kidney tumors petr klézl urologická klinika 3. lf uk a fnkv
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Kidney tumors
Petr Klézl
Urologická klinika 3. LF UK a FNKV
Kidney tumors - incidence
Renal cell carcinoma – 2-3% of all cancersAnnual increase of incidence apx. 2% 2007 CZ 34.8: 100 000 men
19.7: 100 000 womenMen 1756, women 1039Peak incidence 60-75 years1.5:1 ratio men: womenAetiology - smoking, obesity, antihypertensive
treatment
Renal tumors - diagnosis
More than 50% tumors diagnosed incidentallyAsymptomatic tumors are generally smaller and of lower
stage classic triad (flank pain, gross hematuria, palpable mass) –
6-10%Paraneoplastic symptoms ( hypertension, weight loss,
pyrexia, neuromyopathy, anaemia, polycythaemia, amyloidosis, elevated erythrocytes sedimentation rate, abnormal liver function) – apx 20-30% patients
About 20-30% of patients with paraneoplastic symptoms present as a result of metastatic disease
Kidney tumours - TNM system
Tx - Primary tumour cannot be assessed T0 - No evidence of primary tumour T1 - tumour ≤ 7 cm in greatest dimension limited to the kidney T1a tumour < 4 cm in greatest dimension, limited to the kidney T1b tumour > 4 cm but < 7 cm in greatest dimension T2 - tumour > 7 cm in greatest dimension, limited to the kidney T2a tumour > 7 cm in greatest dimension but < 10 cm T2b tumours > 10 cm limited to the kidney T3 - tumour extends into major veins or perinephric tissues, but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia T3a tumour grossly extends into the renal vein or its segmental (muscle-containing)
branches, or tumour invades perirenal and/or renal sinus (peripelvic) fat but not
beyond Gerota’s fascia T3b tumour grossly extends into the vena cava below diaphragm T3c tumour grossly extends into vena cava or its wall above the diaphragm or invades the wall of the vena cava T4 - tumour invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)
Kidney tumours – TNM system
N - Regional lymph nodes NX Regional lymph nodes cannot be assessed No regional lymph node metastasis N1Metastasis in a single regional lymph node N2Metastasis in more than one regional lymph nodeM - Distant metastasis M0 No distant metastasis M1 Distant metastasis
G - HISTOPATOLOGICAL GRADING GX differentiation cannot be assed G1 well differentiated G2 intermediate differentiation G3-4 poor differentiated
STAGE CLASSIFICATION Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 T1,T2,T3 N1 M0 Stage IV T4 N0, N1 M0 any T N2 M0 any T jakékoliv N M1
http://www.uicc.org/tnm
Kidney tumors – histopathological classification
Fuhrman nuclear gradingRenal cell carcinoma – subtypes - clear cell carcinoma (80-90%)
- papillary RCC ( 10-15%) - chromophobe RCC (4-5%) - collecting duct carcinoma (1%)
Other renal tumors
RCC types account for about 85-90% renal malignancies
10-15% variety of uncomon carcinomas, several benign kidney tumor masses
Angiomyolipomas AML– can be differentiated by radiological imaging from RCC
AML – surgery, thermal ablation, embolisationRenal cysts – Bosniak classificationOncocytomas – verified by biopsy, follow-up can be
considered
Kidney tumours - diagnosis
CT scan with intravenous contrast - enhancement
UltrasoundMRI – alternative to CT scanChest X-ray
Bone scanBrain CTRenal biopsy
US - abscessus
US – tumour of lower pole
Tumour on convexity of kidney
Kidney tumours - treatment
Nephron-sparing surgeryNephrectomyAblative therapiesMetastasectomyEmbolisationAdjuvant therapy ( only clinical trials)Systemic therapyRadiotherapy
Localized RCC - treatment
• nephron-sparing surgery - open partial resection - laparoscopic resection – centres - robotic resectionNephrectomy – when nephron-sparing
surgery not indicated - tumour size - unfavourable localization - general health status
Nephron – sparing surgery - indications
Absolute indications - anatomical or functional solitary kidney - bilateral kidney tumours
Relative indications - functioning opposite kidney affected by a condition
that may impair renal function - hereditary forms of RCC with high risk developing tumour in contralateral kidney - elective operation – healthy contralateral kidney
Kidney tumours – treatment
Radical nephrectomy Approach – laparoscopic nephrectomy T1bT2 - open surgery Adrenalectomy Lymphadenectomy
T2
T2
Xantogranulomatous pyelonephitis
Open resection of renal tumour
Specimen after tumour resection
T3b
Minimally invasive alternative treatment
RFA – radio-frequency ablationcryotherapyMicrowave terapieHIFU- Experimental methods- Low morbidity- Risk pacients not fit for surgery- Recurrence rate higher than nephron-
sparing surgery
Embolization
Embolization of primary tumour - gross hematuria - local symptoms – pain - patients unfit for surgical operation - no benefit before radical nephrectomy
• embolization of metastasis - before resection of major bone metastasis
Adjuvant treatment
Adjuvant tumour vaccination may improve duration of progression-free survival – high risk pt – T3
Cytokine therapy does not improve survival 3 phase III studies are ongoing – therapy
with targeting agents
Outside controlled trials no indication for adjuvant therapy
Metastasesectomy
Complete removal of metastases contributes to improved clinical prognosis
Patients with resectable mets and good performance status ( PS)
Radiotherapy for metastases
Non-resectabel brain metastasesBone metsSymptomatic therapy – pain relief
Surgical treatment of metastatic RCC ( mRCC)
Cytoreductive nephrectomy – only palliative Meta analysis comparing NE +
imunotherapy vs imunotherapy alone – increase of long term survival of patients who underwent nephrectomy
No data available for antiangiogenic therapy
Cytoreductive nephrectomy is recommended when possible
Systemic therapy for mRCC
Imunotherapy – IFN-α (patients with PS, preferably sole lung mets)
Targeting agents – sunitinib, bevacuzimab, temsirolimus
Prognostic criteria (MSCC) Motzer - Karnowsky performance status - Hemoglobin - lactate dehydrogenase - serum calcemia
Angiogenesis inhibitor drugs
Advances in molecular biology led to development of novel agents
Vascular endothelial growth factor (VEGF) and platelet –derived growth factor (PDGF) overexpression due to defective VHL protein
Tyrosin kinase inhibitors ( TKIs) – Sorafenib, Sunitib, Pazopanib
VEGF antibodies – BevacuzimabMammalian target of Rapamycin
(mTOR)inhibitors –Temsirolimus, Everolimus
Systemic therapy - RCC
Systemic therapy of mRCC
therapy risk and previous therapy recommended agent
First - line low and intermediate risk sunitinib bevacizumab + IFN-α high risk temsirolimus
Second line prior cytokine therapy sorafenib prior VEGFR therapy everolimus prior mTOR inhibitor therapy clinical trialsdie
Surveillance after treatment for RCC
Low risk - chest X-ray, US Intermediate risk - chest X-ray, US, CT every 2nd yearHigh risk - chest X-ray, US, CT every year