Este documento discute o câncer renal, abordando: 1) O aumento da incidência devido ao envelhecimento da população e ao uso de métodos de imagem; 2) Fatores de risco como tabagismo, obesidade e hipertensão; 3) Diferentes subtipos histológicos com prognósticos distintos; 4) A nefrectomia radical como tratamento padrão.

1. CÂNCER RENAL 2009 Lucas Nogueira Sociedade Brasileira de Urologia Tisbu 100% Coordenador do Grupo de Uroncologia – HC / UFMG

5. Renal Cortical Tumors Median Tumor Size (3.3 cm in 2005)

14. Conventional Clear Cell 64.5% Chromophobe Ca 8.7%

15. Oncocytoma 9.3% Papillary Ca 13.6%

17. VHL Gene (3p25) in Renal Cell Carcinoma Mutations in Sporadic Clear Cell 50% Conv. RCC Nat Genet 7:85-90,1994

31. Progression Free Probability by Histological Subtype Oncocytoma Chromophobe Papillary Conventional (Clear Cell) p=.0027: Papillary vs. Clear Cell p< 0.001 Chromophobe vs. Clear Cell p< 0.0001 Oncocytoma vs. Clear Cell

38. TRATAMENTO

48. Tamanho x Metástases Thompson H, Hill, Babayev, Russo P et al. Risk of metastatic renal cell carcinoma according to tumor size. LANCET ONCOLOGY, IN PRESS

50. Função renal e nefrectomia radical Lancet, 2006

53. Renal Cortical Tumors Partial / All Nephrectomies 60 % Partial 2005

55. MSKCC: DFS Partial and Radical Nephrectomy: Tumors 4cm or less Lee C et al: J Urol 163:730-736. 2000 Lee C et al: J Urol 163:730-736. 2000

56. Conventional (Clear Cell) tumors 4 to 7cm in greatest diameter. Partial Nephrectomy Radical Nephrectomy p = 0.11 ( Dash et al: AUA 2005)

61. Guidelines AUA - 2009

64. Resultados Oncológicos Davol PE, Fulmer BR, Rukstalis DB. Long-term results of cryoablation for renal cancer and complex renal masses. Urology 2006 Hegarty NJ, Kaouk JH, Remer EM, et al. Laparoscopic renal cryoablation: oncological outcomes at 5 years [abstract]. J Endourol 2006 Gill IS, Remer EM, Hasan WA, et al. Renal cryoablation: outcome at 3 years. J Urol 2005;173:1903. Estudo N Tamanho (cm) Sobrevida livre 5a Gill 2005 51 2,3 98% (3a) Hegarty 2006 194 2,3 98% (5a) Davol, 2006 48 2,6 98% (5a)

66. Patterns of Metastases: Organ Sites

73. SSO 2005: Operations for Metastatic RCT MSKCC 1989-present Cytoreductive nephrectomy (N = 39) Median Survival Time: 17.6 months Nephrectomy + complete metastasectomy (N = 61) Median Survival Time: 28.8 months p = 0.02

75. Eggener SE et al. JCO 2006

78. RCC and Therapeutic Targets Motzer and Bukowski. J Clin Oncol. 2006;24:5601.

79. Targeted Approach to RCC Therapy Drugs and Targets = Sunitinib, Sorafenib Sunitinib, Sorafenib Bevacizumab Temsirolimus (CCI-779) VEGF VEGFR VEGF b pVHL HIF a PDGF PDGFR Other

82. Progression-Free Survival (Independent Central Review) No. at Risk Sunitinib: 375 240 156 54 10 1 IFN-α: 375 124 46 15 4 0 α

83. 41 yo with massive kidney cancer metastatic to the liver and lung, treated with sunitinib 7/06. The metastases and the primary tumor decreased dramatically and were removed 14 months later. Dramatic response in metastatic kidney cancer Sunitinib (Sutent)

88. Progression-free survival (investigator assessed) HR=0.63, p<0.0001 Median progression-free survival: Bevacizumab + IFN = 10.2 months Placebo + IFN = 5.4 months Probability of being progression-free Time (months) 0 6 12 18 24 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 5.4 10.2

90. KDR Temsirolimus (CCI-779), Everolimus (RAD001) Bevacizumab Sunitinib, Sorafenib HIF VEGF The Future of mRCC Targeted Therapy: Vertical Combinations – Targeting of VEGF at Multiple Levels Kaelin WG Jr. Clin Cancer Res 2004;10:6290s–6295s