Renal cell carcinoma

Renal cell carcinoma

1. RENAL CELL CARCINOMA SUNIL KUMAR.P 1 SUNIL KUMAR.P

2. SYNONYMS - Adenocarcinoma - Hypernephroma - Grawitz Tumour 2 SUNIL KUMAR.P

3. DEFINITION Renal cell carcinoma (RCC) is a kidney cancer that originates in the lining of the proximal convoluted tubule, a part of the very small tubes in the kidney that transport primary urine. RCC is the most common type of kidney cancer in adults, responsible for approximately 90–95% of cases. 3 SUNIL KUMAR.P9

4. EPIDEMIOLOGY The most common neoplasm of the kidney (75 %) or up to 85% . - Arises from renal tubular cells . - ( 2 – 3 ) % of all adulthood cancers . - ( 40 % ) of patients die of cancer . - Most common in 6th & 7th decades . - Male : Female ratio 2:1 - Blacks at an higher risk than whites. 4 SUNIL KUMAR.P

5. ETIOLOGY & PATHOGENESIS Various etiological factors implicated in the aetiology of the RCC are as follows. 1.Tobacco 2.genetic factors 3.Cystic diseases of the kidney 4.Other risk factors 5 SUNIL KUMAR.P

6. TOBACCO - Tobacco is the major risk factor for RCC - Whether chewed or smoked and accounts for 20-30% cases of RCC - Cigarette smokers have two-fold higher risk of developing RCC 6 SUNIL KUMAR.P

7. GENETIC FACTORS -Hereditary and first –degree relatives of RCC are associated with higher risk. Although majority of the cases of RCC sporadic but about 5% cases are inherited. These cases have following associations 1.Von Hippel Disease (VHL) 2.Herediiatry Clear cell RCC 3.Chromophobe RCC 7 SUNIL KUMAR.P

8. CYTIC DISEASE OF THE KIDNEY -Both hereditary & Acquired cystic disease of the kidney have increased risk of development of RCC. Pt’s .. On long term dialysis develop acquired cystic disease …….. Which may evolve into RCC. Adult PCKD and Multicystic Nephroma is associated with higher occurrence of papillary RCC. 8 SUNIL KUMAR.P

9. OTHER RISK FACTORS Besides above, following other factors are associated with higher incidence of RCC….. 1.Exposure to asbestos, heavy metals, petrochemical products. 2.In women, obesity, & oestrogen therapy 3.Analgesic nephropathy 4.Tuberous sclerosis 9 SUNIL KUMAR.P

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11. CLASSIFICATION Based on Cytogenetics of sporadic and familial tumour , RCC has been Classified in to .. 1.Clear cell renal cell carcinoma. 2.Papillary renal cell carcinoma. 3.Chromophobe renal cell carcinoma. 4.Sarcomatoid type renal cell carcinoma 5.Collecting duct carcinoma. 11 SUNIL KUMAR.P

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14. Renal cell carcinoma arising in the middle pole of the kidney. Fairly circumscribed, The cut surface demonstrates a yellowish areas, white areas, brown areas, and hemorrhagic red areas. 14 SUNIL KUMAR.P

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20. GROSS FINDINGS RCC commonly arises from the poles of the kidney as a solitary and unilateral tumour, more often in the upper pole. The tumour is generally large, golden yellow and circumscribed. Papillary tumours have grossly visible papillae and may be multifocal. About 1% RCC are bilateral . SUNIL KUMAR.P 20

21. C/S – of the tumour commonly shows large areas of ischemic necrosis, cystic change and foci of haemorrhages. Another significant characteristic is the frequent presence of tumour thrombus in the renal vein ………. Which may extend to venacava . SUNIL KUMAR.P 21

22. MICROSCOPY FINDINGS 1. Clear Cell Type (RCC) – 70 % - This is the most common pattern - The clear cytoplasm of tumor is due to removal of glycogen and lipid from the cytoplasm during the processing of the tissue . - The tumour cells have a variety of patterns ; solid, trabecular and tubular, separated by delicate vasculature. SUNIL KUMAR.P 22

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24. 2. Papillary type RCC : 15% - The tumour cells are arranged in papillary pattern over the fibro vascular stalks. The tumour cells are cuboidal with small round nuclei SUNIL KUMAR.P 24

25. 3.Granular cell type : 8% - The tumour cells have abundant acidophilic cytoplasm. These tumours have more marked nuclear pleomorphisim . SUNIL KUMAR.P 25

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29. Occur anywhere in the urinary tract, but they are most common in the bladder. Smoking, exposure to analine or azo dyes, and napthylamine exposure are known to be associated with urothelial cancers. Urothelial tumors often are multicentric . These patients need careful follow-up. 29 SUNIL KUMAR.P

30. Rare . - Often associated with chronic inflammation resulting from stones. - Metastasize early and the prognosis is poor . -Radiosensitive 30 SUNIL KUMAR.P

31. SIGNS AND SYMPTOMS Classic triad of : Hematuria,, Flank pain Abdominal mass 31 SUNIL KUMAR.P

32. Signs may include: Malaise,weight loss and anorexia Abnormal urine color Polycythemia Anemia Fracture of hip Varicocele.enlargement of testicle on left side Pallor or plethora Hirsutism Constipation Hypertension Hypercalcemia Leg and ankle swelling 32 SUNIL KUMAR.P

33. DIAGNOSIS Physical examination: Fever High blood pressure Lab tests: Complete blood count Urineanalysis Serum calcium Imaging tests: Ultrasound abdomen Abdominal CT scan MRI scan PET scan Renal angiography Intravenous pyelogram Chest x ray Bone scan Biopsy Fine needle aspiration Core needle biopsy 33 SUNIL KUMAR.P

34. STAGING Based on examination, imaging and biopsy AJCC (TNM) staging system: T categories for kidney cancer: T0: No evidence of primary tumor T1: The tumor is only in the kidney and is 7cm or less across T2: The tumor is larger than 7cm across but is still in the kidney T3: The tumor is growing into a major vein or tissue around the kidney but not into adrenals or beyond Gerota,s fascia T4: The tumor has spread beyond Gerota,s fascia. It may have grown into the adrenal gland 34 SUNIL KUMAR.P

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37. STAGING 37 SUNIL KUMAR.P

38. TREATMENT If only in kidneys, it can be cured 90% of the time with surgery. If it has spread outside the kidneys into the nodes or the main vein, it must be treated with cytoreductive surgery. RRC is resistant to chemo and radiotherapy in most Cases May respond to immunotherapy PARTIAL NEPHRECTOMY: For treating small renal tumors(< 4cm) Bilateral renal cell carcinoma It can be done via laproscopic techniques 38 SUNIL KUMAR.P

39. RADICAL NEPHRECTOMY: Surgical removal of kidney along with adrenal gland, retroperitoneal lymphnodes , perinephric fat an Gerota's fascia In cases where the tumor has spread into the renal vein, IVC and right atrium, this portion of tumor can be surgically removed as well. Medications like tyrosine kinase inhibitors including 39 SUNIL KUMAR.P

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41. PROGNOSIS For tumors less than 4cm 5 year survival rate is 90-95% For larger tumors confined to kidneys without venous invasion survival is 80-85% For tumors that extend through the renal capsule n local fascia survivability reduces to near 60% For metastasis to lymph nodes survival rate is around 5-15% F or spread to other organs 5 year survival rate is less than 5% 41 SUNIL KUMAR.P

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43. SUMMARY 43 SUNIL KUMAR.P