Partial Nephrectomy: Indications and relevant investigations

Partial Nephrectomy: Indications and relevant investigations
Indications:
• Absolute:
o Solitary kidney
o Bilateral renal masses
o Severe renal insufficiency
• Relative:
o Contralateral kidney with pre-existing renal disease (eg,
nephrolithiasis, recurrent pyelonephritis, PUJO, reflux)
o Medical diseases predisposing to renal insufficiency (eg,
diabetes, hypertension)
o Known multifocality (eg, VHL, papillary histology)
o Symptomatic benign conditions:
• Oncocytoma, AML, obstructed atophied segment
of duplex kidney
• Elective:
o Small lesions less than 4cm (? < 7 cm)
• More recent data supports increasing the cutoff size
to < 7 cm
o Peripheral
o Young healthy patients
Investigations:
• Routine blood tests:
o FBE, U+E, Creatinine, LFT, Coag
o G+H, X-match
• Imaging:
o CXR
o CT or MRI chest/abdo/pelvis:
• Determine location + size of tumour + rule out metastasis
• IVC thrombus (U/S, MRI, 3D CT)
• 3D helical CT:
• Replaced invasive studies (renal arteriogram,
venogram)
• Shows relationship of tumour with collecting
system and vessels
• Renal vasculature and excretory function
o PET/CT scan:
• Not useful in diagnosis:
• Radiotracer uptake (18F-FDG) only moderate in
most primary tumours + radiotracer accumulate in
collecting system
• Useful in staging and re-staging:
• Especially visceral, lymph node and bony disease
o Renal nuclear scintigraphy:
• If contralateral kidney appears atrophic or decreased
excretory function
• If tumour burdened kidney reveals low function, then
consider radical nephrectomy
o Intraoperative ultrasound:
• delineate a tumour in relation to the hilar anatomy
• demarcate the boundary of a surgical margin
• Color and power Doppler U/S:
• can identify arteries, veins, and the urinary
collecting system
• Differentiate vascular vs non vascular structures,
cystic vs solid lesions
• Frozen section:
o Ensure clear margins

Management of
Metastatic Renal Cell
Carcinoma -2007
Sunny Lee WA
• RCC
Most lethal cancer in Urology
•
Cancer specific mortality >40% 1
20-30% present with Mets 2
20-40% undergoing
nephrectomy for localised
RCC with develop Mets
Overall median survival for
M1

• Resection of mets can lead to
long term survival
• Metachronous mets do better
than synchronous mets
•
resection of isolated Lung Mets
especially favourable 1
Better outcome if complete
metastasectomy and

Role of Tyrosine Kinase
Inhibitor (2)
• Motzer 1 et al,
750 pts, no previous systemic Tx,
no brain mets, no high CVS risk,
ECOG 0/1, clear cell histo, 90%
prev CRN
Randomised: Oral Sunitinib 50mg
od vs SC IFNα 3x/wk
Continue until progression
Results (for Sunitinib grp):
• 6 mth median survival advantage
(11 vs 5)
• Higher response rate (31% vs 6%)
• Similar S/E profile (more diarrhoea
in Sunitinib)
• Better quality of life
Identifying good risk patients
through better understanding
of tumour biology
• Tumour vaccine therapy
• Defining role of CRN
Especially with
antiangiogenic therapy
• Adjuvant therapy with TKI
ECOG Trial E2805
SORCE Trial
Role of Tyrosine Kinase
Inhibitor (2)
• Escudier 1 et al
903 pts, progression post
systemic Tx, ECOG 0/1,
intermediate/low risk grp
Oral sorafenib 400mg bd vs
placebo
Median survival benefit 2.7
mths (5.5 vs 2.8)
• S/E of TKI
Diarrhoea, rash, fatigue,
hand-foot skin reactions,
hypertension, cardiac
ischaemia
Management Flow
Chart
The future
• Refining patient selection
for immunotherapy

ACTIVE SURVEILLANCE & INNOVATIVE TREATMENT OF RENAL CELL CANCER.
D.Gyomber
Increased imaging has resulted in frequent detection of small renal masses. (SRM) Most in patients older than 70 yrs with
competing medical co-morbidities. Hollingsworth et al evaluating SEER data determined the relative benefit of renal cancer
surgery declines with decreasing tumour stage and increasing age. Increased treatment of SRM has not decreased mortality,
therefore not all SRM require treatment, analogous to prostate cancer.
Natural History. SRM is < 3cm. Larger SRM are more likely to be malignant, but the ratio of malignant to benign is
approximately the same regardless of size. i.e. 80-90% of SRM are malignant. Schlomer et al J Urol 2006 reviewed 345 renal
lesions 2-2-9cm were benign and malignant 22.9 and 77.1% of the time respectively and those 3-3.9cm 17.5% and 82.5%
Tumour size and pathological findings in 287 SRM

Management of Caval Tumour
T3b and T3c RCC is associated with a particular biological propensity for vascular
invasion, with up to 10% of patients having associated venous tumour thrombus
involving the renal vein or inferior vena cava and 1% having a tumour thrombus that
extends into the right atrium.
Staging techniques-
• Ultrasound (Pre and Intra op)
• CT scan
• MRI
• Cavography
• Trans-oesophagial echo
To identify involvement of renal vein and inferior vena cava
To determine the cephalic extent of the tumour
For preoperative planning
Requirement of Hepatic mobilization
Requirement of cardiac bypass
Assessment of transmural invasion
Surgical management
Preoperative cardiovascular and pulmonary evaluation and therapy
Early ligation of the renal artery to decrease the chance of venous bleeding
?Need for Preoperative arterial embolization
Thrombus extension at and above the level of the hepatic veins poses a particular
challenge because of limited access and difficulty in vascular control
Team Approach
The only curative approach to renal cell carcinoma is surgery. An aggressive
approach is warranted when tumor involves the renal vein and inferior vena cava.
Surgical strategy depends on the level of the inferior vena caval thrombus. Patients
with extension of the thrombus above the diaphragm are a greater technical
challenge. Hypothermic circulatory arrest should be considered when treating vena
caval-atrial tumor thrombus.
References
1. The Mayo Clinic experience with surgical management, complications and outcome for
patients with renal cell carcinoma and venous tumour thrombus. 2004 BJU International
2. American College of Radiology criteria 2007
3. Surgical techniques for treating a Renal neoplasm invading the inferior vena cava JUROL Feb
2003
4. Multidetector computed tomography vs magnetic resonance imaging for defining the upper
limit of tumour thrombus in renal cell carcinoma: a study and review. Nathan Lawrentschuk
2005 BJU International

Management of small renal tumours in the elderly patient.
Evolution of management of small tumours driven by new technologies and recognition that total
nephrectomies predispose patients to chronic renal failure and it’s associated morbidity.
• RCC changing epidemiology:
Increase in incidence, especially in incidental finding of small (

Lymphadenopathy in Renal Tumours
Discussion
Robson (1969)
• Radical nephrectomy with lymphadenectomy
• Para-aortic and paracaval lymphnodes from bifurcation of the aorta to crus of
diaphragm
Arguments for
• Improve accuracy of staging
• Decrease recurrence rates
• Improve survival
Arguments against
• Equal frequency of blood and lymph spread.
• many patients get mets without LN involvment
• Lymphatic drainage of kidney is variable
• Only a small subset of patients will benefit (2-3%)
• Micrometastatic disease
Evidence
1. EORTC study 30881
• No difference in rate of 5yr progression or survival in patients with nonmetastatic
disease with or without LND
2. Pantuck et al. J Urol 2003
• Lymphadenectomy had a role in patients for cytoreductive nephrectomy with
grossly enlarged lymph nodes.
3. Simmons et al. Urol 2007
• Laparoscopic LND is feasible in select population.
Minimal impact on perioperative morbidity
Increased operating time 30min (experts, learning curve)
Unable to assess if lap LND is as efficacious as open (would require RCT but still
difficult to detect a difference)
Case selection: plane around ipsilateral great vessel.

Bleeding During Nephrectomy – Dr Conrad V Bishop
• 56yo man smoker
• Works in IT industry
• PHx : - obesity
- type 2 DM - hypertension
- gout
• Perforated appendix 30 years ago
• Advised right radical nephrectomy
• Offered laparoscopic nephrectomy
•
• Hand assisted right radical nephrectomy
• Hand port via old appendicectomy scar
•
• Right colon and duodenum mobilised
• Kidney elevated by assistant, vessels dissected with hook diathermy
•
• When suddenly…………. Major bleeding
• Calmly alert anaesthetist - fluid resuscitation
- aramine - get blood products
- baseline bloods (FBE, coags inc, fibrinogen)
•
• Get help
• Request open setup, 2 suckers
• Right supracostal incision (12th rib)
•
• Most haemorrhage is venous from avulsion injury
• Avulsion of lumbar vein – posterior to renal vein
– posterior to IVC
• Avulsion of gonadal vein – from IVC on right
– from left renal vein
• Avulsion of adrenal vein
• Direct injury to IVC
•
5mm tear in IVC
Anterior at level of renal vein
Likely hook diathermy injury
Repaired with 5.0 prolene

Management of Renal Cell recurrence
Ahmed Al-Sameraaii
History
Examination
Laboratory testing
Imaging
Surgical and non Surgical ablative procedures
Palliative
*********************************************************
APPROACH
Review type of Surgery :after RN or NSS
Determine site of recurrence :Local (LR) or systemic (SR)
Determine magnitude of recurrence
Local recurrence (LR) of RCC after radical nephrectomy is an uncommon event,
occurring in approximately 2% to 4% of cases.
LR after RN is rare in patients with low-stage pT1-2 N0 M0 RCC.
Only about 40% of local recurrences are isolated; the majority of patients with
local recurrence had original T3 or above and also have systemic recurrence
(SR), and a thorough metastatic evaluation should be pursued.
Personal History
Smoking ( increase risk of recurrence 2 fold),Healthy life style!
Rarely other associated tumours cerebelar hemangioblastomas and retinal
angiomata (VHL disease)
S & S of flank pain, hematuria, wt loss, bone pain , fever cough , hemoptysis
Exam :mass , sudden left varicocele , focal neurological signs, Lymph node dis
Lab Microscopic hematuria, Anaemia, LFT,, increased Hb, Calcium
Imaging
CT C+/-
Most sensitive and cost effective single imaging modality, 85% of such
masses are RCC
MRI
CNS imaging is essential in advanced disease
USS
to evaluate cystic mass
Risk factors include 1) increasing T stage 2) Pathological
staging ,unfavourable pathology and N positive. 3)Familial ( VHL)
Local recurrence in the remnant kidney after nephron-sparing surgery for RCC
is low and has been reported in 1.4% to 10% of patients, and the main risk
factor is advanced T stage.
Treatment
Treatment of Local Recurrence
Treatment of LocoRegiona diseasel
Systemic
Remember that most recurrences are distant from the tumour bed.
Probably a result of unrecognized tumour multicentricity or de novo
occurrence
__________________________________

Isolated local recurrence after Radical Nephrectomy (RN)>>>>Surgical
resection if feasible or EBRT *
Surgery can provide long-term cancer-free status for about 35%
Often a formidable task because the natural tissue barriers are no longer present
and invasion of contiguous organs is not uncommon. En bloc resection of
adjacent organs is often required, and the risk of morbidity can be substantial
Radiation therapy may be of value for palliation of symptomatic local recurrence
in patients who are not operative candidates.
Options for treatment
Recurrence after PN > repeat PN **
or Completion nephrectomy
or RFA*>repeat RFA or surgery
or Cryo>repeat or surgery
Recurrence after RN>Remove local recurrence***
>Adjuvant
>Palliative
>resect the solitary met

Case Presentation and Discussion
Embolisation of Renal Cell Carcinoma
Case Report
Mr. PD
65 year old male
Vague abdominal pain for 6 months
GP – ordered CT scan
Referred to urology clinic with CT
Plan
Operative – open anterior left nephrectomy
Pre-operative embolisation considered
Discussion
Embolisation has role in embolisation of
renal cell carcinoma for palliation of
haematuria and for pre-operative renal
artery control
Occasional used for AMLs and patients
unfit for surgery
Embolisation can be selective (entire
kidney) or nonselective (segmental)
Three embolising modalities: coils,
alcohol, microspheres
Post-infarction syndrome lasts 1-3 days –
includes loin pain, fevers, nausea
Large left cyst and solid cystic renal mass
Close association to spleen and artery
Case Conclusion
Proceeded to surgery without embolisation
Surgery complicated by splenic bleeding
and high drain output (?pancreatitis)
Histopathology demonstrated
rhabdomyosarcoma
Embolisation Conclusion
Role of embolisation declining and remains
controversial
Studies into embolisation small
Palliative embolisation for haematuria
main current application
Selective embolisation available
Large left renal vein
Short left renal artery posterior to vein
References
Munro et al 2003. The role of transarterial
embolisation in the treatment of renal cell
cancer. BJU – 92:240-244
Maxwell et al 2007. Renal artery
embolisation in the palliative treatment of
renal carcinoma. British Journal of
Radiology - 80:96-102

METASTATIC RCC – CASE PRESENTATIONS
CASE 1
79yo man
• 4 month wt loss (4-5kg) and lethargy
• Fe deficiency anaemia
• Mild SOBOE
• Ex-smoker
• Asbestosis
– interstitial lung disease
– extensive pleural plaques
– FEV1 50% predicted
CT abdo – large R upper pole mass abutting liver ?metatasis or direct invasion
CT chest – 3-4x pulmonary metastasis (biopsied)
Confirmed met RCC
Hb 108 ↓, Plt 407↑, LFT normal, Corr Ca 2.75↑
Due to poor performance status, age and comorbidities – unlikely to benefit from debulking
(cytoreductive) nephrectomy which is likely to require an open approach +/- liver resection.
Role of nephrectomy unclear with new systemic therapies targeting angiogenesis pathways
Medical oncology referral for consideration for targeted systemic therapy (Sutent)
CASE 2
46yo man
• R radical nephrectomy 1997 (G3T1) - Mackay
• Rectus muscle metastasis 2002
– solitary 2cm nodule
– excision biopsied
– clear cell renal cell carcinoma
– margins clear
• No immunotherapy
• Annual surveillance USS/CT scans
• USS showed solid left mid pole kidney mass (3.6cm) confirmed on CT Sept 2007
• Primary or secondary?
• Asymptomatic
• Hb 123, Creat 86 (eGFR>60), LDH 180, mildly elevated LFT (hep C)
• Staging CT chest showed solitary left hila mass 3.6cm
• Bone scan NAD
• PET scan showed small area of uptake left gluteus muscle (2cm nodule)
• USS guided biopsies confirmed metastatic RCC
Issues
1. Role of metastasectomy and benefits uncertain (multiple lesions)
2. Solitary kidney - difficult partial nephrectomy and may render dialysis dependent
3. Pulmonary metastasis - hilar lesion ?resectability
4. Gluteus metastasis – prognostic significance
Currently being considered for systemic targeted therapy (tyrosine kinase)