Kidney Cancer

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Contents 1 More Specific Terms 2 Etiology 3 Epidemiology 4 Pathology 5 Genetics 6 Clinical-manifestations 7 Laboratory 8 Radiology 9 Staging 10 Complications 11 Differential-diagnosis 12 Management 13 More General Terms 14 Additional Terms 15 References

More Specific Terms

• renal cell carcinoma (hypernephroma, Grawitz tumor)

Etiology

• predisposing factors

• tobacco
• male sex
• cadmium exposure

Epidemiology

• 3% of all solid tumors in men & women
• renal cell carcinoma most common renal cancer

Pathology

• arises from proximal tubule
• adenoma to carcinoma progression
• metastases

• liver (44%)
• lung (72%)
• bone (10%)
• brain (19%)
• skin (5%)
• adrenal (20%)
• ipsilateral or contralateral kidney (21%)

Genetics

• translocation involving short arm of chromosome 3

• sporadic disease

• near von Hippel-Lindau disease locus

• hereditary renal cell carcinoma

• translocation involving short arm of chromosome 3

• trisomy 2 & 5
• monosomy 19
• other implicated genes WDR45, ANLN, WIPI2, LETMD1, DERPC

Clinical-manifestations

• often asymptomatic until late stages

• often incidental finding during radiologic workup of unrelated medical problem

• hematuria* is most common presentation (late sign) (40%)
• fever, low grade to sporadic (20%)
• flank pain*, usually dull & constant (40%)
• palpable mass* (25%)
• weight loss (33%)
• acute varicocele in 11% of cases

• usually left-sided
• does not reduce in recumbent position

• paraneoplastic phenomena

• polycythemia (3%)
• hypertension (20%)
• amyloidosis (2%)
• neuromyopathy (3%)

• * classic triad (10-20% of presentations)

Laboratory

• urinalysis: hematuria
• complete blood count ( CBC)

• polycythemia (3%)
• anemia (33%)

• serum chemistries

• abnormal liver function tests (in the absence of liver metastases) (15%)
• serum calcium: hypercalcemia (5%)
• serum cortisol: elevated cortisol

• elevated erythrocyte sedimentation rate (ESR) (55%)
• serum antibodies to KCTD3 in 75% of patients

Radiology

• renal ultrasound
• abdominal CT with contrast
• magnetic resonance imaging ( MRI)

• visualization of renal vein & inferior vena cava ( IVC)
• tumor may invade renal vein & travel up the IVC

• staging/ metastatic workup

• technetium-99m bone scan
• lung CT
• head CT if indicated

Staging

• Stage 1: within capsule
• Stage 2: within Gerota's fascia
• Stage 3: involvement of regional lymph node, renal vein,
• inferior vena cava or ipsilateral adrenal gland
• Stage 4: distant metastases
  
• also see renal cell carcinoma

Complications

• 
  
• disease interaction(s) of cancer with Alzheimer's disease

Differential-diagnosis

• renal abscess
• renal cyst - simple cysts generally do not cause hematuria
• angiomyolipoma
• distorted renal architecture from

• infection
• infarction
• congenital anomaly

• granuloma
• metastases to kidney

• more common than primary tumors
• rarely, clinically significant

• other tumors

• oncocytoma
• adult form of Wilm's tumor

Management

• surgery

• radical nephrectomy & regional lymphadenectomy except stage 4 tumors
• solitary metastases
• partial nephrectomy for bilateral disease

• renal cell carcinoma is radioresistant
• chemotherapy

• vinblastine (10% response rate)
• chemotherapy not very effective
• bevacizumab ( Avastin) 10 mg/kg every 2 weeks for up to 1 year plus interferon alfa-2a 9 mIU 3x/week extends progression-free survival from 5-10 months [5]

• immunotherapy

• interferon-alpha
• interleukin-2 (10-20% response rate)
• lymphocyte-activated killer cells
• xenogenieic immune RNA
• bacillus Calmette-Guerin ( BCG)

• hormonal therapy of limited value
• follow-up

• imaging at 1-2 months, then every 6 months for 2-5 years
• as indicated by treatment protocol

• prognosis

• 5 year survival 30% for non-resectable tumor
• small (< 3 cm) tumors do often do not progress in the elderly during several years of follow-up [4],
• observation may be an option in a subset of elderly [4]

More General Terms

• urologic malignancy (urologic cancer)
• kidney neoplasm

Additional Terms

• interferon [IFN]-alpha
• interleukin-2 (IL-2) or T-cell growth factor
• vinblastine; vincaleukoblastine (Velban, Velsar, Alkaban-AQ)

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 560-62
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 521
4. Remzi M et al, Are small renal tumors harmless? Analysis of histopathologic features according to tumors 4 cm of less in diameter. J Urol 2006, 176:896 PMID: [1]
   - Schlomer B et al, Pathological features of renal neoplasms classified by size and symptomatology J Urol 2006, 176:1317 PMID: [2]
   - Matin SF et al, Residual and recurrent disease following renal energy ablative therapy: A multi-institutional study. J Urol 2006, 176:1913 PMID: [3]
5. Escudier B et al, Bevacizumab plus interferon alpha-2a for treatment of metastatic renal cell carcinoma: A randomized, double-blind phase III trial. Lancet 2007, 370:2103 PMID: [4]
6. Kidney Cancer: NIH Institute and Center Resources [5]

kidney cancer