Материал: Oxford American Handbook of Urology ( PDFDrive )
282 CHAPTER 6 Urological neoplasia
Box 6.5 Prognosis—5-year survival
• |
Organ-confined |
T1a |
90–100% |
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T1b |
80–90% |
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T2 |
70–80% |
• |
Capsular transgression/adrenal |
T3a |
60–70% |
• |
Renal vein or IVC thrombus |
T3b/c |
50–80% (25% with |
|
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|
IVC wall invasion) |
• |
Visceral/lymph node involvement |
T4 or N+ |
5–30% |
• |
Distant metastasis |
M+ |
5–100% |
Nomograms have been developed to predict risk of recurrence
Reprinted with permission from Kattan MW, Reuter V, Motzer RJ, Katz J, Russo P. (2001). J Urol 166(1): 63–67.
Table 6.13 TNM staging of RCC
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Tx |
Primary tumor cannot be assessed |
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T0 |
No evidence of primary tumor |
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T1 |
Tumor <7 cm, limited to the kidney |
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T1a |
Tumor is 4 cm or less, limited to kidney |
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T1b |
Tumor >4 cm but <7 cm, limited to kidney |
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T2 |
Tumor >7 cm, limited to the kidney |
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T3 |
Tumor extends outside the kidney, but not beyond Gerota’s |
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(perinephric) fascia |
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T3a |
Tumor invades adrenal gland or perinephric fat |
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T3b |
Tumor grossly extends into renal vein or subdiaphragmatic IVC |
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T3c |
Tumor grossly extends into supradiaphragmatic IVC or heart; |
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|
invades wall of vena cava |
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T4 |
Tumor invades beyond Gerota’s fascia |
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Nx |
Regional (para-aortic) lymph nodes cannot be assessed |
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N0 |
No regional lymph node metastasis |
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N1 |
Metastasis in a single regional node |
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N2 |
Metastasis in 2 or more regional nodes |
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Mx |
Distant metastasis cannot be assessed |
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M0 |
No distant metastasis |
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M1 |
Distant metastasis present |
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284 CHAPTER 6 Urological neoplasia
Renal cell carcinoma: presentation and investigations
More than 50% of RCCs are now detected incidentally on abdominal imaging carried out to investigate vague or unrelated symptoms. Thus, the stage at diagnosis of RCC is lower than it was because of widespread use of imaging modalities.
Presentation
Of the symptomatic RCCs diagnosed, 50% of patients present with hematuria, 40% with flank pain, 30% of patients notice a mass, and 25% have symptoms or signs of metastatic disease (night sweats, fever, fatigue, weight loss, hemoptysis).
Less than 10% patients exhibit the classic triad of hematuria, flank pain, and mass. Less common presenting features include acute varicocele due to obstruction of the testicular vein by tumor within the left renal vein (5%) and lower limb edema due to venous obstruction.
Paraneoplastic syndromes due to ectopic hormone secretion by the tumor occur in 10–40% of patients; these may be associated with any disease stage (Table 6.14).
Investigations
•Radiological evaluation of hematuria, flank pain, and renal masses is described on p. 5.
•Needle biopsy of renal masses is not recommended, since the result may be misleading and complications include hemorrhage and seeding of the biopsy tract.
•Urine cytology and culture should be normal.
•Full blood count may reveal polycythemia or anemia.
•Serum creatinine and electrolytes, calcium, and liver function tests are essential.
When RCC is diagnosed radiologically, staging chest CT and bone scan (if clinically indicated) will follow. Any suggestion of renal vein or IVC involvement on CT may be further investigated with MRI.
Angiography may be helpful in planning partial nephrectomy or surgery for horseshoe kidneys. Contralateral kidney function is assessed by uptake and excretion of CT contrast and the serum creatinine. If doubt persists, an isotope renogram is obtained.
RENAL CELL CARCINOMA: PRESENTATION AND INVESTIGATIONS 285
Table 6.14 Paraneoplastic syndromes
Syndrome associated with RCC Cause
Anemia
Polycythemia
Hypertension (25%)
Hypoglycemia
Cushing
Hypercalcemia (10–20%)
Gynecomastia, amenorrhea, reduced libido, baldness
Stauffer syndrome: hepatic dysfunction (increased liver function testing), fever, anorexia
Hematuria, chronic disease
Ectopic secretion of erythropoietin
Ectopic secretion of renin, renal artery compression, or AV fistula
Ectopic secretion of insulin
Ectopic secretion of ACTH
Ectopic secretion of parathyroid hormone–like substance
Ectopic secretion of gonadotrophins
Unknown; resolves in 60–70% of patients post-nephrectomy
286 CHAPTER 6 Urological neoplasia
Renal cell carcinoma: active surveillance
Surveillance of localized renal tumors is now performed more often in carefully selected patients. For incidental stage T1 renal masses, prolonged follow-up will be necessary, similar to that for low-risk prostate cancer. There are no currently established protocols.
Active surveillance is a reasonable option for patients with limited life expectancy or for those who are unfit for or do not desire intervention, especially those with T1a renal masses (<4 cm). These masses grow slowly growth and very infrequently progress to metastasis.1
The patient should be counseled about the small risk of cancer progression, possible loss of window of opportunity for nephron-sparing surgery, lack of curative salvage therapies if metastases develop, limitations of renal mass biopsy, and deficiencies of the current literature.
1 AUA Guideline for Management of the Clinical Stage 1 Renal Mass (2009). Available at: www. auanet.org/content/guidelines