Figure 7.Surgical treatment distribution of renal cell carcinoma 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, mostly 60-70 years old (24%) with the average rate 51 years old. Similar to the literature which mentioned men and women ratio of 1,5 : 1, aged 60-70 years old. Our datas similiar to the datas of literatur were to be affected 1,5 times of men, mostlyof 60 – 70 years old. 1,2,3,4. According to WHO there are subtypes of renal cell carcinoma based on histology which are; clear cell (70% -80%), papillary (10%-15%), collecting duct (<1%), RCC (1%-3%) and several other rare types such as; multilocular cyst clear cell, medularyrenalis, post-neuroblastoma, mucinous tubular andspindle cell carcinoma. Clear cell and papillary renal cell carcinoma are primarily raised from proximal tubules of the kidney, while chromophobeand collecting duct are derived from more distal nephron component. Based on genetics, the incidence of RCC also has correlation with familial factors, such as von hippellindau (VHL),hereditary papillary RCC (HPRCC), hereditary leiomyomatosis (HLRCC) and birthogg-dube (BHD).4,5,6 Macroscopically most of RCC are surrounded by a pseudo capsule which is renal parenchyma that is suppressed by the tumor, rarely infiltrative, unlike transitional cell carcinoma, except for collecting duct and sarcomatoidtypes. Clear cell type is yellow-gold colored and has worse prognosis compared to papillary and chromophobe. A papillary type has 2 subtypes; papillary 2is more aggressive and appear to have worse prognosis than type 1. Most patients with collecting ducttype are
found in advance stage and have no response to systemic therapy.4,6,7,8 Kidneys are hidden in the retroperitonealwhich makes renal tumors rarely symptomatic, except for big size tumor. The more radiologic diagnostics are used vastly, especially USG, the more coincidental diagnosis are made.4 Three risk factors have close influence to the incidence of RCC, they are tobacco exposure, obesity and hypertension. TNM classification of renal cell carcinoma was made in 2009. Some factors affect the prognosis such as anatomical, histological, clinical, and molecular factors. Anatomical factors are size of the tumor, invasion to the vein, renal capsule, adrenal gland, lymph nodes and also distant metastasis. Clinical factors are performance state, local symptoms, cachexia, anemia and platelet count.9,10,11,12,13. Table 4.Renal cell carcinoma (RCC) based on 2009 TNM system9 Some of molecular markers like carbonic anhydrase IX (CaIX), vascular endothelial growth factor (VEGF), hypoxia inducible factor (HIF), Ki67 (proliferation), p53, PTEN (phosphatase and tensin homolog) (cell cycle), E-cadherin, and CD44 (cell adhesion) have not shown a significance diagnostic value yet.14,15,16. Based on our data, almost all of the chief complaint were mass 25 (86%) and flank pain 17(59%) while classic triad of renal tumor in 9 (31%) patients because the advance stage of prior presentation. Hematuria was found in 13 (45%) patients 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 on M staging tumor, the stage of
presentation in M0 was 23(79%) and M1 6(21%) patients. In order to see the prognosis, categorizing are done into tumor staging where 15 patients are stage II (52%), 10(34%) are stage IV and only 1(3%) is stage I. This is possible because of community’s lack of awareness of the importance of renal tumor’s early treatment, they don’t come for help when it’s early. From pathological results, for as many as 15 patients (52%) the most seen type was clear celltype, followed by papillary cellin 10 patients (34%) and 2(10%) werechromophobetype. In accordance with the literature, clear celltype is the majority type of RCC for about 70-80% followed by papillary and chromophobe3-5%. We didn’t find any other type at Dr. Soetomo hospital. Partial resection for local renal cell carcinoma shows a similar outcome to radical nephrectomy. Adrenalectomy is not performed if the adrenal gland is normal on CT or MRI, and found no nodule during surgery without any seen invasion to the upper pole. Lymph node dissection during nephrectomy is proven to give better prognosis and life expectancy, as well as embolization before nephrectomy. For unfit patients who are not possible for surgery, embolization may reduce pain and gross hematuria.16,17,18,19. Radical nephrectomy is the chosen option for local renal cell carcinoma which is not possible to do partial nephrectomy. Laparoscopy and open surgery have comparable cancer free rates after long period of time, with minimal blood loss and shorter length of stay. Ideal indication for laparoscopy partial nephrectomy is small peripheral tumor. Nephrectomy is curative treatment only as long as all tumors are resectable. In metastatic disease, nephrectomy is palliative, only performed if it is possible. 20,21,22,23,24,25,26 Due to growth of proximal tubule of the kidney, RCC is now showing resistance to some protein drugs, and chemotherapy. In