A 45 yr old male with solitary kidney is detected to have 4 cm exophytic mass involving lower pole of the kidney. Which of the following would be most appropriate line of Rx?
|A||Follow-up with ultrasound|
|B||Radical Nephrectomy with hemodialysis|
|D||Radical Nephrectomy with immediate renal transplant|
This man with solitray kidney has 4 cm RCC which is limited to the kidney and hence can be resected best by partial nephrectomy so the patient can sustain renal function with remaining tissue well and later if required translplant or dialysis may be done.
The 2009 TNM staging classification system
T Primary tumour
a. TX Primary tumour cannot be assessed
b. T0 No evidence of primary tumour
c. T1 Tumour < 7 cm in greatest dimension, limited to the kidney
d. T1a Tumour < 4 cm in greatest dimension, limited to the kidney
e. T1b Tumour >4cm but <7cm in greatest dimension T2
f. T2a 7 cm in greatest dimension, limited to the kidney T2a
g. T2b 7 cm in greatest dimension but ≤10cm T2b Tumours > 10 cm limited to the kidney
h. T3 Tumour extends into major veins or perinephric tissues, but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia.
i. T3a Tumour grossly extends into the renal vein or its segmental (muscle-containing) branches, or tumour invades perirenal and/or renal sinus (peripelvic) fat but not beyond Gerota’s fascia
j. T3b Tumour grossly extends into the vena cava below diaphragm
k. T3c Tumour grossly extends into vena cava or its wall above the diaphragm or invades the wall of the vena cava
l. T4 Tumour invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)
Regional lymph nodes
a. NX Regional lymph nodes cannot be assessed
b. N0 No regional lymph node metastasis
c. N1 Metastasis in a single regional lymph node
d. N2 Metastasis in more than one regional lymph node
a. M0 No distant metastasis
b. M1 Distant metastasis.
a. For localised RCCs, nephron-sparing surgery is recommend- ed. Radical nephrectomy is recommended for patients with localised RCC, who are not suitable for nephron-sparing surgery due to locally advanced tumour growth, when partial resection is technically not feasible due to an unfavour- able localisation of the tumour, or when the patient’s general health has significantly deteriorated. Complete resection of the primary RCC either by open or laparoscopic surgery offers a reasonable chance for cure.
b. If pre-operative imaging is normal, routine adrenalectomy is not indicated. Lymphadenectomy should be restricted to staging because extended lymphadenectomy does not improve survival. In patients who have RCCs with tumour throm- bus and no metastatic spread, prognosis is improved after nephrectomy and complete thrombectomy.
c. Embolisation of the primary tumour is indicated in patients with gross haematuria or local symptoms (e.g. pain), in patients unfit for surgical intervention, and before surgical resection of large skeletal metastases. No benefit is associated with tumour embolisation before routine radical nephrec- tomy.