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Renal Cell Carcinoma

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Arunabha Keshari

on 5 March 2013

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Transcript of Renal Cell Carcinoma

A clinical case study RENAL CELL CARCINOMA AND CT Patient presentation Cancer of the kidney
Accounts for 90% of malignancies in kidneys
Comprises 2-3% of all cancers
Three main histological subtypes: Contrast Enhancement is important for differentiating between benign and malignant solid lesions

A change of 20 HU or greater is strong evidence of enhancement

Nephrographic phase required, as renal masses enhance best in this phase How does CT aid diagnosis? By Arunabha Keshari What is RCC? Sthenic African male
51 years old
Ambulant outpatient with GP referral
Right flank pain radiating to groin.
Haematuria for 4 days
GP requested CT KUB, ? urolithiasis Who gets RCC? this not this Normal kidney Cancerous kidney Non-contrast CT showed large tumour on right kidney
Presented to Footscray the following week for further assessment
4 phase renal C+ CT scan performed
eGFR 61 4-phase renal CT scan CT provides information on: Primary tumour extension with extrarenal spread
Function and morphology of unaffected kidney
Enlargement of regional lymph nodes
Health of liver and adrenal glands
Venous involvement
Vascular supply 1.5:1 predominance of men over women
Peak predominace between 60-70 years of age
Highest incidence in Western countries
Obesity and cigarette smoking are major risk factors Clear cell - 80-90% Papillary - 10-15% Chromophobe 4-5% You would expect a RCC sufferer to look like... What are the symptoms of RCC? Often asymptomatic until late stage
Palpable abdominal mass
Palpable cervical lymph nodes
Non-reducing varicocele
Bilateral lower extremity oedema - venous involvement Can other modalities
aid diagnosis? Ultrasound Nuclear medicine MRI Non-contrast kidneys
Administer contrast
Arterial (15-30 sec)
Late arterial - corticomedullary and portal venous (45-60 sec)
Abdomen scanned in portal venous phase
Nephrographic (80-90 sec)
Excretory (180 sec) 2. CT chest C+ for staging CT is the modality of choice, but MRI, ultrasound and nuclear medicine can assist in staging and clearing ambiguities What are the signs of RCC on CT? "RCC can look like anything" Which CT protocols are used for
diagnosis and staging? 1. 4 phase renal CT with contrast CT and RCC Clear cell RCC Papillary cell RCC Chromophobe cell RCC Enhances to a greater extent
More heterogeneous in appearance than other histologic subtypes
Hypervascular More homogeneous
Significantly lower tumor-to-parenchyma enhancement than other subtypes
Typically hypovascular Typically less hypervascular than clear cell RCC
Tend to have a more peripheral pattern of enhancement;
Hard to differentiate from papillary cell RCC 85 x 67 x 94 mm
Heterogenous exophytic mass lesion
Arising from the lower pole of the right kidney Typically only used when CT cannot be performed
Allergy to iodinated contrast medium
Pregnancy Similar staging accuracies to CT
Very useful for delineating the superior extent of tumor in the IVC Presence and extent of venous thrombus
Distinguish cysts from hypovascular solid tumors
Used intraoperatively to identify multifocal lesions and intrarenal tumor anatomy Has potential for:
detection of unsuspected metastases
follow up 9.9 x 9.2 x 8.4 cm
Heterogeneous, enhancing, highly vascular mass
Compatible with RCC
Likely Robson stage II
Mass extends to the perirenal fascia causing bulging
Mass surrounds the right renal vein
No filling defect to suggest thrombosis
The IVC appears normal
Multiple parasitised vessels from the aorta
The radiologist report stated: References Special thanks to: Focus Radiology and Nuclear Medicine, Shepparton

Shane Reeves - Grade 4 CT supervisor, Western Health

Bill Terry - Grade 3 CT radiographer, Western Health Further imaging Nuclear medicine Ultrasound The patient was assessed further with CT, ultrasound and nuclear medicine
The right renal vein was compressed, but patent
No metastatic disease detected No evidence of bony metastatic disease ? compression right renal vein/IVC The right renal vein is compressed but appears patent
The wave form is abnormal and monophasic, likely to be due to compression For staging How is RCC treated? Localised RCC is treated with:
Radical nephrectomy - entire affected kidney is surgically removed
Partial nephrectomy - only the diseased portion of a kidney is surgically removed THE END Metastatic RCC is treated with immunotherapy

Nephrectomy can be combined with immunotherapy to optimize survial strategy Partial nephrectomy CT Judging by these requests... it is likely that the patient was treated surgically. CT chest C+ for staging of RCC No evidence of thoracic metastatic disease Bath-Hextall, F, Leonardi-Bee, J, Somchand, N, Webster, AC, Delitt, J and Perkins, W
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of Roentgenology, vol. 191, no. 4, pp.1220-1232. for example Mild right-sided ureteric dilatation, suggesting recent passage of a stone
4 mm stone in dependent anterior aspect of the bladder ` How is RCC treated?
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