management of renal cell carcinoma and wilm's tumor

1. MANAGEMENT OF RENALMANAGEMENT OF RENAL
TUMORSTUMORS
By Dr Anil Gupta
Moderator Dr Renu Madan

2. Classification of renal tumors
● Renal parenchymal tumors
Adult renal tumors
- Benign renal tumors- angiomyolipoma, oncocytoma, adenoma, cysts
- Malignant renal tumors- Renal cell carcinoma(mc), sarcoma, lymphoma
Paediatric renal tumors- wilm's tumor, rhabdoid tumor
● Renal Pelvis and Ureter- urothelial carcinoma

3. Renal Pelvis and Ureter
● > 90% urothelial carcinoma
● Accounts for 7% of all kidney tumors and 5% of all urothelial malignancies
● Staging similar to bladder cancer
● Treated in the line of bladder cancer

4. Renal parenchymal tumors

5. WHO classification of renal tumors(2016)

6. RENAL CELL CARCINOMA

7. Introduction
● Malignant tumors of the kidney and renal pelvis account for nearly 4% of
cancer cases and over 2% of cancer deaths in the United States
● RCC represents over 90% of all malignancies of the kidney in adults
● Male:Female ratio is 2:1
● It predominantly in the sixth to eighth decade of life with median age at
diagnosis around 64 years of age
● Highly vascular
● Not grossly infiltrative, except some collecting duct RCC and some
sarcomatoid variants
● No reliable histologic or ultrastructural criteria to differentiate benign from
malignant renal cell epithelial tumors, except oncocytoma which is always
benign

8. Epidemiology

9. Increases were seen mainly for localized cancers
- heightened clinical surveillance
- improved diagnostic capabilities

10. Established
Tobacco exposure
- Increases risk by about 50% in men and 20% in
women
Obesity
- Increases 24% for men and 34% for women
for every 5 kg/m2 increase in BMI
Hypertension
Genetic factors
- Von Hippel-Lindau (VHL) syndrome
- heriditary papillary RCC
- heriditary leiomyoma RCC
- Birt-Hogg-Dube syndrome(BHD)
- TS
-ADPKD
Risk Factors
Putative (generally considered to be)
Lead compounds
Various chemicals (e.g., aromatic
hydrocarbons)
Trichloroethylene exposure
Occupational exposure (metal, chemical,
rubber, and printing industries)
Asbestos or cadmium exposure
CRF on dialysis
 and antihypertensive
Radiation therapy
Dietary (high fat/protein and low
fruits/vegetables)

11. Genetic factors

12. Clinical Presentation
● Called “the great mimicker” or “the internist’s tumor”
● Many remain asymptomatic until the late disease stages
● Classic triad - unilateral flank pain, hematuria, and palpable
mass in 6-10%
● Propensity to present with manifold clinical signs, symptoms,
and paraneoplastic syndromes on the basis of local tumor
extent, distant spread, biological activity
● Can be true incidental tumors, classic triad symptoms, and
constitutional symptoms (weight loss, fever, night sweats,
anorexia, cough, malaise, etc.)

13. ● Anemia (21-41%)
● Elevated sedimentation rate (50-60%)
● Reversible hepatic dysfunction (10-
15%)
● Fever (7-17%)
● Amyloidosis (3-5%)
● Neuromyopathy (3%)
● Hypercalcemia (3-6%)
Paraneoplastic syndromes
● Erythrocytosis (3-4%)
● Hypertension (22-38%)
● Elevated human chorionic
gonadotropin levels
● Cushing syndrome
● Hyperprolactinemia
● Ectopic insulin and glucagon
production
● Raised alkaline phosphatase levels
(10%)
● Cachexia, weight loss (35%Stauffer syndrome
- liver dysfunction secondary to RCC
- due to production of hepatotoxins or IL-6, IL-8

14. GradingFuhrman grading
● A simplified, nuclear grading system, based only on size and shape of
nucleoli, will replace present system (ISUP conference 2015)

15. Prognostic factors
● Overall, tumor related factors such as pathologic stage, tumor size, nuclear grade,
and histologic subtype= independent
● Patient related factors such as CKD and co-morbidity have a significant impact on
overall survival
● Clinical findings s/o compromised prognosis in presumed localized RCC
- Symptomatic presentation
- Weight loss of more than 10% of body weight
- Poor performance status
● Other – molecular prognostic factors,

16. Normogram
Karakiewicz PI et al

17. Diagnostic evaluation
●
Baseline workup
- LFT, KFT, Creatinine clearance, CBC, ESR, coagulation study, urinalysis ,
Renal scintigraphy
● Essential workup
CT Scan
● Complimentary workup
Ultrasound, MRI, PET, renal tumor biopsy

18. ● Emits sounds ( 3 to 7 Mhz) and
receives echo
● Strength of the echo determines the
brightness setting for that cell
white for a strong echo, black for a
weak echo, and varying shades of grey
for everything in between
.
Ultrasonography
Normal Kidney
● Measures 9-11 cm's
● Has the same extent of echoes as liver
● Cortex measures about 2.5 cm's
● Central echoes are from fat
surrounding renal pelvis.
● Renal pelvis is filled with urine and is
echo free. Note the posterior
enhancement behind renal pelvis

19. Major criteria for a single simple cyst
are:
● the mass is round and sharply
demarcated with smooth walls
● no echoes (anechoic) within mass
● strong posterior wall echo indicating
good sound transmission through the
cyst

20. If US equivocal (complex cyst), or
suggestive of malignancy
● solid or complex
● with internal echoes
● and irregular walls
● if calcifications or septae are seen
● if multiple cysts are clustered so
that they may be masking
underlying carcinoma
PROCEED TO CT....

21. CT Imaging
● Radiologist's tumor
● Most reliable method for
detecting and staging renal
cancers
● Ideal CT examination for renal
masses
● - precontrast
● - arterial phase (~25 seconds
post injection)---> useful for
identifying the renal arteries and
for hypervascular masses

22. - nephrographic (~90 seconds post
injection)---> has the highest
sensitivity and specificity for renal
masses
- excretory phase (~5–7 minutes
post injection---> assessment of
collecting system and renal pelvic
involvement by a tumo
● A change of 15 or more HUs
demonstrates enhancement

23. CT provides information on
- Function and morphology of the
contralateral kidney
- Primary tumour extension;
- Venous involvement;
- Enlargement of locoregional LNs;
- Condition of the adrenal glands
and other solid organs
●
A typical finding of RCC
- heterogeneous pattern of
enhancement
-enhancement of iv contrast
material by more than 15 HU
should be considered an RCC until
proved otherwise

24. MRI
● MRI is used to evaluate solid
tumors seen on CT if a patient is
unable to receive IV contrast.
● Vascular invasion, IVC thrombi
are better demonstrated than CT
● Using bight blood technique
running blood shows bright signals
except thrombus which shows as
defects within the lumen

25. PET Scan
● For patients with high risk of
metastatic RCC
● Good specificity but suboptimal
senstivity
● At present its best role is for patients
with equivocal findings in
conventional imaging
● Radiolabelled monoclonal antibody to
CA-IX is virtually present in all
ccRCC
● Monoclonal antibody G250 labelled
PET is explored

26. ● Intravenous pyelography
Pros
- provide valuable information
pertaining to the pyelocalyceal system
- less resources required
Cons
- limited sensitivity for renal
parenchymal pathologies and small
renal masses
- time consuming
-Contrast toxicity
Renal angiogram
- now limited role
- guiding the operative
approach when attempting to
perform a partial nephrectomy

27. Renal tumor biopsy● Can be performed under LA, with core needle or fine needle
● At least two good quality cores should be obtained
● Peripheral biopsies are preferable for larger tumours, to avoid areas of
central necrosis
● A coaxial technique allows multiple biopsies
● Sensitivity- 99.1 %
● Specificity – 99.7%
● Diagnosis of tumour histotype is good

28. ● Complications
- bleeding, infection, arteriovenous fistula, needle track seeding,
pneumothorax
Moreover........
- sampling error,
-difficulty interpreting limited tissue
- now we have improved diagnostic accuracy of imaging modalities
90% of solid renal masses thought to be suspicious
for RCC on imaging prove to be RCC on final
pathologic analysis
● Present day indications
- radiologically indeterminate renal masses
- select patient kept on active surveillance with small renal mass
- obtain histology before ablative treatments
- select the most suitable form of medical and surgical treatment strategy in the setting of
metastatic disease

29. STAGING

30. - Renal hilar
- Caval (paracaval,
precaval, and retrocaval)
-Interaortocaval
- Aortic (paraaortic, preaortic,
retroaortic)

31. Clinical Staging

33. Survival by stage

34. Management of Localized RCC
(Stage I)

35. Radical nephrectomy
● Earlier gold standard( Robson et al,
1969)
Prototype
En bloc removal of the kidney and its
perirenal fat, enveloping Gerota's
fascia with I/L adrenal, proximal one-
half of the ureter, and lymph nodes
dissection from crus till the area of
transection of the renal vessels( or
aortic bifurcation)
● Much has changed now

36. ● Only 7% of patients with RCC tumors larger than 4 cm have micrometastatic
adrenal involvement
● Adrenalectomy only if
- extensive renal involvement
- locally advanced
- upper pole tumor
- SRM adjacent to adrenals
● LN dissection still contoversial
● Recent studies failed to show survival benefit
● More accurate pathological staging
present day indications of LN dissection
- high grade tumor
- sarcomatoid component
- histologic tumor necrosis
- large size of tumor (>10cm)
- pT3 or pT4
Changes in radical nephrectomy

37. ● Open
● Laparoscopic
- Decreased need for postoperative
analgesic drugs(24 mg vs 40 mg
morphine
- Shorter hospital stay(1.5 day vs 5 day
- Shorter recovery period (4 wk vs 8
wk)
Laparoscopy have similar DFS at 5
years and 10 years.as open surgery
Limitations of Laparoscopic procedure
-two-dimensional imaging
-restricted range of motion of the
instruments
-poor ergonomic positioning of the
surgeon

38. ● Advantage over laproscopic
- improved visualization
- more degree of movements
● Limited evidence currently available
for radical nephrectomy
Robot assisted Radical nephrectomy

39. Complications of Radical Nephrectomy
● Intraoperative complication
- injury to any GIT organs or to any major blood vessels, pleural injuries can result
in pneumothorax.
● Postop complications- secondary hemorrhage, atelectasis, ileus, superficial and
deep wound infections,renal failure, and incisional hernia.
● Other well-recognized systemic complications include MI, CHF, pulmonary
embolism, CVA, pneumonia, and thrombophlebitis
● Results in CKD

40. Nephron sparing surgery(NSS)
● Partial nephrectomy (PN)
● Standard of care
● Surgical removal of a kidney tumor along with a thin rim of normal kidney
● Preserves renal functioning

41. Indications of NSS
● Imperative
- solitary kidney
- B/L RCC
● Relative
- opposite kidney dysfunctioning
●
Elective(ideal)
- easily resectable, small (<4 cm), solitary, exophytic renal tumor, not a candidate
for surveillance, and whose medical condition is good enough to undergo surgery
and to benefit from it

42. ● With increasing surgical experience, indications of NSS are increasing and
contraindications decreasing
● Now centrally located tumors can also be resected by NSS
● can also be effectively and safely used to treat patients with tumors up to 7 cm in
diameter
● improved preservation of renal function, superior cardiac outcomes, and improved
overall survival, avoids overtreatment og indolent benign tumors
● Clinical stage1 renal massesrecommendsnephron-sparing surgery as standard of
care(AUA)
- mean warm ischemia time (27.8 vs 17.5
minutes)
- major intraoperative complications (5%
vs 0%)
- postoperative complications(11% vs 2%)
Laparoscopic RSSLaparoscopic RSS
- operative time (3 vs 3.9 hrs)
- blood loss (125 vs 250 ml)
- average recovery time was 4 vs 6 weeks
- analgesic requirement (20.2 vs 252.5 mg
morphine)
- hospital stay ( 2 vs 5 d)

43. Surveillance after PN
● Robotic RSS- if compared with laparoscopic RSS
- operative time (189 vs 174 minutes)
- positive margin rate (3.9% vs 1%)
- Intraoperative blood loss (155 vs 196 ml)
- length of hospital stay (2.4 vs 2.7 days)
- Warm ischemia time(19.7 vs 28.4 minutes)
-Postoperative complication (8.6% vs 10.2%).

44. Minimal invasive surgery
● Are Nonsurgical Focal Therapy for Renal Tumors
● Alternative to NSS
● They are
- technically less demanding
- shorter recovery and fewer complications than extirpative surgery
- minimal impact on postablation renal function
- can be deployed in open,laparoscopic, or percutaneous procedures

45. ● Present day indication:- small renal tumors who are either poor surgical
candidates or at risk for renal insufficiency, including patients with solitary
kidneys, bilateral renal tumors, hereditary syndromes such as von Hippel-
Landau disease, and renal insufficiency
● Cryoablation
● Radiofrequency ablation
● Microwave ablation
● Laser ablation
● High-intensity focused US ablation
● SBRT- as an alternative to thermal ablation is in its infancy

46. ●
Use of lower temperatures (<40o
C) for
destroying tumor
● Now argon based cryoprobes are used
based on joule-thompson principle
● Tissue destruction occurs due to both
freezing and thawing processes
MOA
formation of ice crystals within
cells
coagulation of blood interrupting
bloodflow causing ischemia and
cell death
induction of apoptosis, the so-
called programmed cell death
cascade
● the current recommendation is to
perform a double freeze-thaw cycle to
ensure complete cellular death
Cryoablation

47. Radiofrequency ablation
● Useof radiofrequency energy to heat tissue
to the point of cellular death
Uses electrocautery knife
alternating electric current delivered to
target tissue
vibration of ions within tissue and
resulting in molecular friction and heat
production
cellular protein denaturation and cell
membranedisintegration

48. Active surveillance
● Elderly and comorbid patients with incidental small renal masses have a
low RCC-specific mortality and significant competing-cause mortality
● These patients can be kept for active surveillance

50. Surveillance after surgery

51. Management of Locally Advanced RCC
(Stage II and III, T4 )

52. Locally advanced renal carcinoma
● Aim of therapy
Complete excision of the tumor, including resection of the involved bowel, spleen,
or abdominal wall muscles
● Radical nephrectomy is standard of care
● Extended operations with en bloc resection of adjacent organs are occasionally
indicated.
● IVC thrombus is curable and thombectomy should be done
● 90% died of disease at a median of 12 months after surgery
● Extensive lymphadenectomy in RN remains controversial, as a randomized trial
failed to show a distinct advantage
● R0
resection margins only in 63%

53. Neoadjuvant Radiotherapy
●
No difference in 5-year OS
●
Neither study, however, used doses considered adequate to sterilize even
microscopic disease by current standards.
●
Patients were eligible for participation, regardless of the stage of their
lesions.
●
Two prospective randomized studies failed to show benefit of preoperative
RT

54. Pattern of failure
Local failure
● 2% to 14%
● Increased in the presence of either lymph
node involvement (21% versus 4%,
Distant metastasis
● 26% in 7 yrs
● No survival benefit or DFS seen with
systemic chemotherapy or targeted
therapy

55. Adjuvant radiation therapy
● Used high dose/# ( 2.5 Gy/# for total dose of 50 Gy)
● Used small bowel in portal
● Small-bowel toxicity
● Hepatic dysfunction
● No survival benefit
● Need a multi-institutional study with hundreds of patients who are treated with meticulous
treatment planning and a well-thought-out fractionation scheme for definite conclusion
● Use of IMRT ca reduce toxicity

56. Management of metastatic RCC

57. Prognostic factors

58. Cytoreductive surgery
RATIONALE
● Bulky tumors might inhibit key components of the immune system critical
for combating cancer-- spontaneous regression of metastatic lesions
● Bulky tumor reduces response of systemic therapy
● Removal of large primary tumors may provide symptomatic benefit
● Surgery alone less likely to alter outcome Dekernion et al, 1978
● Several studies favoured nephrectomy f/b adjuvant therapy
Metastectomy
● Solitary metastaic lesion have 5 yr survival rate of 24%( 4% in multiple
metastasis)
● Resection along with nephrectomy is a/w 13% to 50% 5yr survival
Piltz et al

59. Cytokine therapy
Interleukin-2
● High-dose interleukin- 2 can achieve long-lasting complete(in 5% to 7%) or
partial remissions in a small subset of patients with predominantly clear
cell carcinoma
● Lower-dose IL-2 is non inferior
Interferon- α
● The response rates to interferon observed in the two study arms, OS was
improved in the surgery-plus interferon arm (median 11.1 vs. 8.1 months
for interferon alone,P = .05) Flanigan RC et al

60. Adverse effects of cytokine therapy
● Flu like symptoms
● Arthralgias
● Myalgias
● Fever and chills
● malaise
In almost all patients after adminstration
● Adverse effects
Expensive
● Not very good response
● Availability of targeted therapy
NOT USED NOW

61. Chemotherapy in metastatic setting
● RCC is a prototype of chemorefractory tumor ( limited or modest responses to
traditional chemotherpaeutics)
● Expression of multi drug resistance (MDR) proteins
- Eg: MDR-1(also known as p-glycoproteins) and MDR related proteins
- Act as energy dependent efflux pumps for variety of hydrophobic compounds
- contibute to chemorefractory nature of advanced RCC
● However there are some extra features
- RCC is also resistant to drugs like cisplatin and others( that are not handled by
MDR proteins)
- downregulation of MDR-1 in high grade tumors and metastatic RCC
● Medroxyprogestrone acetate was Ist systemic agent used for metastatic RCC
● Low response rates, but some tumor regression and symptom reduction seen
● Only 5-FU + Gemcitabine has shown 10-20% response in some variety

62. ERA OF TARGETED THERAPY

63. How do they act
EGF
PDGF
VEGF
Pericyte
Endothelial cell
Tumor cell
EGF
PDGF
VEGF
EGF
PDGF
VEGF
HIF-1β
VHL
HIF-1α
HIF-1α
HIF-1α
RAS
RAF
MEK
ERK
RAS
RAF
MEK
ERK
RAS
RAF
MEK
ERK
Paracrine
Function
Paracrine
Function
Autocrine
Function

64. Rational Targets in RCC (cont’d)
EGF
PDGF
VEGF
Pericyte
Endothelial cell
Tumor cell
EGF
PDGF
VEGF
EGF
PDGF
VEGF
HIF-1β
VHL
HIF-1α
HIF-1α
HIF-1α
RAS
RAF
MEK
ERK
RAS
RAF
MEK
ERK
RAS
RAF
MEK
ERK
Bevacizumab
Bevacizumab
Bevacizumab
Sunitinib
Sunitinib
Sunitinib
Sunitinib
Sorafenib Sorafenib
Sorafenib
Sorafenib
Sorafenib
Sorafenib
Sorafenib

65. Targets and Inhibitors

66. Multiple tyrosine kinase inhibitors
Targets several signaling pathways simultaneously
●
Sorafenib- PDGFR,VEGF inhibitor
●
Sunitinib- PDGFR,VEGF, stem cell factor receptor (KIT) inhibitor
● Pazopinib
● Axitinib
● Cabozatinib
● Lenvatinib
● Tivozinib
● Regorafenib- inhibits both VEGFR-2 and TIE2 TK
● Dovitinib- has activity against VEGF-R1/2/3, PDGF-R, c-kit, FLT3 and
additionally fibroblast growth factor (FGF) receptor 1, 2 and 3

67. ● Hand foot syndrome- mild to moderate
● Hypertension- frequent, can be serious if not managed properly
● Cardiovascular events
● Haemorrhage- can be life threatening
● Hepatotoxicity- in 3% cases on pazopinib
Adverse effects

68. ● Shown favourable response to sunitinib without any significant
toxicity

69. Monoclonal antibodies
Anti VEGF
● Directly targets VEGF receptors
● Only approved is Bevacizumab
● Given as bevacizumab + Interferon- α
IgG4 anti-PD-1
● Nivolumab
● Blocks a negative regulator of T-cell activation and response, thus
allowing the immune system to attack the tumor
●
2nd
line treatment for renal cell carcinoma

70. mTOR inhibitors
There is dysregulation of mTOR signaling, which can confer higher
susceptibility to inhibitors of mTOR
● Everolimus
● Temsirolimus
● Has immunosupressive action- can cause infections
● Hypercholestrolemia and hyperglycemia

71. Efficacy of targeted therapy

72. ● The vast majority of tumors eventually become refractory to therapy through
a variety of different, as yet poorly understood, mechanisms after a median
time 0f 5-11 months
● Novel agents and rational combinations are in development for the treatment
of mRCC in an attempt to address these resistance mechanisms, and reduce
severe side effects.
Problem with targeted therapy

73. ESMO guidelines for use of Targeted therapy in RCC
ESMO

74. Non ccRCC

75. Role of radiotherapy
● WBRT for brain mets
30 Gy/10# 40Gy/20# or 45Gy/15#
LC at 6m 21% 57%
at 12m 7% 35%
OS at 6m 29% 52%
at 12m 13% 47%
–->dose escalation beyong 30Gy has favourable outcome Shuto T, et al.
● SRS for focal brain lesion
> 3cm- resection
>2cm with symptomatic peritumoral edema- resection
>2 asymptomatic- gamma knife sx
<2 cm – gamma knife sx J.P Kavolius et al

76. ● SBRT for extracranial mets
- stereotactic radiation to lung, liver, and adrenal resulted in complete regression in
30% of cases and either partial regression or stabilization of the lesions in 60%
● Conventional RT for extracranial metastases
- Palliative radiotherapy is effective in relieving symptoms from metastatic RCC.
- solitary bone metastasis- long term survival
- Post metastectomy RT to prevent recurrence
- Complete resolution painful RCC cutaneous metastasis 37.5 Gy/13#
electron case report

77. Sarcomas of the kidney
● represent 1% to 2% of all malignant renal tumors in adults
● peak incidence in the fifth decade of life
● more lethal than sarcoma of any other genitourinary site
● Suspected if
- growth to large size in the absence of lymphadenopathy
- presence of fat or bone suggestive of liposarcoma or osteosarcoma,
- hypovascular pattern on angiography
● Managed by surgical resection ± chemotherapy ± RT

78. WILM'S TUMOR

79. Wilm's tumor
● Accounts for 6% of all pediatric tumors
● The median age of presentation is 3.5 years
● Presents as abdominal mass,abdominal pain or incidental
● WT1 (11p13), WT2 (11p15), and genes in the WNT signaling pathway are
implicated in the development of Wilms’ tumor.
● Also a/w WAGR, the Beckwith- Wiedemann syndrome, and the Denys-
Drash syndrome
● MR scanning is the recommended gold standard for abdominal imaging.

80. ● Surgical resection is the primary therapy for this tumor in the United
States- National Wilms Tumor Study Group (NWTS)
● Preoperative chemotherapy is routinely used in Europe- International
Society of Pediatric Oncology (SIOP)
● PGI follows SIOP guidelines 2001, ammended in 2004
● Has allowed reduction of treatment intensity
● 1.5 % benign tumors asre treated as wilms
● No difference in 5 yr EFS

81. Localised unilateral tumour

82. Preoperative chemotherapy
Two drugs (VCR, ActD) x 4 weeks:
Vincristine: 1.5 mg/m2 intravenous bolus (max 2mg) weeks 1, 2, 3, 4 (5th dose can
be given if week 5 falls before planned surgery)
Actinomycin D: 45 microgram/Kg intravenous bolus (max 2mg), weeks 1, 3
Give 66% of above doses for children weighing <12 Kg. If age < 6mths dose
reduce to 50% of each drug.
Reassessment imaging at week 4
Surgery should be planned for week 5-6

83. Histology
● Favourable histology
- 9 out of 10 wilm's tumor
- Good prognosis
● Unfavourable histology
- Anaplasia, heterologous
epithelial or stromal
components , including
mucinous or squamous
epithelium,skeletal muscle,
cartilage, osteoid, or fat
● Anaplastic wilm's tumor

84. Risk stratification

85. Staging
● By children's oncology group(COG)
● It is Post operative staging
Stage I - Cancer is limited to the kidney and can be completely removed by surgery
Stage II - Cancer has spread to the areas surrounding the kidney and can be
completely removed by surgery
Stage III - Cancer has spread to the areas surrounding the kidney, including blood
vessels, lymph nodes, or other nearby organs, and cannot be completely removed by
surgery, Node +ve, residual disease after surgery, tumour rupture
Stage IV - Cancer has spread into organs such as the lungs, liver, bone, and brain
Stage V - Tumors are found in both kidneys. Each kidney is staged separately

87. Postoperative chemotherapy
STAGE I, LOW RISK
- NO ADJUVANT TREATMENT

90. Metastatic Tumors

91. Drugs (VCR, Act D, Doxorubicin) x 6 weeks
Vincristine; 1.5 mg/m2 intravenous bolus (max 2mg)
Actinomycin D: 45 microgram/Kg intravenous bolus (max 2mg)
Doxorubicin 50 mg/m2 intravenous infusion over 4-6 hours weeks
Give 66% of above doses for children weighing <12 Kg. If age <6 mths dose reduce to
50% of each drug
Reassessment imaging (3D) at week 6
Surgery should be planned for week 7-8
Preoperative chemotherapy

92. Postoperative chemotherapy

94. Stage V- B/L renal tumors

95. PREOPERATIVE CHEMOTHERAPY
● If localized B/L renal tumor- chemotherapy similar to localized WT
● If metastatic B/L tumor- chemotherapy similar to metastatic WT
● Continue till it shows signs of tumor regression, but not beyond 12weeks
● If nephron sparing surgery not feasible then, carboplatin-etoposide chemo may
enable tumor regression
NEPHRON SPARING SURGERY
POSTOPERATIVE CHEMOTHERAPY
● Chemotherapy directed highest stage lesion kidney

96. Drug toxicity
● Hematological toxicity- myelosuppresive chemotherapy.
Mx defer chemotherapy if ANC< 1000, platelets< 1 lac, Hb< 7g
● GI toxicity- emetogenic drugs, VCR causes constipation.
Mx- antiemetics, laxatives, rehydration
● Hepatic complications – actinomycin D
Mx- monitoring with LFT
● Cardiac complications- with doxorubicin
Mx- prolonged infusion, monitioring with ECHO, cumulative dose <200mg/m2

97. ● Secondary infections- herpes relapse due to relative
immunocompromised state.
Mx aciclovir, restart chemo 1 week after resolution of rash
● Neurological toxicity- muscle weakness, hyporeflexia caused by
vincristine
Mx in case of severe neuritis skip the dose of VCR
● Bladder and renal toxicity- cyclophosphamide can cause hemorrhagic
cystitis
Mx prophylactic use of MESNA, I.V fluids and diuretics

98. Aim of radiotherapy
1.To prevent abdominal relapse.
2.To increase control of pulmonary metastases in patients not achieving complete
remission following chemotherapy and surgery
3.To increase control of hepatic metastases in patients who do not achieve complete
remission following chemotherapy and surgery
4.To increase control of brain and bone metastases

99. Timing of radiotherapy
● RT to be started on day 9 and no longer than 14 days
● Delay results in abdominal tumor recurrence ( NWTS-3 and NWTS-4)
● This is often not feasible and so RT should commence as soon as is
practicable
● If both pumonary and abdominal RT indicated, better to give both
together to prevent overlap toxicity

100. COG renal tumor protocol for radiation therapy

101. Flank irradiation
● INDICATIONS
- intermediate risk, stage III
- high risk stage II and III – except stage II
blastemal type
- Stage IV and V disease treated according
to local stage
TECHNIQUE
- AP-PA, 6 MV photons field is
preferred
- PTV- post op bed with 1 cm margin
- Medial border must cross midline to
prevent growth disturbances
Whole abdominal irradiation..

102. Whole abdomen irradiation
● If peritoneal tumor spillage
● AP-PA, 6 MV
● Upper margin- includes diaphragm
● Lower margin- lower border of
obturator foramen with shielding of
acetabulum and femoral head
● Lateral margin- flashing in air

103. Whole lung irradiation
● For pulmonary mets
● A lateral radiograph of the chest
taken ascertain treatment volume
● Dose 15 Gy/ 10#
● A boost of 5-10 Gy could be
considered for areas of gross
residual disease

104. ● Hepatic RT
- for liver mets
- whole liver RT can be given if diffuse
mets
- preferred is focal RT
-20 Gy may be given to the area of R1
resection of metastases(2 Gy/#)
● Whole brain RT
- for brain mets
- 25.5 Gy to whole brain f/b boost of
4.5 Gy with 1.5 Gy/#

105. Radiation Toxicity
Late effects
● Scoliosis
● Congestive heart failure
● Pregnancy related adverse
effects
● Secondary malignancy
● End stage renal disease
Acute effects
● Myelotoxicity
- stop if neutrophil <500, resume if >1000
- stop if platelet count <25,000, resume if
>50,000
- minimum Hb should be 10.0 g, transfusion
to be done if less
● GI toxicity- nausea, vomiting, diarrhea

106. Relapse
● The prognosis of children with relapsed WT depends on tumor histology,
initial stage, site of relapse, previous therapy, and time from initial diagnosis
to relapse
● The 3-year postrelapse survival rates were 44%, 28%, and 11% when the
relapse was confined to the lungs, abdomen, or other sites respectively
● The salvage regiment consisted of surgery when feasible, RT, and
alternating courses of vincristine, doxorubicin, cyclophosphamide, and
etoposide/cyclophosphamide

107. CONCLUSION
● Renal tumors are uncommon
● RCC is mc malignancy
● Radioresistant and chemoresistant
➢ Localized - Partial nephrectomy
➢ Locally advanced- Radical nephrectomy- no effective adjuvant therapy available
➢ Metastatic - Cytoreductive nephrectomy f/b targeted therapy ± RT
● Earlier detection has improved cure rate
● Many newer targeted therapy are underdevelopment which may improve
survival rate
● Wilm's tumor is most common paediatric renal tumor
● Very chemosensitive and radiosensitive
● Multi modality approach has improved survival rate drastically

108. THANK YOU