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Renal Cell Carcinoma

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3% of all cancer-related deaths. 10th most frequent cause of cancer mortality ... Angiogram. Metastatic Work-up. Chest X-ray. CT ... – PowerPoint PPT presentation

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Title: Renal Cell Carcinoma


1
Renal Cell Carcinoma
  • Christopher D. Gran, M.D.
  • Department of Urology

2
Incidence
  • 28,000 new cases/year in the U.S.
  • 19,100 in men
  • (2-31 malefemale)
  • 3 of diagnosed cancers
  • 7th most common cancer
  • 8,900 in women
  • Peak occurrence in 5th-7th decade
  • 2-3 bilateral

3
Mortality
  • 7,200 Deaths/year (male)
  • 3 of all cancer-related deaths
  • 10th most frequent cause of cancer mortality
  • Approximately 12,000 deaths/year total

4
Risk Factors
  • Tobacco use Smokers are twice as likely to
    develop kidney cancer as nonsmokers. The longer
    a person smokes, the higher the risk. Decreased
    for those who quit
  • Obesity
  • Occupational exposures
  • Radiation Women treated with radiation uterine
    CA may have a slightly increased risk of
    developing kidney cancer.
  • Phenacetin drug no longer sold in the United
    States
  • Dialysis ESRD patients on dialysis have an
    increased risk of developing renal cysts and
    renal cancer
  • Von Hippel-Lindau (VHL) disease, Tuberous
    Schlerosis

5
Presenting Symptoms
  • Common symptoms
  • 1. Hematuria/blood in the urine. Blood may be
    present one day and not the next. In some cases,
    a person can actually see the blood, or traces of
    it may be found by urinalysis
  • 2. A lump or mass in the kidney area
  • 3. Pain
  • Classic Triad present in 10 of patients with RCC

6
Presenting Symptoms
  • Less common symptoms
  • Fatigue
  • Loss of appetite
  • Weight loss
  • Recurrent fevers
  • Persistent flank pain
  • Lethargy
  • High blood pressure
  • Anemia

7
Incidental Findings
  • A large number of RCCs will be discovered as an
    incidental finding of a solid kidney mass upon
    testing for abdominal pain, trauma, or in the
    work-up for other medical problems

8
Differential Diagnosis
  • VITAMIN
  • Vascular
  • Infectious
  • Toxic
  • Autoimmune
  • Metabolic
  • Iatrogenic
  • Neoplasm (Cancer)

9
Differential Diagnosis of a Renal Mass
  • Cyst
  • Infection/Abscess
  • Aneurysm
  • Renal Cell Cancer (smokers)
  • Transitional Cell Cancer (history of kidney
    stones)
  • Benign Lesion

10
Anatomy
11
Pathology
  • 85 of renal cell cancers are adenocarcinomas,
    90 of which are of proximal convoluted tubular
    origin
  • Clear Cell Carcinoma (70-80)
  • Papillary (10-15) - slower growing
  • Chromophobe, Sarcomatoid
  • Transitional cell carcinomas - renal pelvis

12
Gross specimen of RCC
13
Evaluation/Workup
  • History
  • Physical Exam
  • Lab Studies
  • urinalysis
  • Radiological Evaluation
  • KUB (x-ray of Kidneys, Ureter and Bladder)
  • IVP (intravenous pyelogram)
  • Cystoscopy

14
History
  • Flank Pain (41)
  • Hematuria (36)
  • Weight loss (36)
  • Flank Mass (24)
  • HTN (20)
  • Hypercalcemia (6)
  • Erythrocitosis (3)

15
Past Medical History
  • Smoking History
  • Environmental Exposures
  • Asbestos, Cadmium, dyes, benzene
  • Family History
  • ESRD and Hemodialysis
  • Von Hippel Lindau
  • Tuberous Schlerosis

16
Physical Exam
  • Abdominal mass
  • Flank pain
  • Bruit
  • Varicocele
  • Hypertension

17
Laboratory Studies
  • Urinalysis
  • Urine culture with sensitivities
  • CBC (anemia)
  • BMP (Cr and Ca)

18
Radiological Studies
  • Ultrasound
  • KUB
  • IVP
  • CT scan
  • MRI
  • RPG (retrograde pyelogram)
  • Angiography

19
Ultrasound
20
IVP
21
CT scan
22
MRI
23
Retrograde Pyelogram
24
Angiogram
25
Metastatic Work-up
  • Chest X-ray
  • CT
  • Abdomen and Pelvis lymphadenopathy or elevated
    liver function tests
  • Head/Chest (mental status changes, lung lesions)
  • Bone scan
  • with bone pain

26
Metastatic Work-up
  • Laboratory Tests
  • Liver Function Tests (LFTs)
  • Serum Calcium
  • Sites of metastases include
  • Lung (69) Bone (43) Liver (34) Lymph Nodes
    (22) Adrenal gland(s) (19) Brain (7)

27
Treatment
  • Radical Nephrectomy
  • Partial Nephrectomy (nephron sparing)
  • Laparoscopic Nephrectomy
  • Radiation
  • Chemotherapy
  • Immunologic Therapy

28
Laparoscopic Nephrectomy
29
Survival
  • Based on Tumor Stage
  • Robsons Classifications
  • Stage 1 - contained within renal capsule
  • Stage 2 - outside capsule but within Gerotas
    fascia
  • Stage 3 - regional lymph node, renal vein or vena
    cava involvement
  • Stage 4 - metastatic

30
Survival
  • 5 year survival according to stage at nephrectomy
  • Stage 1 65-93
  • Stage 2 47-68
  • Stage 3 34-51
  • Stage 4 2-20
  • Spontaneous regression in lt1 of RCC

31
Survival
  • With metastatic disease
  • 30 with metastatic RCC at time of diagnosis
  • Average survival of 4 months
  • 10 survive 1 year

32
Recurrence
  • The prognosis is poor
  • Surgical resection in select patients
  • 15 objective response rate in patients with
    non-bulky pulmonary and/or soft tissue metastases
    with excellent performance status (ECOG 0,1) and
    no weight loss
  • 5 of durable complete remissions
  • Treatment options Interleukin-2 with or without
    lymphokine-activated killer (LAK) lymphocytes
    Interferon alpha External-beam irradiation
    (palliative) Vinblastine Non-myeloablative
    allogeneic stem cell transplantation

33
Rare Malignant Renal Tumors
  • Sarcoma (60 leiomyosarcomas)
  • Hemangiopericytoma
  • Lymphoblastomas
  • Metastatic Renal Tumors

34
Benign Tumors
  • Oncocytoma
  • Angiomyolipoma (Hamartoma)
  • Adenoma
  • Lipoma
  • Fibroma
  • Leiomyoma
  • Angioma
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