RENAL TUMORS RCC

Renal cells carcinoma = Renal Adenocarcinoma =Hypernephroma

malignant tumor of renal cortex, occur commonly in the fifth- sixth decade of life,
male to female ratio is 2/1 it is not from the ten common cancer in Iraq.
Predisposing factors
1. Smoking and coffee consumption.
2. Analgesic abuse, renal disease as stone, infection, D.M. and thyroid diseases.
3. Occupational carcinogens as in shoe workers, leather tanners, worker exposed
to cadmium, asbestos, petroleum product.
4. increase with obesity, diuretic uses, exogenous estrogen.
5. Increase incidence in horseshoe kidney, polycystic kidney, acquired cystic
disease of the kidney from chronic renal failure
The most effective prophylaxis is to avoid smoking and obecity .
PAT HOLOGY
The tumor originated from proximal renal tubular epithelium. Histologically, it is four
different sub type .
Clear cell RCC 80-90% , papillary RCC 10-15% .
Chromophobe RCC 5% and collecting duct Ca 1%
Macroscopically small tumors are homogenous on cut surface but larger tumors can
exhibit hemorrhage, necrosis with secondary cystic areas and occasionally
calcification. It has no true capsule but may have apseudocapsule of compressed renal
parenchyma, fibrous tissue and inflammatory cells. Hypernephroma is vascular tumor
spread directly through renal capsule to the perinephric fat and adjacent visceral
structure, hematogenous spread is the main form of spread, it is to the renal vain,
inferior vena cava, common site of metastasis is to the lungs, liver and bones.
Paraortic lymph nodes also involved by lymphatic spread.
T1-Tumor <7 cm in dimension limited to the kidney .
T2- Tumor >7 cm in dimension limited to the kidney.
T3- Tumor extend into major veins or perinephric tissue and not beyond Gerotas
fascia
T4-Tumour invades beyond Gerotas fascia
CLINICAL FEATURES
 With increase usage of ultrasound significant number of renal tumors detected
incidentally without clinical features, those tumors known as incidenteloma. It
is 50% of patients
 Renal cell cancer and malignant melanoma are associated with wide variety of
presenting clinical features those are known as (internists tumors).
A. Features of the tumors itself, gross hematurea, flank pain and palpable mass
occur in 10% of patients. Those are manifestation of advanced disease.
 Only hematurea macroscopic or microscopic found in 60%.
 Abdominal pain or mass or both found in 40% of patients.
B. Symptoms of secondaries as cough, dyspenia or bone pain, or jaundice in 25%.
C. paraneoplastic syndrom (clinical features caused by substance secreted by
malignant tissue).Found in 25% of patients .
1. Paraneoplastic erythrocytosis occur in 10% of patients either by increased
erythropoiten production by the tumor or by hypoxia of near by renal tissue
producing erythropoiten.
2. Hypercalcemia by parathyroid hormone or parathyroid hormone like protein
secreted by the tumor or by osteodustrection by secondaries in the bone.
3. Hypertension in 40% of patients by renin secretion from the tumor or by ischemia
to compressed non neoplastic renal tissue.
4. Stauffer’s syndrome , is hepatic dysfunction without secondary tumor in the liver.
This is reversible condition disappear after tumor removal. There is increase
S, alkaline phosphatase, bilirubin, prolonged PT, hypoalbuminemia, hypergamma
globulinemia also there is fever, fatigue, weight loses , this syndrome may by
hepatotoxic product of the tumor.
5. Cushing’s syndrome by adrenocorticotropin secreted by the tumor.
6. Galactorrhea by prolactin secretion.
7. Hypoglycemia by insulin.
8. Gynecomastia and decreased libido or hirsutism, amenorrhea and male pattern
blading by gonadtropin.
9. Protein enteropathy by enteroglucogon.
Patients whose paraneoplastic metabolic disturbance fails to normalize after
nephroctomy, has undetectable metastatic disease with poor prognosis.

INVESTIGATIONS (vascular mass by U/S and doppler which

inhanced by contrast with CT is malignant )
In addition to G.U.E, renal function test, the patient need:
1. C.B.P. there is anemia in 30% of patient , which is not by blood losing or
hemolysis and not respond to iron therapy. ESR increased in 75%.
2. U/S show renal mass, solid mass with color doppler it’s vascularity will be
evaluated.
3. I.V.U, plain film may show calcification, with contrast it show renal mass which
should be evaluated by U/S to determine if the mass cystic or solid. The kidney
may not visualized either by massive parenchymal involvement, vascular
involvement or by urteric obstruction.
4. CT scan with contrast is of choice to evaluate solid renal mass (inhenced mass by
contrass is malignant) and detect renal vain or inferior vena cava involvement and
evaluate nearby organ involvement and regional lymph nodes, also for chest and
brain secondaries.
5. Renal anigography, 90% of tumor are hypervasicular. It indicated in patient with
renal tumor in solitary kidney when attempts to perform partial nephroctomy.
6. Needle biopsy indicated for inoperable tumors or Fine needle aspiration cytology
FNA for cystic lesion remains equivocal after full evaluation
7. Cystoscopy- patient with hematurea needs cystoscopy. Blood flow from one
ureteral orifice identifies the origin of bleeding from the upper tract on that side
TREATMENT
Small renal masses in surgically unfit person can be managed by Active
Surveillance to check it frequently and managed by surgical approach when it
begen to enlarge .
Small renal lesion can be manged by Energy ablative therapy that either use
microwave thermotherappy to induce high temperature or by cryotherapy to dustrect
the tumer percutenously.
Small renal lesion can be managed by resection either by open surgical way,
laparoscopic or robotic approch,This way of treatment is known Partial
Nephrectomy or nephron sparing surgery and if partial nephrectomy is
unapplicable so the kidney and its envelopiny fascia is removed Radical
Nephrectomy .
For metastatic renal lesion , the kidney is removed (cytoredaction) and the metastasis
if single resectable also will be removed and other lesions are maneged by
immunotherapy using interferon or Interluken or use what is known as Target
Therapy angiogenesis inhibitor drug as Tyrosine kinase inhibitor as( sorafenib or
sunitinib) or use endothelial growth factor blocker.Renal adenocarcinoma are radio
and chemo resistant tumor .

Nephroblastoma = Wilm’s Tumor.

It is 15% of renal tumor, it contribute to 5% of childhood cancer. Both sexes are
equally affected. Peak age of presentation is third year of life. 1% of those patients
have familial history of the disease. The tumor is associated with variety of congenital
anomalies including (cryptorchoidism, hypospadias, aniridia, and hemihypertrophy).

Pathology- this tumor arise from the metanephric blastema usually it consist of
blastemal, epithelial and stromal elements in varying proportion. Histologically, it has
favorable or unfavorable prognostic group. Presence of focal or diffuse anaplastic
cells, clear cells sarcoma or malignant rhabdoid element all are features of unfavorable
prognosis.

STAGING
I-Tumor limited to the kidney without residual malignant cells by radical
nephrectomy.
II- There is regional extension of the tumor. There is no apparent residual tumor but
their local spillage of cells in the flank.
III-There residual non hematogenous tumor confined to the abdomen.
IV-Hematogenous spread.
V. Bilateral tumor in 5% of cases.
Clinically- usually there is painless abdominal mass, may there abdominal pain,
distention, anorexia, nausea, vomiting, fever and hematurea.
There is hypertension in 50% of children by elevated renin level.

INVESTIGATION
G.U.E. may show hematurea.
C.B.P may show anemia by blood lose.
C:X.R to check for pulmonary involvement.
I.V.U. which show distortion of collecting system with enlargement of the kidney by
renal mass.
U/S give accurate, non invasive, cost effective information about renal mass and to
search for any secondries in the liver.
F.N.A. is indicated only for large tumor, which is difficult to be resected primarily and
for which pre operative chemotherapy is indicated.to change unresectoble mass to
resectable one.

TREATMENT
Renal tumor not crossing mid line or not involving adjacent visceral organ is treated
by radical nephrectomy by trans abdominal approach. For unresectable tumor pre
operatively chemotherapy can debulk the tumor dramatically.
Nephroblastoma is chemosensitive tumor, Actinomycm D, Vinicristine and
Adryamycin used in all stages to control residual tumor and to decrease relapse risk.
Wilm’s tumor is radiosensitive tumor, but irradiation in children has it’s potential
effect on growth and has recognized cardiac, pulmonary and hepatic toxicity. With
efficient chemotherapy there is no place for pre operative radiation which may be used
post operatively for unfavorable histology and for stage IV.

Oncocytoma
– essentially benign renal tumar – it is 7% of solid renal tumor . most of them cannot
be differentiated from malignant RCC by clinical or radiographic means, because of
uncertenity of pre operative diagnosis those are managed as RCC depending on
clinical circumstance .

Angiomyolipoma
–AML benign tumor consist of varying amount of mature adipose tissue , muscle and
thick wall vessels. from its complication is repture so tumor more than 5 cm in
diameter need resection .