Management of Localized and Locally Advanced Disease: Difference between revisions

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 *# '''<span style="color:#ff0000">Sarcoma</span>'''
 *# '''<span style="color:#ff0000">Adrenocortical carcinoma</span>'''
-* '''<span style="color:#ff0000">IVC involvement</span>'''
+* '''<span style="color:#ff0000">IVC involvement (cT3-bN0M0)</span>'''
-** '''See [[Open Kidney Surgery]] Chapter Notes'''
+**'''Tumours associated with IVC thrombi:'''
-** '''<span style="color:#ff0000">A venous tumour thrombus is an intraluminal growth of RCC into the renal venous circulation.</span>'''
+***Children (4):
-*** '''<span style="color:#ff0000">There can be a tumour and benign portion to the thrombus.</span>'''
+***#Wilms tumor
-** '''<span style="color:#ff0000">Diagnosis and evaluation</span>'''
+***#Neuroblastoma
-*** '''<span style="color:#ff0000">IVC tumour thrombus should be suspected in patients with a renal tumour and (7):</span>'''
+***#Adrenocortical carcinoma
-***# '''Lower extremity edema'''
+***#Clear cell sarcoma of the kidney
-***# '''Isolated right-sided varicocele or one that does not collapse with recumbency'''
+***'''Adults (7):'''
-***# '''Dilated superficial abdominal veins'''
+***#'''Renal cell carcinoma (most common cause,''' 18% of all tumours associated with IVC thrombi''')'''
-***# '''Proteinuria'''
+***#'''Urothelial carcinoma of the renal pelvis'''
-***# '''Pulmonary embolism'''
+***#'''Lymphoma'''
-***# '''Right atrial mass'''
+***#'''Retroperitoneal sarcoma'''
-***# '''Non-function of the involved kidney'''
+***#'''Adrenocortical carcinoma'''
-*** '''<span style="color:#ff0000">MRI is the preferred imaging to characterize the extent of the thrombus, though CT may be adequate</span>'''
+***#'''Pheochromocytoma'''
-**** Prognostic significance of IVC thrombus level has been controversial. Even patients with level IV IVC thrombi can be cured with surgical resection
+***#'''Angiomyolipoma'''
-**** Imaging should be obtained as close as possible to the date of surgery because progression of the tumor thrombus may mandate important changes in intraoperative management
+***'''2 components associated with IVC thrombi:'''
-**** Although MRI has been recommended as the test of choice at most centers, several recent studies have demonstrated that multiplanar CT also provides sufficient information for surgical planning, and it has become the preferred diagnostic study at many centers.
+***#'''Tumor thrombus (tumor cells contained within bland thrombus)'''
-**** '''See [[Open Kidney Surgery]] Chapter Notes for staging of the level of IVC thrombus'''
+***##'''<span style="color:#ff0000">A venous tumour thrombus is an intraluminal growth of RCC into the renal venous circulation.</span>'''
-** '''Prognosis'''
+***#'''Bland thrombus (blood coagulum without tumor cells)'''
-*** '''45-70% of patients with RCC and IVC thrombus can be cured with an aggressive surgical approach including RN and IVC thrombectomy'''
+***#*'''Venous drainage is hampered by venous thrombus encouraging formation of bland thrombus'''
-** '''Management'''
+***#*'''Distinction between these two forms of venous thrombus is critical and forms the basis of operative management for IVC thrombi.'''
-*** '''Preoperative renal artery embolization can be considered to attempt to shrink the thrombus and facilitate surgery'''
+***'''RCC with venous thrombus associated with aggressive disease'''
-*** '''See [[Open Kidney Surgery]] Chapter Notes'''
+****10% have associated positive regional lymph nodes
+****25% have associated metastases
+****50% have perirenal fat invasion.
+***'''<span style="color:#ff0000">Diagnosis and evaluation</span>'''
+****'''<span style="color:#ff0000">IVC tumour thrombus should be suspected in patients with a renal tumour and (7):</span>'''
+*****'''Lower extremity edema'''
+*****'''Isolated right-sided varicocele or one that does not collapse with recumbency'''
+*****'''Dilated superficial abdominal veins'''
+*****'''Proteinuria'''
+*****'''Pulmonary embolism'''
+*****'''Right atrial mass'''
+*****'''Non-function of the involved kidney'''
+****'''<span style="color:#ff0000">Imaging</span>'''
+*****'''<span style="color:#ff0000">MRI is the preferred imaging to characterize the extent of the thrombus, though CT may be adequate</span>'''
+******Prognostic significance of IVC thrombus level has been controversial. Even patients with level IV IVC thrombi can be cured with surgical resection
+******Imaging should be obtained as close as possible to the date of surgery because progression of the tumor thrombus may mandate important changes in intraoperative management
+******Although MRI has been recommended as the test of choice at most centers, several recent studies have demonstrated that multiplanar CT also provides sufficient information for surgical planning, and it has become the preferred diagnostic study at many centers.
+******'''See [[Open Kidney Surgery]] Chapter Notes for staging of the level of IVC thrombus'''
+***'''Prognosis'''
+****'''45-70% of patients with RCC and IVC thrombus can be cured with an aggressive surgical approach including RN and IVC thrombectomy'''
+***'''Management'''
+****'''Usually, IVC thrombectomy is accompanied by radical nephrectomy and regional lymph node dissection'''
+****'''Preoperative renal artery embolization can be considered to attempt to shrink the thrombus and facilitate surgery'''
+****'''See [[Open Kidney Surgery]] Chapter Notes'''
 * '''<span style="color:#ff0000">Locally invasive RCC (T4N0M0 (Local tumour extension to adjacent organs without metastatic disease)</span>''')
 ** '''<span style="color:#ff0000">Management</span>'''