Renal cell carcinoma (RCC) can cause paraneoplastic syndromes through the tumor's production of hormones and other substances. Common syndromes include hypercalcemia caused by tumor-secreted factors that increase bone resorption and calcium levels. Hypertension may result from increased renin secretion. Polycythemia can occur due to tumor production of erythropoietin. Rarely, RCC causes a reversible hepatic dysfunction known as Stauffer's syndrome. Management of localized RCC involves surgery such as radical or partial nephrectomy. Biomarkers like hypoxia-inducible factor 1α and carbonic anhydrase IX provide prognostic information. Post-operative surveillance includes lab tests

1. RENAL CELL CARCINOMA
PRESENTOR
DR KARAN R RAWAT
UNDER THE GUIDANCE OF
DR.T.C.SADASUKHI
dr h. L gupta

6. Also known as GRAWITZ TUMOUR ,HYPERNEPHROMA

16. STAUFFER’S SYNDROME –REVERSIBLE HEPATIC DYSFUNCTION

17. PARANEOPLASTIC SYNDROMES
• refers to a constellation of systemic signs and symptoms that are
secondary to the presence of a malignancy
tumor-related syndromes may be the result of one of several factors:
tumor production of humoral substances, or benign tissue production of
humoral factors in response to renal malignancy or via the modulation of
the immune system.
• HYPERCALCAEMIA
Osseous metastatic RCC lesions appear to elaborate substances that
activate osteoclasts, causing the release of calcium from bone. The local
secretion of prostaglandins by metastatic RCC lesions has also been
implicated in the elevated serum calcium levels seen in these patients.
parathyroid hormone (PTH) binds to the PTH receptor in both bone and
renal tissue. This binding leads to increased bone resorption and
decreased renal clearance of calcium as well as increased phosphorus
excretion

18. • Hypertension
• Potential mechanisms of hypertension in these patients include increased
renin secretion, ureteral or parenchymal compression, presence of an
arteriovenous fistula, and poly-cythemia.
Renin is the active form of the prohormone prorenin, which is secreted by
the juxtaglomerular apparatus (JGA) of the nephron. Through its action via
the rennin-aldosterone-angiotensin system, renin overproduction may
result in hypertension
• POLYCYTHAEMIA
elevated serum red blood cell concentrations are believed to be
mediated by erythropoietin (EPO), a glycoprotein that induces
differentiation of erythrocyte colony-forming units in the bone
marrow to promote red blood cell production.Under normal
physiological conditions, EPO is produced by peritubular renal
interstitial cells in response to local tissue hypoxia. However, in RCC,
EPO production occurs in the tumor cells themselves

19. • NONMETASTATIC HEPATIC REVERSIBLE
DYSFUNCTION
The syndrome is characterized by elevations in liver enzymes as well as abnormal
levels of hepatic synthetic products. Elevations of aspartate aminotransferase,
alanine aminotransferase , alkaline phosphatase ], and prothrombin time
The cause of Stauffer’s syndrome is poorly understood. Some believe that the
tumor itself secretes hepatotoxins or lysosomal enzymes that stimulate hepatic
cathepsins or phosphatases, which leads to hepato-cellular injury
Clinically, patients may present with hepatosplenomegaly, fever, and weight loss
• OTHERS : Some are present merely as associated serum findings, such as elevated
human chorionic gonadotropin (HCG) or adrenocorticotropic hormone (ACTH).
Others, however, manifest themselves as clinical syndromes such as galactorrhea,
Cushing’s syndrome, and hyper/ hypoglycemia.
• β-HCG, normally made by the syncytiotrophoblastic cells of the placenta, has
been found in elevated levels in patients with RCC. Elevated levels of this
hormone in any adult male or nonpregnant female should suggest malignancy

30. Management of localized RCC
SURGERY -
•Radical nephrectomy
•Nephron sparing partial
nephrectomy
OTHER MODALITIES
•Radiotherapy
•Chemotherapy
•Targeted molecular therapy

32. APPROACHES TO RADICAL NEPHRECTOMY -

33. • it includes a systematic approach with careful mobilization of
Gerota’s fascia and early vascular control.
• For a flank approach, the posterior peritoneum lateral to the colon
is incised along the length of the descending colon (left side) or
ascending colon (right side) and reflected medially.
• For left-sided exposure, the lienorenal ligament is incised to
mobilize the spleen cephalad.
• On the right side, the hepatic flexure of the colon is mobilized.
• The ureter is identified and encircled with a vessel loop.
• The gonadal vein is ligated and divided.
• The plane between the mesentery of the colon and Gerota’s fascia
is then developed using a combination of sharp and blunt
dissection.
• On the right side, the vena cava is exposed by Kocherizing the
duodenum.
• Using blunt dissection, the retroperitoneal fat overlying the renal
vessels is separated, exposing the renal hilum.
• It is often helpful to ligate and divide the ureter before this to allow
for mobilization and upward displacement of the lower pole of the
kidney

34. • The dissection is then carried cephalad along the vena cava
(right side) or aorta (left side).
• On the right side, the right renal vein is identified entering
into the vena cava, isolated, and clamped
• After identification of the renal artery (exposure may be
enhanced by the use of a vein retractor on the renal vein),
the artery is dissected free and cleaned for a distance of
approximately 2 to 3 cm and clamped with right angle
clamp.
• The sutures are then separated and tied, allowing a safe
distance for division of the artery.
• A small hemoclip or suture ligature may be placed on the
proximal aspect of the artery before division.
• A right-angle clamp is placed under the artery to be divided
and gently elevated, and the artery is cut with either a knife
Metzenbaum scissors.
• The right renal vein is then ligated in a similar fashion

35. • On the left, the renal vein is isolated as it courses over the
aorta.
• The left adrenal and gonadal veins are identified emanating
from the left renal vein, and, if present, a posteriorly
directed lumbar venous tributary is noted.
• A right-angle clamp is passed around the renal vein,
followed by a silk suture proximal to the tributaries, and
tagged.
• The venous tributaries are then individually ligated and
divided with silk and small hemoclips where necessary,
leaving the silk suture on the main renal vein tagged.
• The left renal artery and vein are then ligated similarly to
the technique described above for the right side.

36. • Gerota’s fascia is then mobilized posteriorly and superiorly
using a combination of sharp and blunt dissection.
• Hemoclips along the superior and medial border are useful
to control any potential bleeding during this portion of the
procedure.
• The adrenal hilum is then dissected from caudal to cranial
with the aid of either hemoclips or straight clamps and ties.
• On the right side, the short posteriorly located right adrenal
vein should be anticipated as it exits directly from the vena
cava.
• When encountered, the right adrenal vein is isolated,
ligated, and divided.
• The specimen is then delivered, and meticulous hemostasis
is achieved

37. Complications for radical
nephrectomy
Bleeding
Infection
Post operative pneumonia
INJURY T0 ADJACENT ORGAN –
DUODENUM,INTESTINE,IVC

38. Advantages of laproscopic surgery
• Shorter recovery time
• Shorter hospital stay
• Smaller incision
• Few post operative complications

39. TYPES – POLAR NEPHRECTOMY
WEDGE RESECTION
ENUCLEATION

51. Recent advances – prognostic
biomarkers for RCC
[INDIAN JOURNAL OF UROLOGY FEB-MAR 2013]
• Hypoxia-inducible factor 1 α (HIF-1 α)
Lidgren et al. demonstrated that patients with conventional RCC
having a high HIF-1α level survived significantly longer than those
with low HIF-1α.
• Carbonic anhydrase IX (CAIX)
• Carbonic anhydrase IX is one of the most validated prognostic
biomarkers of RCC. Bui et al. performed immunohistochemical
analysis for CAIX expression on tissue microarrays from patients
with conventional RCC. They demonstrated that 94% of the RCC
tissues expressed CAIX and that decreased expression predicted a
worse outcome for patients with locally advanced RCC and was an
independent predictor of poor survival in patients with metastatic
RCC.

52. • IMMUNOLOGIC MARKERS
• Tumor-infiltrating lymphocytes (TILs)
• there is a paradoxical relation between increased levels
of TILs and diminished cancer-specific survival.[34]
Tumor-infiltrating lymphocytes were shown to be
functionally defective, incompletely activated, depleted
or anergic
Cózar et al., evaluated TILs of RCCs and found
substantial numbers of natural killer (NK) cells and
polarized Th1 CD4+ cells. Moreover, significantly fewer
NK cells in peripheral blood, a lower proportion of
CCR5/CXCR3/CD4+ cells and a higher proportion of
CCR4/CD4+ cells were observed in patients with
metastatic RCC in the study

53. POST OPERATIVE SURVELLIANCE IN PARTIAL OR
RADICAL NEPHRECTOMY PATIENTS
LAB INVESTIGATIONS --
CBC,LFT,S.CALCIUM,BUN,S.ELECTROLYTES.