EVALUATION OF THE OUTCOME OF THE MANAGEMENT OF PATIENTS WITH RENAL CELL CARCINOMA

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1 International Invention Journal of Medicine and Medical Sciences (ISSN: ) Vol. (9) pp , November, 206 Available online Copyright 206 International Invention Journals Full Length Research Paper EVALUATION OF THE OUTCOME OF THE MANAGEMENT OF PATIENTS WITH RENAL CELL CARCINOMA *Anwar Kamel Bahat and Mohamed Abdel-Hafeez Ali Department of General Surgery and Urology, Faculty of Medicine, Al-Azhar University Received 8 November, 206; Accepted 24 November, 206 Radical Nephrectomy remains the standard treatment for localized Renal Carcinoma with an anatomically and functionally normal opposite kidney, a growing number of authors have reported excellent results with nephron sparing surgery. The objective of the study is to evaluate the outcome, prognosis, influence of patient, tumor characteristics and therapeutic interventions on patients with malignant renal tumors. A prospective study was carried out on 9 patients with malignant renal tumors. All patients were subjected to surgical intervention. Flank incision was chosen for Radical or Partial Nephrectomy in a small number of patients. Upper medline incision with extension to flank was used in a large number of patients. Radical Nephrectomy was the most common surgical technique in our patients. Stage PT was the commonest stage of presentation. Nephron sparing surgery is a safe and effective procedure in properly selected patients (solitary, unilateral, sporadic T renal cancers < 7cm in diameter). Keyword: Renal Cell Carcinoma, Kidney, Surgery. INTRODUCTION Renal Cell Carcinoma (RCC) accounts for approximately % of adult malignancies and is the most common type of kidney cancer in adults, responsible for approximately 90-95% of cases (Curit et al., 204). The incidence of RCC is increasing at around 2% per year. This had been attributed to increased detection due to the wide spread of imaging modalities (Wood and Brown, 202). The use of imaging techniques such as ultrasound (US) and computerized tomography (CT) has increased the detection of asymptomatic RCC incidence worldwide with an earlier stage which can be cured by surgery (Ljungberg et al., 200). According to the World Health Organization (WHO), there are three major histological RCC types: clear cell renal cell carcinoma (ccrcc) (75%), papillary renal cell carcinoma (prcc) (0-5%), and chromophobe renal *Corresponding Author anwarkamel7@gmail.com cell carcinoma (chrcc) (5%). prcc can further be divided into two different subtypes, type and type 2 (Ljungberg et al., 200). Immunohistologic and ultrastructural analysis have suggested that the proximal renal tubular epithelium is the tissue of origin of most of renal tumors. Renal tumors tend to be spherical, but may vary widely in size. The average diameter is approximately 7 cm; however, renal tumors can often grow to fill the entire retro peritoneum. Previously, renal lesions 2 cm or less in diameter were considered to be adenoma, now the distinction between benign and malignant tumors is no longer made on the basis of size but on the basis of classic histologic criteria (Linehan et al., 20). Indications for nephron-sparing surgery include situations in which radical nepherectomy would render the patient a nephric with a subsequent immediate need for dialysis. This indication encompasses patients with bilateral RCC or RCC involving a solitary functioning kidney (Ghavamian et al., 2002). Size of the tumor is a significant factor in the decision to perform nephron-sparing surgery (NSS),

2 200 Int. Inv. J. Med. Med. Sci. large and more complex tumors can also be treated with partial nephrectomy by surgeons with a lot of kidney surgery experience (Weight et al., 20). Minimally invasive radical nepherectomy (laparoscopic nepherectomy) has become an established surgical procedure worldwide. Because the laparscopic approach is widely used for more complex ablative and reconstructive procedure, laparscopic radical nepherectomy can be regarded as the first line technique for T renal tumors not suitable for NSS. Since 2006, the laparscopic approach has been regarded the standard of care by the European Association of urology (Linehan et al., 20). Radical neherectomy (RN) is the preferred treatment if the tumor extends into the inferior vena cava and is the standard of care for patients with stage III renal tumors. RN consists of ligation of renal vessels, the en bloc removal of the kidney, adrenal gland, peri renal fat, proximal ureter and Gerota fascia (Wotkowics and Libertino, 20). PATIENTS AND METHODS A prospective study was carried out on 9 patients with renal cell carcinoma from October 20 to April 206 at Sayed Galal Hospital Al Azhar University. Patients age ranged from 28 to 84 years (mean 6 years). All patients were subjected to: I.Preoperative evaluation: - Detaieled medical history including personal history, complaint and presenting symptoms (renal pain was the most common complaint, haematuria and renal mass). Some patients were accidentally discovered tumors on routine investigation. Past history of previous urologic or non urologic operation, history of medical disease, family history of tumor or other renal or medical diseases. 2- Clinical examination: for assessment of renal masses and assessment of any metastatic lesions. - Investigations: Urine analysis and urine culture and sensitivity. Coagulation profile. CBC Kidney functions (urea and creatinine) Full lap investigations. 4- Radiological studies: Abdominal ultrasound. Intravenous urography (IVU). CT abdomen and pelvis CT chest for detection of any metastasis. MRI Angiography was a limited imaging study prior to partial nepherectomy for patients with single kidney. II. Operative Management: All patients (9) included in this study were subjected to the following intervention: ) Radical nepherectomy (25 patients). 2) Nephron sparing surgery (4 patients). Patients were prepared with full assessment, cardiac and chest examination. Radical nepherectomy was done in 25 patients and the indications for RN is localized or locally advanced RCC (T, T2 and T RCC) with tumor size ranged from 4 to 2 cm with normal contralateral kidney. Flank incision was used for small tumors and abdominal incisions for large tumors or suspected vascular invasion. Nephron sparing surgery in 4 patients was indicated in: o Small sized tumors < 4 cm with normal contralateral kidney in 8 patients. o Situations in which RN would render the patient a nephric in 6 patients. Solitary kidney in patients. Bilateral RCC in patient. Decreased renal functions in 2 patients. Types of NSS: Segmented polar nephrectomy in 0 patients. Enucleation in 2 patients. Wedge resection in 2 patients. III. Post operative management and follow up: All patients (9) underwent complete clinical assessment, lap investigations (serum creatinene at 4 weeks post operative Pelvic abdominal US was done for surgically complicated cases (Table ). All patients were scheduled for scheme of follow up Complete history taking. Complete clinical examination. Lap investigations. Radiological investigations (CT abdomen and pelvis). RESULTS Renal cell carcinoma was managed by: ) Radical nepherectomy (25 patients). 2) Nephron sparing surgery (4 patients). Table 2 and reveals that nephron sparing surgery was done for 4 out of 9 patients with RCC (5.89%). Segmental polar nepherectomy was the most common procedure for nepheron sparing surgery. It was done in 0 out of 4 patients (7.42%) (Photo to 4). Clear cell carcinoma was the commonest subtype for RCC, we found it in 27 out of 9 patients (69.2%). Table 4 reveals that: prolonged leakage was the most postoperative complications in our patients with renal cell carcinoma managed by NSS. It occurred in 2 out of 4 patients (4.28), prolonged leakage stopped spontaneously within two weeks. Table 5 reveals that: local recurrence in cases and distant metastasis in case.

3 Bahat and Ali 20 Table. Computed tomography (CT) findings CT findings Number of patients (n=9) % Tumor site Upper Middle Lower Tumor size -7 cm 8-0 cm - cm % 7.69% 6.5% 82.05% 5.8% Pelvicalyceal system dilatation % Thin parenchyma % Inferior vena cava involvement (infrahepatic) 2 5.2% Enlarged lymph node 7 7.9% Distant metastasis Table 2. Technique for nepheron sparing surgery Type of NSS Total (n=4) % Segmental polar nepherectomy % Enucleation % Wedge resection % Table. Tumor characteristics for RCC Tumor characteristics Number of patients (n=9) % Tumor stage Stage pt Stage pt2 Stage pta Stage ptb Stage pt4 2 9 Tumor grade Grade Grade2 Grade Grade4 Tumor site Upper Middle Lower Tumor size -7 cm 8-0 cm - cm Tumor subtype Clear cell Clear and granular Papillary and granular Granular Chromophob Collecting duct carcinoma % 2.07% 7.69% 7.64% 25.64% 56.4% 5.8% 0.76% 7.69% 6.5% 82.05% 5.8% 69.2% 0.25% 0.25% 5.2%

4 202 Int. Inv. J. Med. Med. Sci. Table 4. Surgical complications of patients managed by radical nepherectomy or NSS (9 patients) Complications Radical nepherectomy (n=25) NSS (n=4) Intraoperative complications Bleeding Pleural injury Postoperative complications Chest pain (myocardial infarction) Deep venous thrombosis Paralytic ileus Prolonged leakage Renocutanous fistula (4.00%) (4.00%) (4.00%) (4.00%) (7.4%) (7.4%) 2(4.28%) (7.4%) Re operation due to splenic injury (4.00%) Overall complications 5(20.00%) 5(5.7%) Table 5. Tumor recurrence and distant metastasis Tumor recurrence Subgroup A (RCC) (n=9) % Local recurrence 7.69% Distant metastasis Lung metastasis Bone metastasis % Overall metastasis % Phote. Rt Radical Nephrectomy Post view Phote 2. Rt Radical Nephrectomy Ant view

5 Bahat and Ali 20 Phote. The speciment of Rt Kidney Phote 4. Partial Nephrectomy Rt Kidney DISCUSSION Renal cell carcinoma accounts for 2-% of adults malignancies and is the most common type of kidney cancer in adults responsible for approximately 90-95% of cases (curit et al., 204). Among our patient, the commonest age incidence was the 6 th decade of life. Lee et al. (2000) on their report on 670 RCC patients treated surgically found that the mean age was 6 years. The common diagnostic tool among our patients was the abdominal CT scan (90%) while other imaging studies were required to establish a preoperative definite diagnosis. In our study, CT scan was the gold standard in detecting, characterizing and staging of renal tumors. Curit et al. (204) demonstrated the high sensitivity of CT scanning in diagnosis of renal masses which approached 94%. Contrast enhanced CT scan is the gold standard for detecting and characterizing renal masses as well as for staging RCC, in most cases CT imaging can differentiates cystic masses from solid masses and supplies information about lymph node, renal vein and inferior vena cava involvement (NG et al.,200). In our study, radical nepherectomy was the most common surgical technique; it was done in 25 out of 9 patients. NSS was done for 4 patients with RCC. Radical nepherectomy remains the most commonly performed standard surgical procedure today for treatment of localized RCC (curit et al., 204). Standard RN encompasses the basic principles of early ligation of the renal artery and vein, removal of the kidney outside Gerota fascia, removal of the ipsilateral adrenal gland and performance of a complete regional lymphadenectomy (Wood et al., 202). With improvement in surgical technique partial nepherectomy is safe and effective in properly selected patients. The proper selection of candidates for partial nepherectomy with early stage tumors and normal contra lateral kidney will be the cornerstone to successful outcome (Shuck et al., 2006). In our study, the overall complications of radical nepherectomy for RCC was 5 out of 25 patients (20%), overall complications for NSS for RCC was 5 out of 4 patients (5.7%). Shuck et al. (2006) reported complication rate of 7.6% post RN for malignant renal tumors. Pasticier et al. (2006) reported that the overall complication rate for NSS was 0.7%. CONCLUSION Radical nepherectomy remains the standard treatment for localized RCC with anatomical and functionally normal opposite kidney. NSS is a safe and effective procedure in properly selected patients (solitary, unilateral, sporadic, stage T renal cancers < 7 cm in diameter). REFERENCES Curti B, Jana BRP, Javeed M, Makhoul I, Sachdeva K, Hu W, Perry M, Talavera F (204). Renal Cell Carcinoma. In Harris, JE. Medscape Reference. WebMD. Retrieved 7 March 204. Ghavamian R, John C, Zincke H, Cheville JC (2002). Renal Cell Carcinoma in the solitary kidney: An analysis of complications and outcome after nephron sparing surgery. J Urol; 68:454. Lee C, Katz J, Shi W, Thaler HT (2000). Surgical management of renal tumors 4 cm or less in a contemporary cohort. J Urol; 6:70. Linehan W, Rini B, Yang J (20). Cancer of the kidney In: Devita, Hellman & Rosenberg s Cancer: Principles & Practice of Oncology, Ninth edition. Lippincott Williams & Wilkins ISBN-0: Ljungberg B, Cowan NC, Hanbury DC, Hora M, Kuczyk MA, Merseburger AS, Patard JJ, Mulders PF, Sinescu IC; European Association of Urology Guideline Group (200). EAU Guidelines on Renal Cell Carcinoma: The 200 Update. European Urology (58):

6 204 Int. Inv. J. Med. Med. Sci. Ng C, Wood C, Silverman P, Fritz AG (200): Renal Cell Carcinoma: Diagnosis, Staging, and Surveillance. AJR (9) Pasticier G, Timsit MO, Badet L, De La Torre Abril L, Halila M, Fassi Fehri H, Colombel M, Martin X (2006). Nephron-Sparing Surgery for Renal Cell Carcinoma: detailed analysis of complications over a 5 year period. Eur, urol 49 () : 48. Shuch B, Lam JS, Belldegrun AS (2006). Open partial nephrectomy for treatment of renal cell carcinoma. Cur Urol Rep; 7 ():. Campbell SC, Brian R (202). Malignant Renal tumors. In: Kavoussi, LR, Novick, AC, Partin, AW, Peters, CA, Wein AJ (eds), Campbell s Urology, 0 th edition; 49: Wood S, Brown J (202). Skeletal metastasis in renal cell carcinoma: Current and future management options. Cancer Treat Rev 8(4): Weight CJ, Crispen, Breau, et al;provide other author name (20). Practice-setting and surgeon characteristics heavily influence the decision to perform partial nephrectomy BJU International (5): 7-8. Wotkowic C, Libertino J (20). Renal Cell Cancer: Radical Nephrectomy, BJU international (99) : 2-8. How to cite this article: Bahat AK, Ali MAH (206). EVALUATION OF THE OUTCOME OF THE MANAGEMENT OF PATIENTS WITH RENAL CELL CARCINOMA. Int. Inv. J. Med. Med. Sci. Vol. (9):