Follow-up of patients treated for renal cancer

Grégory Lenczner, Samuel Merran, Paris - France

CCC Chromophobe C Papillary C

CCC Chromophobe C Papillary C

Renal cancer

•  Treatment : Surgery

- Nephrectomy

- Radical nephrectomy

- Nephron spearing surgery

•  Imprevisible evolution •  Regular follow-up

Follow-up frequency Good prognosis pT1 V0 N0 M0 grade 1 2 Anual follow-up •  Blood tests •  Chest-Abomen-Pelvis

CT

Intermediary prognosis pT2-3, V+ ou N1, M0

grade 3 Control every 6 months

during 3 years •  Blood tests •  Chest-Abomen-Pelvis

CT Anual follow-up for the 2

following years

Follow-up frequency

Bad prognosis (pT4, V+ et N2, M1)  Follow-up every 6 month (5 years)

Blood tests CAP CT After 5 years one follow-up a year

Follow-up frequency after nephron spearing surgery

•  Blood tests and CAP CT during the 6

monthes following surgery as a base line CAP CT one time a year

•  Doppler ultrasound in the week after surgery

Results in follow-up after treatment

Metastasis

•  50% of metastasis occurs during the two first years

•  80% winthin 3 to 5 years after treatment

•  5% can occur 10 years after treatment

Results in follow-up after treatment

Metastasis

•  Lung (66 à 80%) •  Bone (24 à 49%) •  Liver (10 à 26%) •  Brain (8 à 13%) •  Adrenal (8 à 11%) •  Skin (2 à 13%)

Results in follow-up after treatment

Metastasis •  Controlateral kidney •  Thyroid •  Prostate, Ovairies •  Gal bladder , Pancreas •  Sinuses •  Controlateral adrenal gland

Back ground (1/2)

•  The wide use of CT and MR and US allowed to discover unsuspected solid renal

•  The masses are both smaller and with a lower Fuhrman grade

W.-H. Chow, S. S. Devesa, J. L. Warren, and J. F. Fraumeni Jr.,

“Rising incidence of renal cell cancer in the United States,”

Journal of the American Medical Association, 1999. 281, 1628–1631,.

Back ground(2/2) •  The « Gold Standard » surgical treatment for renal

cancer used to be nephrectomy or radical nephrectomy •  During the ten past years nephron spearing surgery

becomes the treatment of renal solid masses.

Piper C, et Al.

Organ-preserving renal tumor surgery for renal cell carcinoma >/= T1b : opertive technique, complications and oncological control.

Urologe A 2011 

Ezzat Ael H, et Al.

Nephron sparing surgery for renal tumors

J Egypt Natl Cancer Inst, 2011 23 : 61-6

Nephrectomy versus nephron spearing surgery

•  Survival prognosis : no difference between the two surgical tecnics

•  Complications : More complications are describe with nephron spearing surgery (NSS)

**Van Poppel H et Al.

A prospective randomized EORCT intergroup phase 3 study comparing the complications of elective nephron sparing surgery and radical nephrectomy for low stage RCC

European Association of Urology

* Ross FC, et Al Functional analysis of elective nephron-sparing sugery vs radical

nephrectomy for renal tumors larger than 4 cm. Urology 2012, 79 : 607-14

•  One or multiples of the following may be present :

-Cortical wedge -Rotation of the kidney

-Infiltration of the retoperitoneal fat -Decrease of the retrorenal fat

-Infiltration of the posterior abdominal wall

Usual appearence after NSS

Usual appearence after NSS

A B C

CT before (A) and (B) after injection : solid mass on the the anterior face of the right kidney. (C) post operative follow-up the tumorectomy scar is visible as a cortical wedge

Usual appearence after NSS

A Pre op CT : 15 mm mass of the lateral aspect of the right kidney

A B

B Post op CT : lateral rotation latérale of the right kidney, cortical wedge and important reduction of the retro renal fat. Infiltration of the peri renal fat and the posterior abdominal wall

C

C Post op CT : : the tumorectomy scar was filled with retroperitoneal fat

Infiltration of the peri renal fat and the posterior abdominal wall

A Pre op CT without injection : mass of the superior pole of the left

B Pre op CT after injection the wall of this cystic mass is thick and enhances (Uniloculat type III uniloculaire of Bosniak classification)

A

B

C Pre op MR (T1) the cystic mass is hypointense

D Pre op MR (T2) : the cystic mass is hyperintense and the wall is thick

C

D

A B C

CT coronal reconstructions after NSC before injection (A) arterial phase (B) delayed phase (C) Wedge scar in place of the renal mass Infiltration of the peri renal fat

D

E F

Post op Axial MR image T2 FS (D) coronal MR images after Gadolinium injection (E and F) Wedge scar in place of the renal mass Infiltration of the peri renal fat and thickening of perirenal fascia

A B

C

Axial CT images before injection (A) arterial phase (B) delayed phase (C) post NSS. Infiltration of the retroperitoneal, modification (thickening) of the posterior abdominal wall, infiltration of the sub cutaneous fat

Surgical clips

- The use of surgical clips during NSS generates artifacts on follow-up imaging

- Because of the artifacts the analysis of the adjacent renal parenchyma may be difficult

A B

C D

Pitfalls and pseudo angiomyolipomas

- Pseudo surgical scar

- Pseudo AML

A B

D C

Not surgical scar

Embryological incomplete fusion

A B C

D E

G F

Post op MR the surgical site is filled by the retroperitoneal fat and looks like an AML

A B

Resorbable hemostatic material in the site of tumorectomy

•  To avoid post op bleeding the surgeon fills the site of tumorectomy with resorbable hemostatic material.

•  This material can simulate a renal mass on post op follow-up imaging

A B C

D

A

B

C

Peri renal fluid collections - Hematoma :

* sub capsular * peri renal

- Urinoma

- Lymphocele

A

B

Sub capsular hematoma

The peri renal collection contains contrast media on the delayed phase : fistula of the renal cavities in the peri renal space

A B C

D

Peri renal fluid collection

The delayed scans do not demonstrate contrast media in the collection

A fine needle aspiration find lymph.

Infectious complications - Acute pyelonepritis

- Renal abcess

a b c

A B

Vascular complications - Localised ischmia and renal atrophy

- Faulse aneurism

C

A

D

B

A B C B

A B

C

Post op CT

A C B

CT imageswithout injection (A) arterial phase (B) delayed pahse (C) : small solid hypervascular of the lower third of the left kidney

Post op follow-up : Arterial phase (A) tubular phase (B) : A faulse aneurism is detected in the site of tumorectomy

A B

Selective left renal angiography (A) : confirmation of the faulse aneurism treated with endo vascular coils Saggital and coronal CT reconstructions post embolization the fauls aneurysm is no longer enhancing

A B C

A B C

Post embolisation control : Coils are visible at the inferior pole of the kidney and the faulse aneurysme is no longer enhancing

Local recurrence

A B

C

A B

C

CONCLUSION •  Cross sectional imaging detect small renal

solide mass as incidental findings •  NSS replace radical nephrectomy •  Usual aspects on post operative imaging

have to be recognized by radiologists to avoid faulse diagnosis

•  The different complications must also be recognized to treat them either surgically of by inteventional radiology