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A case of bilateral renal tumours
Rajesh Batajoo, Fellow Tata Medical Center
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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
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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
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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)
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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
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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CT abdomen axial cuts
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Renal CT angioghraphy recon
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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
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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
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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
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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
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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
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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
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Chromophobe rcc
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Chromophobe rcc
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Follow up Patient doing well, CBC, RFT, LFT normal
CT abdomen: no local recurrance
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Discussion 1 Chromophobe RCC
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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).
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Chromophobe RCC Commonly seen in the Birt-Hogg-Dubé syndrome
( associated with cutaneous benign lesions) Most cases are sporadic (Linehan and Ricketts, 2013).
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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.” .
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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)
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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).
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Discussion 2 Partial nephrectomy
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Partial nephrectomy Concept of PN – started when importance of preservation of renal parenchyma was realized. 1890, Czerny performed partial nephrectomy.
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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)
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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
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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
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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)
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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
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Thank you.
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