SlideShare a Scribd company logo
Presented By:
Dr. Vandana
Dept. of Radiotherapy
CSMMU, Lucknow          1
Anatomy of Kidney
            pair of organs located in the abdominal
             cavity on either side of the spine in a
             retroperitoneal position.
            Adrenal glands rest on top of each kidney
            Approx. at vertebral level T12 to L3, right
             kidney being slightly lower than the left.
            Long axis of kidney is directed downward
             and laterally
            Approx. 11–14 cm in length, 6 cm wide and
             4 cm thick
            weighs around 150 gm in males & 135 gm in
             females.
            Mobile Organ, move vertically within
             retroperitoneum 0.9 cm to 1.3 cm., as much
             as 4 cm during normal respiration


                                                           2
 The kidney is surrounded by tough fibrous
  tissue, the renal capsule, which is itself
  surrounded by perinephric fat, renal fascia
  (of Gerota) and paranephric fat.
 parenchyma, of the kidney is divided into
  two major structures: renal cortex and
  renal medulla




 Fig: Anterior relations of kidneys             Fig: Posterior relations of kidneys   3
 Blood Supply
     Approx. 20% of the cardiac output .
     From renal arteries, left and right, which branch directly from the abdominal aorta.
     renal vein emerges from hilum and drains into the inferior vena cava.

 Lymph Drainage : to the lateral aortic lymph nodes around the origin of the renal
  artery.
 Nerve Supply:
     Through renal sympathetic plexus (T10 – L1) fibres, mainly vasomotor.
     Afferent nerves T10 to T12 thoracic nerves.

 Functions
     Excretion of wastes,
     Acid-base homeostasis,
     Osmolality regulation, Blood pressure regulation and Hormone secretion




                                                                                             4
Renal Tumors
 51,000 cases diagnosed and
 more than 12,900 deaths
 annually in the US

 Account for approx. 3% of
 adult malignancy




                               5
Renal tumors…
 Benign
   Oncocytoma
   Papillary adenoma
   Angiomyolipoma


 Malignant
   Renal Cell Carcinoma (Adenocarcinoma of Kidney)




                                                      6
Renal Cell Carcinoma
 First described by Konig in 1826.

 In 1883 Grawitz, noted the fatty content of cancer cells
  similar to that of adrenal cells.

 All these tumors arise from Renal tubular epithelium.

 accounts for 80–85% of kidney cancer

 2% to 4% increase in incidence per year


                                                             7
Epidemiology
 Male predominance (1.6:1.0 M:F)
 Highest incidence between age 50-70
  -Median age of diagnosis is 66 years
  -Median age of death 70 years
 Majority of RCC occurs sporadically
 Highest incidence in Scandinavia and North America,
 lowest in Africa




                                                        8
Risk Factors
 Tobacco smoking contributes to 24-30% of RCC cases
  - Tobacco results in a 2-fold increased risk
 Environmental:
   Cadmium, thorium-di-oxide, petroleum and phenacetin analgesics.
 Occupational:
   leather tanners, shoe workers, asbestos workers.
 Hormonal:
   diethylistillbestrol,
 Obesity, HTN
 35% - 47% pt on long term dialysis develop Acquired
  polycystic kidney disease, out of which 5.8% develops
  Renal cancer.

                                                                     9
RCC is not one disease…
   It is made up of no. of different types of cancers with different histology, different
   clinical courses and caused by different gene.




        Type    Clear cell    Papillary type 1   Papillary type 2    Chromophobe   Oncocytoma

Incidence (%)      75%              5%                10%                5%           5%
  Associated       VHL            c-Met                FH               BHD          BHD
   mutations

 A sarcomatoid variant represents1% to 6% of renal cell carcinoma and these tumors are
 associated with a significantly poorer prognosis.
 BHD=Birt-Hogg-Dubé; FH=fumarate hydratase; VHL=von Hippel-Lindau.
                                                                                           10
Hereditary Renal Cancer Syndromes
 Syndrome    Chromosome    Renal                    Other Manifestations
               Location Manifestations
                (Gene)

Von Hippel-  3p25       Clear cell renal   Retinal and central nervous system
Lindau (VHL) VHL        carcinoma: solid   hemangioblastomas; pheochromocytomas;
                        and/or cystic,     pancreatic cysts and neuroendocrine
                        multiple and       tumors; endolymphatic sac tumors;
                        bilateral          epididymal and broad ligament
                        28%-45%            cystadenomas




                                                                                   11
Syndrome          Chromosome       Renal Manifestations Other Manifestations
                       Location (Gene)
Hereditary papillary   7q31            Papillary renal carcinoma None
renal carcinoma        MET             type 1: solid, multiple and
type1(HPRC)                            bilateral




Hereditary             1q42-43        Papillary renal carcinoma   Uterine leiomyomas
leiomyomatosis and     FH             type 2, collecting duct     and leiomyosarcomas;
renal cell carcinoma                  carcinoma: solitary,        cutaneous leiomyomas
(HLRCC)                               aggressive




                                                                                         12
Syndrome     Chromosome     Renal Manifestations         Other Manifestations
                  Location
                   (Gene)
Birt-Hogg-Dubé 17p11.2     Hybrid oncocytic renal tumors, Benign tumors of hair
syndrome (BHD) BHD         chromophobe and clear cell     follicle (fibrofolliculomas);
                           renal carcinomas, oncocytomas: lung cysts, spontaneous
                           multiple, bilateral            pneumothoraces

Constitutional   3p; Not known; Clear cell renal carcinoma:   None
chromosome 3     VHL somatic multiple, bilateral
translocation    mutations 84%
                 - 98%




                                                                                          13
14
Natural History
 7% diagnosed incidentally
 45% present with localized disease, 25% with
  locally advanced disease, 30% with metastatic
  disease
 Lymph node metastases- 9% to 27% (renal hilar,
  para-aortic and paracaval)
 Renal vein – 21% & IVC 4%
 Distant metastases- lung (75%), soft tissue (36%),
  bone (20%), liver (18%), skin (8%) and CNS (8%)

                                                       15
Clinical Presentation
 Clinically occult for most of its course.
 Classic triad (occur in 5%-10% of patients)
    flank pain,
    hematuria,
    palpable abdominal mass
 Hematuria present 40% of patients
 Systemic symptoms
    Anaemia, Fatigue, Cachexia, Wt. Loss, Hypercalcemia,
     Hepatic Dysfunction
 Paraneoplastic Syndrome
    Parathyroid like hormones, erythropoietin, renin,
     gonadotropins, placental lactogen, prolactin, enteroglucagon,
     insulin like hormones, adrenocorticotropic hormone and
     prostaglandins identified in RCC pt.
                                                                     16
Diagnostic Work-Up
 General-History, Physical examination
 Laboratory studies
    CBC, LFT's, alkaline phosphotase, BUN, creatinine, urinalysis

 Radiographic studies- Increased use of imaging has increased the
  detection of renal lesions most of which are simple cysts.
    X-Ray KUB region
    Ultrasonography- Excellent in distinguishing cystic from solid masses
    Intravenous Urography - Starting point for hematuria evaluations and
     function of contralateral kidney
    Computed tomography- Provides an excellent assessment of the
     parenchyma and nodal status.
    Magnetic Resonance Imaging - excellent demonstration of solid renal
     masses and is image test of choice to demonstrate extent of vena caval
     involvement with tumor. Useful in patients with renal insufficiency

                                                                              17
Metastatic Work-Up
 Chest X-ray or Chest CT
 CT/MRI scan of abdomen or pelvis
 Bone scan with plan films (for elevated alkaline
 phosphatase or bone pain).




                                                     18
Figure : Computed tomography demonstrates
a right renal carcinoma (m) with a large
contralateral adrenal metastasis (a).




  Figure: CT scan shows large left renal mass
  with calcification (m) invading the left renal
  vein (arrow).




                                               19
Figure: T1-weighted magnetic
resonance image demonstrates
tumor (m) and vascular invasion
(arrow). Flowing blood (v) in the
left renal vein is black on this scan.




                         Figure A: Axial T1-weighted
                         image demonstrates a large left
                         renal carcinoma with extension
                         into the left renal vein (m) with
                         protrusion into the IVC (v). B:
                         Sagittal T1-weighted image
                         shows the relation of the tumor
                         thrombus (m) to the IVC (v) in
                         the lateral projection.




                                                        20
Robson Modification Of the Flocks &
         Kadesky Staging of RCC
Tumor Stage   Description
     I        Renal cell carcinoma is confined to the kidneys
    II        Renal cell carcinoma extends through the renal capsule but is
              confined to Gerota’s fascia
    III       Renal cell carcinoma involves the renal vein or inferior vena cava
              (IIIA) or the renal hilar lymph nodes (IIIB)
    IV        Renal cell carcinoma has spread to local adjacent organs (other
              than adrenal gland) or to distant sites




                                                                                   21
TNM staging
T - primary tumour
TX         Primary tumour cannot be assessed
T0         No evidence of primary tumour
T1         Tumour confined to kidney, <7cm
T1a        ≤4cm, confined to kidney
T1b        >4cm but <7cm, confined to kidney
T2         Tumour >7cm, confined to kidney
T3         Tumour extends into major veins or adrenal or perinephric tissue but not beyond Gerota’s fascia
T3a        Direct invasion of adrenal gland, perirenal and/or sinus fat
T3b        Gross extension into renal vein or IVC
T3c        Extends into IVC above diaphragm or wall of IVC
T4         Invasion beyond Gerota’s fascia
N - regional lymph nodes
NX         Nodes cannot be assessed
N0         Regional lymph nodes not involved
N1         Metastasis in a single regional lymph node
N2         Metastases in >1 regional lymph node
M - distant metastases
MX         Metastases cannot be assessed
M0         No distant metastases
M1         Distant metastases
                                                                                                             22
Staging                    I     T1      N0      M0
                                   II    T2      N0      M0
                                         T3      N0      M0
- Stage I-III: Localized disease
                                   III   T1      N1      M0
- Stage IV: Advanced, metastatic         T2      N1      M0
  disease                                T4      N0      M0
                                         T4      N1      M0
                                   IV
                                         Any T   N2      M0
                                         Any T   Any N   M1




                                                              23
Prognostic factors for RCC
 Pathologic stage                5 yr survival
    T1 - 2 organ confined        70-90%
    T3                           50-70%
    N+, M1                       5-30%
 Tumour size
    < 4 cm                       > 90%
    4 - 10 cm                    50%
    > 10 cm                      0%
 Histological type
    Clear cell                   70%
    Papillary, Chromophobe       85%
    Multilocular cystic          100%
    Medullary, Collecting duct   0%

                                                  24
Management
 Localized disease
 Metastatic disease




                           25
Management of Localized disease
             Localized disease




   Surgery                 Radio Therapy



                                       26
Surgery- Radical nephrectomy
Gold standard treatment for localized RCC with
contralateral normal kidney, adequate surgical
margin.

Principles of Surgery- Early ligation of renal artery
and vein , removal of kidney including Gerota’s
fascia, removal of ipsilateral adrenal gland, regional
lymphadenectomy from crus of diaphragm to aortic
bifurcation.

                                                         27
Nephron Sparing Surgery
Indications
 1. Bilateral RCC
 2. RCC in a solitary functioning kidney
 3. Unilateral RCC with contralateral kidney under threat of its future function
 (Renal artery stenosis, Chronic pyelonephritis , Hydronephrosis, Ureteral
 reflux, Calculus disease, Systemic disease such as diabetes )
 4. Tumor less than 4cms with normal opposite kidney.
 5. Five year survival rate 75% to 85%
 6. Local tumor recurrence of 10% is reported.


Other Approaches
  1. Radio frequency ablations
  2. Cryo ablation



                                                                                   28
Radiotherapy
 Radiosensitivity of RCC is variable
 Animal experiments suggest a theoretical benefit
  to preoperative RT (? Reduce intra-operative
  seeding)
 Historically several series suggested clinical
  benefit to adjuvant (post-op) RT
   Limited applicability because of long time span,
    improvements in staging, surgery, changing RT
    technology


                                                       29
Neo-adjuvant radiotherapy
 Rotterdam study
   Radical nephrectomy vs neo-adjuvant RT (30Gy/15#
    APPA) plus nephrectomy
   No overall survival or metastasis-free survival advantage
    (both 50% 5-year survival)
   No improvement in resectability
   Further study to 40Gy - still no advantage
 Swedish study
   Poorer 5-year survival with pre-op RT (47% vs 63%)!


                                                                30
Adjuvant radiotherapy
 Some early studies suggested advantage to post-op
  RT but poorly designed and reported
 Newcastle (UK) study
   Poorer survival with adjuvant RT (55Gy) vs surgery alone
   Not stratified by grade or stage
 Copenhagen study
   Stage II/III disease
   No difference in RCC relapse
   Significantly more GI complications (44%) in RT group
   19% of deaths attributed to RT complications

                                                               31
Role of RT
 MSKCC and Kao retrospective series
   Potential benefit of RT in selected cases where there is a
    high risk of local failure, ie:
       Pre-op RT in unresectable, locally-advanced tumours
        (“downstaging”), including T3a/T3c
           T3b (vena cava invasion) doesn’t necessarily increase risk of local
            failure
       Incomplete resection with positive margins
       Lymph node involvement
   RT in these cases may improve local control but
    probably not overall survival
 Clear role in palliation
                                                                                  32
RT Techniques
 High energy photons (10 mv or above) from linear
  accelerator
 Conventional External Beam Radiation.
   Technique-
     AP/ PA field
     AP/PA + Oblique field (in large tumor)
   Portal
       Upper-     T10 – T11 Vertebra
       Lower-     transverse process of L3
       Medial-    2 cm from midline or covering the opposite renal pelvis
       Lateral-   whole flank or tumor
   For Rt. Sided tumor field reduction after dose of 3600cGy to
    4ooocGy
   Safe dose: 5040 cGy in 180 cGy/# over a period of 5-6 weeks
       Boost of 540 cGy in 3# to small volume
       Total dose: 5580 cGy
                                                                             33
RT techniques
 Pre-op RT 40-50Gy to kidney + lymphatics for
  unresectable lesions may improve resectability
 45-50Gy post-op in 1.8 to 2 Gy daily fraction
  nephrectomy bed and lymph node drainage site
   10-15Gy boost (ie. ~60Gy total) to gross residual disease
   Include scar to reduce chance of scar recurrence
 Dose limitations (fully fractionated)
   Liver D30 <36-40Gy
   Contralateral kidney <20Gy max
   Spinal cord <45Gy max

                                                                34
Three-dimensional (3D) conformal radiation
                therapy
 CT planned, to image and reconstruct the tumor &
  surrounding kidney tissue in 3D

 Multiple field techniques, radiation beams can be
  shaped exactly to the contour of the treatment
  area, nearby normal tissue is usually spared.




                                                      35
Figure: A CT-based treatment plan using a combination of four fields (anterior, posterior, right
lateral, and right posterior oblique) to cover the tumor bed (dark oval) with 54 Gy (isodose line
displayed). This combination of fields and beam’s-eye-view shaping allows sparing of the liver,
bowel, and spinal cord
                                                                                                    36
Intensity Modulated Radiation Therapy
                  (IMRT)
 State-of-the-art radiation system.
 Treat difficult-to-reach tumors.
 Effectively treat tumor that surrounds spinal cord with very
  little radiation reaching cord.
 Reasonable consideration in kidney cancer due to
  sensitivity of adjacent surrounding structures.
 Useful if previously had conventional radiation therapy for
  kidney cancer, and are experiencing recurrent tumors in
  the treated area.


                                                                37
Management of Metastatic Disease

                     Metastatic
                      Disease



            Radio     Chemo       Targeted   Immuno
 Surgery
           Therapy    Therapy     Therapy    Therapy




                                                       38
Surgery
 Palliative Nephrectomy – Indicated in patients with
    Severe hemorrhage,
    Severe pain,
    Paraneoplastic syndrome
    or compression of adjacent viscera
    Solitary metastasis can be resected and may show some survival
     advantage
 Therapeutic:
    Not curative but produce some long-term survivors.
    The possibility of disease-free survival increases after resection of
     primary tumor and isolated metastasis excision.
    to decrease tumor burden in preparation for subsequent therapy


                                                                             39
Surgery…
 Resection of met’s
    in pt. not relieved from palliative RT
    In solitary mets.
 Spontaneous regression of met’s
    < 1 % of cases
    only 4 (0.8%) of 474 patients in 9 series who underwent
     nephrectomy experienced regression of metastatic foci




                                                               40
Radio Therapy
 Palliation
    Used for local or symptomatic metastatic disease, such
     as painful osseous lesions or brain metastasis.
    Treatment field encompasses metastatic deposit (or
     local recurrence) with 2-3cm margins
    Higher doses (up to 35-40Gy) may be required to
     overcome radioresistance
    Symptomatic relief in 64-84% of patients




                                                              41
Chemotherapy
 RCC is a chemo resistant tumor. Phenomenon due to
    presence of multi drug resistant glycoprotein (MDR)
    in tumor cell - causes extrusion of the drug
   Conventional therapy has little to offer
   5-FU alone has a response rate of 10%,
   On-going clinical trials of combination chemotherapy
    including Gemcitabine and 5-FU
   Limited data reveals some response in non-clear cell
    RCC to Carboplatin, Cisplatin plus Gemcitabine


                                                           42
Targeted Molecular Therapy
 New treatment approach that targets only the cancer.
 In renal cell carcinoma patients, this type of therapy
  uses drugs that stop the new blood vessels from
  growing, and targets certain factors that cause the cells
  to grow.
 Tyrosine kinase (TK) inhibitors block the
  intracellular domain of the VGEF receptor
- Sunitinib (Sutent)
- Sorafenib (Nexavar)


                                                          43
Targeted Molecular Therapy…
 Monoclonal antibody that binds circulating VEGF
  preventing the activation of the VEGF receptor
- Bevacizumab (Avastin)
 Mammalian target of rapamycin (mTor) inhibitors
   Temsirolimus (TMSR)




                                                    44
Immunotherapy
 Systemic type of treatment used to improve the body’s
    natural defenses.
    Boosts the immune system and slows down the cancer
    growth
   Clinical response to immunotherapy seen in patients with
    1. Good performance status
    2. Had a prior nephrectomy
    3. Non bulky pulmonary or soft tissue metastasis
    4. Asymptomatic patient
   Interferon (IFN)
   Interleukin (IL -2)

                                                               45
Summary
 RCC is relatively rare but increasing incidence
 Associated with tobacco and inherited disorders
 Surgery is the only curative modality for Stage I, II, and
  III
 RCC is radio resistant, RT’s role in paliation
 Stage IV disease holds poor prognosis despite
  advancements in molecular understanding
 IL-2, Sorafenib, Sunitinib, and Temsirolimus are FDA
  approved treatments for advanced RCC

                                                           46
Thank you !




              47

More Related Content

What's hot

testicular tumors
testicular tumorstesticular tumors
testicular tumors
DrAyush Garg
 
Prostate cancer
Prostate cancerProstate cancer
Prostate cancer
FarazaJaved
 
Polycystic kidney disease for students
Polycystic kidney disease for studentsPolycystic kidney disease for students
Polycystic kidney disease for students
Mohammad Manzoor
 
Kidney cancers
Kidney cancersKidney cancers
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
Sumudu Himesha Meawela
 
Prostate cancer
Prostate cancerProstate cancer
Prostate cancer
ANILKUMAR BR
 
Cancer of the Bladder
Cancer of the BladderCancer of the Bladder
Cancer of the Bladder
Robert J Miller MD
 
Bladder tumor
Bladder tumorBladder tumor
Bladder tumor
Hussein Ali Ramadhan
 
Pancreas Cancer
Pancreas CancerPancreas Cancer
Pancreas Cancer
Robert J Miller MD
 
Ovarian cancer
Ovarian cancerOvarian cancer
Ovarian cancer
Uma Chidiebere
 
Cancer of bladder
Cancer of bladderCancer of bladder
Cancer of bladder
Jinumol Jacob
 
Haematuria
HaematuriaHaematuria
Haematuria
Dr Subodh Shah
 
Testicular tumours
Testicular tumoursTesticular tumours
Testicular tumours
Shubham Lavania
 
congenital anomalies of renal system
congenital anomalies of renal systemcongenital anomalies of renal system
congenital anomalies of renal system
Ria Saira
 
Bladder cancer
Bladder cancerBladder cancer
Bladder cancer
LAKSHMI DEEPTHI GEDELA
 
Thyroid cancer
Thyroid cancerThyroid cancer
Thyroid cancer
Ratheesh R
 
Colon cancer
Colon cancer Colon cancer
Colon cancer
Areej Abu Hanieh
 
Orchitis & epididymitis
Orchitis & epididymitisOrchitis & epididymitis
Orchitis & epididymitis
Kaey Shins
 
Colorectal Cancer
Colorectal CancerColorectal Cancer
Colorectal Cancer
Suneet Khurana
 
Penile cancer
Penile cancerPenile cancer
Penile cancer
sonia dagar
 

What's hot (20)

testicular tumors
testicular tumorstesticular tumors
testicular tumors
 
Prostate cancer
Prostate cancerProstate cancer
Prostate cancer
 
Polycystic kidney disease for students
Polycystic kidney disease for studentsPolycystic kidney disease for students
Polycystic kidney disease for students
 
Kidney cancers
Kidney cancersKidney cancers
Kidney cancers
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
 
Prostate cancer
Prostate cancerProstate cancer
Prostate cancer
 
Cancer of the Bladder
Cancer of the BladderCancer of the Bladder
Cancer of the Bladder
 
Bladder tumor
Bladder tumorBladder tumor
Bladder tumor
 
Pancreas Cancer
Pancreas CancerPancreas Cancer
Pancreas Cancer
 
Ovarian cancer
Ovarian cancerOvarian cancer
Ovarian cancer
 
Cancer of bladder
Cancer of bladderCancer of bladder
Cancer of bladder
 
Haematuria
HaematuriaHaematuria
Haematuria
 
Testicular tumours
Testicular tumoursTesticular tumours
Testicular tumours
 
congenital anomalies of renal system
congenital anomalies of renal systemcongenital anomalies of renal system
congenital anomalies of renal system
 
Bladder cancer
Bladder cancerBladder cancer
Bladder cancer
 
Thyroid cancer
Thyroid cancerThyroid cancer
Thyroid cancer
 
Colon cancer
Colon cancer Colon cancer
Colon cancer
 
Orchitis & epididymitis
Orchitis & epididymitisOrchitis & epididymitis
Orchitis & epididymitis
 
Colorectal Cancer
Colorectal CancerColorectal Cancer
Colorectal Cancer
 
Penile cancer
Penile cancerPenile cancer
Penile cancer
 

Viewers also liked

Diagnostic Imaging of Renal Tumors
Diagnostic Imaging of Renal TumorsDiagnostic Imaging of Renal Tumors
Diagnostic Imaging of Renal Tumors
Mohamed M.A. Zaitoun
 
Tumors of kidney & urinary tract 2012
Tumors of kidney & urinary tract 2012Tumors of kidney & urinary tract 2012
Tumors of kidney & urinary tract 2012
ayeayetun08
 
Main paragangliomas
Main paragangliomas Main paragangliomas
Main paragangliomas
Eunice Abdulai
 
RENAL CELL CARCINOMA
RENAL CELL CARCINOMARENAL CELL CARCINOMA
RENAL CELL CARCINOMA
Karan Rawat
 
renal cell carcinoma radiology
renal cell carcinoma radiologyrenal cell carcinoma radiology
renal cell carcinoma radiology
docaashishgupt
 
Kidney and ureteric tumors
Kidney and ureteric tumorsKidney and ureteric tumors
Kidney and ureteric tumors
Dr./ Ihab Samy
 
Renal tumors
Renal tumorsRenal tumors
Renal tumors
drneelammalik
 
Kidney Cancer (renal cancer)
Kidney Cancer (renal cancer)Kidney Cancer (renal cancer)
Kidney Cancer (renal cancer)
Zahraa Samer
 
Cystic disease of the kidney
Cystic disease of the kidneyCystic disease of the kidney
Cystic disease of the kidney
Hofstra Northwell School of Medicine
 
Focal Glomerulosclerosis
Focal GlomerulosclerosisFocal Glomerulosclerosis
Focal Glomerulosclerosis
edwinchowyw
 
Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...
Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...
Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...
PAWAN V. KULKARNI
 
Kidney function test
Kidney function testKidney function test
Kidney function test
Gavin Yap
 
Kidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function TestsKidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function Tests
Madhukar Vedantham
 
Renal Replacement Therapies
Renal Replacement TherapiesRenal Replacement Therapies
Renal Replacement Therapies
aungp
 
Renal replacement therapy
Renal replacement therapyRenal replacement therapy
Renal replacement therapy
nagarjunanri
 
Nsf
NsfNsf
Renal biopsy
Renal biopsyRenal biopsy
Renal biopsy
FarragBahbah
 
Kidney
KidneyKidney
Hepatitis C in kidney transplantation
Hepatitis C in kidney transplantationHepatitis C in kidney transplantation
Hepatitis C in kidney transplantation
Salwa Ibrahim
 
Renal Replacement therapy
Renal Replacement therapyRenal Replacement therapy
Renal Replacement therapy
Dr Amber Z Jafferi
 

Viewers also liked (20)

Diagnostic Imaging of Renal Tumors
Diagnostic Imaging of Renal TumorsDiagnostic Imaging of Renal Tumors
Diagnostic Imaging of Renal Tumors
 
Tumors of kidney & urinary tract 2012
Tumors of kidney & urinary tract 2012Tumors of kidney & urinary tract 2012
Tumors of kidney & urinary tract 2012
 
Main paragangliomas
Main paragangliomas Main paragangliomas
Main paragangliomas
 
RENAL CELL CARCINOMA
RENAL CELL CARCINOMARENAL CELL CARCINOMA
RENAL CELL CARCINOMA
 
renal cell carcinoma radiology
renal cell carcinoma radiologyrenal cell carcinoma radiology
renal cell carcinoma radiology
 
Kidney and ureteric tumors
Kidney and ureteric tumorsKidney and ureteric tumors
Kidney and ureteric tumors
 
Renal tumors
Renal tumorsRenal tumors
Renal tumors
 
Kidney Cancer (renal cancer)
Kidney Cancer (renal cancer)Kidney Cancer (renal cancer)
Kidney Cancer (renal cancer)
 
Cystic disease of the kidney
Cystic disease of the kidneyCystic disease of the kidney
Cystic disease of the kidney
 
Focal Glomerulosclerosis
Focal GlomerulosclerosisFocal Glomerulosclerosis
Focal Glomerulosclerosis
 
Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...
Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...
Review of new alerts on PROTON PUMP INHIBITORS (PPI) adverse effects 2016 UPD...
 
Kidney function test
Kidney function testKidney function test
Kidney function test
 
Kidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function TestsKidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function Tests
 
Renal Replacement Therapies
Renal Replacement TherapiesRenal Replacement Therapies
Renal Replacement Therapies
 
Renal replacement therapy
Renal replacement therapyRenal replacement therapy
Renal replacement therapy
 
Nsf
NsfNsf
Nsf
 
Renal biopsy
Renal biopsyRenal biopsy
Renal biopsy
 
Kidney
KidneyKidney
Kidney
 
Hepatitis C in kidney transplantation
Hepatitis C in kidney transplantationHepatitis C in kidney transplantation
Hepatitis C in kidney transplantation
 
Renal Replacement therapy
Renal Replacement therapyRenal Replacement therapy
Renal Replacement therapy
 

Similar to Renal Tumors, Renal Cell Carcinoma- Dr. Vandana

Renal malignancies
Renal  malignanciesRenal  malignancies
Renal malignancies
Venkatesh Kolla
 
rccclass-160824074458.pptx
rccclass-160824074458.pptxrccclass-160824074458.pptx
rccclass-160824074458.pptx
Islah Raoof
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
gbanstha
 
Renal_cell_carcinoma_ppt_Akhil.pptx
Renal_cell_carcinoma_ppt_Akhil.pptxRenal_cell_carcinoma_ppt_Akhil.pptx
Renal_cell_carcinoma_ppt_Akhil.pptx
Akhilesh Maurya
 
Renal tumors.pptx
Renal tumors.pptxRenal tumors.pptx
Renal tumors.pptx
Lara Masri
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
Mohammad Ihmeidan
 
RENAL ANATOMY & RENAL CELL CANCERS
RENAL ANATOMY & RENAL CELL CANCERSRENAL ANATOMY & RENAL CELL CANCERS
RENAL ANATOMY & RENAL CELL CANCERS
Isha Jaiswal
 
Etiopathogenesis of Renal Tumors.pptx
Etiopathogenesis of Renal Tumors.pptxEtiopathogenesis of Renal Tumors.pptx
Etiopathogenesis of Renal Tumors.pptx
Anees Puthawala
 
Pediatric Renal Masses radiology of head and neck
Pediatric Renal Masses radiology of head and neckPediatric Renal Masses radiology of head and neck
Pediatric Renal Masses radiology of head and neck
Shubham661884
 
Renal cell carcinoma.pptx
Renal cell carcinoma.pptxRenal cell carcinoma.pptx
Renal cell carcinoma.pptx
Dr.Manojit Sarkar
 
Renal tumors (2)-1.pptx
Renal tumors (2)-1.pptxRenal tumors (2)-1.pptx
Renal tumors (2)-1.pptx
ssuser0c1992
 
Retroperitoneal mass
Retroperitoneal  massRetroperitoneal  mass
4 renal tumors written
4  renal tumors written4  renal tumors written
4 renal tumors written
Nuramalina Yahaya
 
臨床上較少見之肝臟腫瘤20130906
臨床上較少見之肝臟腫瘤20130906臨床上較少見之肝臟腫瘤20130906
臨床上較少見之肝臟腫瘤20130906
Chien-Wei Su
 
renaltumors upasana sahu Group 50.pptxism
renaltumors upasana sahu Group 50.pptxismrenaltumors upasana sahu Group 50.pptxism
renaltumors upasana sahu Group 50.pptxism
thxz2fdqxw
 
Renal tumors
Renal tumorsRenal tumors
Renal tumors
ShrutiDevendra
 
cystickidneydiseases-161210202710 (1).pdf
cystickidneydiseases-161210202710 (1).pdfcystickidneydiseases-161210202710 (1).pdf
cystickidneydiseases-161210202710 (1).pdf
HARYANVITRAVLLER
 
Cystic kidney diseases
Cystic kidney diseasesCystic kidney diseases
Cystic kidney diseases
sahar Hamdy
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
Gagan Adhikari
 
CT and MRI Imaging of Hepatic metastases
CT and MRI Imaging of Hepatic metastasesCT and MRI Imaging of Hepatic metastases
CT and MRI Imaging of Hepatic metastases
Dr Priyanka Vishwakarma
 

Similar to Renal Tumors, Renal Cell Carcinoma- Dr. Vandana (20)

Renal malignancies
Renal  malignanciesRenal  malignancies
Renal malignancies
 
rccclass-160824074458.pptx
rccclass-160824074458.pptxrccclass-160824074458.pptx
rccclass-160824074458.pptx
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
 
Renal_cell_carcinoma_ppt_Akhil.pptx
Renal_cell_carcinoma_ppt_Akhil.pptxRenal_cell_carcinoma_ppt_Akhil.pptx
Renal_cell_carcinoma_ppt_Akhil.pptx
 
Renal tumors.pptx
Renal tumors.pptxRenal tumors.pptx
Renal tumors.pptx
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
 
RENAL ANATOMY & RENAL CELL CANCERS
RENAL ANATOMY & RENAL CELL CANCERSRENAL ANATOMY & RENAL CELL CANCERS
RENAL ANATOMY & RENAL CELL CANCERS
 
Etiopathogenesis of Renal Tumors.pptx
Etiopathogenesis of Renal Tumors.pptxEtiopathogenesis of Renal Tumors.pptx
Etiopathogenesis of Renal Tumors.pptx
 
Pediatric Renal Masses radiology of head and neck
Pediatric Renal Masses radiology of head and neckPediatric Renal Masses radiology of head and neck
Pediatric Renal Masses radiology of head and neck
 
Renal cell carcinoma.pptx
Renal cell carcinoma.pptxRenal cell carcinoma.pptx
Renal cell carcinoma.pptx
 
Renal tumors (2)-1.pptx
Renal tumors (2)-1.pptxRenal tumors (2)-1.pptx
Renal tumors (2)-1.pptx
 
Retroperitoneal mass
Retroperitoneal  massRetroperitoneal  mass
Retroperitoneal mass
 
4 renal tumors written
4  renal tumors written4  renal tumors written
4 renal tumors written
 
臨床上較少見之肝臟腫瘤20130906
臨床上較少見之肝臟腫瘤20130906臨床上較少見之肝臟腫瘤20130906
臨床上較少見之肝臟腫瘤20130906
 
renaltumors upasana sahu Group 50.pptxism
renaltumors upasana sahu Group 50.pptxismrenaltumors upasana sahu Group 50.pptxism
renaltumors upasana sahu Group 50.pptxism
 
Renal tumors
Renal tumorsRenal tumors
Renal tumors
 
cystickidneydiseases-161210202710 (1).pdf
cystickidneydiseases-161210202710 (1).pdfcystickidneydiseases-161210202710 (1).pdf
cystickidneydiseases-161210202710 (1).pdf
 
Cystic kidney diseases
Cystic kidney diseasesCystic kidney diseases
Cystic kidney diseases
 
Renal cell carcinoma
Renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma
 
CT and MRI Imaging of Hepatic metastases
CT and MRI Imaging of Hepatic metastasesCT and MRI Imaging of Hepatic metastases
CT and MRI Imaging of Hepatic metastases
 

More from Dr Vandana Singh Kushwaha

Cell survival curve
Cell survival curveCell survival curve
Cell survival curve
Dr Vandana Singh Kushwaha
 
Ewings sarcoma - Dr. Vandana
Ewings sarcoma - Dr. VandanaEwings sarcoma - Dr. Vandana
Ewings sarcoma - Dr. Vandana
Dr Vandana Singh Kushwaha
 
Part ii management of testicular carcinoma - dr vandana
Part ii   management of testicular carcinoma - dr vandanaPart ii   management of testicular carcinoma - dr vandana
Part ii management of testicular carcinoma - dr vandana
Dr Vandana Singh Kushwaha
 
Part 1 management of testicular carcinoma - dr vandana
Part 1  management of testicular carcinoma - dr vandanaPart 1  management of testicular carcinoma - dr vandana
Part 1 management of testicular carcinoma - dr vandana
Dr Vandana Singh Kushwaha
 
Carcinoma oesophagus
Carcinoma oesophagusCarcinoma oesophagus
Carcinoma oesophagus
Dr Vandana Singh Kushwaha
 
Retinoblastoma dr vandana
Retinoblastoma dr vandanaRetinoblastoma dr vandana
Retinoblastoma dr vandana
Dr Vandana Singh Kushwaha
 
Carcinoma rectum (Rectal Cancer)
Carcinoma rectum (Rectal Cancer)Carcinoma rectum (Rectal Cancer)
Carcinoma rectum (Rectal Cancer)
Dr Vandana Singh Kushwaha
 
Diagnosis, Treatment & Management of Medulloblastoma
Diagnosis, Treatment & Management of Medulloblastoma Diagnosis, Treatment & Management of Medulloblastoma
Diagnosis, Treatment & Management of Medulloblastoma
Dr Vandana Singh Kushwaha
 
LET, RBE & OER - dr vandana
LET, RBE & OER - dr vandanaLET, RBE & OER - dr vandana
LET, RBE & OER - dr vandana
Dr Vandana Singh Kushwaha
 
Interaction of radiation with Matter - Dr. Vandana
Interaction of radiation with Matter -  Dr. VandanaInteraction of radiation with Matter -  Dr. Vandana
Interaction of radiation with Matter - Dr. Vandana
Dr Vandana Singh Kushwaha
 

More from Dr Vandana Singh Kushwaha (10)

Cell survival curve
Cell survival curveCell survival curve
Cell survival curve
 
Ewings sarcoma - Dr. Vandana
Ewings sarcoma - Dr. VandanaEwings sarcoma - Dr. Vandana
Ewings sarcoma - Dr. Vandana
 
Part ii management of testicular carcinoma - dr vandana
Part ii   management of testicular carcinoma - dr vandanaPart ii   management of testicular carcinoma - dr vandana
Part ii management of testicular carcinoma - dr vandana
 
Part 1 management of testicular carcinoma - dr vandana
Part 1  management of testicular carcinoma - dr vandanaPart 1  management of testicular carcinoma - dr vandana
Part 1 management of testicular carcinoma - dr vandana
 
Carcinoma oesophagus
Carcinoma oesophagusCarcinoma oesophagus
Carcinoma oesophagus
 
Retinoblastoma dr vandana
Retinoblastoma dr vandanaRetinoblastoma dr vandana
Retinoblastoma dr vandana
 
Carcinoma rectum (Rectal Cancer)
Carcinoma rectum (Rectal Cancer)Carcinoma rectum (Rectal Cancer)
Carcinoma rectum (Rectal Cancer)
 
Diagnosis, Treatment & Management of Medulloblastoma
Diagnosis, Treatment & Management of Medulloblastoma Diagnosis, Treatment & Management of Medulloblastoma
Diagnosis, Treatment & Management of Medulloblastoma
 
LET, RBE & OER - dr vandana
LET, RBE & OER - dr vandanaLET, RBE & OER - dr vandana
LET, RBE & OER - dr vandana
 
Interaction of radiation with Matter - Dr. Vandana
Interaction of radiation with Matter -  Dr. VandanaInteraction of radiation with Matter -  Dr. Vandana
Interaction of radiation with Matter - Dr. Vandana
 

Recently uploaded

General Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormonesGeneral Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormones
MedicoseAcademics
 
2nd week of Human development .embryology
2nd week of Human development .embryology2nd week of Human development .embryology
2nd week of Human development .embryology
Mithilesh Chaurasia
 
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptxHow to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
AmandaChou9
 
medical law and ethics presentation .ppt
medical law and ethics presentation .pptmedical law and ethics presentation .ppt
medical law and ethics presentation .ppt
PseudoPocket
 
BCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotionsBCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotions
sathya swaroop patnaik
 
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...
Internal medicine department, faculty of Medicine Beni-Suef University Egypt
 
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
ED PIllsForever
 
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptxOBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
Niranjan Chavan
 
THE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptxTHE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptx
Bright Chipili
 
Text Book of Operation Theater Nursing OT Nursing
Text Book of Operation Theater Nursing OT NursingText Book of Operation Theater Nursing OT Nursing
Text Book of Operation Theater Nursing OT Nursing
BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL
 
Interpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac ArrhythmiasInterpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac Arrhythmias
MedicoseAcademics
 
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptxPICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
Aloy Okechukwu Ugwu
 
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Anindya Das Adhikary
 
STAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHY
STAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHYSTAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHY
STAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHY
DRPREETHIJAMESP
 
anthelmintic-drugs.pptx pharmacology dep
anthelmintic-drugs.pptx pharmacology depanthelmintic-drugs.pptx pharmacology dep
anthelmintic-drugs.pptx pharmacology dep
sapnasirswal
 
Rice Bran Oil Manufacturing Process
Rice Bran Oil Manufacturing ProcessRice Bran Oil Manufacturing Process
Rice Bran Oil Manufacturing Process
nishurani4455
 
THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...
THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...
THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...
DRPREETHIJAMESP
 
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
CarriePoppy
 
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
paridubey2024#G05
 
MEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate careMEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate care
Debre Berhan University
 

Recently uploaded (20)

General Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormonesGeneral Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormones
 
2nd week of Human development .embryology
2nd week of Human development .embryology2nd week of Human development .embryology
2nd week of Human development .embryology
 
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptxHow to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
 
medical law and ethics presentation .ppt
medical law and ethics presentation .pptmedical law and ethics presentation .ppt
medical law and ethics presentation .ppt
 
BCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotionsBCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotions
 
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of...
 
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
Overcoming Erectile Dysfunction Lifestyle Changes and the Role of Sildigra 25...
 
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptxOBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
OBSTETRICS SEPSIS - BUNDLE APPROACH.pptx
 
THE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptxTHE MANAGEMENT OF PROSTATE CANCER . pptx
THE MANAGEMENT OF PROSTATE CANCER . pptx
 
Text Book of Operation Theater Nursing OT Nursing
Text Book of Operation Theater Nursing OT NursingText Book of Operation Theater Nursing OT Nursing
Text Book of Operation Theater Nursing OT Nursing
 
Interpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac ArrhythmiasInterpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac Arrhythmias
 
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptxPICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
 
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
 
STAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHY
STAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHYSTAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHY
STAPHYSAGRIA.BHMS.MATERIA MEDICA.HOMOEOPATHY
 
anthelmintic-drugs.pptx pharmacology dep
anthelmintic-drugs.pptx pharmacology depanthelmintic-drugs.pptx pharmacology dep
anthelmintic-drugs.pptx pharmacology dep
 
Rice Bran Oil Manufacturing Process
Rice Bran Oil Manufacturing ProcessRice Bran Oil Manufacturing Process
Rice Bran Oil Manufacturing Process
 
THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...
THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...
THE REVIEW OF THE ENCYCLOPEDIA OF PURE MATERIA MEDICA.BHMS.MATERIA MEDICA.HOM...
 
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
 
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
Bangalore @Girls @Call WhatsApp Numbers 🫦0000XX0000🫦 List For Friendship Girl...
 
MEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate careMEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate care
 

Renal Tumors, Renal Cell Carcinoma- Dr. Vandana

  • 1. Presented By: Dr. Vandana Dept. of Radiotherapy CSMMU, Lucknow 1
  • 2. Anatomy of Kidney  pair of organs located in the abdominal cavity on either side of the spine in a retroperitoneal position.  Adrenal glands rest on top of each kidney  Approx. at vertebral level T12 to L3, right kidney being slightly lower than the left.  Long axis of kidney is directed downward and laterally  Approx. 11–14 cm in length, 6 cm wide and 4 cm thick  weighs around 150 gm in males & 135 gm in females.  Mobile Organ, move vertically within retroperitoneum 0.9 cm to 1.3 cm., as much as 4 cm during normal respiration 2
  • 3.  The kidney is surrounded by tough fibrous tissue, the renal capsule, which is itself surrounded by perinephric fat, renal fascia (of Gerota) and paranephric fat.  parenchyma, of the kidney is divided into two major structures: renal cortex and renal medulla Fig: Anterior relations of kidneys Fig: Posterior relations of kidneys 3
  • 4.  Blood Supply  Approx. 20% of the cardiac output .  From renal arteries, left and right, which branch directly from the abdominal aorta.  renal vein emerges from hilum and drains into the inferior vena cava.  Lymph Drainage : to the lateral aortic lymph nodes around the origin of the renal artery.  Nerve Supply:  Through renal sympathetic plexus (T10 – L1) fibres, mainly vasomotor.  Afferent nerves T10 to T12 thoracic nerves.  Functions  Excretion of wastes,  Acid-base homeostasis,  Osmolality regulation, Blood pressure regulation and Hormone secretion 4
  • 5. Renal Tumors  51,000 cases diagnosed and more than 12,900 deaths annually in the US  Account for approx. 3% of adult malignancy 5
  • 6. Renal tumors…  Benign  Oncocytoma  Papillary adenoma  Angiomyolipoma  Malignant  Renal Cell Carcinoma (Adenocarcinoma of Kidney) 6
  • 7. Renal Cell Carcinoma  First described by Konig in 1826.  In 1883 Grawitz, noted the fatty content of cancer cells similar to that of adrenal cells.  All these tumors arise from Renal tubular epithelium.  accounts for 80–85% of kidney cancer  2% to 4% increase in incidence per year 7
  • 8. Epidemiology  Male predominance (1.6:1.0 M:F)  Highest incidence between age 50-70 -Median age of diagnosis is 66 years -Median age of death 70 years  Majority of RCC occurs sporadically  Highest incidence in Scandinavia and North America, lowest in Africa 8
  • 9. Risk Factors  Tobacco smoking contributes to 24-30% of RCC cases - Tobacco results in a 2-fold increased risk  Environmental: Cadmium, thorium-di-oxide, petroleum and phenacetin analgesics.  Occupational: leather tanners, shoe workers, asbestos workers.  Hormonal: diethylistillbestrol,  Obesity, HTN  35% - 47% pt on long term dialysis develop Acquired polycystic kidney disease, out of which 5.8% develops Renal cancer. 9
  • 10. RCC is not one disease… It is made up of no. of different types of cancers with different histology, different clinical courses and caused by different gene. Type Clear cell Papillary type 1 Papillary type 2 Chromophobe Oncocytoma Incidence (%) 75% 5% 10% 5% 5% Associated VHL c-Met FH BHD BHD mutations A sarcomatoid variant represents1% to 6% of renal cell carcinoma and these tumors are associated with a significantly poorer prognosis. BHD=Birt-Hogg-Dubé; FH=fumarate hydratase; VHL=von Hippel-Lindau. 10
  • 11. Hereditary Renal Cancer Syndromes Syndrome Chromosome Renal Other Manifestations Location Manifestations (Gene) Von Hippel- 3p25 Clear cell renal Retinal and central nervous system Lindau (VHL) VHL carcinoma: solid hemangioblastomas; pheochromocytomas; and/or cystic, pancreatic cysts and neuroendocrine multiple and tumors; endolymphatic sac tumors; bilateral epididymal and broad ligament 28%-45% cystadenomas 11
  • 12. Syndrome Chromosome Renal Manifestations Other Manifestations Location (Gene) Hereditary papillary 7q31 Papillary renal carcinoma None renal carcinoma MET type 1: solid, multiple and type1(HPRC) bilateral Hereditary 1q42-43 Papillary renal carcinoma Uterine leiomyomas leiomyomatosis and FH type 2, collecting duct and leiomyosarcomas; renal cell carcinoma carcinoma: solitary, cutaneous leiomyomas (HLRCC) aggressive 12
  • 13. Syndrome Chromosome Renal Manifestations Other Manifestations Location (Gene) Birt-Hogg-Dubé 17p11.2 Hybrid oncocytic renal tumors, Benign tumors of hair syndrome (BHD) BHD chromophobe and clear cell follicle (fibrofolliculomas); renal carcinomas, oncocytomas: lung cysts, spontaneous multiple, bilateral pneumothoraces Constitutional 3p; Not known; Clear cell renal carcinoma: None chromosome 3 VHL somatic multiple, bilateral translocation mutations 84% - 98% 13
  • 14. 14
  • 15. Natural History  7% diagnosed incidentally  45% present with localized disease, 25% with locally advanced disease, 30% with metastatic disease  Lymph node metastases- 9% to 27% (renal hilar, para-aortic and paracaval)  Renal vein – 21% & IVC 4%  Distant metastases- lung (75%), soft tissue (36%), bone (20%), liver (18%), skin (8%) and CNS (8%) 15
  • 16. Clinical Presentation  Clinically occult for most of its course.  Classic triad (occur in 5%-10% of patients)  flank pain,  hematuria,  palpable abdominal mass  Hematuria present 40% of patients  Systemic symptoms  Anaemia, Fatigue, Cachexia, Wt. Loss, Hypercalcemia, Hepatic Dysfunction  Paraneoplastic Syndrome  Parathyroid like hormones, erythropoietin, renin, gonadotropins, placental lactogen, prolactin, enteroglucagon, insulin like hormones, adrenocorticotropic hormone and prostaglandins identified in RCC pt. 16
  • 17. Diagnostic Work-Up  General-History, Physical examination  Laboratory studies  CBC, LFT's, alkaline phosphotase, BUN, creatinine, urinalysis  Radiographic studies- Increased use of imaging has increased the detection of renal lesions most of which are simple cysts.  X-Ray KUB region  Ultrasonography- Excellent in distinguishing cystic from solid masses  Intravenous Urography - Starting point for hematuria evaluations and function of contralateral kidney  Computed tomography- Provides an excellent assessment of the parenchyma and nodal status.  Magnetic Resonance Imaging - excellent demonstration of solid renal masses and is image test of choice to demonstrate extent of vena caval involvement with tumor. Useful in patients with renal insufficiency 17
  • 18. Metastatic Work-Up  Chest X-ray or Chest CT  CT/MRI scan of abdomen or pelvis  Bone scan with plan films (for elevated alkaline phosphatase or bone pain). 18
  • 19. Figure : Computed tomography demonstrates a right renal carcinoma (m) with a large contralateral adrenal metastasis (a). Figure: CT scan shows large left renal mass with calcification (m) invading the left renal vein (arrow). 19
  • 20. Figure: T1-weighted magnetic resonance image demonstrates tumor (m) and vascular invasion (arrow). Flowing blood (v) in the left renal vein is black on this scan. Figure A: Axial T1-weighted image demonstrates a large left renal carcinoma with extension into the left renal vein (m) with protrusion into the IVC (v). B: Sagittal T1-weighted image shows the relation of the tumor thrombus (m) to the IVC (v) in the lateral projection. 20
  • 21. Robson Modification Of the Flocks & Kadesky Staging of RCC Tumor Stage Description I Renal cell carcinoma is confined to the kidneys II Renal cell carcinoma extends through the renal capsule but is confined to Gerota’s fascia III Renal cell carcinoma involves the renal vein or inferior vena cava (IIIA) or the renal hilar lymph nodes (IIIB) IV Renal cell carcinoma has spread to local adjacent organs (other than adrenal gland) or to distant sites 21
  • 22. TNM staging T - primary tumour TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to kidney, <7cm T1a ≤4cm, confined to kidney T1b >4cm but <7cm, confined to kidney T2 Tumour >7cm, confined to kidney T3 Tumour extends into major veins or adrenal or perinephric tissue but not beyond Gerota’s fascia T3a Direct invasion of adrenal gland, perirenal and/or sinus fat T3b Gross extension into renal vein or IVC T3c Extends into IVC above diaphragm or wall of IVC T4 Invasion beyond Gerota’s fascia N - regional lymph nodes NX Nodes cannot be assessed N0 Regional lymph nodes not involved N1 Metastasis in a single regional lymph node N2 Metastases in >1 regional lymph node M - distant metastases MX Metastases cannot be assessed M0 No distant metastases M1 Distant metastases 22
  • 23. Staging I T1 N0 M0 II T2 N0 M0 T3 N0 M0 - Stage I-III: Localized disease III T1 N1 M0 - Stage IV: Advanced, metastatic T2 N1 M0 disease T4 N0 M0 T4 N1 M0 IV Any T N2 M0 Any T Any N M1 23
  • 24. Prognostic factors for RCC  Pathologic stage 5 yr survival  T1 - 2 organ confined 70-90%  T3 50-70%  N+, M1 5-30%  Tumour size  < 4 cm > 90%  4 - 10 cm 50%  > 10 cm 0%  Histological type  Clear cell 70%  Papillary, Chromophobe 85%  Multilocular cystic 100%  Medullary, Collecting duct 0% 24
  • 25. Management  Localized disease  Metastatic disease 25
  • 26. Management of Localized disease Localized disease Surgery Radio Therapy 26
  • 27. Surgery- Radical nephrectomy Gold standard treatment for localized RCC with contralateral normal kidney, adequate surgical margin. Principles of Surgery- Early ligation of renal artery and vein , removal of kidney including Gerota’s fascia, removal of ipsilateral adrenal gland, regional lymphadenectomy from crus of diaphragm to aortic bifurcation. 27
  • 28. Nephron Sparing Surgery Indications 1. Bilateral RCC 2. RCC in a solitary functioning kidney 3. Unilateral RCC with contralateral kidney under threat of its future function (Renal artery stenosis, Chronic pyelonephritis , Hydronephrosis, Ureteral reflux, Calculus disease, Systemic disease such as diabetes ) 4. Tumor less than 4cms with normal opposite kidney. 5. Five year survival rate 75% to 85% 6. Local tumor recurrence of 10% is reported. Other Approaches 1. Radio frequency ablations 2. Cryo ablation 28
  • 29. Radiotherapy  Radiosensitivity of RCC is variable  Animal experiments suggest a theoretical benefit to preoperative RT (? Reduce intra-operative seeding)  Historically several series suggested clinical benefit to adjuvant (post-op) RT  Limited applicability because of long time span, improvements in staging, surgery, changing RT technology 29
  • 30. Neo-adjuvant radiotherapy  Rotterdam study  Radical nephrectomy vs neo-adjuvant RT (30Gy/15# APPA) plus nephrectomy  No overall survival or metastasis-free survival advantage (both 50% 5-year survival)  No improvement in resectability  Further study to 40Gy - still no advantage  Swedish study  Poorer 5-year survival with pre-op RT (47% vs 63%)! 30
  • 31. Adjuvant radiotherapy  Some early studies suggested advantage to post-op RT but poorly designed and reported  Newcastle (UK) study  Poorer survival with adjuvant RT (55Gy) vs surgery alone  Not stratified by grade or stage  Copenhagen study  Stage II/III disease  No difference in RCC relapse  Significantly more GI complications (44%) in RT group  19% of deaths attributed to RT complications 31
  • 32. Role of RT  MSKCC and Kao retrospective series  Potential benefit of RT in selected cases where there is a high risk of local failure, ie:  Pre-op RT in unresectable, locally-advanced tumours (“downstaging”), including T3a/T3c  T3b (vena cava invasion) doesn’t necessarily increase risk of local failure  Incomplete resection with positive margins  Lymph node involvement  RT in these cases may improve local control but probably not overall survival  Clear role in palliation 32
  • 33. RT Techniques  High energy photons (10 mv or above) from linear accelerator  Conventional External Beam Radiation.  Technique-  AP/ PA field  AP/PA + Oblique field (in large tumor)  Portal  Upper- T10 – T11 Vertebra  Lower- transverse process of L3  Medial- 2 cm from midline or covering the opposite renal pelvis  Lateral- whole flank or tumor  For Rt. Sided tumor field reduction after dose of 3600cGy to 4ooocGy  Safe dose: 5040 cGy in 180 cGy/# over a period of 5-6 weeks  Boost of 540 cGy in 3# to small volume  Total dose: 5580 cGy 33
  • 34. RT techniques  Pre-op RT 40-50Gy to kidney + lymphatics for unresectable lesions may improve resectability  45-50Gy post-op in 1.8 to 2 Gy daily fraction nephrectomy bed and lymph node drainage site  10-15Gy boost (ie. ~60Gy total) to gross residual disease  Include scar to reduce chance of scar recurrence  Dose limitations (fully fractionated)  Liver D30 <36-40Gy  Contralateral kidney <20Gy max  Spinal cord <45Gy max 34
  • 35. Three-dimensional (3D) conformal radiation therapy  CT planned, to image and reconstruct the tumor & surrounding kidney tissue in 3D  Multiple field techniques, radiation beams can be shaped exactly to the contour of the treatment area, nearby normal tissue is usually spared. 35
  • 36. Figure: A CT-based treatment plan using a combination of four fields (anterior, posterior, right lateral, and right posterior oblique) to cover the tumor bed (dark oval) with 54 Gy (isodose line displayed). This combination of fields and beam’s-eye-view shaping allows sparing of the liver, bowel, and spinal cord 36
  • 37. Intensity Modulated Radiation Therapy (IMRT)  State-of-the-art radiation system.  Treat difficult-to-reach tumors.  Effectively treat tumor that surrounds spinal cord with very little radiation reaching cord.  Reasonable consideration in kidney cancer due to sensitivity of adjacent surrounding structures.  Useful if previously had conventional radiation therapy for kidney cancer, and are experiencing recurrent tumors in the treated area. 37
  • 38. Management of Metastatic Disease Metastatic Disease Radio Chemo Targeted Immuno Surgery Therapy Therapy Therapy Therapy 38
  • 39. Surgery  Palliative Nephrectomy – Indicated in patients with  Severe hemorrhage,  Severe pain,  Paraneoplastic syndrome  or compression of adjacent viscera  Solitary metastasis can be resected and may show some survival advantage  Therapeutic:  Not curative but produce some long-term survivors.  The possibility of disease-free survival increases after resection of primary tumor and isolated metastasis excision.  to decrease tumor burden in preparation for subsequent therapy 39
  • 40. Surgery…  Resection of met’s  in pt. not relieved from palliative RT  In solitary mets.  Spontaneous regression of met’s  < 1 % of cases  only 4 (0.8%) of 474 patients in 9 series who underwent nephrectomy experienced regression of metastatic foci 40
  • 41. Radio Therapy  Palliation  Used for local or symptomatic metastatic disease, such as painful osseous lesions or brain metastasis.  Treatment field encompasses metastatic deposit (or local recurrence) with 2-3cm margins  Higher doses (up to 35-40Gy) may be required to overcome radioresistance  Symptomatic relief in 64-84% of patients 41
  • 42. Chemotherapy  RCC is a chemo resistant tumor. Phenomenon due to presence of multi drug resistant glycoprotein (MDR) in tumor cell - causes extrusion of the drug  Conventional therapy has little to offer  5-FU alone has a response rate of 10%,  On-going clinical trials of combination chemotherapy including Gemcitabine and 5-FU  Limited data reveals some response in non-clear cell RCC to Carboplatin, Cisplatin plus Gemcitabine 42
  • 43. Targeted Molecular Therapy  New treatment approach that targets only the cancer.  In renal cell carcinoma patients, this type of therapy uses drugs that stop the new blood vessels from growing, and targets certain factors that cause the cells to grow.  Tyrosine kinase (TK) inhibitors block the intracellular domain of the VGEF receptor - Sunitinib (Sutent) - Sorafenib (Nexavar) 43
  • 44. Targeted Molecular Therapy…  Monoclonal antibody that binds circulating VEGF preventing the activation of the VEGF receptor - Bevacizumab (Avastin)  Mammalian target of rapamycin (mTor) inhibitors  Temsirolimus (TMSR) 44
  • 45. Immunotherapy  Systemic type of treatment used to improve the body’s natural defenses.  Boosts the immune system and slows down the cancer growth  Clinical response to immunotherapy seen in patients with 1. Good performance status 2. Had a prior nephrectomy 3. Non bulky pulmonary or soft tissue metastasis 4. Asymptomatic patient  Interferon (IFN)  Interleukin (IL -2) 45
  • 46. Summary  RCC is relatively rare but increasing incidence  Associated with tobacco and inherited disorders  Surgery is the only curative modality for Stage I, II, and III  RCC is radio resistant, RT’s role in paliation  Stage IV disease holds poor prognosis despite advancements in molecular understanding  IL-2, Sorafenib, Sunitinib, and Temsirolimus are FDA approved treatments for advanced RCC 46