rcc

1. Risk Model
• Memorial Sloan Kettering Cancer Center (MSKCC)
Prognostic Factors Prognostic Risk Group
1. Interval from diagnosis to treatment less than 1 year
2. Karnofsky < 80%
3. Serum LDH > 1,5x
4. Corrected serum calcium > nilai normal
5. Serum Hb < normal (anemia)
1. Low risk : no prognostic factor
2. Intermediate : 1-2
3. Poor risk : > 2
• International Metastatic Renal Cell Carcinoma Database Consortium (IMDC)
Prognostic Factors
1. Less than one year from time of diagnosis to systemic therapy
2. Karnofsky < 80%
3. Hb < normal (anemia)
4. Calcium > normal (hipercalcemia)
5. Neutrophil > normal
6. Platelet > normal
Karnofsky Score

2. Survival Rates
Risk Factors
1. Rokok
2. Obesity/dyslipidemia
3. Hypertension
4. Diabetes
5. First degree relative with kidney cancer (5-8%)
6. Acquired cystic disease
7. Arsenic??
Trias
• Flank pain, hematuria, massa (6-10%)
Pemeriksaan Fisik
• Jika pada pemeriksaan fisik tidak didapati adanya massa, tidak perlu ballotement
• Ballotement dilakukan untuk evaluasi, massa apakah dari retroperitoneal
o Tempatkan tangan pada costovertebra angle, dorong ke arah atas
o Tangan yang lain tempatkan pada anterior abdomen. Saat deep inspiration,
diraba apakah ada massa
• Yang meraba yang di perut, karena di punggung terhalang otot
Laboratorium
• Ur/Cr
• Serum calcium
o Corrected Ca = 0,8 x (normal calcium-current calcium)
o Hiperkalsemia dan ⬆ alkali fosfatase = bone metastasis
• Urinalisis
• OT/PT

3. • LDH
• Alkali fosfatase > jika tinggi pertimbangkan bone scan
• Albumin
• Cytology urin (jika curiga urotelial/central mass)
Paraneoplastic Syndrome
• Bisa reversible jika tumor direseksi
• Prevalensi 20-30%
• Tanda dan gejala
o LED meningkat
o Weight loss, cachexia
o Demam
o Anemia
o Hypertension (renin meningkat)
o Hypercalcemia
o Staffer's syndrome (hepatic disfunction) -> hepatitis
o Alkaline phosphatase meningkat
o Polycythemia
Imaging
• CT whole abdoment contrast enhanced
• Bone scan
o Jika ada keluhan
o Peningkatan serum alkaline phosphatase
• Wunderlich syndrome : spontaneous, nontraumatic kidney bleeding confined to the
subcapsular and perirenal space. It may be the first manifestation of a
renal angiomyolipoma (AML), or the rupture of a renal artery or intraparenchymal aneurysm
Bosniak Classification
Kategori Karakteristik %
Malignancy
Therapy
1 Simple cyst, hairline-thin wall
septa (-), calcification (-), solid component (-), enhancement (-)
1.7% Do nothing
2 Septa few thin-hairline, calcification (+/-), size < 3 cm,
enhancement (-)
18.5% Do nothing
2f Septa multiple thin-hairline, minimal wall enchancement,
calcification (+), thickening of septa/wall, size > 3 cm
18.5 Follow up
3 Measureable enchancement (+), Thick irregular wall or Septa
enhancement (+)
33% Nephrectomy
4 Enchance soft tissue component 92.5% Nephrectomy
Radical
Histopatologi
• Clear Cell vs non-clear cell
• Terbanyak (90%) adalah RCC, RCC dibagi menjadi 3
1. Clear cell
2. Papillary clear cell
i. Tipe 1 : more common
ii. Tipe 2 : high gprade, cenderung metastasis

4. 3. Chromophobe clear cell
Renal Nephrometry Score
• Low = 4-6
• Moderate = 7-9
• High = 10-12 -> nefrektomi
Thrombus Classification
Thrombus
Level
Definisi Intervention
0 Limited to renal vein Ligation of renal vein at the ostium
1 Extend to IVC, < 2cm above renal
vein
Pulled back to renal vein with milking maneuver + clamp
at the level of ostium, atau Thrombectomy
2 Extend to IVC, > 2 cm above renal
vein, below hepatic vein
Thrombectomy
3 Above hepatic vein, below
diaphragm
Thrombectomy
4 Above diaphragm, arterial
thrombus
Thrombectomy

5. Algoritma Therapy

6. Renal Biopsy
• Accuracy 90.3%
• Indikasi
o Jika direncanakan ablative surgery
o Pada metastasis untuk menentukan apakah operasi/obat
o Unresectable untuk sistemik terapi
• Kontraindikasi
o Jika hasil biopsi tidak menentukan terapi (paliatif-watchfull waiting)
• Cara ambil sampel
o Minimal 2 cores yang bagus, jika > 7 cm - 4 cores
o Tidak pada area nekrotik (doppler dulu)
o Jika tumor besar, biopsi pada daerah perifer (daerah tengah biasa nekrotik)
Active Surveilance
• Indikasi
o Stadium 1 (ukuran < 2 cm)
o Benign, low metastasis potential
o Massa T1 dengan risiko tinggi morbiditas dan mortalitas pasca intervensi
• CT scan per 6 bulan
Radikal Nefrektomi
• Perifascial + perirenal fat + regional lymph node + ipsilateral adrenal gland + 1/3 ureter
proksimal
• Adrenalektomi, dengan syarat (2-10% tumor ginjal meta ke adrenal)
o Upper pole tumor size > 7 cm
o Thrombus mencapai adrenal vein
o Pada preoperatif CT, adrenal tidak jelas/tidak normal

7. o Kecurigaan intraoperatif
• Tumor thrombus should be removed
• Regional lymph nodes
o LND tidak meningkatkan survival rate dan tidak meningkat morbiditas
Partial Nefrektomi (Nephron-Sparing)
• Indikasi
o Unilateral stadium 1-3
o Feasible
o Single kidney / CKD / Bilateral mass / Familial renal cell cancer
o Tend to decrease renal function
• Young age, comorbid (hipertensi, diabetes, batu ginjal)
• Partial Nephrectomy Resection Techniques
o Polar resection (guillotine)
o Simple enucleation
o Cone/Wedge resection
o Enucleoresection/excavation
Ipsilateral Adrenalectomy
• Bergantung ukuran, bukan lokasi (upper pole)
• Overall survival tidak berbeda
o Upper pole tumor size > 7 cm
o Thrombus mencapai adrenal vein
o Pada preoperatif CT, adrenal tidak jelas/tidak normal
o Kecurigaan intraoperatif
Embolisasi
• Embolisasi sebelum nefrektomi tidak bermanfaat
• Hanya untuk terapi sympotmatik pada pasien unresectable (hematuria)
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SISTEMIK TERAPI
• Dibagi 2 golongan, MTOR vs TKI
• Indikasi
1. Tumor Relaps post Radical Nefrektomi
2. Stage 4 Unresectable
3. Stage 4 dengan Multiple Metastasis paska Sitoreduktif Nefrektomi
4. Usia pasien > 75 Tahun
5. Metastasis Otak
Targeted therapy:
1. MTOR (Mammalian Target of Rapamycin)
o Temsirolimus
• 25g IV, weekly
o Efek samping
• Stomatitis, weakness
• Nausea, vomiting, diarrhea
• Hyperglycemia
2. TKI (Tyrosine Kinase Inhibitor)
• Mekanisme : menghambat enzim tirosine kinase yang memfosforilasi phosphat ke
protein yang pada akhirnya menghambat signaling tranduction oleh
phosporilated protein
• Efek samping

8. • Hand foot syndrome
• Diarrhea
• Fatigue
• Cardiotoxic
• Hipertensi
• Depresi
• Nama obat
Nama Obat Dosis
Sorafenib 2x400 mg
Pazopanib 1x800 mg
Sunitinib 1x50 mg
3. Immunotherapy:
o Interleukin-2
o Interferon

10. Image source: Kirkali Z, Canda AE. Open partial nephrectomy in the management of small renal
masses. Adv Urol. 2008;2008:309760. doi:10.1155/2008/309760

11. Follow Up