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Kidney

Renal Cell Carcinoma

  • Key Imaging Questions
    - Size of primary tumor
    - Evidence of venous invasion
    - Adjacent organ invasion
    - Nodal metastasis
    - Distant metastases
  • Partial Nephrectomy: Patient Selection
    - Previously tumor was 4 cm or less and now 7 cm is the usual cutoff (T1 tumor)
    - Partial nephrectomy can be used in T2 tumors (> 7cm) in select cases such as solitary kidney or overall poor renal function and the need to “save kidney”
    - Location of tumor is then a critical factor in selecting patients for partial nephrectomy
  • “ Clinical node staging is inaccurate. The positive predictive value of the finding of nodes larger than 1 cm on preoperative imaging is only 42%.”
    Renal Cell Carcinoma: What the Surgeon and Treating Physician Need to Know
    Chapin BF et al.
    AJR 2011; 196:1255-1282
  • Renal Cell Carcinoma: Sites of Metastases
    - Lung (75% of cases)
    - Liver (40% of cases)
    - Bone (40% of cases)
    - Soft tissue (34% of cases)
    - Pleura (31% of cases)
  • Recurrent Renal Cell Carcinoma: Facts
    - Metastases can occur early in the post operative course (under 1 year) as well as late in the post-operative course (over 10 years later)
    - Metastases tend to follow the vascularity of the primary tumor and most are hypervascular
    - Arterial phase CT is critical in lesion detection especially in liver and pancreas

  • "Patients with renal cell carcinoma in whom multidetector computerized tomography fails to detect tumor thrombus are unlikely to have a tumor thrombus found at surgery that would change the surgical approach."

    The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma
    Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME
    J Urology Vol 181,486-491 February 2009

  • "Multidetector computerized tomography with 3-dimensional mapping is an effective imaging modality for accurately characterizing the level of venous thrombus in patients with renal cell carcinoma. The modality effectively identified patients with clinically significant venous thrombus"

    The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma
    Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME
    J Urology Vol 181,486-491 February 2009

  • MDCT Evaluation of Venous Extension in RCC

    J Urol. 2009 Feb;181(2):486-90; discussion 491. Epub 2008 Dec 19.

    The accuracy of multidetector computerized tomography for evaluating tumor thrombus in patients with renal cell carcinoma.

    Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME.

    The James Buchanan Brady Urologic Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA. tguzzo1@jhmi.edu

    Abstract

    PURPOSE: New advances in computerized tomography, including multidetector computerized tomography with 3-dimensional reformatting has recently called into question the absolute need for magnetic resonance imaging for evaluating renal cell carcinoma with suspected venous involvement. We assessed the accuracy of multidetector computerized tomography for predicting tumor thrombus and the level of venous involvement in patients with renal cell carcinoma.

    MATERIALS AND METHODS: We retrospectively reviewed clinical and pathological features in 41 patients with renal cell carcinoma who underwent staging multidetector computerized tomography before surgery. Multidetector computerized tomography findings regarding the presence and level of tumor thrombus were compared to findings at surgery and at final pathological evaluation. All multidetector computerized tomography studies were read by a single radiologist (EKF) before surgery.

    RESULTS: When excluding patients with segmental venous involvement only, the concordance rate between multidetector computerized tomography and pathological findings was 84%. Multidetector computerized tomography accurately predicted the level of tumor thrombus in 26 of 27 patients (96%). Four cases of negative multidetector computerized tomography findings were up staged to renal vein involvement based on pathological findings. All 4 patients had early distal thrombi that did not change operative management.

    CONCLUSIONS: Multidetector computerized tomography with 3-dimensional mapping is an effective imaging modality for accurately characterizing the level of venous thrombus in patients with renal cell carcinoma. This modality effectively identified patients with clinically significant venous thrombus. Patients with renal cell carcinoma in whom multidetector computerized tomography fails to detect tumor thrombus are unlikely to have a tumor thrombus found at surgery that would change the surgical approach.


  • Surgery (open vs laparoscopic surgery)
    - Classic nephrectomy
    - Partial nephrectomy (nephron sparing surgery)

    Percutaneous therapy (RF ablation)

    Chemotherapy

    Immunotherapy

    Vaccine therapy

  • Renal Cell Carcinoma: Stage IV (any of these)
    - Tumor that has spread directly through the fatty tissue and the fascia ligament-like tissue that surrounds the kidney. Involvement of more than one lymph node near the kidney
    - Involvement of any lymph node not near the kidney
    - Distant metastases, such as in the lungs, bone, or brain.
  • Renal Cell Carcinoma: Stage III (either)
    - Tumor of any size with involvement of a nearby lymph node but no metastases to distant organs. Tumor of this stage may be with or without spread to fatty tissue around the kidney, with or without spread into the large veins leading from the kidney to the heart.
    - Tumor with spread to fatty tissue around the kidney and/or spread into the large veins leading from the kidney to the heart, but without spread to any lymph nodes or other organs.

  • Renal Cell Carcinoma: Stage II

    Tumor larger than 7.0 cm but still limited to the kidney. No lymph node involvement or metastases to distant organs.

  • Renal Cell Carcinoma: Stage I

    Tumor of a diameter of 7 cm (approx. 2 3/4 inches) or smaller, and limited to the kidney. No lymph node involvement or metastases to distant organs.

  • Renal Cell Carcinoma: Sites of Tumor Spread
    - Lung (75%)
    - Soft tissues (36%)
    - Bone (20%)
    - Liver (18%)
    - CNS (8%)
    - Fact: up to 30% of patients with renal cell carcinoma present with metastatic disease at time of presentation
  • Renal Cell Carcinoma: Presentation
    - Hematuria (40%)
    - Flank pain (40%)
    - Palpable mass in flank or abdomen (25%)
    - Weight loss (33%)
    - Fever (20%)
    - Hypercalcemia (5%)
  • Renal Cancer (RCC and TCC): Facts
    - 58,240 Americans will be diagnosed with renal cancer in 2010 and an estimated 13,040 will die from renal carcinoma in 2010. (Deaths worldwide are over 100,000 annually)
    - Over 40,000 of these cases and over 12,000 deaths will be due to renal cell carcinoma
    - Typical age is over 55 years and occurs more frequently in men
    - 92% of cases are clear cell renal cell carcinoma and around 8% are papillary type renal cell carcinoma

  • SEER data: Cancer Statistics

    http://seer.cancer.gov/statistics/

    Renal Cancer (RCC and TCC): Facts
    - 58,240 Americans will be diagnosed with renal cancer in 2010 and an estimated 13,040 will die from renal carcinoma in 2010. (Deaths worldwide are over 100,000 annually)
    - Over 40,000 of these cases and over 12,000 deaths will be due to renal cell carcinoma
    - Typical age is over 55 years and occurs more frequently in men
    - 92% of cases are clear cell renal cell carcinoma and around 8% are papillary type renal cell carcinoma
  • irt-Hogg-Dube Syndrome: Facts
    - Rare autosomal dominant disease
    - Syndrome includes hair follicle hamartomas, renal tumors, and pulmonary cysts
    - Tumors usually occur at an earlier age and are multiple
    - Renal tumors are usually chromophobe RCC
  • Renal Cell Carcinoma and Syndromes
    - 3-5% of cases are associated with syndromes
    - Syndromes include:
    - Von Hippel-Lindau syndrome
    - Birt-Hogg-Dube syndrome
    - Hereditary papillary
    - renal cell carcinoma
  • Renal Cell Carcinoma: Sites of Metastases
    - Lung (75% of cases)
    - Liver (40% of cases)
    - Bone (40% of cases)
    - Soft tissue (34% of cases)
    - Pleura (31% of cases)

  • "Tumor long axis measurements and volumetric mean tumor attenuation of target lesions on CECT images were correlated with time to progression in 53 patients with metastatic clear cell RCC treated with first line sorafenib or sunitinib."

    Assessing Tumor Response and Detecting Recurrence in Metastatic Renal Cell Carcinoma on Targeted Therapy: Importance of Size and Attenuation on Contrast Enhance CT
    Smith AD et al.
    AJR 2010; 194:157-165

  • "One or more target metastatic lesions had decreased attenuation of = 40 HU in 59% of patients with progression free survival of >250 days after initiating targeted therapy; 0% of patients with earlier disease progression had this finding."

    Assessing Tumor Response and Detecting Recurrence in Metastatic Renal Cell Carcinoma on Targeted Therapy: Importance of Size and Attenuation on Contrast Enhance
    CT Smith AD et al.
    AJR 2010; 194:157-165

  • "Objectively measuring changes in both tumor size and attenuation on the first CECT after initiating targeted therapy for metastatic RCC markedly improves response assessment. Distinct patterns of disease recurrence are seen in patients with metastatic RCC on targeted therapy."

    Assessing Tumor Response and Detecting Recurrence in Metastatic Renal Cell Carcinoma on Targeted Therapy: Importance of Size and Attenuation on Contrast Enhance
    CT Smith AD et al.
    AJR 2010; 194:157-165

  • "Patients with highly vascularized metastatic RCC as shown by high baseline tumor blood flow appear to have a worse prognosis than those who do not. Tumor perfusion may be a useful biomarker of prognosis and additionally in the future, may assist in treatment stratification."

    Perfusion CT in Patients With Metastatic Renal Cell Carcinoma Treated With Interferon
    Ng CS et al.
    AJR 2010; 194:166-171

  • Kidney: Renal Cell Carcinoma: Basic Facts
    - 3% of all cancer cases and deaths in the USA
    - 38,900 new cases and 12,840 deaths per year
    - Increasing at rate of 2% per year for 30 years

  • "Tumor growth rates do not correlate with initial tumor volume and the distribution of histologic subtypes and growth rates among small renal tumors is similar to that among larger tumors."

    Distribution of Renal Tumor Growth Rates Determined by Using Serial Volumetric CT Measurements
    Zhang J et al.
    Radiology 2009;250:137-144

     

  • "Growth rates in renal tumors of different sizes, subtypes, and grades represent a wide range and overlap substantially. Small renal tumors appear to be similar to larger ones in nature."

    Distribution of Renal Tumor Growth Rates Determined by Using Serial Volumetric CT Measurements
    Zhang J et al.
    Radiology 2009;250:137-144
All images on this site are © 2012 Elliot K. Fishman, MD.