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RENAL CELL CARCINOMA CLINICAL PROGRESS AND CURRENT MANAGEMENT

RCC : SURGICAL OR MEDICAL DISEASE ?. Early initial diagnosis and advent of laparoscopic surgery has provided different treatment options.Molecular pathology of these lesions is better understoodAdvanced lesions remain difficult to treat by conventional cytoreductive surgery or biological respon

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RENAL CELL CARCINOMA CLINICAL PROGRESS AND CURRENT MANAGEMENT

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    1. RENAL CELL CARCINOMA CLINICAL PROGRESS AND CURRENT MANAGEMENT DR KALYAN K SARKAR MS FRCSEd

    2. RCC : SURGICAL OR MEDICAL DISEASE ? Early initial diagnosis and advent of laparoscopic surgery has provided different treatment options. Molecular pathology of these lesions is better understood Advanced lesions remain difficult to treat by conventional cytoreductive surgery or biological response modifier therapy Please select a region from the drop-down menu or simply click on the map to see region details.     General Considerations This remains a surgical disease for the most part but the individual approach to each case has been modified by the greater incidence of smaller lesions noted at initial diagnosis and the advent of laparoscopic surgery which provides different treatment options. The molecular pathology of these lesions is better understood, yet advanced lesions remain difficult to treat by conventional cytoreductive or biological response modifier therapy. Incidence There are approximately 30,000 new cases per year and 12,000 cancer related deaths Incidence is rising 6.1 to 9.3 per 100,000 over 20 years Mortality rate has not decreased even with greater detection of small tumors Lead time bias Short follow up Natural history of smaller lesions less aggressive? 25% of tumors present with advanced disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Please select a region from the drop-down menu or simply click on the map to see region details.     General Considerations This remains a surgical disease for the most part but the individual approach to each case has been modified by the greater incidence of smaller lesions noted at initial diagnosis and the advent of laparoscopic surgery which provides different treatment options. The molecular pathology of these lesions is better understood, yet advanced lesions remain difficult to treat by conventional cytoreductive or biological response modifier therapy. Incidence There are approximately 30,000 new cases per year and 12,000 cancer related deaths Incidence is rising 6.1 to 9.3 per 100,000 over 20 years Mortality rate has not decreased even with greater detection of small tumors Lead time bias Short follow up Natural history of smaller lesions less aggressive? 25% of tumors present with advanced disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    3. INCIDENCE Incidence There are approximately 30,000 new cases per year and 12,000 cancer related deaths Incidence is rising 6.1 to 9.3 per 100,000 over 20 years Mortality rate has not decreased even with greater detection of small tumors Lead time bias Short follow up Less aggressive? 25% of tumors present with advanced disease Please select a region from the drop-down menu or simply click on the map to see region details.     General Considerations This remains a surgical disease for the most part but the individual approach to each case has been modified by the greater incidence of smaller lesions noted at initial diagnosis and the advent of laparoscopic surgery which provides different treatment options. The molecular pathology of these lesions is better understood, yet advanced lesions remain difficult to treat by conventional cytoreductive or biological response modifier therapy. Incidence There are approximately 30,000 new cases per year and 12,000 cancer related deaths Incidence is rising 6.1 to 9.3 per 100,000 over 20 years Mortality rate has not decreased even with greater detection of small tumors Lead time bias Short follow up Natural history of smaller lesions less aggressive? 25% of tumors present with advanced disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Please select a region from the drop-down menu or simply click on the map to see region details.     General Considerations This remains a surgical disease for the most part but the individual approach to each case has been modified by the greater incidence of smaller lesions noted at initial diagnosis and the advent of laparoscopic surgery which provides different treatment options. The molecular pathology of these lesions is better understood, yet advanced lesions remain difficult to treat by conventional cytoreductive or biological response modifier therapy. Incidence There are approximately 30,000 new cases per year and 12,000 cancer related deaths Incidence is rising 6.1 to 9.3 per 100,000 over 20 years Mortality rate has not decreased even with greater detection of small tumors Lead time bias Short follow up Natural history of smaller lesions less aggressive? 25% of tumors present with advanced disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

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    5. EPIDEMIOLOGY Equal racial distribution 2:1 male to female distribution Occurs in 5th to 7th decade of life Tobacco greatest risk factor Obesity may be a risk factor Most cases sporadic, yet also occurs with Von Hippel-Lindau disease (VHL) [45%], and less commonly with tuberous sclerosis, and in rare familial distributions Epidemiology    Tuesday, 16 May 2006 Equal racial distribution 2:1 male to female distribution Occurs in 5th to 7th decade of life Tobacco greatest risk factor Obesity may be a risk factor Most cases sporadic, yet also occurs with con Hippel-Lindau disease (VHL) [45%], and less commonly with tuberous sclerosis, and in rare familial distributions References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Epidemiology    Tuesday, 16 May 2006 Equal racial distribution 2:1 male to female distribution Occurs in 5th to 7th decade of life Tobacco greatest risk factor Obesity may be a risk factor Most cases sporadic, yet also occurs with con Hippel-Lindau disease (VHL) [45%], and less commonly with tuberous sclerosis, and in rare familial distributions References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    6. PATHOLOGY RENAL CELL CARCINOMA Clear cell renal cell carcinoma Papillary renal cell carcinoma Oncocytoma Chromophobe renal cell carcinoma Collecting duct renal cell carcinoma Other parenchymal renal tumours Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival Read more on "A Molecular Classification of Papillary Renal Cell Carcinoma" Chromophobe tumors: 5 % of cases Loss on chromosome 1 Collecting duct carcinoma: one percent or less of cases Can mimic transitional cell Ca Generally poor outcome Oncocytoma: 5 % of renal tumors Generally localized and encapsulated. 5% bilaterality Mahogany brown color, acidophilic cells secondary to dense mitochondrial hyperplasia Distinction from renal cell cancer difficult on imaging or needle biopsy. Best treated with surgical removal Angiomyolipoma: Renal Hamartomas comprised of fat, muscle and blood vessels. Tissue signature on CT by demonstration of negative Hounsfield units. Sporadic, isolated lesions present age 35-50 with a 4:1 female ratio Tuberous Sclerosis patients demonstrate multiple and bilateral lesions. 80% of patients will develop AML. Treatment based on tumor size: those <4 cm are observed, those >4cm undergo selective angioembolization or partial nephrectomy Renal Sarcoma Pure sarcoma is rare and usually lieomyosarcoma All tumor types can degenerate towards sarcoma Generally poorer outcome Rare Renal lesions Adult Wilms tumor Lymphoma Xanthogranulomatous Pyelonephritis [XPG] Haemangiopericytoma From the BJU International Mini Reviews: Renal Haemangiopericytoma: The Characteristics of a Rare Tumour. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival

    7. PATHOLOGY Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principAL event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary renal cell carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival Read more on "A Molecular Classification of Papillary Renal Cell Carcinoma" Chromophobe tumors: 5 % of cases Loss on chromosome 1 Collecting duct carcinoma: one percent or less of cases Can mimic transitional cell Ca Generally poor outcome Oncocytoma: 5 % of renal tumors Generally localized and encapsulated. 5% bilaterality Mahogany brown color, acidophilic cells secondary to dense mitochondrial hyperplasia Distinction from renal cell cancer difficult on imaging or needle biopsy. Best treated with surgical removal Angiomyolipoma: Renal Hamartomas comprised of fat, muscle and blood vessels. Tissue signature on CT by demonstration of negative Hounsfield units. Sporadic, isolated lesions present age 35-50 with a 4:1 female ratio Tuberous Sclerosis patients demonstrate multiple and bilateral lesions. 80% of patients will develop AML. Treatment based on tumor size: those <4 cm are observed, those >4cm undergo selective angioembolization or partial nephrectomy Renal Sarcoma Pure sarcoma is rare and usually lieomyosarcoma All tumor types can degenerate towards sarcoma Generally poorer outcome Rare Renal lesions Adult Wilms tumor Lymphoma Xanthogranulomatous Pyelonephritis [XPG] Haemangiopericytoma From the BJU International Mini Reviews: Renal Haemangiopericytoma: The Characteristics of a Rare Tumour. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival

    8. PATHOLOGY Chromophobe tumors: 5 % of cases Loss on chromosome 1 Collecting duct carcinoma: one percent or less of cases Can mimic transitional cell Ca Generally poor outcome Oncocytoma: 5 % of renal tumors Generally localized and encapsulated. 5% bilaterality Mahogany brown color, acidophilic cells secondary to dense mitochondrial hyperplasia Distinction from renal cell cancer difficult on imaging or needle biopsy. Best treated with surgical removal Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival Read more on "A Molecular Classification of Papillary Renal Cell Carcinoma" Chromophobe tumors: 5 % of cases Loss on chromosome 1 Collecting duct carcinoma: one percent or less of cases Can mimic transitional cell Ca Generally poor outcome Oncocytoma: 5 % of renal tumors Generally localized and encapsulated. 5% bilaterality Mahogany brown color, acidophilic cells secondary to dense mitochondrial hyperplasia Distinction from renal cell cancer difficult on imaging or needle biopsy. Best treated with surgical removal Angiomyolipoma: Renal Hamartomas comprised of fat, muscle and blood vessels. Tissue signature on CT by demonstration of negative Hounsfield units. Sporadic, isolated lesions present age 35-50 with a 4:1 female ratio Tuberous Sclerosis patients demonstrate multiple and bilateral lesions. 80% of patients will develop AML. Treatment based on tumor size: those <4 cm are observed, those >4cm undergo selective angioembolization or partial nephrectomy Renal Sarcoma Pure sarcoma is rare and usually lieomyosarcoma All tumor types can degenerate towards sarcoma Generally poorer outcome Rare Renal lesions Adult Wilms tumor Lymphoma Xanthogranulomatous Pyelonephritis [XPG] Haemangiopericytoma From the BJU International Mini Reviews: Renal Haemangiopericytoma: The Characteristics of a Rare Tumour. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival

    9. PATHOLOGY Angiomyolipoma: Renal Hamartomas comprised of fat, muscle and blood vessels. Tissue signature on CT by demonstration of negative Hounsfield units. Sporadic, isolated lesions present age 35-50 with a 4:1 female ratio Tuberous Sclerosis patients demonstrate multiple and bilateral lesions. 80% of patients will develop AML. Tumours <4 cm are observed, those >4cm undergo selective angioembolization or partial nephrectomy Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival Read more on "A Molecular Classification of Papillary Renal Cell Carcinoma" Chromophobe tumors: 5 % of cases Loss on chromosome 1 Collecting duct carcinoma: one percent or less of cases Can mimic transitional cell Ca Generally poor outcome Oncocytoma: 5 % of renal tumors Generally localized and encapsulated. 5% bilaterality Mahogany brown color, acidophilic cells secondary to dense mitochondrial hyperplasia Distinction from renal cell cancer difficult on imaging or needle biopsy. Best treated with surgical removal Angiomyolipoma: Renal Hamartomas comprised of fat, muscle and blood vessels. Tissue signature on CT by demonstration of negative Hounsfield units. Sporadic, isolated lesions present age 35-50 with a 4:1 female ratio Tuberous Sclerosis patients demonstrate multiple and bilateral lesions. 80% of patients will develop AML. Treatment based on tumor size: those <4 cm are observed, those >4cm undergo selective angioembolization or partial nephrectomy Renal Sarcoma Pure sarcoma is rare and usually lieomyosarcoma All tumor types can degenerate towards sarcoma Generally poorer outcome Rare Renal lesions Adult Wilms tumor Lymphoma Xanthogranulomatous Pyelonephritis [XPG] Haemangiopericytoma From the BJU International Mini Reviews: Renal Haemangiopericytoma: The Characteristics of a Rare Tumour. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival

    10. PATHOLOGY Renal Sarcoma Pure sarcoma is rare and usually lieomyosarcoma All tumor types can degenerate towards sarcoma Generally poorer outcome Rare Renal lesions Adult Wilms tumor Lymphoma Xanthogranulomatous Pyelonephritis [XPG] Haemangiopericytoma Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival Read more on "A Molecular Classification of Papillary Renal Cell Carcinoma" Chromophobe tumors: 5 % of cases Loss on chromosome 1 Collecting duct carcinoma: one percent or less of cases Can mimic transitional cell Ca Generally poor outcome Oncocytoma: 5 % of renal tumors Generally localized and encapsulated. 5% bilaterality Mahogany brown color, acidophilic cells secondary to dense mitochondrial hyperplasia Distinction from renal cell cancer difficult on imaging or needle biopsy. Best treated with surgical removal Angiomyolipoma: Renal Hamartomas comprised of fat, muscle and blood vessels. Tissue signature on CT by demonstration of negative Hounsfield units. Sporadic, isolated lesions present age 35-50 with a 4:1 female ratio Tuberous Sclerosis patients demonstrate multiple and bilateral lesions. 80% of patients will develop AML. Treatment based on tumor size: those <4 cm are observed, those >4cm undergo selective angioembolization or partial nephrectomy Renal Sarcoma Pure sarcoma is rare and usually lieomyosarcoma All tumor types can degenerate towards sarcoma Generally poorer outcome Rare Renal lesions Adult Wilms tumor Lymphoma Xanthogranulomatous Pyelonephritis [XPG] Haemangiopericytoma From the BJU International Mini Reviews: Renal Haemangiopericytoma: The Characteristics of a Rare Tumour. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Pathology    Tuesday, 16 May 2006 Clear cell carcinoma: comprises >70% of renal lesions VHL gene mutation principle event. Recent association between VHL protein and hypoxia inducing factor [HIF] protein ties pathology into angiogenesis cascade pathway. Papillary carcinoma: comprises 10-15% of renal lesions Sporadic and hereditary forms Associated with alterations in chromosomes 7, 17, and Y Generally better survival

    11. GRADING Fuhrman grading system Grade is an important variable Fuhrman system has issues with interobserver variability Grading & Staging    Tuesday, 16 May 2006 Fuhrman grading system Grade is an important variable Fuhrman system has issues with interobserver variability UICC-AJCC system is generally accepted Table 1 Currently T1 lesion is 7 cm or less in size, yet 4.0 cm Associated with very low recurrence rate T1a category of <4.0 cm suggested Table 1: Tumor Node Metastasis (TNM) Staging System for Renal Tumors American Joint Commission for Cancer (AJCC) 1997 Primary Tumor (T)TXPrimary tumor cannot be assessedTONo evidence of primary tumorT1Tumor 7 cm or less in dimension limited to the kidneyT2Tumor more than 7 cm in dimension limited to the kidneyT3aTumor invades adrenal gland or perinephric tissues but not Gerota's fasciaT3bTumor grossly extends into renal vein or vena cava below diaphragmT3cTumor grossly extends into vena cava above diaphragmRegional Lymph Nodes (N)NXRegional lymph nodes cannot be assessedNONo regional lymph node metastasisN1Metastasis in a single regional lymph node or nodesN2Metastasis in more than one regional lymph nodeDistant Metastasis (M)MXDistant metastasis cannot be assessedMONo distant metastasisM1Distant Metastasis Staging GroupingIT1NOMOIIT2NOMOIIIT1N1MOT2N1MOT3aNOMOT3aN1MOT3bNOMOT3bN1MOT3cNOMOT3cN1MOIV`T4T4NOMOAny TN2MOAny TAny NM1 References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Grading & Staging    Tuesday, 16 May 2006 Fuhrman grading system Grade is an important variable Fuhrman system has issues with interobserver variability UICC-AJCC system is generally accepted Table 1 Currently T1 lesion is 7 cm or less in size, yet 4.0 cm Associated with very low recurrence rate T1a category of <4.0 cm suggested Table 1: Tumor Node Metastasis (TNM) Staging System for Renal Tumors American Joint Commission for Cancer (AJCC) 1997 Primary Tumor (T)TXPrimary tumor cannot be assessedTONo evidence of primary tumorT1Tumor 7 cm or less in dimension limited to the kidneyT2Tumor more than 7 cm in dimension limited to the kidneyT3aTumor invades adrenal gland or perinephric tissues but not Gerota's fasciaT3bTumor grossly extends into renal vein or vena cava below diaphragmT3cTumor grossly extends into vena cava above diaphragmRegional Lymph Nodes (N)NXRegional lymph nodes cannot be assessedNONo regional lymph node metastasisN1Metastasis in a single regional lymph node or nodesN2Metastasis in more than one regional lymph nodeDistant Metastasis (M)MXDistant metastasis cannot be assessedMONo distant metastasisM1Distant MetastasisStaging GroupingIT1NOMOIIT2NOMOIIIT1N1MOT2N1MOT3aNOMOT3aN1MOT3bNOMOT3bN1MOT3cNOMOT3cN1MOIV`T4T4NOMOAny TN2MOAny TAny NM1 References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    12. STAGING UICC-AJCC system is generally accepted Currently T1 lesion is 7 cm or less in size, yet 4.0 cm associated with very low recurrence rate T1a category of <4.0 cm suggested Grading & Staging    Tuesday, 16 May 2006 Fuhrman grading system Grade is an important variable Fuhrman system has issues with interobserver variability UICC-AJCC system is generally accepted Table 1 Currently T1 lesion is 7 cm or less in size, yet 4.0 cm Associated with very low recurrence rate T1a category of <4.0 cm suggested Table 1: Tumor Node Metastasis (TNM) Staging System for Renal Tumors American Joint Commission for Cancer (AJCC) 1997 Primary Tumor (T)TXPrimary tumor cannot be assessedTONo evidence of primary tumorT1Tumor 7 cm or less in dimension limited to the kidneyT2Tumor more than 7 cm in dimension limited to the kidneyT3aTumor invades adrenal gland or perinephric tissues but not Gerota's fasciaT3bTumor grossly extends into renal vein or vena cava below diaphragmT3cTumor grossly extends into vena cava above diaphragmRegional Lymph Nodes (N)NXRegional lymph nodes cannot be assessedNONo regional lymph node metastasisN1Metastasis in a single regional lymph node or nodesN2Metastasis in more than one regional lymph nodeDistant Metastasis (M)MXDistant metastasis cannot be assessedMONo distant metastasisM1Distant Metastasis Staging GroupingIT1NOMOIIT2NOMOIIIT1N1MOT2N1MOT3aNOMOT3aN1MOT3bNOMOT3bN1MOT3cNOMOT3cN1MOIV`T4T4NOMOAny TN2MOAny TAny NM1 References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Grading & Staging    Tuesday, 16 May 2006 Fuhrman grading system Grade is an important variable Fuhrman system has issues with interobserver variability UICC-AJCC system is generally accepted Table 1 Currently T1 lesion is 7 cm or less in size, yet 4.0 cm Associated with very low recurrence rate T1a category of <4.0 cm suggested Table 1: Tumor Node Metastasis (TNM) Staging System for Renal Tumors American Joint Commission for Cancer (AJCC) 1997 Primary Tumor (T)TXPrimary tumor cannot be assessedTONo evidence of primary tumorT1Tumor 7 cm or less in dimension limited to the kidneyT2Tumor more than 7 cm in dimension limited to the kidneyT3aTumor invades adrenal gland or perinephric tissues but not Gerota's fasciaT3bTumor grossly extends into renal vein or vena cava below diaphragmT3cTumor grossly extends into vena cava above diaphragmRegional Lymph Nodes (N)NXRegional lymph nodes cannot be assessedNONo regional lymph node metastasisN1Metastasis in a single regional lymph node or nodesN2Metastasis in more than one regional lymph nodeDistant Metastasis (M)MXDistant metastasis cannot be assessedMONo distant metastasisM1Distant MetastasisStaging GroupingIT1NOMOIIT2NOMOIIIT1N1MOT2N1MOT3aNOMOT3aN1MOT3bNOMOT3bN1MOT3cNOMOT3cN1MOIV`T4T4NOMOAny TN2MOAny TAny NM1 References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    14. PROGNOSIS Prognosis    Tuesday, 16 May 2006 Few recurrences are local [renal bed]. Most are pulomary, hepatic, or bone. Disease specific cancer survival is stage dependent at 5 and 10 years Stage5 yrs10 yrsI9080II8070III5035IV103 Partial nephrectomy in <4 cm lesions has a disease free survival approaching 100% at 5 years Incidentally found, unilateral and small lesions perform best Memorial Sloan-Kettering Nomogram Researchers at Memorial Sloan-Kettering have developed a nomogram that combines prognostic factors to predict the likelihood of recurrence after surgery for renal cell carcinoma. This nomogram can be used to predict the five-year probability of treatment failure among patients with newly-diagnosed renal cell carcinoma. http://www.mskcc.org/mskcc/html/6156.cfm References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Prognosis    Tuesday, 16 May 2006 Few recurrences are local [renal bed]. Most are pulomary, hepatic, or bone. Disease specific cancer survival is stage dependent at 5 and 10 years Stage5 yrs10 yrsI9080II8070III5035IV103 Partial nephrectomy in <4 cm lesions has a disease free survival approaching 100% at 5 years Incidentally found, unilateral and small lesions perform best Memorial Sloan-Kettering Nomogram Researchers at Memorial Sloan-Kettering have developed a nomogram that combines prognostic factors to predict the likelihood of recurrence after surgery for renal cell carcinoma. This nomogram can be used to predict the five-year probability of treatment failure among patients with newly-diagnosed renal cell carcinoma. http://www.mskcc.org/mskcc/html/6156.cfm References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    15. FOLLOW-UP Traditionally, most patients with sporadic RCC are followed every 6 months or yearly with a history and physical examination (H&P), liver function studies, serum chemistry (including alkaline phosphatase), CXR, and abdominal cross-sectional imaging. T1: H&P, serum chemistry, and CXR yearly for 5 years T2: H&P, serum chemistry, and CXR every 6 months; abdominal CT scan at 2 and 5 years for 5 years T3: H&P, serum chemistry, and CXR at 3 months, then every 6 months; abdominal CT scan at 2 and 5 years Clinical Follow Up    Tuesday, 16 May 2006 Traditionally, most patients with sporadic RCC are followed every 6 months or yearly with a history and physical examination (H&P), liver function studies, serum chemistry (including alkaline phosphatase), CXR, and abdominal cross-sectional imaging. However, contemporary series from M.D. Anderson and the Cleveland Clinic suggest that recurrence is generally a rare event for T1 and T2 lesions. In addition, pulmonary metastasis are most common and usually can be diagnosed by chest radiography. Stage-specific follow-up guidelines have been proposed as follows. TI: H&P, serum chemistry, and CXR yearly for 5 years T2: H&P, serum chemistry, and CXR every 6 months; abdominal CT scan at 2 and 5 years for 5 years T3: H&P, serum chemistry, and CXR at 3 months, then every 6 months; abdominal CT scan at 2 and 5 years References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Clinical Follow Up    Tuesday, 16 May 2006 Traditionally, most patients with sporadic RCC are followed every 6 months or yearly with a history and physical examination (H&P), liver function studies, serum chemistry (including alkaline phosphatase), CXR, and abdominal cross-sectional imaging. However, contemporary series from M.D. Anderson and the Cleveland Clinic suggest that recurrence is generally a rare event for T1 and T2 lesions. In addition, pulmonary metastasis are most common and usually can be diagnosed by chest radiography. Stage-specific follow-up guidelines have been proposed as follows. TI: H&P, serum chemistry, and CXR yearly for 5 years T2: H&P, serum chemistry, and CXR every 6 months; abdominal CT scan at 2 and 5 years for 5 years T3: H&P, serum chemistry, and CXR at 3 months, then every 6 months; abdominal CT scan at 2 and 5 years References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    16. CLINICAL PRESENTATION A QUARTER PRESENT WITH ADVANCED DISEASE, LOCALLY ADVANCED OR METASTATIC A THIRD OF PATIENTS POST SURGERY FOR LOCALISED DISEASE WILL RELAPSE WITH METASTATIC DISEASE THE MEDIAN SURVIVAL IS 13 MONTHS    Tuesday, 16 May 2006 "Classic triad": flank pain, a palpable mass, and hematuria is now seen in less than 10% of patients. Hematuria (gross or microscopic) seen most often among the classic symptoms Increasing number of lesions (>25%) are seen as incidental findings on imaging for other conditions Systemic syndromes Anemia, fatigue, cachexia, weight loss 20-40% Hypercalcemia 10-15 % Hepatic dysfunction (Stauffer's syndrome) 5% Rare syndromes: Erthrocytosis, protein wasting enteropathy, neuomyopathy, amyloidosis References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.    Tuesday, 16 May 2006 "Classic triad": flank pain, a palpable mass, and hematuria is now seen in less than 10% of patients. Hematuria (gross or microscopic) seen most often among the classic symptoms Increasing number of lesions (>25%) are seen as incidental findings on imaging for other conditions Systemic syndromes Anemia, fatigue, cachexia, weight loss 20-40% Hypercalcemia 10-15 % Hepatic dysfunction (Stauffer's syndrome) 5% Rare syndromes: Erthrocytosis, protein wasting enteropathy, neuomyopathy, amyloidosis References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    17. CLINICAL PRESENTATION THE CLASSIC TRIAD <10 % INCIDENTAL DETECTION ALMOST 50% SYSTEMIC SYNDROMES ANAEMIA, FATIGUE, CACHEXIA, WEIGHT LOSS, HYPERCALCEMIA, HEPATIC DYSFUNCTION RARE SYNDROMES ERYTHROCYTOSIS, ENtEROPATHY, NEUROPATHY, AMYLOIDOSIS    Tuesday, 16 May 2006 "Classic triad": flank pain, a palpable mass, and hematuria is now seen in less than 10% of patients. Hematuria (gross or microscopic) seen most often among the classic symptoms Increasing number of lesions (>25%) are seen as incidental findings on imaging for other conditions Systemic syndromes Anemia, fatigue, cachexia, weight loss 20-40% Hypercalcemia 10-15 % Hepatic dysfunction (Stauffer's syndrome) 5% Rare syndromes: Erthrocytosis, protein wasting enteropathy, neuomyopathy, amyloidosis References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.    Tuesday, 16 May 2006 "Classic triad": flank pain, a palpable mass, and hematuria is now seen in less than 10% of patients. Hematuria (gross or microscopic) seen most often among the classic symptoms Increasing number of lesions (>25%) are seen as incidental findings on imaging for other conditions Systemic syndromes Anemia, fatigue, cachexia, weight loss 20-40% Hypercalcemia 10-15 % Hepatic dysfunction (Stauffer's syndrome) 5% Rare syndromes: Erthrocytosis, protein wasting enteropathy, neuomyopathy, amyloidosis References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    18. Imaging Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing.    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    19. Imaging Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines. I [Simple cyst] 0% cancer risk II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    20. Imaging Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    21. Imaging Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    22. Imaging Magnetic Resonance Imaging Non ionizing radiation modality provides 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    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    23. Imaging Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!    Tuesday, 16 May 2006 Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing. Computed tomography Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available Magnetic Resonance Imaging Non ionizing radiation modality provides 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 Ultrasonagraphy Excellent in distinguishing cystic from solid masses. 30-50% of patients >50 years will have renal cysts Bosniak classification provides guidelines for cysts From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses. I [Simple cyst] 0% II [Minimally complicated] 2-10% cancer risk III [Indeterminate cyst] up to 50% cancer risk IV [Cystic renal cell] up to 90% cancer risk Intravenous Urography Starting point for hematuria evaluations Abnormal findings require other imaging for conformation Calcification pattern suggestive Speckled or mottled, 90% cancer Rim calcification 10-20% cancer Angiography Generally supplanted by MRI angiography Used for embolization of large lesions preoperatively Radionuclide Imaging Most useful in detecting pseudo-masses Tumors and cysts are photo-deficient areas Percutaneous biopsy Generally not useful due to the high [30-50 percent] false positive rate Some value in ruling out metastatic disease or lymphoma References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!

    24. CLINICAL STAGING 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). Laboratory: CBC, LFT's, alkaline phosphotase, BUN, creatinine. Clinical Staging    Tuesday, 16 May 2006 Chest X-ray or Chest CT CT/MRI scan of abdomen or pelvis Bone scan with plan films (for elevated alkaline phosphotase or bone pain. Laboratory: CBC, Chempanel -LFT's, alkaline phosphotase, BUN, creatinine. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Clinical Staging    Tuesday, 16 May 2006 Chest X-ray or Chest CT CT/MRI scan of abdomen or pelvis Bone scan with plan films (for elevated alkaline phosphotase or bone pain. Laboratory: CBC, Chempanel -LFT's, alkaline phosphotase, BUN, creatinine. References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

    25. SURGICAL TREATMENT OPTIONS IN RCC CLASSICAL RADICAL NEPHRECTOMY OPEN PARTIAL NEPHRECTOMY LAPAROSCOPIC PARTIAL NEPHRECTOMY ENERGY APPLICATIONS PERCUTANEOUS, EXTRACORPOREAL, LAPAROSCOPIC EXPECTANT TREATMENT

    27. TREATMENT Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    30. TREATMENT Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    31. TREATMENT Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    32. TREATMENT Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    34. TREATMENT Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    35. TREATMENT Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach. Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    36. TREATMENT Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    37. TREATMENT Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.) Metastatic disease - Surgery Outcome with metastatic disease depends on performance status Low volume metastasis, especially pulmonary involvement tend to respond best. Recent data to suggest a slight but statistically significant survival benefit if nephrectomy performed in conjunction with immunotherapy. Patients with significant disease burden and poor performance status less likely to benefit. Metastatic disease - Medical therapy Few cytoreductive agents have any significant impact on renal cell carcinoma Radiation therapy has little proven effect on renal cell carcinoma Cytokine therapy [IL-2] demonstrates a complete response in 4% of patients and a partial response in 12-20% of patients Antiangiogenesis agents have theoretical promise for this disease References Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999. Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998. Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998. Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989. Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996. Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993. Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994. Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989. Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989. Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994. Reader Comments Please log-in or register in order to submit comments. Powered by AkoComment!Treatment    Tuesday, 16 May 2006 Expectant management Small lesions [<3.0 cm] have a minimal risk of metastasis and increase in size approximately 6 mm per year. In elderly and very ill patients minimal intervention may be warranted. Percutaneous or laparoscopic ablation CT guided radiofrequency ablation - potential minimally invasive therapy requiring further follow-up Laparoscopic cryosurgical ablation - less invasive ablation technique will require further follow-up These and similar technologies promising and suited to the higher incidence of smaller lesions detected incidentally. Nephron-sparing surgery Local recurrence rate 1-2% 15% of small lesions may not be renal cell Ca Preservation of renal function is laudable Indicated in small lesions [<4cm], patients with poor renal function, bilateral disease, and solitary kidney Renal cooling and intraoperative ultrasound required in more difficult cases. Open vs. laparoscopic approach based on tumor location, size, and operator experience. Laparoscopic nephrectomy Pure laparoscopic and "hand-assisted" techniques available. Hand- assisted approach has promulgated the technique, feasible for most tumors <8-10 cm depending on location. Operative time longer, hospital stay and pain requirement less, time to normal function shorter than flank incision. Learning curve associated with this approach Classic Radical Nephrectomy Gold standard of comparison. Performed through several different flank or subcostal approaches. Well tolerated. Minimal role for aggressive lymphadenectomy. Nodes generally removed from ipsilateral great vessel. Adrenalectomy not required if preoperative imaging is normal or if the renal tumor is in the mid or lower pole of the kidney. Inferior vena cava extension Sub classification based on cranial extent of lesion figure 1 Patient prognoses based on stage of lesion and not extent of thrombus Complexity of surgery ranges from partial clamping of the vena cava to cardiopulmonary bypass with hypothermia and circulatory arrest. Mortality 2-14 %. Figure 1 The different classifications of renal tumors with inferior vena caval involvement. Each presentation requires implementation of specific surgical techniques. (Reproduced from Skinner DG, Lieskovsky G, eds: Diagnosis and Management of Genitourinary Cancer, 1988, p 697.)

    38. THANK YOU

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