1. A case of bilateral renal tumours
Rajesh Batajoo, Fellow
Tata Medical Center

2. Clinical details 52 years/male, from Bangladesh Chief complaint
- B/L loin pain L>R x 6 months
History
Pain dull aching,
No h/o haematuria, no LUTS, no weight loss and fever
Smoker
No significant family history
Comorbidity : Diabetic on regular treatment. No h/o HTN

3. Clinical details - ECOG 0 - Thinly built, general condition fair,
O/E
- ECOG 0
- Thinly built, general condition fair,
- Vitals: Stable, no pallor, or lymphadenopahty
P/A: Soft, non tender, no organomegaly
External genitalia: Normal
DRE: Small benign feeling prostate

4. Investigations CBC- Hb 13.6 gm/dl, TC 11100, PLT 278000
S. Creat- 0.83, Urea 28, Sodium 134, Potassium 4.2
LFT normal
Urine C/S: sterile
USG KUB: Left renal mass 6.5cmx6.4 cm at mid pole.
(Done in Bangladesh)

5. Investigations cont..
CT thorax and abdomen
CT thorax: Normal.
CT whole abdomen showed bilateral renal masses
Right superior and inferior polar lesions 4cm, and 2.1 cm
Left mid polar lesion 7.5 x 7.1 cm lesion

6. CT abdomen axial cuts

7. CT abdomen axial cuts

8. CT abdomen axial cuts

9. CT abdomen axial cuts

10. CT abdomen axial cuts

11. CT abdomen axial cuts

12. CT abdomen axial cuts

13. CT abdomen axial cuts

14. CT abdomen axial cuts

15. Renal CT angioghraphy recon

16. Planning - B/L renal SOLs,
2 SOLs in right kidney, large midpolar mass in left kidney
MDT discussion
Surgery planned in two sessions
Right side opted first ( Partial nephrectomy)
(technically less challenging due to exophytic polar lesions)
Left side planned radical/partial nephrectomy in second session

17. Right open partial nephrectomy (PN)
Right loin incision, retroperitoneal approach (prior right ureteric stenting).
Kidney mobilization and hilar control
Renal artery clamped, excision of upper and lower pole lesions
Frozen section of deep margins of both lesions: negative
Cold ischaemia time 30 min

18. Right PN Good post op recovery S. cr. 0.99mg/dl and HB 13gm/dl
Biopsy report:
Chromophobe renal cell carcinoma, pT1b(m)Nx
Resection margin free, no LVI, no sarcomoid differentiation
Sizes: 4.2 cm upper pole lesion,
2 cm. lower pole lesion

19. No haematuria, wound healed well. RFT: Normal (s. creatinine 0.8)
Post right PN follow up
Patient doing well
No haematuria, wound healed well.
RFT: Normal (s. creatinine 0.8)
DMSA scan (after 1month of right PN)
Differential function:
Rt. kidney % & Lt. kidney %
2. Large left parapelvic SOL photophenic area

20. Left partial nephrectomy (PN)
Left loin incision retroperitoneal approach (prior left ureteric stenting)
Kidney completely mobilized
Pelvis dissected from mass
Hilar dissection continued to segmental arteries, selective ligation of artery supplying renal mass
Frozen section of deep cut margin: negative

21. Left PN Post op period: good recovery S. cr. 0.8mg/dl, HB 10.6gm/dl
Biopsy report:
Chromophobe Renal cell Carcinoma, pT2a
Resection margin free,
Size 8.2 cm

22. Chromophobe rcc

23. Chromophobe rcc

24. Follow up Patient doing well, CBC, RFT, LFT normal
CT abdomen: no local recurrance

25. Discussion 1
Chromophobe RCC

26. Chromophobe RCC
First described by Thoenes and colleagues in 1985, as a distinctive histologic subtype of RCC
Represents 5% of all RCCs
Derived from the cortical portion of the collecting duct
(Algaba et al, 2011).

27. Chromophobe RCC Commonly seen in the Birt-Hogg-Dubé syndrome
( associated with cutaneous benign lesions)
Most cases are sporadic
(Linehan and Ricketts, 2013).

28. Chromophobe RCC Morphologically
Chromophobe RCC typically appears as a well circumscribed, homogeneous, tan tumor
Microscopically
Chromophobe RCC include distinct cytoplasmic borders, perinuclear “halos,” and nuclear “raisins.” .

29. Chromophobe RCC
Most studies suggest a better prognosis for localized chromophobe RCC than for clear cell RCC
Poor outcome in the subset of patients with sarcomatoid features or metastatic disease
(Renshaw et al, 1996; Klatte et al, 2008)

30. Chromophobe RCC
> 90% 5 years disease free survival for localised chromophobe rcc after treatment
(Klatte et al, 2008; Deng and Melamed, 2012).
Limited data exist regarding treatment of
metastatic chromophobe RCC
(Tannir et al, 2012; Kroeger et al, 2013).

31. Discussion 2
Partial nephrectomy

32. Partial nephrectomy
Concept of PN – started when importance of preservation of renal parenchyma was realized.
1890, Czerny performed partial nephrectomy.

33. Partial nephrectomy Significant renal functional advantage
Incidence of Grade 3 CKD was more common with RN
( 65% v/s 20%)
More severe CKD (eGFR < 60 mL/min/1.73m2 ) was also more common with RN ( 36% v/s 5%)
(Huang et al, 2006; Russo and Huang, 2008 – Memorial Sloan Kettering Cancer Center)

34. Uzzo and Novick, 2001; Campbell et al 2009
Partial nephrectomy
Long term oncologic outcome equivalent to radical nephrectomy
Curr Opin Urol 2015 Mar;25(2):95-9. doi /MOU
Anatomic partial nephrectomy: technique evolution.
Azhar RA Metcalfe C Gill I
T1a & T1b RCC with overall Cancer free survival rate over 90%.
Uzzo and Novick, 2001; Campbell et al 2009

35. Indications of PN
All patients with cT1 RCC whenever feasible Especially in Pts. with a solitary kidney Multiple small and/ or bilateral tumours Pts. with or at risk of chronic renal disease

36. Guidelines recommend partial nephrectomy whenever technically feasible, independent of tumor size
(Campbell 2009; Ljungberg 2015)
“is recommended in patients with clinical T1a tumours and should be favoured above radical nephrectomy in clinical T1b tumours whenever technically feasible”
(Grade A and B recommendations EAU2016)

37. Bilateral renal tumours
The simpler partial nephrectomy is performed first
MAG3 renogram in the postoperative kidney.
Then more complicated partial or radical nephrectomy is performed on the contralateral kidney

38. Thank you.