Renal Cell Carcinoma Solitary Renal Mass

Transcription

1 Renal Cell Carcinoma Solitary Renal Mass (Page 1 of 8) PRESEN- TATION Solitary renal mass Initial CT of abdomen and pelvis CBC, Na, K, CO BUN, creatinine, alkaline phosphatase, calcium, albumin Potential metastatic lesion identified?* Alkaline phosphatase increased? Biopsy isoenzymes Met(s) confirmed? Increased bone fraction? Follow appropriate metastatic guidelines Bone scan and plain films of any symptomatic or suspicious areas Lesion identified? Further imaging as needed Biopsy of lesion Follow appropriate Metastatic guidelines Met(s) identified? Follow bilateral guideline Medical oncology Individualized *te: Retroperitoneal lymph nodes up to 3 cm do not imply unresectable disease. Lymph node biopsy not indicated. Mass in contralateral kidney? Impaired renal function or morphologically abnormal contralateral kidney? Split renal function test MRI of brain Bone scan Consider nephrology consultation Special anatomic considerations, e.g., inferior vena cava thrombus above hepatic vein or invasion of adjacent organs? Clinical suspicion of transitional cell carcinoma (TCC)? Individualized assessment of Resectability Special imaging Additional surgical consultation obtain tissue TCC confirmed? Radial Nephrectomy OR Consider Nnephron sparing surgery in highly selected patients Individualized assessment of Resectability Complete resection? Grade <_ 2 and papillary? pt4 or N+ or M+? Medical oncology Consult Nephroureterectomy including bladder cuff Adjuvant Clinical trial if available or Individualized decision regarding systemic or observation

2 Renal Cell Carcinoma Bilateral Renal Masses (Page 2 of 8) Bilateral renal masses Complete staging: CT of chest, abdomen, and pelvis CT brain Bone scan CBC, Na, K, Cl, CO 2, BUN, creatinine, alkaline phosphatase, calcium, albumin Split renal function test Clinical evidence of von Hippel-Lindau disease? Medical genetics consultation Family counseling Follow Appropriate Metastaic Guideline Metastasis identified? Nephron-sparing surgery Post-Op Follow -up Either or both lesions amenable to partial nephrectomy? Nephrology consultation Individualized decision regarding bilateral nephrectomy VS observation

3 Renal Cell Carcinoma Solitary Metastasis at Presentation (Page 3 of 8) Solitary metastasis at presentation calcium, albumin, aspartate aminotransferase More disease detected? Solitary metastasis potentially resectable? Primary symptomatic? threatening? Primary tumor symptomatic? Specialized local therapy (surgery and, if possible, Follow multiple mets at presentation guideline candidate for systemic? Metastasis cleanly resected? Is solitary metastatic site easily resectable at laparotomy? e.g., adrenal or mesenteric implant? accepts systemic? Follow Renal primary guideline but add CT chest and MRI brain to initial staging and treat as high-risk patient post Nepherectomy CT of chest, abdomen, and pelvis CBC, Na, K, Cl, CO 2, BUN, creatinine, alkaline phosphatase, calcium, albumin, aspartate aminotransferase MRI of brain if clinically indicated Bone scan if clinically indicated Nephrectomy and resection of metastasis if possible or or Symptomatic and supportive care +_ embolization of primary tumor and/or metastasis or Embolization of primary tumor or Nephrectomy in selected patients More disease detected? Nephrectomy and resection of metastasis Nephrectomy Biopsy for diagnosis (either primary or metastatic site acceptable Variant histology? Variant histology? Primary tumor symptomatic? Follow guideline for multiple metastases at presentation Embolization of primary tumor or Nephrectomy in selected patients Individualized decision regarding systemic or observation or Adjuvant Clinical trial if available or if disease not cleanly resected Clinical trial for : collecting-duct sarcomatoid Individualized therapy for others accepts systemic? Resection of metastatic disease Clinical trial for collecting-duct and sarcomatoid tumors Individualized therapy for others Clinical trial: systemic to best response followed by resection of metastatic disease (plus nephrectomy if not already done)

4 Renal Cell Carcinoma Multiple Metastases at Presentation (Page 4 of 8) Solitary Met at reccurence threatening * For example: - Brain lesion - Threatened pathologic fracture - Biliary obstruction Specialized local therapy (surgery and, if possible, calcium, albumin, aspartate aminotransferase calcium, albumin, aspartate aminotransferase More sites? Potentially Resectable More disease detected? Follow Muttiple Mets at Reccurence Guidelines Metastatic Site cleanly resected Follow Muttiple Mets at Presentation Guidelines >1yr since initial accepts systemic Resection OR Adjuvant clinical trial if available OR Radiotherapy to sites OR Combined modality or observation OR Adjuvant Clinical Trial if available Biopsy Symptomatic Clinical Trial: to best response followed by resection of Metastatic Disease Biopsy OR aftyer biopsy or Local after biopsy Clinical trial :Embolization +/- Treatment or

5 Renal Cell Carcinoma (Page 5 of 8) Multiple metastasis at Presentation threatening?* Specialized local therapy (surgery +/- if possible, CT of chest, abdomen, and pelvis calcium, albumin, aspartate aminotransferase or Radiotherapy to symptomatic sites or Combined-modality or CT of chest, abdomen, and pelvis calcium, albumin, aspartate aminotransferase Biopsy Variant Histology? threatening?* Resectable to grossly NED? Clinical trial for sarcomatoid or collecting duct Individualized Therapy for others accepts systemic? Specialised Local therapy Surgical +/- Radiotherapy if possible Primary Symptomatic? Symptomatic Nephrectomy At least Stable disease? Clinical trial:embolization of Metastatic Site or systemic or Symptomatic and supportive care or Clinical trial: Treatment to best followed by resection of Metastatic disease plus Nephrectomy Alternative At least Stable disease?

6 Renal Cell Carcinoma Multiple Metastases at Recurrence (Page 6 of 8) Multiple metastases at recurrence threatening?* Specialized local therapy (surgery and, if possible, calcium, albumin, aspartate aminotransferase or Radiotherapy to symptomatic sites or Combined-modality therapy or or Symptomatic and supportive care * For example: - Brain Lesion - Threatened pathologic failure - Biliary obstuction calcium, albumin, aspartate aminotransferase threatening?* Biopsy (optional) Potentially resectable to no gross evidence of disease? Symptomatic? Specialized local therapy (surgery and, if possible, accepts systemic therapy? >1 yr since initial? Resect to NED Symptomatic? Clinical trial: embolization of Metastaic Site or or Symptomatic and supportive care Clinical trial: embolization of metastases or Symptomatic and supportive care or

7 Renal Cell Carcinoma Selection of Treatment (Page 7 of 8) candidate for systemic Previous? Offer investigation -al accepts Relatively favorable prognostic/ patient factors?* Clinical trial Clinical trial if available or Interleukin-2- based therapy Response after 2 cycles? Continue to maximum response Resectable to NED status Clinical Trial: FUD/IFN/c-RA Clinical trial: systemic to best response followed by resection of metastatic disease Previous interleukin-2? Interferon-based (single agent or combination) *Examples of favorable prognostic factors: -Age <_ 60 -"Sites" of metastases <_ 2 -Metastases predominantly in lung - bone or brain involvement -Karnofsky score >_ 80 -Absence of constitutional symptoms -rmal calcium level Response after 2 cycles? Continue to maximum response Resectable to NED status Alternative systemic therapy or or Symptomatic and supportive care Clinical trial: systemic to best response followed by resection of metastatic disease

8 Renal Cell Carcinoma (Page 8 of 8) Stage T1 Follow -up : Months History x - x - x x x Physical exam x - x - x x x CT of abdomen x - x - x x x LFT/alk phos* x - x - x x x Stage T2 Follow -up : Months History - - x x x x x x x x Physical exam - - x x x x x x x x CT of abdomen x x - - x x x x x x x x LFT/alk phos* - - x x x x x x x x Stage T3: Months History - x x x x x x x x x Physical exam - x x x x x x x x x CT of abdomen x x - x x x x x x x x x LFT/alk phos* - x x x x x x x x x *LFT/alk phos = liver function tests/alkaline phosphatase.