3. CASE REPORT
46 YEAR OLD FEMALE, WITH NKCM
C/O PAIN IN THE LEFT LUMBAR REGION SINCE 1
MONTH
She was having difficulty in changes of posture
Pain was radiating to the left leg
PMH: Not significant
PSH: C-section 8 years ago
DH: NKDA
FH: +ve H/O HTN, IHD. No H/O DM, Asthma or Cancers
PH: Having difficulty in sleeping, normal micturition, bowel
movements
SH: Housewife. No addictions.
ROS: H/O weight loss and decreased appetite since 3
months
4. O/E
A 46 year old female lying on the bed comfortably
well oriented in time, place, person.
Patient was vitally stable
A+, J-, C-,K-,L-,E-,D-
ABDOMINAL EXAMINATION----
Soft, tenderness in the Left lumbar region.
Hard mass felt in the region on abdominal
ballottement
5. CT SCAN WHOLE ABDOMEN WITH NON IONIC CONTRAST
(April 4th
2016)
A large sharply marginated well circumscribed mass lesion seen arising
from posterior aspect of the upper and mid pole of left kidney.
Its centrally necrotic and demonstrates enhancement in the arteroportal
phase of circulation with washout on delayed imaging, the enhanced
vascular channels are seen predominantly encircling the mass
peripherally where few collateral channels are also seen along its
posterior aspect. It measure 15.4 x 4.8 x 12 cms in (CC, AP, TS)
dimensions.
Anteriorly: Forward displacement of the renal parenchyma with
anterosuperior displacement of pancreatic body and tail.
Posteromedially: the posterior abdominal wall
Medially: Its abutting the psoas and Quadratus muscles
All surrounding fat interfaces are well preserved around this mass with
no evidence of any infiltration or invasion
Overall findings are suggestive of neoplastic Left renal mass.
6. INVESTIGATIONS:
Blood: (April 9th
2016)
CBC: Hb:9, PCV: 29, TLC: 5.6, PLT:468
UCE: Normal
LFT: Normal
PT, INR: Normal
Hep Profile: Negative
URINE D/R: Normal (No blood)
CXR: Normal
8. Renal Tumor Embolization
(April 11th
2016)
1 PCV was transfused before the embolization
procedure/ Consent was taken, procedure was
explained
Right femoral artery approach was used.
Initial angiogram showed a large tumor in left renal
region. It showed AV shunting with venous
aneurysms.
Subsequently multiple vessels were selectively
cannulated and embolization was performed using
gelfoam.
Major vascularity was occluded
No complication was seen.
9. INVESTIGATIONS:
Patient remained vitally stable. There was no active
issues. She was counselled about surgery and consent
was taken.
PRE-OPS: were done
Anesthesia review: ASA GRADE 2
(Patients with mild systemic disease, No functional limitations)
4 PCV’s were arranged
10. SURGERY: Left Radical Nephrectomy
Left subcoastal incision was given
Peritoneum was opened
Splenic Flexure of Colon was mobilized
Left renal pedicle was tied
Radical nephrectomy was done
Omentum was packed in the remaining space
Drain was inserted in the renal bed
Patient was transfused with 1 PCV
POST OP ORDERS:
- Shift patient to SICU for further workup and management
- NPO TFO
- Strict I/O charting
- Apply TED stockings
- Inj R/L @ 125 ml/hr
- Inj Cefuroxime 750 mg TDS
- Inj Nalbuphine, Metoclopramide
- Spirometry 4 hourly
- Nebulize with steam and Iprtropium
11. SICU Course (April 12th
)
Patient was received from the OT
She remained vitally stable
Systemic examination was unremarkable
NG by gravity drain
Urine was adequate but was reddish
Was started on Pethidine infusion 50mg in 50mL
@5mg/hr
12. SICU Day 1 (April 13th
)
She remained vitally stable
CBC: Hb: 8.8, PCV: 27, TLC: 14.5, PLT: 375
UCE: N:138, K:4.8, CL:103, HC:25.8, U:37, Cr:1.15
Ca: 8.96 PT: 13.9 INR: 0.8
NG with gravity drain
Drain: Intact, No output
Dressing was intact, clean
I/O charting was adequate, Urine appeared reddish
dark
13. SICU Day 2 (April 14th
)
She developed a temperature spike in the morning and
was given Paracetamol 1gm stat.
She developed pain at the site and infusion was increased
to 8ml/hr
Drain: Intact, No output
I/O charting was adequate, Urine appeared reddish dark
Later, her NG tube was removed, sips were allowed R/L
and Cefuroxime, steam inhalation were continued.
Pethidine infusion was stopped, she was started on:
- Inj Nalbupheine 10mg TDS
- Inj Enoxaparin 60mg OD
- Inj Paracetamol 1gm SOS
1 PCV was transfused
Patient was mobilized out of bed
She remained stable and was shifted to the ward
14. Ward Course (14th
April-12PM onward)
Patient remained stable
Foleys and drain were removed
Patient was mobilized
Dressing was changed
IV fluids were reduced to 75ml/hr and later stopped as
patient was orally tolerating
- Inj Nalbuphine was tapered to SOS
- Inj Paracetamol every 6H
- Niflam mouth wash was added
SURGERY (T)/
POST OP
9-Apr T 12-Apr 13-Apr T 14-Apr 15-Apr
Hb 9 T 8.8 8.3 T 9
Hct 29 T 28 27 T 28
TLC 5.6 T 14.5 12.4 T 11.4
PLT 468 T 375 338 T 309
Urea 24 T 34 T 34 24
Cr 0.86 T 1.18 T 1.11 9.7
15. Discharge (April 15th
)
Patient was discharged after getting a shower/ COD
D/C meds:
- Tab Cefuroxime 250 mg 2 Tabs BD
- Tab Nuberol forte TDS
- Cap Tramadol 50mg SOS (In case of severe pain)
- Cap Fefol Vit OD for 1 month
Take daily shower, allowed regular diet
Mobilization, activity as tolerated
Follow up on April 22th with Biopsy report with
Urologist.
17. 3% of all adult malignancies
M>F, ratio 2:1
50 – 80 years
It is an adenocarcinoma arising from renal tubular
cells, most common site is proximal renal tubule.
This noncapsulated tumour is very vascular.
30% presenting with metastatic disease
18.
19. BHD=Birt-Hogg-Dubé; FH=fumarate hydratase; VHL=von Hippel-Lindau.
Modified from Linehan WM et al. J Urol. 2003;170:2163-2172.
Clear cell
75%
Type
Incidence (%)
Associated
mutations
VHL
Papillary type 1
5%
c-Met
10%
Chromophobe
5%
BHD
5%
D
*2004 WHO lists over 50 different types of kidney
cancer
(Sarcomatoid variant can occur with any subtype)
20. Renal Cell Carcinoma (RCC) – Risk
Factors
Smoking
Obesity (especially in women)
Use of phenacetin analgesics
Patients on dialysis, who acquire cystic kidney
disease
Occupational risk factors
Leather tanning (TCC – dye and textile industry)
Asbestos exposure
Genetic risk factors
Von Hippel Lindau disease
Adult polycystic disease
21. Renal Cell Carcinoma – Clinical
Presentation
Most are asymptomatic until development of metastasis
Classical triad (19% of cases):
LOIN PAIN
FLANK MASS
HAEMATURIA
Fever and sweats /Weight loss / Malaise
Varicocele in 2% of males (due to compression of left renal vein)
Paraneoplastic syndrome
Polycythaemia due to EPO-like molecules
Hypertension due to renin
Hypercalcaemia due to PTH-related peptide
Stauffer syndrome
22. Renal Cell Carcinoma - Spread
Local
Adrenal Glands
Renal Veins
Inferior Vena Cava
Gerota’s fascia (anterior to
perinephric space)
Perinephric Tissue
Lymphatics
Lymph nodes at renal hilum
Abdominal para-aortic nodes
Paracaval nodes
Blood
Lung
Bone
Soft tissue
Central nervous system
23. Renal Cell Carcinoma – Investigations and
Staging
CBC, ESR, UCE, LFTs, Calcium levels, UA
CXR or CT chest
U/S, abdomen—size, extension, lymph node involvement,
spread to the liver, status of renal vein and IVC.
Thin-slice renal CT scan with and without IV contrast is the
best test for diagnosing renal masses
Pharmacoangiogram (Inject noradrenaline along with dye
while doing angiogram).
Bone scan to see bone secondary's.
MRI: to evaluate collecting system and IVC involvement
30. Renal Cell Carcinoma – Biological Treatment
Cytokine therapy
Interferon α
Interleukin 2
Signal transduction inhibitors that regulate cell growth, cell
proliferation, protein synthesis, and transcription
Tyrosine kinase inhibitors
Sunitinib
Sorafenib
Serine/threonine protein kinase inhibitors - MTOR
(mammalian target of rapamycin)
Temsirolimus
Everolimus
31.
32. Renal Cell Carcinoma - Sunitinib
Oral small molecule TK Inhibitor of Vascular endothelial
growth factor (VEGF) and Platelet derived growth factor
(PDGF)
First-line for advanced and/or metastatic renal cell carcinoma
Presented at ASCO in 2006: In a phase 3 study -
Median progression-free survival: Sunitinib (11 months) vs
Interferon α (5 months)
Secondary endpoints: 28% of patients had significant
tumor shrinkage with Sunitinib compared to 5% with
Interferon α.
Patients receiving Sunitinib had a better quality of life than
interferon α.
(N Engl J Med 356 (2): 115–124)
33. Prognosis Stage 5-year survival rate
I 88~100%
II 60%
III 15~20%
IV 0~20%
Editor's Notes
7-6…….10-11
Left subcoastal incision was given
Peritoneum was opened
Splenic Flexure of Colon was mobilized
Left renal pedicle was tied
Radical nephrectomy was done
Omentum was packed in the remaining space
Drain was inserted in the renal bed
POST OP ORDERS:
-Prop patient up at 45 degrees
-Oxygen inhalation
-Daily Chest X-ray
Treatment: IV Tazocin, Amikacin, Omeprazole.
She developed a temperature spike in the morning and was given Falgan 1gm stat.
She developed pain at the site and infusion was increased to 8ml/hr
Later, her NG tube was removed, sips were allowed R/L and Cefuroxime, steam inhalation were continued. Pethidine infusion was stopped, she was started on:
Inj Nalbupheine 10mg TDS
Inj Enoxaparin 60mg OD
Inj Paracetamol 1gm SOS
1 PCV was transfused
Patient was mobilized out of bed and was shifted to the ward
Common epithelial neoplasms of the kidney can be either familial
or sporadic
Mutations in the gene for VHL, c-Met, FH, or BHD are common in both the familial and sporadic forms of kidney neoplasms.1,2
Cases of familial neoplasm arise from inherited germline mutations earlier than cases of sporadic neoplasm.
Familial neoplasm requires only one additional mutation to inactivate the gene while sporadic neoplasm requires multiple subsequent mutations in order to inactivate the gene.1
Clear-cell RCC is the predominant histological type (75%).1,2
There are two types of papillary renal cell cancer: Type II is very aggressive; Type I less so.
Oncocytoma is no longer considered to be malignant tumor, it is a benign neoplasm.3
Ultrasonography
Intravenous Urography (IVU):
CT scanning: more sensitive, mass+renal hilum, perinephric space and vena cava, adrenals, regional LN and adjacent organs
Renal Angiography
MRI: to evaluate collecting system and IVC involvement
Pharmacoangiogram
(Inject noradrenaline along with dye
while doing angiogram). As tumour vessels are
autonomous they will not constrict whereas adjacent
normal vessels will constrict, so tumour blush is
visualised.
T3: Tumor extends into major veins or directly invades adrenal gland or perinephric tissues but not beyond Gerota's fascia.
T3a: Tumor directly invades adrenal gland or perinephric tissues (including renal sinus) but not beyond the renal fascia.
T1: Tumor 7 cm or less, limited to the kidney.
T1a: Tumor less than 4 cm and limited to the kidney.
T1b: Tumor greater than 4 cm and limited to the kidney.
T2: Tumor greater than 7 cm and limited to the kidney.
T2 a: Tumor greater than 7 cm and less than 10 cm and limited to the kidney.
T2 b: Tumor greater than 10 cm and limited to the kidney.
T3: Tumor extends into major veins or directly invades adrenal gland or perinephric tissues but not beyond Gerota's fascia.
T3a: Tumor directly invades adrenal gland or perinephric tissues (including renal sinus) but not beyond the renal fascia.
T3b: Tumor grossly extends into renal vein(s) or caval vein below diaphragm.
T3c: Tumor grossly extends into caval vein or wall of vena cava above diaphragm.
T4: Tumor directly invades beyond the renal fascia.
Radical nephrectomy – removal of kidney, adrenal gland, perirenal fat within gerota’s fascia +/- LN dissection
Partial nephrectomy -(NSS)
Tumor < 4cm / Bilateral RCCa
Solitary kidney / Polar tumor
Patients being considered for immunotherapy
Arterial embolization
Radiofrequency ablation
Removal of solitary metastasis