2. Epidemiology
• Male predominance (M:F 1.5:1).
• Most common in sixth to eighth decades; peak
incidence in sixth decade
• Metastatic disease in 30% at diagnosis, and eventually
in 50% (lung, liver, bone, distant LN, adrenal, brain,
opposite kidney, soft tissue)
• Most sporadic RCCs are unilateral and unifocal
3. • Stage at diagnosis is the most important prognostic factor
• Predominant histologic type: adenocarcinoma arising from
tubular epithelium
• Adenocarcinoma subtypes:
– clear cell (75–85%)
– chromophilic/ papillary (10–15%)
– chromophobe (5–10%)
– oncocytic (rare)
– Sarcomatoid (1–6%; poor prognosis)
5. Risk factors
• Tobacco , urban environmental toxins (cadmium/ asbestos/ petrols),
obesity, high dietary fat intake, acquired cystic renal disease from renal
failure
• Association with von Hippel-Lindau disease:
– autosomal dominant
– loss of 3p
– >70% chance developing RCC (almost all clear cell histology) risk of developing
multiple other benign and malignant tumors (retinal angiomas, CNS
hemangioblastomas, pheochromocytoma , pancreatic cancer)
6. Pathology
• Round to ovoid
• Circumscribed by a pseudo capsule of compressed
parenchyma and fibrous tissue
• Nuclear features can be highly variable
7. Diagnosis
• Common signs and symptoms:
– hematuria (80%)
– flank pain (45%)
– flank mass (15%)
– classic triad of prior three only present in 10%
– normocytic/normochromic anemia, fever, weight loss
• Less common signs and symptoms:
– hepatic dysfunction without mets
– Polycythemia
– hypercalcemia (occurs in 25% of patients with RCC mets)
16. RCC with IVC Tumor Thrombus
• 4 to 10 percent cases present with IVC involvement,
generally with tumor thrombus.
• Classified most commonly by Neves Zincke System.
• I : Renal Vein
• II : Infrahepatic IVC
• III: Retrohepatic IVC
• IIIa : below major hepatic vessels
• IIIb : reaching ostia of major hepatic vessels
• IIIc : extending above major hepatic vessles but below diaphragm
• IIId : subdiaphramatic IVC reaching intrapericardial IVC
• IV : Right Atrium
• Transesophageal Echocardiography is widely
recommended for correct staging especially for level III
and IV.
18. Management
Stage I-III
Nephrectomy
• Open radical nephrectomy, but laparoscopic gaining
popularity
• Nephron sparing surgery via partial nephrectomy, if
possible (open or laparoscopic)
• Possible to spare adrenal gland in ~75% cases
No role for adjuvant chemo/immunotherapy
19. No widely accepted role for neoadjuvant or adjuvant
radiotherapy.
Retrospective data suggest possible utility in select
cases:
– Positive surgical margins
– Locally advanced disease with perinephric fat invasion
and adrenal invasion (IVC/renal vein extension alone
does not increase local recurrence significantly)
– LN+
– Unresectable (pre-op RT)
21. Systemic therapy
• Immunotherapy (IL-2, interferon alpha, or combination)
• High dose IL-2 only FDA approved treatment for
• Biologic agents show promise in recent trials
• Bevacizumab
• Sorafenib or sunitinib
• Temsirolimus
Consider chemo (gemcitabine ± 5-FU or capecitabine)
Focal palliation of metastases
• RT alone
• Metastasectomy
• Combination of both
22. Active Surveillance for Renal Tumours
• Least invasive
• For some patient no intervention is ever needed, while for others a
‘trigger for intervention’ is reached and therapy initiated.
• Ideal for candidates with tumor less than 2cm however, patients
with tumors upto 4cm can be safely watched based on following
factors : patients with poor kidney function, hereditary forms of
kidney cancer, elderly patients who are medically fragile, patients
who have drug eluting heart stents and need to be on blood
thinners, extremely anxious about having surgery or do not wish to
have treatment and patient recovering from a serious medical
illness.
• Imaging every three to six monthsfor 2 years then 6 to 12 months
annually
23. Percutaneous Cryoablation for Renal
Cell Carcinoma
• Percutaneous ablation for RCC is now performed as a standard therapeutic
nephron-sparing option in patients who are poor candidates for resection or when
there is a need to preserve renal function due to comorbid conditions, multiple
renal cell carcinomas, and/or heritable renal cancer syndromes.
• Clinical studies to date indicate that cryoablation is a safe and effective therapeutic
method with acceptable short and long term outcomes and with a low risk, in the
appropriate setting.
• low incidence of serious complications, less immediate morbidity and mortality
compared to surgery, lower cost and faster mobilization
• Cryoablation seems to offer some advantages over RFA and other thermal ablation
techniques for renal masses.
• These recommendations are supported by prospective, long-term studies (5-year)
• Treatment failure and local recurrence are uncommon, comparable to that of
partial-nephrectomy and do not preclude repeat treatment.
• In addition, cryoablation appears to be safer than any surgical option. Based on
these data, patients with tumors that are stage 1A or B amenable to percutaneous
cryoablation, should be offered the option of percutaneous, image guided
cryoablation (or thermal ablation).
24. Physics of Cryoablation
• Pressurized argon (or other gases that obey the
Joules-Thomson law) flows through the double-
tubed cryoprobe and as it expands (still inside the
probe), cools.
• Temperature below −20°C has been shown to be
sufficient for complete destruction of normal
renal parenchyma.
• Many authors believe that neoplastic cells are
more cryoresistant and may require
temperatures as low as −40°C to ensure cell
death.
