Nestor Pagkatipunan Jr, DPBU

3rd year lecture

RENAL NEOPLASMS
Content

Epidemiology and Etiology

Diagnosis and Staging
Classification and Prognosis
Other renal tumors
Treatment
Localized
Metastatic
Surveillance
Epidemiology

2-3% of all cancers

Highest incidence in Western countries
Renal cell carcinoma
Most common solid tumor of the kidney
90% of all kidney malignancies
1.5:1 predominance in men over women
Peak between 60-70 yrs old
Increasing incidental RCC
Etiology

Arise from the proximal convoluted tubule

Chromophobic and papillary RCC- derived
from more distal components

Viruses
Lead compounds, hydrocarbons
Tobacco use
Von Hippel-Lindau disease- RCC occurs in
50%
Predisposing Factors

Smoking*
Obesity
Hypertension
Kidney cancer in first degree relative
Diagnosis
Symptoms

Asymptomatic and non-palpable

>50% non-specific symptom complexes
Classic triad (rarely encountered 6-10%)
Flank pain
Gross hematuria
Palpable abdominal mass
Symptoms of metastases
Bone pains
cough
Paraneoplastic Syndromes

Hypertension Elevated ESR

Cachexia Anemia
Weight loss Abnormal liver
Pyrexia function
Neuromyopathy Hypercalcemia
amyloidosis polycythemia
Physical Examination

Palpable abdominal mass

Palpable cervical lymphadenopathy
Non reducing varicocele
Bilateral lower extremity edema
Laboratory findings

Serum creatinine
GFR*
Hemoglobin
Erythrocyte sedimentation rate
Alkaline phosphatase
LDH
Serum corrected calcium
Familial Renal Cell CA
Syndromes
Von Hippel Lindau
Clear cell carcinoma
Hereditary papillary RCC
Type 1 papillary RCC
Familial leiomyomatosis and RCC
Type 2 papillary RCC
Birt Hogg Dube
Chromophobe RCC
Screening and Clinical
Association
Staging
(Robsons)
Radiologic Investigations

Ultrasonography
CT scan
MRI

Used to classify renal mass into solid or cystic

Radiologic Investigation

CT scan
Change of 20 Hu or greater is strong evidence of
enhancement

Provides information on
Function and morphology of the contralateral kidney
Primary tumor extension with extrarenal spread
Venous involvement
Enlargement of locoregional LN
Condition of adrenal gland and the liver
Radiologic Investigations

Presence of enhancement- most important

criterion for differentiating malignant lesion
for solid renal masses

Contrast enhanced ultrasound may be helpful

in renal failure
CT Scan
Radiologic Investigatrions

Contrast enhanced CT scan angiography may

provide detailed information on vascular
supply
Radiologic Investigations

MRI
Indicated if CT results are indeterminate
Indicated in patients with contrast allergy,
pregnancy or renal failure

Provide additional information to

Demonstrate enhancement in renal masses
Investigate locally advanced malignancy
Investigate venous involvement badly defined on
CT with extension to IVC
Radiologic Investigations

Metastatic investigations
Chest CT for chest staging
Chest xray at the very least
If clinically indicated
Bone scan
Brain CT scan
Renal Scan
Bosniak classification
(for renal cysts)
Category I- simple uncomplicated cyst
Category II- minimally complicated, benign
Septated, calcium, infected
Category III- more complicated, cannot be
distinguished from malignancy
Irregular margin, thickened septa, thick irreg
calcifn
Category IV- large cystic components, some
solid enhancing portions- malignant
Bosniak I
Bosniak II
Bosniak III
Bosniak IV
Renal Biopsy

For diagnosis, follow-up surveillance and in

ablative therapies
10-20% non conclusive
Indicated in metastatic patients before
starting systemic therapy
Recommended in surveillance strategies to
stratify follow up
Rarely required for large renal masses
Histologic Diagnosis

Renal cell carcinoma

Clear cell (80-90%)
Papillary (10-15%)
Type 1 small cell, pale cytoplasm
Type 2 large cells and eosinophilic cytoplasm- worse
prognosis
Chromophobe (4-5%)
Classification and Prognosis
 TNM Classification
T - P rimary tumour
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
T1 Tumour 7 cm in greatest dimension, limited to the kidney
T1a Tumour 4 cm in greatest dimension, limited to the kidney
T1b Tumour > 4 cm but 7 cm in greatest dimension
T2 Tumour > 7 cm in greatest dimension, limited to the kidney
T2a Tumour > 7 cm but 10 cm in greatest dimension
T2b Tumours > 10 cm limited to the kidney
T3 Tumour extends into major veins or directly invades adrenal gland or perinephric tissues but not
into the ipsilateral adrenal gland and not beyond Gerotas fascia
T3a Tumour grossly extends into the renal vein or its segmental (muscle-containing)
branches or tumour invades perirenal and/or renal sinus (peripelvic) fat but not beyond Gerotas
fascia
T3b Tumour grossly extends into the vena cava below the diaphragm
T3c Tumour grossly extends into vena cava above the diaphragm or invades the wall of
the vena cava
T4 Tumour invades beyond Gerotas fascia (including contiguous extension into the
ipsilateral adrenal gland)
 N - Regional lymph nodes
NX Regional lymph nodes cannot be
assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single regional lymph
node
N2 Metastasis in more than 1 regional
lymph node
M - Distant metastasis
M0 No distant metastasis
M1 Distant metastasis
TNM Stage Grouping

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1, T2, T3 N1 M0
Stage IV T4 Any N M0
Any T N2 M0
Any T Any N M1
Prognostic Factors
Anatomical
Histological
Clinical
Molecular
Anatomical

Tumour size
Venous invasion
Renal capsule invasion
Adrenal involvement
Lymph node involvement
Distant metastasis
Histological

Fuhrman grading system

Renal cell carcinoma subtype
Conventional clear cell worse prognosis
Papillary
Type I- low grade tumors, chromophobic better
prognosis
Type II- high grade tumors, eosinophilic - favorable
Chromophobe better prognosis
Clinical

Performance status
10% wt loss, bone pains
Localized symptoms
Cachexia
Anemia
Platelet count
Other renal tumors
Sarcomatoid variants of RCC: High Surgery
Multilocular clear cell RCC: Low, no metastasis
Surgery, NSS
Papillary adenoma: Benign Observation
Carcinoma of the collecting ducts of Bellini: High,
very aggressive Surgery, in M+ discussable
Renal medullary carcinoma: High, very aggressive
Surgery
Translocation carcinoma: Intermediate Surgery,
NSS
Mucinous tubular and spindle cell carcinoma:
Intermediate Surgery, NSS
Carcinoma associated with end-stage renal
disease: Variable Surgery
Metanephric tumours: Benign Surgery, NSS
Renal epithelial and stromal tumours (REST): Low
Surgery, NSS
Oncocytoma: Benign Observation/surgery
Hereditary kidney tumours :High Surgery, NSS
Angiomyolipoma: Benign Consider treatment
when >4 cm
Unclassified RCC : Variable Surgery, NSS
Treatment
Small tumors

Watchful waiting for small tumor

<1/2 cm usually benign
<1cm slow growing
3-4cm- intervene
Localized renal cell
carcinoma
Nephron sparing surgery
Indications
Absolute solitary kidney
Relative presence of a condition that may impair
contralateral kidney function
Elective T1 disease, normally functioning
contralateral kidney
Associated procedures
Adrenalectomy if indicated
Partial nephrectomy (Nephron sparing surgery)
Alternative approaches to
surgery
Surveillance- appropriate for short term
monitoring of small tumors
Alternative approaches to
surgery
Percutaneous approaches
Percutaneous radiofrequency ablation (RFA)
Cryotherapy
Microwave ablation
Laser ablation
High-intensity focused ultrasound ablation (HIFU)
Indications for minimally
invasive approach
small, incidentally found, renal cortical lesions in
elderly patients;
patients with a genetic predisposition for
developing multiple tumours;
patients with bilateral tumours;
patients with a solitary kidney at high risk of
complete loss of renal function following surgical
tumour resection
Contradindication to
minimally invasive technique
poor life expectancy of < 1 year;
multiple metastases;
low possibility of successful treatment due
to size or location of tumour. In general,
tumours > 3 cm or tumours in the hilum,
near the proximal ureter or the central
collecting system are not typically
recommended for ablative techniques via
a percutaneous approach
Radical Nephrectomy

Entails early ligation of the renal vessels followed

by en bloc removal of the kidney, perirenal fat
within and including the Gerotas fascia as well as
the upper ureter
Gold standard for localized disease
Controversy on necessity of lymph node
dissection and adrenalectomy (recently found to
have no benefit)
May be done even with venous tumor thrombus
extension
Laparoscopic radical
nephrectomy
Tumor nephrectomy

Combined with metastasectomy

Systemic therapy

Chemotherapy
High levels of expression of multiple drug
resistance protein, P-glycoprotein= resistant
to most chemotherapies
Moderately effective if combined with 5-FU
Immunotherapy

Interferon alpha combined with bevacizumab

Not recommended as first line therapy for
metastatic RCCA
Has role only in clear cell type with good
performance status, lung metastases
Interleukin 2
More toxic than IFN alpha
Complete responders with high dose in some
cases
In renal cell carcinoma
progression

Increased production of vascular endothelial

growth factor (VEGF) and transforming
growth factor (TGF)
Loss of VHL tumor suppressor gene
Angiogenesis inhibitor drugs

Sorafenib
Sunitinib
Bevacizumab (combined with IFN)
Pazopanib
Temsirolimus
Everolimus
Surveillance after surgery
Why do we do surveillance

To monitor
Post operative complications
Renal function
Local recurrence after partial nephrectomy or
ablative treatment
Recurrence in the contralateral kidney
Development of metastases
 There is no consensus on surveillance and no
evidence that early versus later diagnosis of
recurrence improves survival
 History
Physical examination
Creatinine
GFR
If low relapse is expected

Chest X ray
Ultrasound
If risk is intermediate to
high

CT scan of the chest and abdomen