RCC in ADPKD / CKD / ESRD

Transcription

1 RCC in ADPKD / CKD / ESRD FOIU 2018 David A. Goldfarb, MD,FACS Professor of Surgery, Cleveland Clinic Lerner College of Medicine Glickman Urological and Kidney Institute Cleveland Clinic, Cleveland, Ohio

2 Disclosure No financial disclosures Discussion of off label use of mtor inhibitors

3 vol 1 Figure 3.1 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and year, (a) Unadjusted Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. 1b adjusted for age/sex/race and 1c adjusted for age/sex/race/comorbidities. Standard population Medicare 2014 patients. Abbreviation: CKD, chronic kidney disease Annual Data Report Volume 1 CKD, Chapter 3 3

4 vol 2 Table 5.4 Expected remaining lifetime (years) by age, sex, and treatment modality of prevalent dialysis patients and transplant patients, and the general U.S. population, 2013 Dialysis ESRD patients 2013 Transplant General U.S. population 2013 Age Male Female Male Female Male Female a 8.6 a Data Source: Reference Table H.13; special analyses, USRDS ESRD Database; and National Vital Statistics Report. Table 7. Life expectancy at selected ages, by race, Hispanic origin, race for non-hispanic population, and sex: United States, 2013 (2016). Expected remaining lifetimes (years) of the general U.S. population and of period prevalent dialysis and transplant patients. a Cell values combine ages 75+. Abbreviation: ESRD, end-stage renal disease Annual Data Report Volume 1 CKD, Chapter 3 4

5 Acquired Renal Cystic Disease Common in CKD / ESRD Associated with RCC Etiology??

6 Epidemiology of ESRD and Renal Cancer How you sample drives the incidence Autopsy: dialysis population - Dunhill 1977: ARCD (47%), RCCa (20%) - Miller 1989: ARCD(58%), AD(16%), RCCa(2%) US screening - Terasawa 1994:RCCa(2.6%) (1603 dialysis pts) - Gulanikar 1998:ARCD (31%), RCCa(3.8%) Nephrectomy at Tx (selected ESRD /CKD population study, 260 kidneys) - Denton 2002: ARCD 85/260 (33%), AD 35/260 (14%), RCC 11/260 (4.2%)

7 Incidence of Renal Cancer Assymptomatic General Population* 0.045% ESRD / dialysis 2-8% x 100 = 4.5% *Tosaka, J Urol, 146:618, 1991

8 Associations with ARCD Age Dialysis duration Male AA vs. Caucasian HD vs. PD Diagnosis: GN, DM

9 Pathology of RCCa in ESRD 52 ESRD pts., 66 kidneys, 261 tumors ~40% tumors are classic papillary(15%), clear cell(18%), chromophobe(8%) ~60% are new histological classifications - Acquired renal cystic disease associated RCCa (ARC-RCC) 36% - Clear cell tubulo-papillary RCC 23% Tickoo, Am J Surg Path, 2006

10 Acquired Renal Cystic Disease Associated Renal Cell Carcinoma Abundant eosinophilic cytoplasm Clear cytoplasmic vacuoles giving sieve like appearance Large nuclei, prominent nucleoli Oxalate crysstals

11 Acquired Renal Cystic Disease Associated Renal Cell Carcinoma Pryzbycin et al, Am, J Surg Path, pts, , multi-institutional 90% dialysis, mean duration 80 mos. F/U 32 pts - 24 (67%) Alive, NED, 27 months - 4 died of other causes - 4 adverse events: local recurrence, metastasis, DOD Unique pattern local recurrence Distinct entity in 2016 WHO classification

12 New Categorization of RCCa in ESRD / ARCD ARD RCC Differences in histology, molecular markers and genetic markers suggests the possibility of a different biology (oncogenesis and natural history) from conventional histological types

13 ADPKD and Renal Cell Cancer Literature sparse A clear association never shown No clinical epidemiological or molecular data to demonstrate increased risk Several studies now support an association

14 ADPKD / RCCa Hajj et al, Urology, 74:631, 2009 Surgical path, , 79 pts / 89 Nx s 50/79 (63%) on HD, or Tx x 1 year 11/89 (12.3%) with cancer, 5 Nx s due to mass All pt1a, mean size=1.8cm 58% clear cell, 42% tubulopapillary Lane et al, Open J Urology, 1:11, 2011 Surgical path, ,177cases, 6 cases ADPKD 2 cases RCCa (clear cell), 1 papillary adenoma

15 ADPKD / RCCa Jilg et al, Nephron Clin Practice, 123:13, 2013 Surgical path, 301 kidneys/891 registry pts Indication: Tx, symptoms, mass 16 malignancies 5.3% 66.7% of those on dialysis Histology: Papillary 63%, Clear cell 31% Suprisingly high incidence of RCCa

16 RCC in ADPKD The role of dialysis and the confounding influence of ARCD is unknown Surgical series can underestimate the incidence as it is driven by radiologic dx. Activation of mtor pathway, favor renal tubular cell proliferation

17 Imaging Challenges for CKD / ESRD: US, CT, MRI US CT MRI

18 Imaging in ESRD US for screening low resolution CT +/- contrast, nephrotoxicity, allergy MRI warning for GBCA and NSF Potential new technologies - Lanzman, Radiology, 265:799, 2012 Arterial spin labelling, noncontrast MRI - Taouli, Radiology, :388, 2009 Diffusion weighted MRI -Tumors with lower ADC than cyst

19 Transplantation for Renal Cell Carcinoma: Wait Time Penn. Transplantation. 55:742, 1993 Goldfarb et al, Transplantation,12:1726, 1997 High Risk Low Risk High stage ( T2) Low stage ( T2) Extensive disease Low volume disease Synchronous B/L Nx Nephron sparing surgery Symptomatic Incidental / screening Waiting Period No Waiting Period

20 Wait Time: Contemporary Assessment Predictive tools to calculate outcomes based on pre- and post-op findings Kutikov, JCO, 2010 competing risks calculator Kutikov, J Urol, 2012 competing risk calculator adjusted for comorbidity Cancernomogrms.com

21 Survival on Dialysis is the Better Comparator USRDS USRDS 5yr survival 46yo=0.44 Modality Survival Probability at 5yrs Dialysis 0.35 Transplant 0.73 USRDS 5yr survival 66yo=0.27 Varies by age, dialysis modality, diagnosis, era, race, gender

22 2 patients 5 year predictions Using Competing Risks 46 yo Male Dialysis 2.5cm mass Kutikov 2010 nomo - RCCa 1% - Other 3% 66 yo Male Dialysis, PTCA/stent 7cm mass Kutikov 2012 nomo - RCCa 7.7% - Other 20.1%

23 40 yo, man, VHL Angioma, stable CNS R radical, L partial Proof of Principle Preemtive Transplant in VHL with Tumor Can be low risk for recurrence Unresectable recurrence egfr L NX with LUD Tx Multifocal T1a Clear cell, Fuhrman 2 IL2/FK/MMF/Pred Creat 2 mtor switch at 6 mos Creat 3 yrs

24 Transplant in RCCa - Limitations 30 yo, female, VHL CNS hemangioblastoma egfr 25 B/L Nephrectomy Clear cell / papillary Fuhrman 2 Venous invasion pt3a Wait time needed