Renal Cancer

Pathologic Subtypes

Renal Cell Carcinoma

  • Epidemiology: account for 80-85% of primary renal neoplasms
  • Risk Factors
  • Physiology: originate from the renal cortex
  • Metastasis: hematogenous
    • Commonly metastasizes to lung: lung is only site of metastasis in 27% of cases

Urothelial Cell Carcinoma (Transitional Cell Carcinoma) of the Renal Pelvis (see Urothelial Cell Carcinoma, [[Urothelial Cell Carcinoma]])

  • Epidemiology: account for 8% of primary renal neoplasms
  • Physiology: originate from
  • Metastasis: xxx

Sarcoma

  • Epidemiology: rare

Wilm’s Tumor (Nephroblastoma)

  • Epidemiology: accounts for 5-6% of all primary renal neoplasms
    • Occurs in children

Clinical Manifestations of Renal Cell Carcinoma

General Features

  • Asymptomatic: many cases
    • 25% of cases have either advanced local/regional disease or distant metastases on presentation
    • Classic symptom triad of flank pain, hematuria, and palpable renal mass is present in only 9% of cases: when present, it usually indicates locally advanced disease

Renal Manifestations

  • Flank Pain (see Flank Pain, [[Flank Pain]])
  • Hematuria (see Hematuria, [[Hematuria]]): occurs only when the tumor invades the collecting system
    • Presence of clots can be diagnostically useful, as glomerular bleeding does not produce clots
  • Renal Mass (see Renal Mass, [[Renal Mass]])
    • Diagnosis
      • Abdominal/Pelvic CT
      • Abdominal/Pelvic MRI
  • Scrotal Varicoceles: usually left-sided
    • Mechanism: kidney tumor obstructs the gonadal vein where it enters the renal vein
    • Clinical: varicocele fails to empty in the recumbent position

Paraneoplastic Syndromes

  • General Features: may occur due to the ectopic production of erythropoietin, parathyroid hormone-related protein (PTHrp), gonadotropins, human chorionic somatomammotropin, an ACTH-like substance, renin, glucagon, and insulin
  • AA (Secondary) Amyloidosis (see Amyloidosis, [[Amyloidosis]]): occurs in 3-5% of cases
    • Mechanism: reflects a chronic inflammatory response (as the amyloid fibrils are composed of fragments of the acute phase reactant serum amyloid A protein)
  • Anemia (see Anemia, [[Anemia]]): reported in 29-88% of patients with advanced disease
    • May precede the diagnosis of renal cell carcinoma you several months
    • Degree of anemia may be disproportionately severe
    • Anemia can be microcytic or normocytic
    • Iron studies are consistent with anemia of chronic disease
  • Cachexia
  • Erythrocytosis (see Polycythemia, [[Polycythemia]]): occurs in 1-5% of cases
    • Mechanism
      • Constitutive production of erythropoietin
      • Mutated von Hippel-Lindau protein -> impaired degradation of hypoxia-inducible transcription factors under normoxic conditions
  • Fever (see Fever, [[Fever]]): occurs in up to 20% of cases
    • Usually intermittent
    • May be accompanied by night sweats, anorexia, weight loss, and fatigue
  • Hypercalcemia (see Hypercalcemia, [[Hypercalcemia]]): occurs in 15% of cases
    • Mechanisms: lytic bone metastases, parathyroid hormone-related protein (PTHrp) production, increased IL-6 (which enhances effect of PTHrp), and prostaglandin-induced enhancement of bone resorption
  • Polymyalgia Rheumatica-Like Syndrome (see Polymyalgia Rheumatica, [[Polymyalgia Rheumatica]])
    • Epidemiology: cases have been reported
    • Treatment
      • Does not respond to prednisone treatment (in contrast to idiopathic polymyalgia rheumatica)
      • Nephrectomy appears to be effective
  • Stauffer’s Syndrome: hepatic dysfunction in renal cell carcinoma in the absence of liver metastases
    • Mechanism: may be due to tumor production of GM-CSF and IL-6
    • Elevated Alkaline Phosphatase: occurs in 21% of cases
    • Frequently associated with fever, weight loss, fatigue, and a poor prognosis
    • Nephrectomy may result in the improvement in the hepatic dysfunction
    • Recurrent liver function test elevations in such patients may signal the onset of local recurrence or distant metastases
  • Thrombocytosis (see Thrombocytosis, [[Thrombocytosis]]): rare in renal cell carcinoma
    • Mechanism: may be due to tumor synthesis of IL-6
    • Presence is associated with a poor prognosis

Metastases

Inferior Vena Cava (IVC) Involvement

  • May result in IVC obstruction with lower extremity edema, ascites, Budd-Chiari syndrome, or pulmonary embolism

Lung Metastases

  • Epidemiology: common early site of metastasis
  • Clinical
    • Lung Nodule/Mass (see Lung Nodule or Mass, [[Lung Nodule or Mass]])
      • Size: 3 mm-6 cm (of various size) smooth or slightly lobulated nodules
      • Location: lower-lobe predilection
      • Calcification: rare
      • Cavitation: sometimes
      • Usually absent hilar/mediastinal nodes

Brain Metastases

  • Epidemiology: common early site of metastasis

Bone Metastases

  • Epidemiology: common early site of metastasis

Liver Metastases

  • Epidemiology: common early site of metastasis

Lymph Node Metastases

  • Epidemiology: common early site of metastasis

Treatment of Renal Cell Carcinoma

Surgery

Radical Nephrectomy

  • Indication
  • Technique
    • Robotic Radical Nephrectomy
    • Laparoscopic Radical Nephrectomy

Partial Nephrectomy

  • Indication
  • Technique
    • Robotic Radical Nephrectomy
    • Laparoscopic Radical Nephrectomy

Pulmonary Metastatectomy

  • Indication: single pulmonary metastases

Ablation

  • xxxx

Chemotherapy

  • xxx

References

  • xxxx