal intensity
changes can be measuredchanges can be measured

 Large right renal cell carcinoma with renal vein and inferior venaLarge right renal cell carcinoma with renal vein and inferior vena
cava invasion. T1-weighted axial MRI before contrast enhancementcava invasion. T1-weighted axial MRI before contrast enhancement

cava invasion. T1-weighted contrast-enhanced axial MRIcava invasion. T1-weighted contrast-enhanced axial MRI

 T1-weighted imagesT1-weighted images
 NonenhancedNonenhanced
 RCC’s usually appear isointense or hypointense relative toRCC’s usually appear isointense or hypointense relative to
the remainder of the kidneythe remainder of the kidney
 With chemical shift imaging, some clear cell carcinomasWith chemical shift imaging, some clear cell carcinomas
show focal or diffuse loss of signal intensityshow focal or diffuse loss of signal intensity

cava invasion. T2-weighted axial MRIcava invasion. T2-weighted axial MRI

 T2-weighted imagesT2-weighted images
 RCC’s are usually hyperintense and most oftenRCC’s are usually hyperintense and most often
heterogeneousheterogeneous

 MRIMRI
 Necrosis or hemorrhage may alter signal intensityNecrosis or hemorrhage may alter signal intensity
characteristicscharacteristics
 Especially helpful in determining invasion into renalEspecially helpful in determining invasion into renal
vein and IVCvein and IVC
 The degree of confidence in the diagnosis of RCCThe degree of confidence in the diagnosis of RCC
with MRI is similar to that of CTwith MRI is similar to that of CT
 MRI has no advantage compared with contrast enhancedMRI has no advantage compared with contrast enhanced
CT for the diagnosis of RCC but it is better for staging ofCT for the diagnosis of RCC but it is better for staging of
locally advanced caseslocally advanced cases

 Renal BiopsyRenal Biopsy
 Gaining popularityGaining popularity
 Older literature of fine needle aspiration biopsies showedOlder literature of fine needle aspiration biopsies showed
40% malignancy, 24% benign and 36% indeterminate40% malignancy, 24% benign and 36% indeterminate
 Recent literature of core biopsies shows 75% malignancy,Recent literature of core biopsies shows 75% malignancy,
20% benign and 5% indeterminate20% benign and 5% indeterminate
 Renal biopsy may be most useful in patients with a priorRenal biopsy may be most useful in patients with a prior
malignancy (? Mets), lymphoma or multiple masses (? Mets)malignancy (? Mets), lymphoma or multiple masses (? Mets)
 ““If in doubt, cut it out!”If in doubt, cut it out!”

 ManagementManagement
 Surgery – “A chance to cut is a chance to cure”Surgery – “A chance to cut is a chance to cure”
 Unresectable RCC’s have a 5 year survival rate ofUnresectable RCC’s have a 5 year survival rate of
<20%<20%
 RCC’s are resistant to chemotherapy and radiationRCC’s are resistant to chemotherapy and radiation
therapytherapy

 Surgical optionsSurgical options
 Open radical nephrectomyOpen radical nephrectomy
 Laparoscopic radical nephrectomyLaparoscopic radical nephrectomy
 Open partial nephrectomyOpen partial nephrectomy
 Laparoscopic partial nephrectomyLaparoscopic partial nephrectomy

Normal Renal AnatomyNormal Renal Anatomy

 3D CT scan of a small RCC that is peripheral3D CT scan of a small RCC that is peripheral
and exophytic which is ideal for nephron sparingand exophytic which is ideal for nephron sparing
surgerysurgery

 3D CT scan showing a left lower pole RCC3D CT scan showing a left lower pole RCC
extending into the renal hilumextending into the renal hilum

 3D CT scan obtained during the excretory phase in the3D CT scan obtained during the excretory phase in the
coronal plane shows the mass abutting the inferior surfacecoronal plane shows the mass abutting the inferior surface
of the renal pelvis and invades the lower pole calicesof the renal pelvis and invades the lower pole calices

 Recurrent renal cell carcinoma. Status post–right nephrectomy withRecurrent renal cell carcinoma. Status post–right nephrectomy with
local recurrence (arrow) in nephrectomy bed. Contrast-enhanced CTlocal recurrence (arrow) in nephrectomy bed. Contrast-enhanced CT

 Minimally invasive image guided treatmentsMinimally invasive image guided treatments
 Radiofrequency ablation (RFA)Radiofrequency ablation (RFA)
 CryotherapyCryotherapy
 Especially for patients with a high surgical risk,Especially for patients with a high surgical risk,
aversion to surgery or bilateral lesionsaversion to surgery or bilateral lesions
 Minimal morbidity but higher recurrence ratesMinimal morbidity but higher recurrence rates
versus standard surgical excisionversus standard surgical excision

 Metastatic RCCMetastatic RCC
 Role of radical nephrectomy in metastatic RCCRole of radical nephrectomy in metastatic RCC
 Tyrosine kinase inhibitorsTyrosine kinase inhibitors
 SorefanibSorefanib
 SunitinibSunitinib
 m-TOR inhibitorsm-TOR inhibitors
 TemsirolimusTemsirolimus
 EverolimusEverolimus

 Recurrent renal cell carcinoma. Status post left nephrectomy withRecurrent renal cell carcinoma. Status post left nephrectomy with
metastatic disease to the contralateral adrenal glandmetastatic disease to the contralateral adrenal gland

 Recurrent renal cell carcinoma. Status post rightRecurrent renal cell carcinoma. Status post right
nephrectomy with metastatic disease to the livernephrectomy with metastatic disease to the liver

 Questions?Questions?
 Comments?Comments?

APPROACH ADVANTAGES DISADVANTAGES
Flank Subcostal • Useful for surgery on lower renal
pole, ureteropelvic junction, and
upper ureter, as well as simple
nephrectomy.
• Extraperitoneal approach prevents
peritoneal contamination
• Abdominal panniculus falls away
from incision
• Poor option in patients
with significant scoliosis
or who will not tolerate
flank position.
• Provides poor access to
renal hilum and renal
vasculature
• Risks chronic flank pain
and bulge
Supracostal • Useful for modest-sized tumor
and partial nephrectomy
• Extraperitoneal, extrapleural
approach
• Good renal, suprarenal, and
retroperitoneal exposure
• Permits pivoting of the 11th or
12th rib on a single articulating
• Poor option in patients
with significant scoliosis
or who will not tolerate
flank position.
• Risks chronic flank pain
and bulge

Thoracoabdominal • For large renal masses, esp upper
pole
• Right-sided tumors in which the
liver and hepatic veins would
reduce exposure
• Renal tumors with venous
extension and those involving
adjacent structures as well as
excision of suprarenal masses
• Provides maximal suprarenal
exposure
• Permits synchronous biopsy or
resection of pulmonary lesions
• Longer operative time
• Greater potential
pulmonary morbidity
• Damage to phrenic nerve

Anterior Subcostal
(extraperitoneal
or
transperitoneal)
Useful for open renal
biopsy, nephrectomy
and
renovascular surgery
Favorable approach for
upper pole tumors and
in
patients with a wide
subcostal angle
Provides good access
to the superior and
lateral
aspect of kidney; the
transperitoneal
approach
permits good access to
the renal hilum
The extraperitoneal
approach diminishes

Rcc

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