The profile of Renal Cell Carcinomaat DrSoetomo General Hospital
January 2006 – December 2010
Sriyono1, L. Hakim1, W.D. Soesanto1, S.H. Wijoto1
1
Department of Urology, Dr. Soetomo Hospital, Airlangga School of Medicine Surabaya
Abstract
Objectives: To review clinical characteristic of Renal Cell Carcinoma at DrSoetomo
General Hospital
Methods: A retrospective study of medical records patients suffering Renal Cell
Carcinoma recorded at DrSoetomo General Hospital since January 2006 until December
2010.
Results: There were collected 29 patients, 18 male in majority (62%), with ratio of 1,6:1 to
female. The age range was 30-70 years old, mostly 60-70 years old (24%), at mean of 51
years old. Renal tumor classic triad was seen on 9 patients (31%). Major pathological
finding was clear cell in 15 (52%) patients, 34% and 10% of papillary and chromophobe,
respectively. According to TNM system 2009, the stage presentation T1 was 1(3%)
patient,T2a 7(24%), 2b 10(35%), T3a 6(21%) and T4 5(17%) patients. N0 were 21(73%),
N1 5(17%) and N2 3(10%) patients. M0 were 23(79%) and M1 6(21%) patients. StageI
was 1 (3%) patient,stage II 15(52%), stage III 3(10%)and stage IV 10(34%). Twenty one
(72%) patients were, dominantly, underwent nephrectomy,the other 2(7%) underwent
partial nephrectomy; 6 (21%) patients underwent palliative nephrectomy and combined
withsunitinib in 4 (14%) patients. On three months follow up post operatively, it was found
that 2 (7%) patients died and 7 (24%) developed local recurrence tumor.
Conclusion:The Renal Cell Carcinomain our department; majority were male with ratio
1,6; 1. TheT criteria according to TNM 2009patient camein T1 was 1(3%) patient,T2a
7(24%), 2b 10(35%), T3a 6(21%) and T4 5(17%) patients.Stage of the patient according
to 2009 TNM staging systemmost of patient were stage II 15(52%) and stage IV in
10(35%) patient. On short follow up post opoperatively, 2 (7%) patients died and 7 (24%)
developed local recurrence tumor.
Keywords: Renal cell carcinoma, clear cell carcinoma, radical nephrectomy
malignancies in adults and role as the most
INTRODUCTION
Renal
cell
carcinoma
(RCC)accounts for 2 until 3 % of all
lethal of urologic cancers. In USA within
2010,
approximately
58.240
new
RCCdiagnoses were made, and 13.040 died
treatment and short outcome RCCwere
of RCC. This is primarily a disease of
collected form medical record, of Urology
elderly patient of 60 – 70 years old. Men
department of DrSoetomo hospital.
are more often to be affected 1,5 times than
RESULTS
women. RCCin childhood is uncommon,
There
about
2.3%-6.6%
amongst
all
renal
neoplasms in children. 1,2,3,4.
Kidneys
are
hidden
were
total
29
patients
managed within 5 years of 2006 to 2010 in
DrSoetomo hospital Surabaya, 18 (62%)
in
the
were men and 11 (38%) were women.
retroperitonealspace which makes renal
tumor rarely symptomatic in early stage,
Table
radiologic diagnostics are used widely,
carcinoma based on gender
especially USG, the more coincidental
The mean age is 51 years old, mostly 30-70
diagnosis are made.4This study’s aim to
years old, at peak of aged 60-70 years old.
provide a profile of RCC patients managed
in dr. Soetomo hospital, Surabaya, East
Java, Indonesia within 5 years, January
1.
Percentage
until growth as big size tumor. The more
Distribution
of
renal
cell
30%
20%
10%
0%
2006 until December 2010.
< 30 30 - 40 - 50 - 60 - >70
40 50 60 70
Age (year)
MATERIAL AND METHODS
Figure 1.Age distribution of renal cell
This is a retrospective study. The
carcinoma
samples are all RCC patients who have
The most frequent symptoms was
admitted to Dr. Soetomoacademic hospital
palpable mass in 25 (86%), followed with
within 5 years, from January 2006 to
flank pain in 17 (59%) and hematuria in
December 2010. Data about gender, age,
13(45%).
symtoms,
laboratory,
stage,
Triads
of
renal
histology,
waspositive in 9 (31%) patients.
tumor
Percentage
40%
30%
20%
10%
0%
T1a T2a T2b T3a T4
Primary Tumor
Table 2.Symptoms distribution of renal cell
Figure 2.Primary tumor distribution of renal
carcinoma
Based
on
laboratory
results,
13(45%) patients had hematuria, 3(10%)
had anemia, 4(14%) had leukocytosis and
5(17%) had decrease of renal function test.
cell carcinoma
Based on N Staging tumor, the stage of
presentation in N0 was 21(73%), N1
5(17%) and N2 3(10%) patients.
17%
10%
N0
N1
73%
N2
Table 3.Laboratory results distribution of
renal cell carcinoma
Figure 3.N staging tumor distribution of
Based on primary tumor, the stage
renal cell carcinoma
of presentation in T1 was 1(3%) patient,
Based on M staging tumor, the stage
T2a 7(24%), 2b 10(35%), T3a 6(21%) and
of presentation in M0 was 23(79%) and M1
T4 5(17%) patient.
6(21%) patients, where 3(50%) patient
metastatik was T4, 2(33%) was T3a and
one(13%) patient was T2b.
21%
M0
79%
M1
Figure 4.M staging tumor distribution of
Figure 6.Histology distribution of renal cell
renal cell carcinoma
carcinoma
After TNM staging group 2009
Twenty two patients (72 %) were
were used, most of renal cell carcinoma
underwent radical nephrectomy, 2 (7%)
were stage II 15(52%) and stage IV in
partial nephrectomy and 6 (21%) palliative
10(35%) and only 1(3%) came in first
nephrectomy followed with Sunitib in 4
stage.
(14%) patients.
3%
35%
10%
52%
stage 1
stage 2
stage 3
stage 4
Figure 7.Surgical treatment distribution of
renal cell carcinoma
Figure 5.Staging distribution of renal cell
carcinoma
Based on histologic picture, the
most common type is clear cell in 15(52%)
followed by papillary in 10 (34%) and
chromophobein 2 (7%) patients.
After three months evaluation, 2
(7%) patients were passed, and 7 (24%)
recurrent.
DISCUSSION
Within 5 years of 2006 until 2010 in
DrSoetomo hospital Surabaya has been
managed patient with RCC, itsappear to be
more common in men, 18 (62%) with ratio
6:1 to women, in age of 30 to 70 years old,
(VHL),hereditary papillary RCC (HPRCC),
mostly 60-70 years old (24%) with the
hereditary leiomyomatosis (HLRCC) and
average rate 51 years old. Similar to the
birthogg-dube (BHD).4,5,6
literature which mentioned men and women
Macroscopically most of RCC are
ratio of 1,5 : 1, aged 60-70 years old. Our
surrounded by a pseudo capsule which is
datas similiar to the datas of literatur were
renal parenchyma that is suppressed by the
to be affected 1,5 times of men, mostlyof
tumor, rarely infiltrative, unlike transitional
60 – 70 years old. 1,2,3,4.
cell carcinoma, except for collecting duct
According
to
WHO
there
are
and sarcomatoidtypes. Clear cell type is
subtypes of renal cell carcinoma based on
yellow-gold
histology which are; clear cell (70% -80%),
prognosis
papillary (10%-15%), chromophobe(3%-
chromophobe. A papillary type has 2
5%), collecting duct (<1%), unclassified
subtypes; papillary 2is more aggressive and
RCC (1%-3%) and several other rare types
appear to have worse prognosis than type 1.
such as; multilocular cyst clear cell,
Most patients with collecting ducttype are
medularyrenalis,
found in advance stage and have no
mucinous
post-neuroblastoma,
tubular
andspindle
cell
carcinoma. Clear cell and papillary renal
colored
and
compared to
has
worse
papillary and
response to systemic therapy.4,6,7,8
Kidneys
are
hidden
in
the
cell carcinoma are primarily raised from
retroperitonealwhich makes renal tumors
proximal tubules of the kidney, while
rarely symptomatic, except for big size
chromophobeand
are
tumor. The more radiologic diagnostics are
nephron
used vastly, especially USG, the more
derived
from
component.
collecting
more
Based
on
distal
duct
genetics,
the
coincidental diagnosis are made.4
Three
incidence of RCC also has correlation with
risk factors have close influence to the
familial factors, such as von hippellindau
incidence of RCC, they are tobacco
exposure, obesity and hypertension. TNM
p53,
PTEN
(phosphatase
and
tensin
classification of renal cell carcinoma was
homolog) (cell cycle), E-cadherin, and
made in 2009. Some factors affect the
CD44 (cell adhesion) have not shown a
prognosis such as anatomical, histological,
significance diagnostic value yet.14,15,16.
clinical, and molecular factors. Anatomical
Based on our data, almost all of the
factors are size of the tumor, invasion to the
chief complaint were mass 25 (86%) and
vein, renal capsule, adrenal gland, lymph
flank pain 17(59%) while classic triad of
nodes and also distant metastasis. Clinical
renal tumor in 9 (31%) patients because the
factors
advance
are
performance
state,
local
stage
of
prior
presentation.
symptoms, cachexia, anemia and platelet
Hematuria was found in 13 (45%) patients
count.9,10,11,12,13.
of renal cell carcinoma which suggest a
suspicion of renal neoplasms besides other
urologic cancer.Based on the TNM system
2009,the primary tumor then most of the
patients present in T2 (17/58%), T3a in
6(21%), T4 in 5(17%) and only one patient
come in T1. Based on N Staging tumor, the
stage of presentation in N0 was 21(73%),
N1 5(17%) and N2 3(10%) patients. Based
Table 4.Renal cell carcinoma (RCC) based
on
on 2009 TNM system9
presentation in M0 was 23(79%) and M1
Some of molecular markers like
M
staging
tumor,
the
stage
of
6(21%) patients.
IX (CaIX), vascular
In order to see the prognosis,
endothelial growth factor (VEGF), hypoxia
categorizing are done into tumor staging
inducible factor (HIF), Ki67 (proliferation),
where 15 patients are stage II (52%),
carbonic anhydrase
10(34%) are stage IV and only 1(3%) is
embolization before nephrectomy. For unfit
stage I. This is possible because of
patients who are not possible for surgery,
community’s lack of awareness of the
embolization may reduce pain and gross
importance
hematuria.16,17,18,19.
of
renal
tumor’s
early
treatment, they don’t come for help when
it’s early.
Radical nephrectomy is the chosen
option for local renal cell carcinoma which
From pathological results, for as
is not possible to do partial nephrectomy.
many as 15 patients (52%) the most seen
Laparoscopy
type was clear celltype, followed by
comparable cancer free rates after long
papillary cellin 10 patients (34%) and
period of time, with minimal blood loss and
2(10%)
In
shorter length of stay. Ideal indication for
clear
laparoscopy partial nephrectomy is small
celltype is the majority type of RCC for
peripheral tumor. Nephrectomy is curative
about 70-80% followed by papillary 10-
treatment only as long as all tumors are
15% and chromophobe3-5%. We didn’t
resectable.
find any other type at Dr. Soetomo hospital.
nephrectomy is palliative, only performed if
werechromophobetype.
accordance
with
the
literature,
Partial resection for local renal cell
and
In
open
surgery
metastatic
have
disease,
it is possible. 20,21,22,23,24,25,26
carcinoma shows a similar outcome to
Due to growth of proximal tubule
radical nephrectomy. Adrenalectomy is not
of the kidney, RCC is now showing
performed if the adrenal gland is normal on
resistance to some protein drugs, P-
CT or MRI, and found no nodule during
glycoprotein
surgery without any seen invasion to the
metastatic RCC, immunotherapy such as
upper pole. Lymph node dissection during
alpha-Interferon (IFN-α) and Interleukin-2
nephrectomy is proven to give better
(IL2)
prognosis and life expectancy, as well as
20%.Interleukin-2 is more toxic than alpha-
show
and
chemotherapy.
response
about
In
15-
IFN and only clear cell type give response
showing worse prognosis. Surgery is the
to immunotherapy. 27,28,29.
first choice for local recurrence without
Some targeted therapy which inhibit
the vascular endothelial growth factor
(VEGF);
sunitinib,
distant metastasis. If there is any metastasis,
we may give systemic therapy. 36,37,38
sorafenib,
Based on our data, 21(72%) patients
bevacizumabmaupunpazofenibandmammali
were
an target of rapamycin (mTOR) pathways;
2(7%) patients partial nephrectomy, and
temsirolimus and also everolimus, give
6(21%)
patients
better outcome than immunotherapy with
radical
nephrectomy,
more
treatment of Sunitibin 4(14%). Radical
tolerable
Biphosponator
complications.
Zoledronic
acid
performed
radical
nephrectomy,
underwent
palliative
followed
with
are
nephrectomy was performed in almost all
recommended for ones with hyperkalemia
patients who were possible for surgery with
with normal kidney function, which are
good performance state, because RCC is
given 4 mg every 4 weeks intravenously.
radio and chemo resistance, so that there
4,30,31,32,33,34,35
would be no further treatment after surgery.
Surveillance is for follow up of
By resecting the kidney along with fascia
possibility of recurrence and metastasis.
Gerota and perirenal fat, we expect no
Recurrence mostly occurs after 3 years of
metastasis and recurrence.
operation, 43% occur in the first year, 70%
Two patients were performed partial
in the second year, 80% in the third year
nephrectomy because the tumors were
and 93% in the fifth year. Metastasis is
localized in lower pole of the kidney. While
common to the lung, bone, liver, brain and
patients who already had metastasis were
local
areas.
Local
recurrence
after
still underwent palliative nephrectomy. The
nephrectomy
occurs
in
with
purpose is reducing huge mass effect, and
contralateral recurrence about 1,2% and
stops the growth of the primary tumor. Four
2.9%,
of them who were performed palliative
IV in 10(35%) patient. On short follow up
nephrectomy, were given Sunitib; which is
post opoperatively, 2 (7%) patients died and
a targeted therapy treatments to inhibit
7 (24%) developed local recurrence tumor.
vascular endothelial growth factor (VEGF)
Campaign is needed for general
then followed further for the hope of better
practitioners and radiologist to become
outcome.
aware of renal tumor, so that more RCC
Three months of evaluation we
will be found at earlier stage. Further study
2(7%) patients were dead and
must be done to evaluate side effects and
found
residive
in
7(24%)
Furthermoreevaluation
were
patients.
benefits of systemic drug in metastatic
difficult
renal
cell
carcinoma,
to
gain
more
because most of the samples live outside
conclusive advantage of targeted therapy.
Surabaya and might have no complaint
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The Renal Cell Carcinomain our
4.
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