Renal Cell Carcinoma 5th Annual RVH Imaging Symposium March 25, 2010 - PowerPoint PPT Presentation

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Renal Cell Carcinoma 5th Annual RVH Imaging Symposium March 25, 2010

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Renal Cell Carcinoma 5th Annual RVH Imaging Symposium March 25, 2010 Dr. Angelo J. Iocca B.Sc., M.D., FRCSC Uro-Oncology Fellowship (Mayo Clinic) Staff Urologist – PowerPoint PPT presentation

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Title: Renal Cell Carcinoma 5th Annual RVH Imaging Symposium March 25, 2010


1
Renal Cell Carcinoma5th Annual RVH Imaging
SymposiumMarch 25, 2010
Dr. Angelo J. Iocca B.Sc., M.D.,
FRCSC Uro-Oncology Fellowship (Mayo Clinic) Staff
Urologist Royal Victoria Hospital Barrie, Ontario
2
Renal Cell Carcinoma
3
Renal Cell Carcinoma
  • Most common primary renal malignant neoplasm in
    adults
  • 90 of renal tumours
  • 2 of all adult malignancies
  • More common in men (1.6 to 1)
  • Incidence peaks in patients 55-84 years old
  • Approximately 5,800 new cases in Canada in 2009
  • Approximately 1,300 deaths in Canada in 2009

4
Renal Cell Carcinoma
  • 20 of cases present with metastatic disease
  • 2 of cases present with simultaneous bilateral
    disease
  • Most cases are found in early stages incidentally
    due to widespread use of medical imaging in
    general
  • Incidentaloma

5
Renal Cell Carcinoma
  • Risk factors
  • Male
  • Smoking
  • Cadmium
  • Benzene
  • Trichloroethylene
  • Asbestos exposure
  • Elevated body mass index
  • Chronic dialysis
  • Genetic syndromes (familial RCC, hereditary
    papillary RCC, von Hippel-Lindau syndrome and
    tuberous sclerosis)

6
Renal Cell Carcinoma
  • RCCs arise from the tubular epithelium and are
    based in the renal cortex
  • Pathologic subtypes
  • Clear cell
  • Papillary
  • Granular cell
  • Chromophobe cell
  • Sarcomatoid

7
Renal Cell Carcinoma
  • Clear cell carcinoma

8
Renal Cell Carcinoma
  • Bilateral RCCs are more common in von Hippel
    Lindau syndrome, tuberous sclerosis and chronic
    dialysis

9
Renal Cell Carcinoma
  • Spread may occur by direct local invasion of
    adjacent structures
  • Adrenal glands
  • Liver
  • Spleen
  • Colon
  • Pancreas

10
Renal Cell Carcinoma
  • Local regional lymph node metastases are also
    common
  • Renal vein or IVC thrombus may occur
  • Distant metastases
  • Lungs (most common)
  • Liver
  • Bone
  • Adrenal gland
  • Contralateral kidney

11
Renal Cell Carcinoma
  • Primary tumor (T)
  • TX - Primary tumor cannot be assessed
  • T0 - No evidence of primary tumor
  • T1 - Tumor 7 cm or smaller in greatest dimension,
    limited to the kidney
  • T2 - Tumor larger than 7 cm in greatest
    dimension, limited to the kidney
  • T3 - Tumor extends into major veins or invades
    adrenal gland or perinephric tissues but not
    beyond the Gerota fascia
  • T3a - Tumor invades adrenal gland or perinephric
    tissues but not beyond the Gerota fascia
  • T3b - Tumor grossly extends into the renal
    vein(s) or vena cava below the diaphragm
  • T3c - Tumor grossly extends into the renal
    vein(s) or vena cava above the diaphragm
  • T4 - Tumor invading beyond the Gerota fascia
  • Regional lymph nodes (N) - Laterality does not
    affect the N classification
  • NX - Regional lymph nodes cannot be assessed
  • N0 - No regional lymph node metastasis
  • N1 - Metastasis in a single regional lymph node
  • N2 - Metastasis in more than 1 regional lymph
    node
  • Distant metastasis (M)
  • MX - Distant metastasis cannot be assessed
  • M0 - No distant metastasis
  • M1 - Distant metastasis

12
Renal Cell Carcinoma
  • TNM staging system
  • Stage I
  • 7cm or less and confined to the kidney
  • Stage II
  • gt7cm but still organ confined
  • Stage III
  • Extend into the renal vein or vena cava, involve
    the ipsilateral adrenal gland and/or perinephric
    fat, or have spread to one local lymph node
  • Stage IV
  • Extend beyond Gerotas fascia, to more than one
    local node or have distant metastases

13
Renal Cell Carcinoma
  • Prognosis
  • Dependent on stage
  • Survial after surgical resection
  • T1 (lt7cm)
  • 5yr 95
  • 10yr 91
  • T2 (gt7cm)
  • 5yr 80
  • 10yr 70
  • T3 5 yr 59
  • T4 5 yr 20
  • Suvival for unresectable RCC is lt20 at 5 years

14
Renal Cell Carcinoma
  • Presentation
  • Incidental finding on imaging (incidentaloma)
  • Hematuria
  • Flank pain
  • Flank mass
  • Fever, nausea, anorexia, malaise, night sweats
    and weight loss

15
Renal Cell Carcinoma
  • Preferred imaging
  • Dedicated renal computed tomography (CT)
  • In most cases, this single examination can be
    used to detect and stage RCC and to provide
    information for surgical planning without
    additional imaging

16
Renal Cell Carcinoma
  • In the few patients in whom the CT findings are
    equivocal, MRI or U/S can be useful
  • Angiography is rarely used in the workup of RCC

17
Renal Cell Carcinoma
  • Large renal cell carcinoma (U/S)
  • For the workup in RCC, US is used primarily to
    differentiate solid masses from simple cysts

18
Renal Cell Carcinoma
  • Large renal cell carcinoma (contrast enhanced CT)

19
Renal Cell Carcinoma
  • Small renal cell carcinoma (contrast enhanced CT)

20
Renal Cell Carcinoma
  • Limitations of imaging techniques (CT)
  • Pseudoenhancement of masses smaller than 8-10mm
    may be a problem for CT
  • U/S may help in characterizing some of these as
    cysts
  • If contrast cannot be given then CT is a poor
    choice so MRI may be more helpful

21
Renal Cell Carcinoma
  • Limitations of imaging techniques (U/S)
  • Incomplete staging (bones, lungs and regional
    nodes)
  • Difficult to detect small non-contour deforming
    masses
  • Large patients may not be good candidates for U/S
    because of technical difficulties in obtaining
    good quality images of the kidneys

22
Renal Cell Carcinoma
  • Limitations of imaging techniques (MRI)
  • Patient cooperation because MRI is more sensitive
    to motion artifact than CT
  • MRI is more expensive and less readily available
    than CT
  • Patients with pacemakers, medical implants and
    severe claustrophobia are excluded
  • Benefit
  • No radiation exposure

23
Renal Cell Carcinoma
  • Differntial diagnosis
  • Oncocytoma
  • Other problems to be considered
  • Angiomyolipoma
  • Collecting duct carcinoma
  • Hemorrhagic cyst
  • Infected cyst
  • Lymphoma
  • Metastatic disease
  • Renal abscess
  • Transitional cell carcinoma

24
Renal Cell Carcinoma
  • Renal cell carcinoma. Dedicated renal CT scan
    obtained before contrast enhancement. Right
    kidney has an attenuation measurement of 45.7 HU

25
Renal Cell Carcinoma
  • Renal cell carcinoma. Contrast-enhanced dedicated
    renal CT scan with an attenuation measurement of
    101.7 HU

26
Renal Cell Carcinoma
  • Typical renal cell carcinoma. CT scan obtained
    before contrast enhancement has an attenuation
    measurement of 33.9 HU

27
Renal Cell Carcinoma
  • Typical renal cell carcinoma. Contrast-enhanced
    CT scan has an attenuation measurement of 75.8 HU

28
Renal Cell Carcinoma
  • Multifocal renal cell carcinoma in a patient with
    Von Hippel-Lindau disease. Contrast-enhanced CT
    scan

29
Renal Cell Carcinoma
  • Multifocal renal cell carcinoma in a patient with
    Von Hippel Lindau disease. Patient had already
    undergone a right nephrectomy. Contrast-enhanced
    CT scan

30
Renal Cell Carcinoma
  • Multifocal renal cell carcinoma in patient
    presenting with palpable mass. Nonenhanced CT
    scan

31
Renal Cell Carcinoma
  • Cystic renal cell carcinoma. Nonenhanced CT scan
    with an attenuation measurement of 25.8 HU

32
Renal Cell Carcinoma
  • Cystic renal cell carcinoma. Contrast-enhanced CT
    scan with an attenuation measurement of 47.1 HU

33
Renal Cell Carcinoma
  • Dedicated renal CT
  • Thin section 2.5-5 mm helical imaging of the
    kidneys before IV contrast, followed by 60-70
    seconds and 3-5 minute after IV contrast
  • Imaging parameters (kilovoltage, microamperage,
    field of view, section thickness) should be kept
    constant for all phases of imaging to enable
    comparison of the attenuation measurements

34
Renal Cell Carcinoma
  • The addition of an arterial phase CT with thinner
    slices (1-2 mm) may be helpful to evaluate
    arterial anatomy, especially if partial resection
    is contemplated

35
Renal Cell Carcinoma
  • Historically, enhancement was considered present
    if the attenuation of the lesion increased by
    more than 10 HU from baseline
  • However, with recent advances in CT hardware,
    this definition may need to be changed to 15-20 HU

36
Renal Cell Carcinoma
  • On initial nonenhanced CT scans, RCCs may appear
    as isoattenuating, hypoattenuating, or
    hyperattenuating relative to the remainder of the
    kidney. Calcifications may be present and are
    usually amorphous and internal, although rimlike
    calcifications can also be present.
  • On contrast-enhanced CT scans, RCC is usually
    solid, and decreased attenuation suggestive of
    necrosis is often present. Sometimes RCC is a
    predominantly cystic mass, with thick septa and
    wall nodularity.
  • RCC may also appear as a completely solid and
    highly enhancing mass.

37
Renal Cell Carcinoma
  • Degree of confidence in the imaging
  • If a solitary mass is enhancing, the degree of
    confidence in diagnosing RCC is high. When masses
    are multiple, metastatic disease and lymphoma
    must be considered, especially if the patient has
    a history of a primary malignancy. When a mass is
    predominantly cystic, the confidence level
    decreases. In these patients, US may be useful.

38
Renal Cell Carcinoma
  • False-positive results for CT
  • Pseudoenhancement of small masses (cysts)
  • Bosniak type 2 cysts
  • Thin septa, hyperattenuation, or small amounts of
    mural or septal calcifications
  • Bosniak type 3 cysts
  • Mural nodularity, thick septa, or irregular or
    thick calcifications that often require surgical
    exploration
  • Oncocytomas (indistinguishable from RCC on CT)
  • Angiomyolipomas that do not contain visible fat

39
Renal Cell Carcinoma
  • False-negative results for CT
  • If the attenuation is not carefully measured
    before and after IV contrast
  • If cystic masses are not carefully examined for
    septa or nodularity
  • If enhancement of a lesion is missed (i.e. lack
    of enhancement at the time of scanning)
  • If the mass is too small for adequate
    characterization

40
Renal Cell Carcinoma
  • MRI
  • Findings are similar to those of CT
  • Numeric criteria for enhancement are not defined
    for MRI as they are for CT, but MRI signal
    intensity changes can be measured

41
Renal Cell Carcinoma
  • Large right renal cell carcinoma with renal vein
    and inferior vena cava invasion. T1-weighted
    axial MRI before contrast enhancement

42
Renal Cell Carcinoma
  • Large right renal cell carcinoma with renal vein
    and inferior vena cava invasion. T1-weighted
    contrast-enhanced axial MRI

43
Renal Cell Carcinoma
  • T1-weighted images
  • Nonenhanced
  • RCCs usually appear isointense or hypointense
    relative to the remainder of the kidney
  • With chemical shift imaging, some clear cell
    carcinomas show focal or diffuse loss of signal
    intensity

44
Renal Cell Carcinoma
  • Large right renal cell carcinoma with renal vein
    and inferior vena cava invasion. T2-weighted
    axial MRI

45
Renal Cell Carcinoma
  • T2-weighted images
  • RCCs are usually hyperintense and most often
    heterogeneous

46
Renal Cell Carcinoma
  • MRI
  • Necrosis or hemorrhage may alter signal intensity
    characteristics
  • Especially helpful in determining invasion into
    renal vein and IVC
  • The degree of confidence in the diagnosis of RCC
    with MRI is similar to that of CT
  • MRI has no advantage compared with contrast
    enhanced CT for the diagnosis of RCC but it is
    better for staging of locally advanced cases

47
Renal Cell Carcinoma
  • Renal Biopsy
  • Gaining popularity
  • Older literature of fine needle aspiration
    biopsies showed 40 malignancy, 24 benign and
    36 indeterminate
  • Recent literature of core biopsies shows 75
    malignancy, 20 benign and 5 indeterminate
  • Renal biopsy may be most useful in patients with
    a prior malignancy (? Mets), lymphoma or multiple
    masses (? Mets)
  • If in doubt, cut it out!

48
Renal Cell Carcinoma
  • Management
  • Surgery A chance to cut is a chance to cure
  • Unresectable RCCs have a 5 year survival rate of
    lt20
  • RCCs are resistant to chemotherapy and radiation
    therapy

49
Renal Cell Carcinoma
  • Surgical options
  • Open radical nephrectomy
  • Laparoscopic radical nephrectomy
  • Open partial nephrectomy
  • Laparoscopic partial nephrectomy

50
Normal Renal Anatomy
51
Radical Nephrectomy Patient in the Operating Room
52
A Chance to Cut is a Chance to Cure
53
Renal Cell Carcinoma
  • 3D CT scan of a small RCC that is peripheral and
    exophytic which is ideal for nephron sparing
    surgery

54
Renal Cell Carcinoma
  • 3D CT scan showing a left lower pole RCC
    extending into the renal hilum

55
Renal Cell Carcinoma
  • 3D CT scan obtained during the excretory phase in
    the coronal plane shows the mass abutting the
    inferior surface of the renal pelvis and invades
    the lower pole calices

56
Renal Cell Carcinoma
  • Recurrent renal cell carcinoma. Status postright
    nephrectomy with local recurrence (arrow) in
    nephrectomy bed. Contrast-enhanced CT

57
Renal Cell Carcinoma
  • Minimally invasive image guided treatments
  • Radiofrequency ablation (RFA)
  • Cryotherapy
  • Especially for patients with a high surgical
    risk, aversion to surgery or bilateral lesions
  • Minimal morbidity but higher recurrence rates
    versus standard surgical excision

58
Renal Cell Carcinoma
  • Metastatic RCC
  • Role of radical nephrectomy in metastatic RCC
  • Tyrosine kinase inhibitors
  • Sorefanib
  • Sunitinib
  • m-TOR inhibitors
  • Temsirolimus
  • Everolimus

59
Renal Cell Carcinoma
  • Recurrent renal cell carcinoma. Status post left
    nephrectomy with metastatic disease to the
    contralateral adrenal gland

60
Renal Cell Carcinoma
  • Recurrent renal cell carcinoma. Status post right
    nephrectomy with metastatic disease to the liver

61
Renal Cell Carcinoma
  • Questions?
  • Comments?
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