This document discusses staging and treatment of renal cell carcinoma. It covers screening recommendations, risk factors, staging evaluations including imaging and biomarkers, prognostic factors like tumor size and grade, and treatment options for localized RCC including radical nephrectomy and partial nephrectomy. Pathologic stage is identified as the most important prognostic factor, with organ-confined disease having better outcomes than tumors involving adjacent structures or with lymph node or distant metastases.
Renal cell carcinoma (RCC) is a common and lethal urologic cancer, accounting for 2-3% of all adult malignancies. RCC most often occurs in the sixth and seventh decades of life and is more common in males. While most RCCs are sporadic, 2-3% are familial. Historically, clear cell and papillary RCC were thought to arise from the proximal convoluted tubules, while chromophobe and collecting duct RCC arise from more distal regions. RCCs are often circumscribed by compressed parenchyma rather than a true capsule. Prognostic tools combining multiple factors have improved predictions for patient outcomes. Approximately one-third of RCC patients present with
Staging and investigation of ca kidney and bladderAtulGupta369
This document discusses staging and investigations for kidney and bladder cancer. It provides details on:
- Risk factors, pathological subtypes, and epidemiology of kidney cancer
- Genetic and non-genetic risk factors for bladder cancer
- Evaluations for diagnosis of both cancers including lab tests, imaging like CT, MRI, and pathology examination
- Presenting signs, symptoms, and classifications of bladder cancer
It is an informative overview of kidney and bladder cancers covering their risk factors, diagnostic workup, classifications, and epidemiology.
Prostate cancer updates were presented. Key points include:
1) The Gleason score is used to assess tumor aggressiveness and has shifted to include higher scores over time.
2) Screening results do not support widespread mass screening, but early detection may be offered to informed men with baseline PSA testing at age 40 and screening intervals of 8 years if initial PSA is low.
3) For localized disease, treatment options include active surveillance, radical prostatectomy, or radiation therapy depending on risk level and life expectancy. Deferred treatment may be appropriate for many cases.
The document discusses therapeutic principles for treating germ cell tumors (GCTs), including:
1) An aggressive treatment approach is recommended to cure patients and avoid unnecessary death or side effects, including rapid diagnosis, staging, and expedient chemotherapy and surgery.
2) Chemotherapy is often administered even if patients have low blood counts or kidney issues, and all residual disease is surgically removed after chemotherapy.
3) Treatment is most successful at high-volume centers, where surgeons have extensive experience performing complex procedures like retroperitoneal lymph node dissection (RPLND).
Hepatocellular carcinoma—role of interventional radiologist Dr. Muhammad Bin ...Dr. Muhammad Bin Zulfiqar
Hepatocellular carcinoma is a leading cause of cancer death worldwide. Interventional radiologists play an important role in diagnosing and treating hepatocellular carcinoma. They can perform biopsies to determine disease, facilitate surgical treatment through techniques like portal vein embolization to increase eligibility for resection, and provide locoregional therapies for patients who are not surgical candidates like radiofrequency ablation, transarterial chemoembolization, and radioembolization. While offering palliation, these minimally invasive treatments can achieve local tumor control and prolong survival for some patients with hepatocellular carcinoma.
Dr. Naina Kumar Agarwal's document discusses carcinoma of the anal canal. It covers the anatomy of the anal canal, epidemiology and risk factors for anal carcinoma including HPV infection and immunosuppression. It discusses screening and prevention strategies as well as the pathology, signs and symptoms, staging, and treatment of anal carcinoma. Definitive chemoradiation is the standard of care for localized squamous cell carcinoma of the anal canal, with the addition of chemotherapy to radiation therapy improving local control rates and survival compared to radiation alone. Prognostic factors include tumor size, lymph node involvement, and gender.
This document discusses metastatic colorectal liver cancer. It outlines risk factors, evaluation, and treatment options including surgery, chemotherapy, local tumor ablation, and radiotherapy. Surgery offers the best chance of survival if metastases are resectable, with 5-year survival rates of 24-58% for resection. Neoadjuvant chemotherapy can help make previously unresectable tumors operable. Local ablation techniques are alternatives for tumors that cannot be surgically removed.
This document discusses various minimally invasive interventions for liver tumors. It describes procedures such as transarterial chemoembolization (TACE), radiofrequency ablation (RFA), microwave ablation, cryoablation, ethanol ablation, and drug-eluting bead chemoembolization. For each procedure, it covers the mechanism of action, patient selection criteria, technical details, imaging guidance and follow up. It emphasizes that these minimally invasive therapies can be used to treat primary and secondary liver malignancies when surgery is not possible or as an adjunct to other treatments, with the aim of improving patient prognosis.
Renal cell carcinoma (RCC) is a common and lethal urologic cancer, accounting for 2-3% of all adult malignancies. RCC most often occurs in the sixth and seventh decades of life and is more common in males. While most RCCs are sporadic, 2-3% are familial. Historically, clear cell and papillary RCC were thought to arise from the proximal convoluted tubules, while chromophobe and collecting duct RCC arise from more distal regions. RCCs are often circumscribed by compressed parenchyma rather than a true capsule. Prognostic tools combining multiple factors have improved predictions for patient outcomes. Approximately one-third of RCC patients present with
Staging and investigation of ca kidney and bladderAtulGupta369
This document discusses staging and investigations for kidney and bladder cancer. It provides details on:
- Risk factors, pathological subtypes, and epidemiology of kidney cancer
- Genetic and non-genetic risk factors for bladder cancer
- Evaluations for diagnosis of both cancers including lab tests, imaging like CT, MRI, and pathology examination
- Presenting signs, symptoms, and classifications of bladder cancer
It is an informative overview of kidney and bladder cancers covering their risk factors, diagnostic workup, classifications, and epidemiology.
Prostate cancer updates were presented. Key points include:
1) The Gleason score is used to assess tumor aggressiveness and has shifted to include higher scores over time.
2) Screening results do not support widespread mass screening, but early detection may be offered to informed men with baseline PSA testing at age 40 and screening intervals of 8 years if initial PSA is low.
3) For localized disease, treatment options include active surveillance, radical prostatectomy, or radiation therapy depending on risk level and life expectancy. Deferred treatment may be appropriate for many cases.
The document discusses therapeutic principles for treating germ cell tumors (GCTs), including:
1) An aggressive treatment approach is recommended to cure patients and avoid unnecessary death or side effects, including rapid diagnosis, staging, and expedient chemotherapy and surgery.
2) Chemotherapy is often administered even if patients have low blood counts or kidney issues, and all residual disease is surgically removed after chemotherapy.
3) Treatment is most successful at high-volume centers, where surgeons have extensive experience performing complex procedures like retroperitoneal lymph node dissection (RPLND).
Hepatocellular carcinoma—role of interventional radiologist Dr. Muhammad Bin ...Dr. Muhammad Bin Zulfiqar
Hepatocellular carcinoma is a leading cause of cancer death worldwide. Interventional radiologists play an important role in diagnosing and treating hepatocellular carcinoma. They can perform biopsies to determine disease, facilitate surgical treatment through techniques like portal vein embolization to increase eligibility for resection, and provide locoregional therapies for patients who are not surgical candidates like radiofrequency ablation, transarterial chemoembolization, and radioembolization. While offering palliation, these minimally invasive treatments can achieve local tumor control and prolong survival for some patients with hepatocellular carcinoma.
Dr. Naina Kumar Agarwal's document discusses carcinoma of the anal canal. It covers the anatomy of the anal canal, epidemiology and risk factors for anal carcinoma including HPV infection and immunosuppression. It discusses screening and prevention strategies as well as the pathology, signs and symptoms, staging, and treatment of anal carcinoma. Definitive chemoradiation is the standard of care for localized squamous cell carcinoma of the anal canal, with the addition of chemotherapy to radiation therapy improving local control rates and survival compared to radiation alone. Prognostic factors include tumor size, lymph node involvement, and gender.
This document discusses metastatic colorectal liver cancer. It outlines risk factors, evaluation, and treatment options including surgery, chemotherapy, local tumor ablation, and radiotherapy. Surgery offers the best chance of survival if metastases are resectable, with 5-year survival rates of 24-58% for resection. Neoadjuvant chemotherapy can help make previously unresectable tumors operable. Local ablation techniques are alternatives for tumors that cannot be surgically removed.
This document discusses various minimally invasive interventions for liver tumors. It describes procedures such as transarterial chemoembolization (TACE), radiofrequency ablation (RFA), microwave ablation, cryoablation, ethanol ablation, and drug-eluting bead chemoembolization. For each procedure, it covers the mechanism of action, patient selection criteria, technical details, imaging guidance and follow up. It emphasizes that these minimally invasive therapies can be used to treat primary and secondary liver malignancies when surgery is not possible or as an adjunct to other treatments, with the aim of improving patient prognosis.
Locally advanced Ca prostate
Courtesy : NCCN , Perez, Gunderson and Tepper
Brief outline on management
ADT, Radiotherapy, Surgery indications and Standard of care
This document discusses perihilar cholangiocarcinoma (PCH), a type of bile duct cancer. It notes that surgical resection is the only cure, and imaging such as CT, MRI, and IR are important for diagnosis, assessing tumor extent, and pre-surgery planning. The Bismuth-Corlette classification and AJCC TNM staging systems are commonly used for PCH. Surgery depends on the location and extent of tumor involvement, ranging from right hepatectomy to extended hepatectomies, with the goal of achieving negative margins. Adjuvant therapies and liver transplantation may also be considerations in certain cases.
1. Screening for lung cancer through low-dose helical CT is more sensitive than chest X-rays and can detect early-stage lung cancers when treatment may work better.
2. Early detection of lung cancer through screening improves survival rates as prognosis is better if the disease is detected before it has spread beyond early stages.
3. Biomarkers from sputum, blood, and other non-invasive sample types show promise as screening tools but require further validation before use in widespread screening.
This document summarizes the long-term outcomes and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the PORTEC-1 trial. The key findings were:
1) At 15 years of follow-up, locoregional recurrence was lower in the radiotherapy group (5.8%) compared to the no additional treatment group (15.5%), however overall survival was similar between groups.
2) Of the 246 patients who responded to the quality of life survey at a median follow-up of 13.3 years, those treated with radiotherapy reported lower scores on all scales of the general health status questionnaire compared to those who did not receive radiotherapy.
This document provides an overview of renal cell carcinoma (RCC). It discusses the epidemiology, etiology, molecular genetics, classification, clinical presentation, imaging, and TNM staging of RCC. Some key points include:
- RCC accounts for 2-3% of all cancers and 90% of renal malignancies. Risk factors include tobacco, obesity, hypertension, and family history.
- Clear cell RCC is the most common type, accounting for 70-80% of cases. Other types include papillary and chromophobe RCC.
- RCC is often asymptomatic and detected incidentally via imaging such as ultrasound, CT, or MRI. When symptomatic, it can present with hematuria
This document discusses the use of radiotherapy to treat biliary tract cancers. It begins by describing biliary tract anatomy and types of biliary cancers like cholangiocarcinoma. It then covers diagnosis, staging, surgical and non-surgical treatment options. It emphasizes that complete surgical resection offers the best chance of long-term survival. The document also discusses the role of radiotherapy as adjuvant or palliative treatment. Newer radiation techniques like IMRT allow safer delivery of higher radiation doses to tumors while minimizing doses to surrounding healthy organs.
Management of Advances Hepatocellular CarcinomaPratap Tiwari
Hepatocellular carcinoma (HCC) is a leading cause of cancer death worldwide. For advanced HCC that cannot be treated with surgery or transplantation, the standard of care has been sorafenib. Lenvatinib and cabozantinib have also shown efficacy in advanced HCC. Immunotherapy with nivolumab has shown promise based on phase II data. Combination therapies and future targeted agents may provide additional treatment options for this difficult to treat cancer.
This document discusses imaging of the liver preoperatively for liver transplantation. Radiologists play a key role in evaluating patients' anatomy and suitability for transplantation. Preoperative imaging assesses liver parenchyma for tumors or other abnormalities, calculates liver volumes, and precisely maps the hepatic vasculature. Living donor liver transplantation requires imaging the donor's liver to ensure the safety of donation and adequate remnant liver volume. The document outlines various surgical techniques for cadaveric and living donor transplantation.
FDG PET/CT plays an important role in staging, restaging, prognostication, planning treatment strategies, monitoring therapy, and detecting relapse. In this lecture I try my best to explain it for our fellows .
- This document summarizes a randomized controlled trial that compared mFOLFOX6 alone versus mFOLFOX6 plus bevacizumab as first-line treatment for RAS mutant unresectable colorectal liver-limited metastases.
- 241 patients were randomly assigned to receive either mFOLFOX6 plus bevacizumab (arm A) or mFOLFOX6 alone (arm B). The primary endpoint was the rate of conversion to radical liver resection.
- After treatment, 28 patients in arm A and 8 patients in arm B were determined to be eligible for radical liver resection. However, 2 patients refused surgery. The trial aims to determine if the addition of bevacizumab results in
The document discusses hepatocellular carcinoma (HCC). It is the most common type of primary liver cancer, accounting for 90% of cases. Risk factors include cirrhosis of the liver caused by hepatitis B, hepatitis C, alcohol use, and non-alcoholic fatty liver disease. Chronic hepatitis B infection significantly increases the risk. The risk of developing HCC is also higher in men than women and increases with age. Precancerous lesions can develop due to chronic liver damage and increase the risk of HCC.
1) Liver transplantation provides the best chance of cure for hepatocellular carcinoma (HCC) in cirrhotic livers, but is limited by organ availability. The Milan criteria, which select patients with very early HCC, have been expanded to include slightly larger tumors without reducing survival.
2) Patients with HCC can be prioritized for liver transplant by receiving exception MELD scores, but these are only granted if tumors can be downstaged within defined criteria through treatments like ablation. Successful downstaging selects less aggressive tumors and predicts good post-transplant survival.
3) While downstaging expands access to transplant for some patients with larger tumors, eligibility criteria remain unclear as very advanced disease carries a
The document provides an overview of the Egyptian HCC Guidelines presented by Mohamed A. Ezzel Arab MD. It summarizes the guidelines on primary, secondary, and tertiary prevention of HCC. It also outlines recommendations for screening, diagnosis, staging, treatment including surgical resection, locoregional therapies, transplantation, and systemic therapies. Post-treatment monitoring guidelines are also presented. The document aims to provide evidence-based guidelines tailored to factors in Egypt based on international guidelines and expert opinion.
LUNG CANCER MANAGEMENT IN LOW RESOURCE SETTINGSKanhu Charan
The document provides information on lung cancer management in low resource settings. It discusses limited resources for setup, equipment, manpower, money and management. It also discusses potential sources of support including government, NGOs, donations and volunteers. Statistics on lung cancer prevalence and mortality are presented. The epidemiology, risk factors, diagnosis, staging and treatment of lung cancer are summarized.
Detailed Information regarding MSKCC,IMDC score with evidence .
SSIGN Score, Fuhrman's grading described .
Prognostic significance of risk score explained
Tobacco smoking and occupational exposure to chemicals are the most important risk factors for non-muscle-invasive bladder cancer. Diagnosis involves cystoscopy, urinary cytology, and biopsy of any lesions found. Tumors are graded based on histology. Carcinoma in situ is diagnosed through cystoscopy and random bladder biopsies. Resection of tumors aims to completely remove all visible lesions while obtaining detrusor muscle in specimens. New techniques like photodynamic diagnosis and narrow-band imaging aid in visualizing lesions.
This study retrospectively analyzed 69 patients who underwent total thyroidectomy with lymph node dissection for papillary thyroid cancer with clinical nodal metastases. The rate of locoregional recurrence with positive cervical lymph nodes after an average 8-year follow-up was 34.7%, which was higher than the 4.2% recurrence rate reported in patients without nodal metastases. Nodal metastases were found to be a predictor of local recurrence. Male gender and age under 50 were associated with higher risk of nodal recurrence. The study concludes that nodal metastases increase the likelihood of local recurrence after surgery for papillary thyroid cancer.
This document provides information about gynecologic cancers including ovarian cancer, cervical cancer, and endometrial cancer. It discusses risk factors, signs and symptoms, screening and prevention methods, staging, treatment options, and survival rates for each cancer. The key points are that ovarian cancer has no effective early screening test and often presents at advanced stages, while cervical and endometrial cancers can be prevented or detected early through regular pelvic exams and Pap/HPV testing. Treatment may involve surgery, radiation, chemotherapy, or a combination depending on the cancer type and stage. Overall survival rates vary but early detection improves prognosis. The document emphasizes patient education and advocacy.
Renal cell carcinoma (RCC) is a type of kidney cancer that arises from renal tubular epithelial cells. It comprises approximately 3.8% of new cancers and 2-3% of adult cancers. RCC is typically diagnosed in the 6th and 7th decades of life. Risk factors include tobacco use, obesity, and occupational exposures. RCC is staged based on tumor size and spread. Treatment depends on stage but may include surgery, targeted therapy, immunotherapy, and radiation therapy. Prognosis depends on stage, grade, performance status, and biomarkers.
Locally advanced Ca prostate
Courtesy : NCCN , Perez, Gunderson and Tepper
Brief outline on management
ADT, Radiotherapy, Surgery indications and Standard of care
This document discusses perihilar cholangiocarcinoma (PCH), a type of bile duct cancer. It notes that surgical resection is the only cure, and imaging such as CT, MRI, and IR are important for diagnosis, assessing tumor extent, and pre-surgery planning. The Bismuth-Corlette classification and AJCC TNM staging systems are commonly used for PCH. Surgery depends on the location and extent of tumor involvement, ranging from right hepatectomy to extended hepatectomies, with the goal of achieving negative margins. Adjuvant therapies and liver transplantation may also be considerations in certain cases.
1. Screening for lung cancer through low-dose helical CT is more sensitive than chest X-rays and can detect early-stage lung cancers when treatment may work better.
2. Early detection of lung cancer through screening improves survival rates as prognosis is better if the disease is detected before it has spread beyond early stages.
3. Biomarkers from sputum, blood, and other non-invasive sample types show promise as screening tools but require further validation before use in widespread screening.
This document summarizes the long-term outcomes and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the PORTEC-1 trial. The key findings were:
1) At 15 years of follow-up, locoregional recurrence was lower in the radiotherapy group (5.8%) compared to the no additional treatment group (15.5%), however overall survival was similar between groups.
2) Of the 246 patients who responded to the quality of life survey at a median follow-up of 13.3 years, those treated with radiotherapy reported lower scores on all scales of the general health status questionnaire compared to those who did not receive radiotherapy.
This document provides an overview of renal cell carcinoma (RCC). It discusses the epidemiology, etiology, molecular genetics, classification, clinical presentation, imaging, and TNM staging of RCC. Some key points include:
- RCC accounts for 2-3% of all cancers and 90% of renal malignancies. Risk factors include tobacco, obesity, hypertension, and family history.
- Clear cell RCC is the most common type, accounting for 70-80% of cases. Other types include papillary and chromophobe RCC.
- RCC is often asymptomatic and detected incidentally via imaging such as ultrasound, CT, or MRI. When symptomatic, it can present with hematuria
This document discusses the use of radiotherapy to treat biliary tract cancers. It begins by describing biliary tract anatomy and types of biliary cancers like cholangiocarcinoma. It then covers diagnosis, staging, surgical and non-surgical treatment options. It emphasizes that complete surgical resection offers the best chance of long-term survival. The document also discusses the role of radiotherapy as adjuvant or palliative treatment. Newer radiation techniques like IMRT allow safer delivery of higher radiation doses to tumors while minimizing doses to surrounding healthy organs.
Management of Advances Hepatocellular CarcinomaPratap Tiwari
Hepatocellular carcinoma (HCC) is a leading cause of cancer death worldwide. For advanced HCC that cannot be treated with surgery or transplantation, the standard of care has been sorafenib. Lenvatinib and cabozantinib have also shown efficacy in advanced HCC. Immunotherapy with nivolumab has shown promise based on phase II data. Combination therapies and future targeted agents may provide additional treatment options for this difficult to treat cancer.
This document discusses imaging of the liver preoperatively for liver transplantation. Radiologists play a key role in evaluating patients' anatomy and suitability for transplantation. Preoperative imaging assesses liver parenchyma for tumors or other abnormalities, calculates liver volumes, and precisely maps the hepatic vasculature. Living donor liver transplantation requires imaging the donor's liver to ensure the safety of donation and adequate remnant liver volume. The document outlines various surgical techniques for cadaveric and living donor transplantation.
FDG PET/CT plays an important role in staging, restaging, prognostication, planning treatment strategies, monitoring therapy, and detecting relapse. In this lecture I try my best to explain it for our fellows .
- This document summarizes a randomized controlled trial that compared mFOLFOX6 alone versus mFOLFOX6 plus bevacizumab as first-line treatment for RAS mutant unresectable colorectal liver-limited metastases.
- 241 patients were randomly assigned to receive either mFOLFOX6 plus bevacizumab (arm A) or mFOLFOX6 alone (arm B). The primary endpoint was the rate of conversion to radical liver resection.
- After treatment, 28 patients in arm A and 8 patients in arm B were determined to be eligible for radical liver resection. However, 2 patients refused surgery. The trial aims to determine if the addition of bevacizumab results in
The document discusses hepatocellular carcinoma (HCC). It is the most common type of primary liver cancer, accounting for 90% of cases. Risk factors include cirrhosis of the liver caused by hepatitis B, hepatitis C, alcohol use, and non-alcoholic fatty liver disease. Chronic hepatitis B infection significantly increases the risk. The risk of developing HCC is also higher in men than women and increases with age. Precancerous lesions can develop due to chronic liver damage and increase the risk of HCC.
1) Liver transplantation provides the best chance of cure for hepatocellular carcinoma (HCC) in cirrhotic livers, but is limited by organ availability. The Milan criteria, which select patients with very early HCC, have been expanded to include slightly larger tumors without reducing survival.
2) Patients with HCC can be prioritized for liver transplant by receiving exception MELD scores, but these are only granted if tumors can be downstaged within defined criteria through treatments like ablation. Successful downstaging selects less aggressive tumors and predicts good post-transplant survival.
3) While downstaging expands access to transplant for some patients with larger tumors, eligibility criteria remain unclear as very advanced disease carries a
The document provides an overview of the Egyptian HCC Guidelines presented by Mohamed A. Ezzel Arab MD. It summarizes the guidelines on primary, secondary, and tertiary prevention of HCC. It also outlines recommendations for screening, diagnosis, staging, treatment including surgical resection, locoregional therapies, transplantation, and systemic therapies. Post-treatment monitoring guidelines are also presented. The document aims to provide evidence-based guidelines tailored to factors in Egypt based on international guidelines and expert opinion.
LUNG CANCER MANAGEMENT IN LOW RESOURCE SETTINGSKanhu Charan
The document provides information on lung cancer management in low resource settings. It discusses limited resources for setup, equipment, manpower, money and management. It also discusses potential sources of support including government, NGOs, donations and volunteers. Statistics on lung cancer prevalence and mortality are presented. The epidemiology, risk factors, diagnosis, staging and treatment of lung cancer are summarized.
Detailed Information regarding MSKCC,IMDC score with evidence .
SSIGN Score, Fuhrman's grading described .
Prognostic significance of risk score explained
Tobacco smoking and occupational exposure to chemicals are the most important risk factors for non-muscle-invasive bladder cancer. Diagnosis involves cystoscopy, urinary cytology, and biopsy of any lesions found. Tumors are graded based on histology. Carcinoma in situ is diagnosed through cystoscopy and random bladder biopsies. Resection of tumors aims to completely remove all visible lesions while obtaining detrusor muscle in specimens. New techniques like photodynamic diagnosis and narrow-band imaging aid in visualizing lesions.
This study retrospectively analyzed 69 patients who underwent total thyroidectomy with lymph node dissection for papillary thyroid cancer with clinical nodal metastases. The rate of locoregional recurrence with positive cervical lymph nodes after an average 8-year follow-up was 34.7%, which was higher than the 4.2% recurrence rate reported in patients without nodal metastases. Nodal metastases were found to be a predictor of local recurrence. Male gender and age under 50 were associated with higher risk of nodal recurrence. The study concludes that nodal metastases increase the likelihood of local recurrence after surgery for papillary thyroid cancer.
This document provides information about gynecologic cancers including ovarian cancer, cervical cancer, and endometrial cancer. It discusses risk factors, signs and symptoms, screening and prevention methods, staging, treatment options, and survival rates for each cancer. The key points are that ovarian cancer has no effective early screening test and often presents at advanced stages, while cervical and endometrial cancers can be prevented or detected early through regular pelvic exams and Pap/HPV testing. Treatment may involve surgery, radiation, chemotherapy, or a combination depending on the cancer type and stage. Overall survival rates vary but early detection improves prognosis. The document emphasizes patient education and advocacy.
Renal cell carcinoma (RCC) is a type of kidney cancer that arises from renal tubular epithelial cells. It comprises approximately 3.8% of new cancers and 2-3% of adult cancers. RCC is typically diagnosed in the 6th and 7th decades of life. Risk factors include tobacco use, obesity, and occupational exposures. RCC is staged based on tumor size and spread. Treatment depends on stage but may include surgery, targeted therapy, immunotherapy, and radiation therapy. Prognosis depends on stage, grade, performance status, and biomarkers.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
Total Nroadjuvant Therapy- Carcinoma RectumRohit Kabre
This document discusses management strategies for locally advanced rectal cancer. It summarizes that trimodality treatment with neoadjuvant chemoradiation and total mesorectal excision surgery is the standard of care, but has limitations including poor adjuvant chemotherapy compliance and high distant relapse rates. Newer approaches discussed include total neoadjuvant treatment without radiation, selective radiation sparing, non-operative management for patients with a clinical complete response, and the use of pathological and radiological tools to better assess tumor response to guide treatment. The document reviews evidence from ongoing clinical trials investigating these novel strategies.
Kidney transplant recipients have a 2-3x higher risk of developing cancer compared to the general population due to factors related to CKD, immunosuppression, and viral infections. Specific cancers like non-Hodgkin lymphoma, skin cancers, and cancers of the kidney and urinary tract are more common. Immunosuppression drugs like calcineurin inhibitors and mTOR inhibitors can influence cancer risk. Screening for cancers in kidney transplant patients requires individualization based on life expectancy and risks. Managing cancer often involves modifying immunosuppression to balance cancer treatment and risk of organ rejection.
- Recurrent retroperitoneal sarcoma is common, occurring in 50% of patients within 5 years of primary resection. Late recurrences beyond 5 years are also possible, requiring long-term follow-up.
- Patterns of recurrence vary depending on histological subtype. Well-differentiated liposarcoma often recurs locally, which can sometimes be managed with additional surgery. Leiomyosarcoma commonly spreads to distant sites, with 50% of patients experiencing metastases.
- Complete surgical resection remains the main treatment for recurrent retroperitoneal sarcoma when possible. Management decisions must consider the likelihood and implications of local versus distant failure based on histological factors.
This document provides information on renal cell carcinoma (RCC), including epidemiology, risk factors, histologic subtypes, staging, clinical presentation, investigations, and management. RCC accounts for 2-3% of adult cancers. Clear cell RCC is the most common subtype. Presentation is often nonspecific, though flank pain, hematuria, and abdominal mass may occur. Imaging like CT and MRI are used to stage and characterize lesions. Treatment involves surgery (radical or partial nephrectomy) for localized disease. Up to 30% of patients experience relapse post-surgery.
This document provides an overview of colorectal cancer. It discusses that colon and rectal cancers are separate but share a similar path of carcinogenesis. Colon cancer is more common and preventable/curable. 90% of cases occur after age 50. Screening has reduced mortality by nearly 50% in the US. Staging determines prognosis and treatment. Common diagnostic tests include colonoscopy, biopsy, and imaging. Surgery is the primary treatment while radiation poses toxicity risks.
Management Guideline in Colorectal Cancer.pptxAtulGupta369
1. The document provides guidelines for the management of colorectal cancer including epidemiology, screening principles, diagnostic workup, treatment guidelines, and follow up principles.
2. Screening and surveillance recommendations are provided for average risk and high risk populations. Colonoscopy is the primary screening tool for average risk individuals beginning at age 50.
3. Treatment for localized colon cancer involves surgical resection with or without adjuvant chemotherapy depending on risk factors. Treatment for rectal cancer may involve neoadjuvant chemoradiation followed by surgery.
Hepatic carcinoma, also known as hepatocellular carcinoma (HCC), is one of the most common and deadly cancers worldwide, killing over 1 million people per year. Risk factors include hepatitis B and C infections, cirrhosis, alcohol use, and aflatoxin exposure. HCC typically presents in patients with cirrhosis as an asymptomatic liver mass and is diagnosed through blood tests showing elevated AFP levels and imaging exams like ultrasound, CT, or MRI. Treatment depends on the stage but may include surgical resection, liver transplantation, ablation procedures, embolization, or chemotherapy. Long-term surveillance after treatment is important for early detection of recurrence.
Hepatocellular carcinoma is a primary malignancy of the liver that is now the third leading cause of cancer deaths worldwide. Chronic hepatitis B or C infection and cirrhosis are major risk factors. Treatment options include surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and systemic therapies, with resection and transplantation offering the best outcomes for eligible patients with early-stage disease. However, hepatocellular carcinoma commonly recurs within 2 years despite treatment.
Surgery plays an important role in treating metastatic colorectal cancer. The document discusses:
1) The liver is the most common site of metastasis and surgical resection of isolated liver metastases can provide a 5-year survival rate of 45-60%, compared to just 6-9 months with no treatment.
2) Other potentially resectable isolated metastases, such as those in the lungs or peritoneum, may also be treated with surgery, providing 5-year survival rates around 20-40%.
3) Neoadjuvant chemotherapy can downsize initially unresectable liver metastases to make them resectable and improve long-term outcomes compared to surgery alone.
Colon cancer is the most common type of cancer in developed Western nations. Risk factors include age, family history, and lifestyle. Genetic conditions like Lynch syndrome and familial adenomatous polyposis increase risk. Screening allows early detection of precancerous polyps. Staging involves TNM classification. Treatment depends on stage but commonly includes surgery with or without adjuvant chemotherapy or radiation. Prognosis depends on stage, grade, lymph node involvement and other high risk features. Long term surveillance is important after initial treatment.
RCC typically presents in the 6th and 7th decade of life and accounts for 2-3% of adult malignancies. Clear cell RCC arises from the proximal convoluted tubules and is associated with VHL gene mutations. Established risk factors include tobacco, obesity, and hypertension. CT scan is the preferred imaging modality and can identify enhancing renal masses. Surgical resection is the main treatment, with partial nephrectomy preferred for smaller tumors when possible to preserve renal function. Follow up involves history, exam, bloodwork and imaging depending on pathologic stage.
Here are the main options for the timing of resection:
- Colon first (staged approach): Resect the primary colon tumor first, followed by chemotherapy, then resect the liver metastases at a later date if the patient responds well to chemotherapy.
- Colon and liver simultaneously: Resect both the primary colon tumor and liver metastases in one surgery. This is typically only done if the tumors are resectable upfront with low risk.
management of metastatic ca colon with chemotherapy evolution in ca colon.pptxDr Kartik Kadia
This document discusses the management of metastatic colon carcinoma and the evolution of chemotherapy for this disease. It notes that approximately 50-60% of colon cancer patients will develop metastases, most commonly in the liver. A variety of local therapies can be used for non-surgical candidates to treat metastatic lesions. For chemotherapy, 5-fluorouracil was the first widely used drug but combining it with leucovorin enhances its effectiveness based on preclinical studies. Several clinical trials in the 1980s established 5-FU plus leucovorin as a standard first-line chemotherapy regimen for metastatic colon cancer.
The document provides information on the embryology, anatomy, histology, physiology and functions of the adrenal glands. It discusses that the adrenal cortex and medulla develop from different embryonic origins and produce different hormones. The adrenal cortex consists of three zones that secrete mineralocorticoids, glucocorticoids and sex steroids. The adrenal medulla produces catecholamines. The hormones regulate sodium balance, stress response, growth and sexual development.
This document provides information on wound dressings, including their history, principles, types, components, and application techniques. It discusses how dressings are used to cover wounds and provide a moist environment for healing. The key concepts of occlusion and absorption in dressing selection are outlined. Various types of dressings are described, including dry, wet, non-adherent fabrics, absorptive, occlusive, creams/ointments, and transparent dressings. Application techniques for antiseptic dressing and post-operative wound cleaning are also summarized.
The document provides an overview of the segmental anatomy of the liver. It discusses:
- The historical understanding of liver anatomy dating back to ancient times.
- The location, lobes, surfaces, ligaments, and supports of the liver.
- Couinaud's functional division of the liver into eight segments based on vascular distribution.
- The three major hepatic veins and associated fissures that divide the liver into sectors and segments.
- Advances in liver surgery that have improved safety and allowed for more extensive resections.
This presentation contains about how Liver regenerate and what are different method which can be used to augment the liver function before undergoing hepatectomy for treatment of tumor or liver transplant.
1. Abdominal aortic aneurysm (AAA) is defined as a dilation of the aorta greater than 30 mm or 1.5 times the normal diameter. AAA is usually asymptomatic and detected incidentally on imaging.
2. Treatment options for AAA include open surgical repair for aneurysms over 5.5 cm, those growing rapidly, or with anatomy unsuitable for endovascular repair. Endovascular aneurysm repair (EVAR) has become more common due to shorter recovery.
3. Complications of AAA include endoleak, graft failure, infection, and rupture, with rupture having a high mortality rate. Postoperative surveillance with imaging is important to monitor for complications.
A retired colonel presented to the emergency room with chronic chest pain. Further evaluation revealed he had a massive haemothorax secondary to a ruptured aortic aneurysm. Autopsy showed aortic aneurysms are caused by alterations to the delicate balance in the aortic wall that leads to dilatation. Thoracic aortic aneurysms are generally repaired electively when they reach a diameter of 6 cm or greater to prevent fatal rupture. Treatment options include open surgical repair or endovascular stent graft placement depending on the location and extent of the aneurysm.
Electrosurgery devices use electrical energy to cut, coagulate, and ablate tissue. Common devices include monopolar and bipolar electrosurgery, which use radiofrequency energy. Ultrasonic devices like the Harmonic scalpel use ultrasonic vibrations for cutting and coagulation without electricity. Other technologies for tissue effects include vessel sealing devices, lasers which use light energy, cryosurgery using extreme cold, and microwave ablation. Proper use and monitoring of electrosurgical devices is important to prevent unintended tissue damage and burns.
The document discusses difficult abdominal wall closure, techniques for temporary abdominal closure, and definitive abdominal wall reconstruction. It provides details on:
- Ideal suture materials that resist infection and provide strength for closure.
- Indications for leaving the abdomen open such as damage control surgery or intra-abdominal hypertension.
- Temporary abdominal closure techniques including negative pressure devices that control fluids and promote primary fascial closure in 70-80% of cases.
- Factors to consider before definitive reconstruction such as optimizing patient status and using tension-free techniques like component separation with mesh reinforcement for a durable repair.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
RCC- Staging and treatment of Renal Cell Carcinoma
1.
2. Staging and Treatment of Renal Cell
Carcinoma
Dr. Bikash Chandra Sah.
JR General Surgery.
3.
4. Screening
• RCC remains primarily a surgical disease
requiring early diagnosis to optimize the
opportunity for cure.
• Primary factor that limits the widespread
implementation of screening for RCC is the
relatively low incidence of RCC in the general
population
5. Risk factor for RCC
General
Male gender,
Increased age, and
Heavy tobacco use.
Generalized screening would be difficult to
justify because the increase in relative risk
associated with each of these factors is at best
twofold to threefold.
6. Targeted population risk factor
Patients with
End-stage renal disease (5- to 20-fold higher than that in the general population)
Acquired renal cystic disease,
Tuberous sclerosis, and
Familial RCC( Molecular screening, C-MET
protooncogene mutation like others)
Renal transplant recipients remain at high risk for RCC
in the native kidneys, with detection in between 1.4% and 2.3% of
patients within 3 years of transplantation.
Patients suspected of having von Hippel-Lindau disease,
or the appropriate relatives of those with documented
disease.
7. Investigators at the National Institutes
of Health have recommended that such
patients be evaluated with
(1) Annual physical examination and ophthalmologic
evaluation beginning in infancy;
(2) Estimation of urinary catecholamines at the age
of 2 years and every 1 to 2 years thereafter;
(3) MRI of the central nervous system biannually
beginning at the age of 11 years;
(4) Ultrasound examination of the abdomen and
pelvis annually beginning at the age of 11 years,
followed by CT every 6 months if cysts or tumors
develop; and
(5) Periodic auditory examination.
10. Staging.
• Until the 1990s the most commonly used staging
system for RCC was Robson’s modification of
the system of Flocks and Kadesky.
• Limitations of this classification scheme are
– Tumors with lymphatic metastases, a very poor
prognostic finding, were combined with those with
venous involvement, many of which can be treated and
potentially cured with an aggressive surgical approach.
– The extent of venous involvement was not delineated
in this system, and
– Tumor size, an important prognostic parameter, was
not incorporated.
11. • TNM staging classically is defined by the most
advanced feature demonstrated by the tumor,
yet important prognostic information can be lost
in the process
• Systemic symptoms such as
– Significant weight loss (>10% of body weight),
– Cachexia, or
– Poor performance status at presentation all suggest
advanced disease, as do physical examination
findings of a palpable mass or lymphadenopathy.
– A non reducing varicocele and lower extremity
edema suggest venous involvement.
12. Significant anemia, hypercalcemia, abnormal liver
function parameters or sedimentation rate, or elevated
serum alkaline phosphatase or lactate dehydrogenase
level all point to the probability of advanced disease.
Radiographic staging of RCC by high-quality
abdominal CT scan and a routine chest
radiograph:
13. CT Scan.
• Enlarged hilar or retroperitoneal lymph nodes
(2 cm or more in diameter),
• But, this should be confirmed by surgical
exploration or percutaneous biopsy if the
patient is not a surgical candidate.
• Many smaller nodes prove to be
inflammatory rather than neoplastic and
should not preclude surgical therapy.
14. • The sensitivities of CT for
detection of renal venous
tumor thrombus and IVC
involvement are 78% and 96%,
respectively .
• CT findings suggestive of
venous involvement include
– Venous enlargement,
– Abrupt change in the caliber
of the vein,
– Filling defects.
15. • patients with right-sided tumors produce Most
false-negative findings because of short
length of the vein and the mass effect from
the tumor combine to make detection of the
tumor thrombus difficult.
• Venacavography is now best reserved for
patients with equivocal MRI or CT findings or
for patients who cannot tolerate or have other
contraindications to cross-sectional imaging.
16. Metastatic evaluation in all cases should include
– Routine chest radiograph,
– Systematic review of the abdominal and pelvic CT or MRI, and
– Liver function tests.
– Bone scintiscan can be reserved for patients with elevated serum
alkaline phosphatase, bone pain, or poor performance status
– chest CT scan for patients with pulmonary symptoms or an
abnormal chest radiograph .
– Patients with locally advanced disease, enlarged retroperitoneal
lymph nodes, or significant comorbid disease may mandate more
thorough imaging to rule out metastatic disease and to aid in
treatment planning.
– Positron emission tomography (PET) has also been investigated for
patients with high risk of metastatic RCC.
• Biopsy of the primary tumor and/or potential metastatic sites is also
selectively required as part of the staging process.
17.
18. • Five year survival rate of Renal Cell Cancer.
19.
20.
21. Other factor like
Patient-related factors such as:
• Age,
• CKD, and
• Other comorbidities have a significant impact
on overall survival and should be a primary
consideration during treatment planning for
patients with localized RCC
• Compromised prognosis in patients with
presumed localized RCC include systemic
symptomatic
22. Pathologic staging
Pathologic stage has proved to be the single
most important prognostic factor for RCC.
• Renal sinus involvement is classified along with
perinephric fat invasion as T3a are higher risk
of metastasis because of access to the venous
system.
• Collecting system invasion has also been
shown to confer poorer prognosis in otherwise
organ-confined RCC.
23. • Several studies demonstrate 5-year survival
rates of 70% to 90% for organ-confined disease
and document a 15% to 20% reduction in
survival associated with invasion of the
perinephric fat.
• Patients with direct or metastatic ipsilateral
adrenal involvement,
– Found in 1% to 2% of cases,
– Suggesting a hematogenous route of dissemination
or a highly invasive phenotype.
– Eventually succumb to systemic disease progression
with poor prognosis.
24. Venous involvement
• Once thought to be a very poor prognostic
finding for RCC,
• Several reports demonstrate that many patients
with tumor thrombi can be salvaged with an
aggressive surgical approach.
• These studies document 45% to 69% 5-year
survival rates for patients with venous tumor
thrombi as long as the tumor is otherwise
confined to the kidney.
25. • Patients with venous tumor thrombi and
concomitant lymph node or systemic
metastases have markedly decreased survival,
and those with tumor extending into the
perinephric fat have intermediate survival.
• Direct invasion of the wall of the vein appears
to be a more important prognostic factor than
level of tumor thrombus and is now classified
as pT3c independent of the level of tumor
thrombus
26. • The major drop in prognosis comes in patients
whose tumor extends beyond the Gerota fascia to
involve contiguous organs (stage T4) and in
patients with lymph node or systemic metastases
• Lymph node involvement has long been recognized
as a dire prognostic sign because it is associated
with 5- and 10-year survival rates of 5% to 30% and
0% to 5%,
• Systemic metastases also portend a particularly
poor prognosis for RCC, traditionally with 1-year
survival of less than 50%, 5-year survival of 5% to
30%, and 10-year survival of 0% to 5%.
• Patients presenting with synchronous metastases
fare worse.
27. Tumor size
• An independent prognostic factor for both
organ-confined and invasive RCC.
• Larger tumors are more likely to exhibit clear
cell histology and high nuclear grade, and both
of these factors correlate with a compromised
prognosis.
28.
29. Nuclear grade and histologic subtype
• RCC have been proposed on the basis of nuclear
size and morphology and presence or absence of
nucleoli.
• Nuclear grade has proved in most cases to be an
independent prognostic factor
• Histologic subtype also carries prognostic
significance.
– The presence of sarcomatoid differentiation or
collecting duct, renal medullary, or unclassified
histologic subtype denotes a poor prognosis.
30. • The SSIGN score can be used to estimate
cancer-specific survival based on TNM stage,
tumor size, nuclear grade, and presence of tumor
necrosis (Frank et al, 2002).
• The SSIGN score has been validated in
multiple data sets,
• But the inclusion of histologic necrosis as a
predictor limits its clinical usefulness.
31. Nutshell
• RCC prognosis depends on clinical presentation,
TNM staging, Histologic grading and other factor
like age, stages of CKD, other comorbidities.
• Pathologic stage has proved to be the single
most important prognostic factor for RCC
• organ confined RCC have better prognosis in
comparison to involvement to adrenal gland,
perinephric fat and collecting system
involvement .
• If Venous thrombus or IVC involved thrombus
level and invasion of wall determine prognosis
32. • Lymph node invasion, systemic metastasis ,
synchronous metastasis have worst long term
prognosis.
• Tumor size show independent prognostic
factor.
• Nuclear grading in multivariate studies have
proved to be independent of prognostic value
nevertheless, Histologic sub variants have
prognostic role.
34. TREATMENT OF LOCALIZED RENAL
CELL CARCINOMA
• After recognizing great heterogeneity in the
tumor biology of these lesions, and multiple
management strategies are now available,
including
1. Radical Nephrectomy (RN),
2. partial nephrectomy (PN),
3. Thermal ablation (TA),
4. Active surveillance (AS)
35. Renal Function after Surgery for Localized Renal
Cell
• Surgery remains the mainstay for curative
treatment of this disease.
• The objective of surgical therapy is to excise
all tumor with an adequate surgical margin.
• RN when Robson and colleagues (1969)
established this procedure as the gold
standard curative operation for localized
RCC.
36. • RN is still a preferred option for
– Many patients with localized RCC, such as those with
very large tumors (most clinical T2 tumors).
– The relatively limited subgroup of patients with
clinical T1 tumors that are not amenable to
nephron-sparing approaches.
• The main concern with RN is that it predisposes
to CKD, which is potentially associated with
morbid cardiovascular events and increased
mortality rates.
37. Though Partial Nephrectomy (PN) is not a stronger
oncologic intervention than RN, and the only reasonable
way to explain an advantage for PN .
Significant results in favor of PN in mangment for T1
mass :
(1) A 61% risk reduction for the development of severe
CKD,
(2) A 19% risk reduction in overall mortality, and
(3) A 29% risk reduction in cancer-specific mortality.
39. Radical Nephrectomy:
The prototypical concept of RN encompasses
the basic principles of
• Early ligation of the renal artery and vein,
• Removal of the kidney with primary dissection
external to the Gerota fascia,
• Excision of the ipsilateral adrenal gland, and
• Performance of an extended lymphadenectomy from
the crus of the diaphragm to the aortic bifurcation.
40. • Performance of a perifascial nephrectomy is of
during RN to prevent postoperative local tumor
recurrence as approx 25% of clinical T1b/T2
RCCs manifest perinephric fat involvement.
• Tumor located in the upper portion of the kidney
immediately adjacent to the adrenal gland is
another relative indication for adrenalectomy
41. • RCC metastasizes through the bloodstream
independent of the lymphatic system in many
patients, involved lymph nodes in many of
these patients would be removed by
conventional RN, which incorporates the
renal hilar and immediately adjacent
paracaval or paraaortic lymph nodes.
42. Approach
The operation is usually performed through
– Transperitoneal incision to allow abdominal exploration for
metastatic disease and early access to the renal vessels.
– Extended subcostal incision for most patients undergoing
open RN.
– Midline incision is a reasonable alternative, and the
– Thoracoabdominal approach can be useful for
• very large and potentially invasive tumors involving the
upper portion of the kidney.
– Extraperitoneal flank incision may be appropriate in
• Elderly patients or patients of poor surgical risk, but
• Limited exposure, particularly for large tumors or those
with contentious hilar anatomy.
43. • Laparoscopic RN is now established as a less
morbid alternative to open surgery in the
management of
1. Low - to moderate volume (10 to 12 cm or
smaller),
2. Localized RCCs with no local invasion,
3. Limited or no venous involvement, and
4. Manageable lymphadenopathy.
• Robotic assisted surgery.
47. PN for the treatment of a renal tumor
• First described by Czerny in 1890
• Nephron-sparing surgery entails complete local resection of
the tumor while leaving the largest possible amount of
normal functioning parenchyma in the involved kidney.
• Margin width appears to be immaterial as long as the final
margins are negative;
– This is particularly relevant when the tumor is located within the
hilum and preservation of renal function is at a premium.
• Gold standard management of small renal masses (clinical
T1a) in the presence of a normal contralateral kidney,
presuming that the mass is amenable to this approach.
48. Indication PN
1. Pt. with bilateral RCC or RCC involving a solitary
functioning kidney.
– A solitary functioning kidney may be the result of unilateral
renal agenesis, prior removal of the contralateral kidney, or
irreversible impairment of contralateral renal function by a
benign disorder.
2. Relative indication for PN was represented by patients
with unilateral RCC and a functioning opposite kidney
affected by a condition that might threaten its future
function,
– Such as renal artery stenosis, hydronephrosis, chronic
pyelonephritis, ureteral reflux, calculus disease, or systemic
diseases such as diabetes and nephrosclerosis.
49. • A functioning renal remnant of at least 20% to
30% of one kidney is necessary to avoid end-
stage renal failure, although this presumes good
functional status of the remaining parenchyma.
• So, pt must be advised about the potential
need for temporary or permanent dialysis
postoperatively.
• Local recurrence after PN for imperative
indications traditionally ranged from 3% to 5%,
mainly when tumor is located in hilar region.
50. • The RENAL scoring
– Radius,
– Endophytic vs. exophytic,
– Nearness to collecting system,
– Anterior/posterior,
– Location relative to polar lines
• Other nephrometry scoring systems allow for
assessment of the complexity of the tumor and
have facilitated comparison of evolving surgical
techniques for PN in this era.
54. Long term complication
• Pt. increased risk for development of
proteinuria, focal segmental
glomerulosclerosis, and progressive renal
failure due to
– Patients who undergo nephron-sparing surgery for
RCC may be left with a relatively small amount of
renal tissue and are at risk for development of
long-term renal functional impairment from
hyperfiltration renal injury.
55. Patients with bilateral RCC and von
Hippel-Lindau disease require
• Surgery is the mainstay of treatment.
– Bilateral nephrectomy and renal replacement therapy
or
– Nephron-sparing approaches such as PN
• For PN, an enucleative approach is often preferred rather
than wide resection or TA to avoid end-stage renal disease.
• Local recurrence rates for patients treated with
PN were 100% and 81%, respectively.
• Survival free of local recurrence after PN was
71% at 5 years but only 15% at 10 years.
56. • LLocal recurrence, which was defined as any
persistent or recurrent disease present in the
treated kidney or ipsilateral renal fossa after
initial treatment
57. Thermal Ablative Therapies
Includes
1. Renal cryosurgery and
2. Radiofrequency ablation (RFA).
3. High Intensity Focused Ultrasound ( HIFU)
• Both can be administered percutaneously or
through laparoscopic .
58. Ideal candidates for TA procedures
1. patients with advanced age or
2. Significant comorbidities who prefer a proactive approach
but are not optimal candidates for conventional surgery,
3. patients with local recurrence after previous
nephronsparing surgery.
4. patients with hereditary renal cancer who present with
multifocal lesions for which multiple PNs might be
cumbersome.
5. Patient preference must also be considered, and some
patients not fitting these criteria may also select TA, a
decision that can be supported as long as balanced
counseling about the current status of these modalities has
been provided
6. Tumor size <4 cm.
59. Renal cryosurgery
• Prerequisites for successful cryosurgery include rapid
freezing, gradual thawing, and a repetition of the freeze-
thaw cycle.
• The mechanism underlying tissue cryodestruction is
– Involve immediate membrane and cellular damage followed by
microcirculatory failure .
– Intracellular ice irreversibly disrupts cell organelles and the cell
membrane, a lethal event.
– Delayed microcirculatory failure occurs during the slow thaw
phase of the freeze-thaw cycle, leading to circulation arrest and
cellular anoxia.
– Cells that survive the initial cryogenic assault are destroyed by
this secondary insult of ischemia.
– Repetition of the rapid freeze–slow thaw cycle potentiates the
damage.
60.
61.
62. • Campbell and coworkers (1998) confirmed that
the target lethal temperature of −20°C was
achieved at a distance of 3.1 mm inside the
leading edge of the iceball as visualized by real-
time ultrasonography.
• In practice, we routinely extend the iceball
approximately 1 cm beyond the edge of the
tumor
• Encouraging outcomes for smaller tumors,
particularly those less than 3.0 cm in
diameter.
63. Complications associated with cryoablation
Include
– Renal fracture,
– Hemorrhage,
– Adjacent organ injury,
– Ileus, and
– Wound infection,
– Incidence of treatment.
– Local recurrences (may require repetitive ablation
or conventional surgery)
64. Radio Frequency Ablation
• Application of high-frequency electrical current by
RFA induces excitation of ions, frictional forces, and
heat, which in turn cause denaturation of intracellular
proteins and melting of cellular membranes, a lethal
sequence of events.
• These effects are observed at tissue temperatures above
41°C but increase directly with increasing temperature
and duration of treatment.
• Temperatures in excess of 100°C are typically obtained
at the tips of the probes, and thermosensors can be used
to monitor progress during active treatment.
65.
66. Complications from RFA
• Are uncommon but have included
– Acute renal failure,
– Stricture of the ureteropelvic junction,
– Necrotizing pancreatitis, and
– Lumbar radiculopathy.
– Relatively low rates of local recurrence, although
some patients require repeat treatments to achieve
local control, which is an infrequent event with
cryoablation.
67.
68. Other exciting new technologies
Such as
– High-Intensity focused Ultrasound (HIFU) and
– Frameless, image-guided radiosurgical treatments
(CyberKnife),
– These are also under development and may allow
extracorporeal treatment of small renal tumors in
the future .
• However, at present cell kill with these
modalities is not sufficiently reliable and
they are best considered developmental.
69. Active Surveillance
• Indication : The incidental discovery of many
small RCCs in
– Small, solid, enhancing, well-marginated, homogeneous
renal lesions ; Tumor <3.5cm.
– Asymptomatic elderly patients orThose of poor surgical
risk
– Patients who are unable or unwilling to undergo
surgery.
– Those tumors grew at slow and variable rates of up to
1.1 cm per year, with a median growth rate of 0.36
cm per year.
• It can safely be managed with observation and serial
renal imaging at 6-month or 1-year intervals.
70. AS is not appropriate for patients with
– Larger (>3 to 4 cm), poorly marginated, or
nonhomogeneous solid renal lesions,
– when biopsy indicates a potentially aggressive
RCC,
– Exception in patients with limited life
expectancy .
75. Inferior Vena Caval Involvement
• RCC has frequent pattern of growth intra-
luminally into the renal venous circulation,
also known as venous tumor thrombus.
• 4-10% of RCC involves IVC
• 45% to 70 % of patients with RCC and IVC
thrombus can be cured with an aggressive
surgical approach including RN and IVC
thrombectomy.
76. IVC tumor thrombus
It should be suspected in patients with a renal
tumor who also have
– Lower extremity edema,
– Isolated right-sided varicocele or one that does not
collapse with recumbency,
– Dilated superficial abdominal veins,
– Proteinuria,
– Pulmonary embolism,
– Right atrial mass, or nonfunction of the involved
kidney.
77. Imaging
• MRI:
– Noninvasive and accurate modality
– Demonstrates both the presence and the cephalad extent of
vena caval involvement and
– The preferred diagnostic .
– Gadolinium contrast MRI: Enhance the tumor thrombus
which differentiate from bland thrombus as it does not
enhances
78. Renal vein thromus level
Staging of the level of IVC thrombus is as follows:
Level I: Adjacent to the ostium of the renal
vein;
Level II: extending up to the lower aspect of the
liver;
Level III :involving the intrahepatic portion of
the IVC but below the diaphragm; and
Level IV: extending above the diaphragm.
79.
80.
81. Transesophageal echocardiography
• Is an invasive study
• Unnecessary before surgery,
• Important intraoperative diagnostic modality for
evaluation of
– Thrombus extension,
– Monitoring for embolic phenomena,
– Recognition of residual tumor during and after
resection, and
– Assessment of preload/cardiac function during IVC
clamping.
82. Treatment
• The surgical approach is tailored to the level of IVC
thrombus,
• In general it uniformly begins with careful
mobilization of the kidney and early ligation of
the arterial blood supply .
• level I thrombi are isolated by a Satinsky clamp and
are thus readily addressed.
• Level II thrombi require sequential clamping of the
caudal IVC, contralateral renal vasculature, and
cephalad IVC along with mobilization of the relevant
segment of the IVC and occlusion of lumbar veins.
The renal ostium is then opened and the thrombus is
removed, all in a bloodless field.
83. • Vascular control for level III and level IV
IVC thrombi requires more extensive
dissection, venovenous bypass, or
cardiopulmonary bypass and hypothermic
circulatory arrest.
• For level III thrombi, mobilization of the liver
and exposure of the intrahepatic IVC will often
allow the thrombus to be mobilized caudad to
the hepatic veins, and venous isolation can then
proceed as for a level II thrombus.
84.
85. Locally Invasive Renal Cell Carcinoma
• Patients with pathologic stage T4 disease have
represented less than 2% of surgical series.
• Patients with locally advanced RCC usually
present with pain, generally from invasion of
the posterior abdominal wall, nerve roots, or
paraspinous muscles.
• Large tumors may indent and compress
adjacent liver parenchyma.
86. • Surgical therapy :
– The only potentially curative management for RCC.
– Extended operations with en bloc resection of
adjacent organs are occasionally indicated.
• The aim of therapy is
– Complete excision of the tumor, including resection
of the involved bowel, spleen, or abdominal wall
muscles.
• Incomplete excision of a large primary
tumor, or debulking, is rarely indicated as
survival estimates are only 10% to 20% at 12
months.
87. Lymph Node Dissection for Renal Cell
Carcinoma
• The need for extensive lymphadenectomy in
patients undergoing RN remains
controversial, as a randomized trial of
lymphadenectomy at nephrectomy failed to
show a distinct advantage.
88. Adjuvant Therapy for Renal Cell
Carcinoma
• Unfortunately, recurrence develops in a
significant proportion of patients thought to be
rendered disease free after surgical resection,
primarily due to occult micrometastatic
disease.
• Distant metastases develop in 20% to 35% and
• Local recurrence in 2% to 5% of patients .
89. • A strong rationale for systemic adjuvant
therapy exists in high-risk patients.
• However, none of the adjuvant studies in this
field have been convincingly positive thus far,
and the standard of care remains observation
if the patient will not consider an adjuvant
trial.
90.
91. Metastatic Tumors
• Metastatic tumors are the most common malignant
neoplasms in the kidney, outnumbering primary renal
tumors by a wide margin.
• The profuse vascularity of the kidney makes it a fertile soil
for the deposition and growth of cancer cells.
• Autopsy studies have shown that 12% of patients dying of
cancer have renal metastases.
• The most frequent sources of renal metastases include
– Lung,
– Breast, and
– Gastrointestinal cancers,
– Malignant melanoma, and
– Hematologic malignant neoplasms .
92. • Most renal metastases are
– Multifocal, and
– Almost all are associated with widespread nonrenal
metastases
• The typical pattern of renal metastases consists of
– Multiple small nodules that are often clinically
silent,
– Although they can lead to hematuria or flank pain in
exceptional circumstances .
– CT typically demonstrates isodense masses that
enhance only moderately (5 to 30 HU) after
administration of intravenous contrast material .
93. • Renal metastases should be suspected in any
patient with
– Multiple renal lesions and widespread systemic
metastases or
– History of nonrenal primary cancer.
• If there is any uncertainty about the diagnosis,
percutaneous renal biopsy usually provides
pathologic confirmation
94. Management
• Most patients with renal metastases are
managed with
– Systemic therapy or
– Placed on a palliative care pathway,
– Depending on the clinical circumstances.
– Nephrectomy is almost never required except in
extenuating circumstances, such as renal
hemorrhage that is refractory to embolization.
95.
96. Be the ray of hope when there is no hope
- Oncosurgeon