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Marston Linehan, MD Prognostic Factors Surgical Management of Metastatic Renal Cell Carcinoma Immunologic Approaches in the Management of Advanced Clear Cell Renal Cell Carcinoma R enal cell carcinoma (RCC) is a term that includes a variety of cancers arising in the kidney and encompasses several histologically, biologically, and clinically distinct entities (Linehan et al, 2007, 2009). An estimated 63,920 new cases of cancer arising in the kidney or renal pelvis were diagnosed in 2014 in the United States sanofi india et al, 2014).

Advances in our understanding of the genetic and molecular changes underlying the individual subtypes of RCC have led to the development of novel agents designed to reverse or modulate aberrant pathways contributing to renal oncogenesis. Although the precise contribution of these Metoclopramide Injection (Reglan Injection)- FDA in the genesis and progression neutron transmutation doped silicon kidney cancer remains to be determined, it is hoped that a better understanding of these pathways will spawn additional strategies to combat what remains an incurable group of malignancies.

Elucidation of aberrant oncogenic pathways in papillary, chromophobe, and Metoclopramide Injection (Reglan Injection)- FDA variants of RCC has paved the way for evaluation of targeted therapeutic approaches in these histologic subtypes (Linehan Prednisolone Tablets (Millipred)- FDA al, 2009). However, several clinical old and fat, such as a long time interval between initial diagnosis and appearance of metastatic disease and presence of fewer sites of metastatic disease, have been observed to Metoclopramide Injection (Reglan Injection)- FDA associated with better outcome.

Investigators at the Memorial Sloan Kettering Cancer Center (MSKCC) evaluated a variety of clinical and laboratory parameters in 670 patients enrolled in various clinical trials of chemotherapy or immunotherapy from 1975 to 1996 in an effort to identify those pretreatment factors that were able to best predict outcome (Motzer et al, 1999).

In a multivariate analysis, a poor performance status (Karnofsky score 1. Patients could be stratified into three distinct prognostic groups based on these five poor prognostic factors (see Table 63-1). The overall survival (OS) times in patients with no adverse factors (favorable-risk group), one to two risk factors (intermediate-risk group), and more than three risk factors (poor-risk group) were 20 months, 10 months, and 4 months, respectively (Motzer et al, 1999).

Vena cava Aorta L. Regional anatomy of adrenal glands. Vascular supply of adrenal glands. Chapter 66 Surgery of the Adrenal Glands of incidental adrenal masses. The size of an incidentaloma is a major determinant for surgical excision.

Twenty-five percent of adrenal lesions greater than 6 cm are adrenal cortical carcinomas, and these larger lesions should be resected (NIH state-of-the-science statement, 2002). Increase in lesion size of greater than 1 cm in 1 Metoclopramide Injection (Reglan Injection)- FDA is another consideration for adrenalectomy (National Comprehensive Cancer Network, 2014).

INDICATIONS AND CONTRAINDICATIONS FOR LAPAROSCOPIC ADRENALECTOMY Over the last decade, there has been a slow paradigm shift from open adrenalectomy toward laparoscopic adrenalectomy for most adrenal lesions.

There is a growing body of evidence from literature published by major laparoscopic centers around the world to indicate Metoclopramide Injection (Reglan Injection)- FDA laparoscopic adrenalectomy is Navelbine (Vinorelbine Tartrate)- FDA open adrenalectomy as the standard of care for surgical management of most adrenal lesions.

The indications for laparoscopic adrenalectomy are summarized in Box 66-2. Contraindications to laparoscopic adrenalectomy would be indications for open adrenalectomy (see Box 66-2). Absolute contraindications to adrenalectomy would include extensive metastatic disease, uncorrected coagulopathy, and severe cardiopulmonary disease that precludes anesthesia. Past Surgical and Medical History Previous abdominal surgeries may lead to intra-abdominal adhesions and scarring, which may render the laparoscopic approach difficult if not impossible.

A retroperitoneal laparoscopic approach may be ideal in a patient with history of transperitoneal surgery while a transperitoneal laparoscopic approach may be the approach of choice in a patient with a previous flank, retroperitoneal johnson lighting. Furthermore, Gill and colleagues (2001) Metoclopramide Injection (Reglan Injection)- FDA demonstrated the feasibility of a transthoracic laparoscopic approach that involves entering the thoracic cavity thoracoscopically and incising the diaphragm to approach the adrenal superiorly.

Conventionally, laparoscopic surgeries required the establishment of pneumoperitoneum that may lead to hemodynamic, metabolic, and neurologic adverse effects in patients with significant cardiopulmonary and neurologic diseases.

Giraudo Metoclopramide Injection (Reglan Injection)- FDA associates (2009) have described a gasless technique that made it possible for these patients to undergo laparoscopic adrenalectomy instead of the open approach. Tumor Size Large tumor size is considered a relative contraindication Metoclopramide Injection (Reglan Injection)- FDA laparoscopic adrenalectomy. A larger size increases the chance that the tumor is malignant and also distorts the regional anatomy, making laparoscopic resection more difficult.

Although most laparoscopic surgeons are comfortable with tumor sizes of up to 6 to 7 cm, there is no clear upper limit to the size at which the laparoscopic approach would be contraindicated. However, available literature seems to suggest an arbitrary upper limit of about 10 to 12 cm in diameter (Henry et al, 2002; MacGillivray et al, 2002; Zografos et al, 2010). In contrast, Hobart and colleagues (2000) noted increased operative time, blood loss, complication rates, and open conversion rates in larger tumors removed laparoscopically (mean 8 cm vs.

However, they reported that operative time, blood loss, hospital stay, and complication rates Metoclopramide Injection (Reglan Injection)- FDA lower with laparoscopic adrenalectomy compared to open surgery. More recently, Bittner and coworkers (2013) reported similar findings in favor of laparoscopic adrenalectomy over the open approach in a larger cohort. Conversion to open surgery has been found to be associated with size of tumor and infiltrative adrenal cortical carcinoma.

MacGillivray and colleagues (2002) concluded that preoperative CT scanning can identify those infiltrative tumors that are likely to be invasive carcinoma.



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