RENAL CELL CARCINOMA

SURGICAL TREATMENT

BY
DR BILAL AHMAD
RESIDENT SURGEON
UROLOGY BBH RAWALPINDI
 RENAL CELL CARCINOMA

Adenocarcinoma.
Arises from proximal convoluted tubules.
Majority of VHL gene deletions occur in distal
convoluted tubule.
85% of renal malignancies… sporadic and
hereditary.
 CAUSES

ENVIRONMENTAL: cigarette, asbestos, obesity,

dialysis, analgesics.

ANATOMICAL: polycystic disease / horseshoe

kidneys.

GENETIC: VHL syndrome, loss of tumor

suppressor gene on chromosome 3p25 and 26.
 SPREAD

Direct Extension: adrenal gland (7.5%), renal

capsule(25%), renal vein(44%), IVC(5%).

Lymphatics: hilor and paraaortic lymph nodes.

Hematogenous: lungs (75%) , bones(20%),

liver(18%), brain (8%)
 Histological Classification

Conventional (80%)
Papillary (10-15%)
Chromophobe (5%)
Medullary cell: rare
Sarcomatoid : infiltrative poorly differentiated
variant of any type in 5 to 25%, coagulative necrosis
in 30%.
 DIAGNOSTIC EVALUATION

60% detected incidently.

Symptoms are due to tumor growth, hemorrhage,
paraneoplastic syndromes or metastatic disease.
Physical Exam: cervical lympadenopathy, non
reducing vericocele in case of males and B/L lower
limbs edema.
Laboratory findings: s. cret , GFR, CBC, ESR,
LDH , S.corrected Ca, lfts, urine cytology
 Cont…

imaging investigations: usg abd , CT with

contrast and MRI. CT provide function and
morphology of contralateral kidney, tumor
extension, lymph nodes and condition of adrenal
glands and other organs.
MRI: provide additional information on venous
involvement if thrombus in IVC is poorly defined by
CT. MRI for patients with renal insufficiency or
allergy to contrast or pregnancy with normal
kidneys.
 Cont…

Renal arteriography and inferior venacavography

have limited role in selected patients.

Ct chest is accurate for chest staging.

STAGING
 PROGNOSTIC FACTORS

Classified into:
ANATOMICAL FACTORS: tumor size , venous, capsular and adrenal
involvement, lymph nodes and distant metastases.

HISTOLOGICAL: tumor grade, sarcomatoid features, necrosis , micro

vascular invasion, and invasion of collecting system. Fuhrman grading
system is widely accepted.

MOLECULAR FACTORS: carbonic anhydrase IX, hypoxia inducible

factors, p53, p21, e cadherin, and other cell cycle and proliferative
markers.

CLINICAL FACTORS: performance status, cachexia, anemia, platelete

count, CRP and albumins.
 DISEASE MANAGEMENT
Treatment of localized tumor.
Nephron sparing vs radical nephrectomy.

Offer surgery to achieve cure in localized renal cell

cancer(strong).
Offer partial nephrectomy to pts with T1 tumors(strong).
Do not perform ipsilateral adrenalectomy if there is no evidence
of invasion(strong).
Offer an extended lymph node dissection in patients with adverse
features(weak).
Offer embolization to patients unfit for surgery presenting with
massive hematuria(weak).
Open vs Laparascopic surgery.

Offer lap RN to patient with T2 tumors and localized

masses not suitable for PN(strong).
Do no perform minimally invasive RN in patients
with T1 tumors for whome PN is feasible by any
approach including open(strong).
Do not perform minimally invasive surgery if this
approach may compromise oncological, functional
and perioperative outcomes(strong).
 Treatment of locally advanced RCC

Management of clinically positive lymph nodes

(cN+)
In the presence of clinically positive LNs (cN+).
Low level data suggest that tumour thrombus in the
setting of
non-metastatic disease should be excised.
Adjunctive procedures such as tumour embolisation or
inferior vena cava filter do not appear to offer any
benefits in the treatment of tumour thrombus.
In patients unfit for surgery, or with non-resectable
disease, embolisation can control symptoms, including
visible haematuria or flank pain.
 Treatment of advanced/metastatic RCC

Management of RCC with venous tumour

thrombus
In patients with clinically enlarged lymph nodes
(LNs), perform LN dissection for staging purposes or
local control. (Weak)
Remove the renal tumour and thrombus in case of
venous involvement in non-metastatic disease.
(Strong)
 Cytoreductive nephrectomy

Tumour nephrectomy is curative only if all tumour

deposits are excised.
This includes patients with the primary tumour in
place and single- or oligo-metastatic resectable
disease.
For Renal Cell Carcinoma most patients with
metastatic disease, cytoreductive nephrectomy is
palliative and systemic treatments are necessary.
 Immunotherapy

 Interferon-α may only be effective in some patient subgroups,

including patients with ccRCC, favourable-risk criteria, and lung
metastases only.
 Interleukin-2 (IL-2), vaccines and targeted immunotherapy have
no place in the standard treatment of advanced/mRCC.
 Immune checkpoint inhibition of programmed death receptor
(PD-1) and ligand (PD-L1) inhibition have been investigated in
mRCC.
 Randomised data support the use of nivolumab (a PD-1
inhibitor) in VEGF-refractory disease.
 A combination of two immune checkpoint inhibitors ipilimumab
and nivolumab versus sunitinib in a phase III study on mRCC
showed superior survival for a combination of ipilimumab and
nivolumab in intermediate- and poor-risk patients.
 Alternatives to surgery

Surveillance
Elderly and comorbid patients with incidental small
renal masses have a low RCC-specific mortality.
In selected patients with advanced age and/or
comorbidities, active surveillance (AS) is appropriate to
initially monitor small renal masses, followed, if
required, by treatment for progression.
The concept of AS differs from the concept of watchful
waiting.
Watchful waiting is reserved for patients whose
comorbidities contraindicate any subsequent active
treatment and who do not require follow-up imaging,
unless clinically indicated.
 RADICAL NEPHRECTOMY

Gold standard treatment for T2-4 and T1 patients unsuitable for

partial nephrectomy.

Involvement of IVC renders the task of complete excision more

difficult.

5 years survival rate 40 to 68% reported.

Best results: no fats or nodes involved.

Preoperative radiography to asses the distal segment of tumor

thrombus.
Inferior vena cavography indicated when contrast
enhanced usg or MRI contraindicated.

Renal arteriography helpful in pts with RCC ivolving

IVC because arterization of a tumor thrombus is
observed in 5 to 40%.

When present pre op embolization of the kidney

causes shrinkage of thrombus that fascilitates
intraoperative removal.
 Standard Radical Nephrectomy

Extended or b/l subcostal incision.

Thoracoabdominal incision for large upper pole

tumor.

Encompasses early ligation of renal artry & vein ,

removal of gerotas fasia, ipsilateral adrenal gland.

Complete regional lymphadenectomy from crus of

diaghpragm just below to SMA to aortic bifurcation.
Trans peritoneal approach .. Abdomen explore for mets
and early access to renal vessels with minimal tumor
manipulation.

Operation is initiated with dissection of renal

pedicle.
 Radical Nephrectomy With Infra
hepatic IVC Involvement
B/L subcostal transperitoneal incison given as it provides good
exposure.

Renal artery & ureter ligated and divide.

Kidney mobilized outside Gerotas leaving the kidney attached

only to renal vein.

Vena cava is completely dissected from surrounding structures

above and below renal vein.

Contralateral renal vein is also mobilized.

Infra renal and supra renal vena cava clamped with
satinsky clamp and renal vein with bulldog clamp.

Anterior surface of renal vein is incised over the

thrombus continued posteriorly just beneath the
thromus.

After renal vein is circumscribed, gently downward

traction exerted on kidney to extract thrombus from
vena cava.
 Radical Nephrectomy With Intra Or
Supra Hepatic Vena Caval Involvement

Significantly increased difficulty for excision.

b/l subcostal incision for abdominal portion.

After confirming resectability, median sternotomy is

made.

Kidney is mobilized with division of renal artery and

ureter such that kidney attached by only renal vein.
Infra renal vena cava and contralateral renal vein is also exposed.
Mobilize the left kidney with a window in mesentery of left colon.
This manure yields excellent exposure.

After this heart and great vessels are exposed and right atrial
venous and ascending aortic cannula placed.

Cardioplegia done.

Heparinize the patient.

Hypothermia initiated by reducing arterial inflow
blood temp to 10C*.

Abdomen and head packed with ice to bring core

temp to 18 to 20 C* in 30 mints.

At this point perfusion machine is stopped and no

blood flow to any organ.
IVC is incised at the entrance of involved renal vein and
ostium is circumscribed.
When tumor extend to atrium , it is opened at the same
time.

Hypothermic circulatory arrest is safely maintained for

40 mints.

Following removal of tumor , vena cava is closed with

suture 5/0 in continous manner, right atrium is also
closed.
Rewarming is initiated taking 20 to 45 mints until
body temp 37C*.

Protamine to reverse heparinization, platelets ad

ffps for clotting profile.
 Partial nephrectomy

Gold standard , indications:

Absolute: tumor in single anatomical/functional
kidney, B/L tumors.
Relative: multifocal RCC, particularly VHL
syndrome, contralateral kidney threatened by other
conditions.
Elective: T1 tumor less than 4cm with normal
contralateral kidney until the tumor is close to the
pelvi calyceal system.
Open trans peritoneal or loin approach is used.

Renal artery is clamped and packed with ice to

prevent warm ischaemia.

If surgical margin clear of tumor, depth of the

margin(>1mm) does not influence risk of local
recurrence.
Robot assisted or lap partial nephrectomy is
becoming standard approach. Oncological outcomes
are comparable with open.

Disadvantages include long warm ischemia time and

increased per operative complications.
Functional recovery is within hours after 20 mint of
warm ischemia, days after 30 mints andit may take
several weeks after 60 mints of clamping.
 MCQ
A 45-year-old woman presents with a 7-cm renal cell
carcinoma with radiologic evidence of abdominal
lymph node involvement with no distant metastases.
Which of the following is the most appropriate
management of this patient?
a. Radical nephrectomy
b. Radiation
c. Chemotherapy
d. Radiation followed by nephrectomy
e. Chemotherapy followed by nephrectomy
The answer is a. (Townsend, pp 2273-2274.) Renal cell
cancer is not responsive to radiation and chemotherapy;
therefore, radical nephrectomy remains the main
treatment for localized renal cancer. A radical
nephrectomy should be offered as a possible curative
procedure in this patient because many nodes initially
suspected of having metastatic disease on imaging are
enlarged due to reactive inflammation.
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