Cancer 3 Flashcards
What is renal cell carcinoma `? (RCC)
Most common form of kidney malignant cancer in adults
- arise in the epithelial cells of the PCT of kidney (renal cortex / parenchyma)
- linked to mutation in chromosome 3.
Can either be: 0 Sporadic 0 Inherited syndrome (e.g Von - Hippel - Lindau disease
- more common in older men - when carcinoma is sporadic
- accounts for 85% of kidney cancers.
- silent cancer , often asymptomatic until tumour is very large.
What is Von Hippel Lindau syndrome ?
Inherited disorder
- formation of tumors
and cysts in different areas of the body.
- number 1 cause of death is development of Renal cell carcinoma.
CAUSE
- mutation in VHL (tumour supressor gene )
Common characteristic
Hemangioblastomas - o non - cancerous tumours in the lower part of the brain, spinal cord, or retina. The tumor develops in the lining of a blood vessel. o don't invade nearby tissue. o cause ; if in brain or spinal cord
- headaches
- vomiting
- weakness
- ataxia (loss of muscle coordination)
if in retina (back of eye )
- cause vision loss
Associated with :
0 cyst in kidneys , pancreas , genital tract
0 increased risk of :
- kidney cancer (RCC - renal cell carcinoma )
- pancreatic neuroendocrine tumour - pancreatic cancer
- Pheochrmomcytoma - in andrenal gland (particularly dangerous in times of stress or surgery.) (associate with: -headaches - panic attacks - excess sweating - dangerously high blood pressure that may not respond to medication.
- endolymohatic sac tumours - in inner ear
present with :
Hearing loss
What are the symptoms of Renal cell carcinoma ?
Classic triad:
0 Flank pain
0 Haematuria
0 Palpable abdominal mass
all three can can happen as part of the triad or on its own.
They can have other symptoms which are more uncommon
0 non specific systemic : - pallor - weight loss - sweats - cachexia - myoneuropathy (dysfunction of the nerves supplying the muscle ?)
0 signs of hepatic dysfunction
- ascities
- hepatomegaly
- spider angiomata (naevus ) - swollen BV found under the skin.
others too.
Risk factors of Renal cell carcinoma ?
0 Smoking 0 male sex 0 aged over 55 years 0 black / american -indian ethnicity 0 Fx of RCC 0 Obesity 0 Hypertension 0 History of heritary conditions - Von Hippel Lindau -0 History of acquired renal cystic disease. ( condition occurs in end stage renal disease - common in people on renal dialysis. cysts develop in the kidneys.
Polycystic kidney disease vs acquired renal(kidney cystic disease?
Polycystic kidney disease - multiple/ clusters of cysts develop in the kidney , causing enlargement and loss of function.
- genetic
- kidneys become enlarged
- cyst can develop in other parts of the body e.g liver.
Acquired cystic renal disease
- no genetic link
(happens in end stage renal disease) - kidneys are normal sized or smaller
- cyst on develop in kidney.
Investigation of Renal cell carcinoma ?
0 CT abdomen / pelvis - can be contrast enhanced.
diagnosis and staging
(looking for renal mass , regional lymphadenopathhy , visceral / bone metastastes
0 MRI abdomen / pelvis
- can be used ADJUNCT to CT
or when contrast is contraindicated.
0 Ultrasound - pelvic /abdo
(contrast induced is best )
0 urinalysis -presence of blood or protein
0 Creatinine
elevated levels signal reduced renal clearance
0 LFT
(elevated AST - aspartate animotransferase, ALT - alanine animotransferase)
- metastastes
- Paraneoplastic syndrome
(conditions / signs & symptoms due having a cancer in the body due to ;
o Production of chemical signalling models e.g hormones
0 Immune response against tumour.
e.g - reduced HB , elevated RBC - FBC
Elevated RBC - (cause by tumour producing EPO —————-> increased RBC production & polycthemia
0 Hypertension - tumor releases renin.
0 corrected calcium -elevated
- Tumour releases PTHrH - (parathyroid related hormone )
0 Tumour can release ATCH ————-> cortidol release from adrenal gland——————> cushings syndrome.
- If tumour invades left renal vein into IVC then cancer will spread via the blood and reach the lungs .
Stages of renal cell carcinoma ?
Early stage RCC
Stage 1 and 2
0 confined to kidney with no regional lymph node or distant metastasis.
Stage 3
may be outside the kidney - but still in renal / Gerota’s fascia
- spread to nearby nodes, no distant metastasis
Stage 4
- tumour beyond renal fascia - may have grown into adrenal gland
(absolute )
can either or not spread to lymph node & distant organs.
Difference between kidney cancer / mass in the left vs the right kidney/?
Left testicular vein ————————-> left renal vein ——————> IVC
Right testicular vein ————————–> IVC
0 Mass in left kidney can grow large enough to compress the left renal vein preventing drainage of the left testicle - varicoclele on testicle appear.
Compression of renal vein can also cause hydronephrosis - kidney fills with urine becoming stretched and swollen.
Right testicular veins drains straight into the IVC - bypasses Right renal vein - so its compression will not affect it.
Treatment of renal cell carcinoma ?
RCC does not respond well to chemo and radiotherpay usually .
Small mass / RCC stage 1 or 2
1st line
Surgery - surgical resection
or
Local ablation therapy (LAT)
(ABLATION clinical intervention which destroys or removes body part
uses either :
o Radiofrequency Ablation - heat generated from current used to destroy tumour.
o cyroablation - kill tumour with extreme cold.
NON SURGICAL CANDIDATE - <3CM and slow growing
1st line
0 Survelilance
NON SURGICAL CANDIDATE - >3CM and fast growing
1st line
Sureveillance
ADJUNCT
- LAT
- consider for clinical trials.
RCC Stage 3
1st line 0 Surgery 0 ADJUNCT - Sunitinib - protein kinase inhibitor - blocks abnormal protein cancer cells need to multiply.
NON SURGERY CANDIDATE
1st line
- consider for clinical trails.
RCC Stage 4 (metastatic / advanced )
1st line
0 target therapy
e.g immunotherapy
pembrolizumab +axitinib
OR
nivolumab +
ipilimumab
OR
pazopanib
OR
sunitinib
etc.
- umabs
- tinibs
-limus
(everolimus or temsirolimus )
ADJUCNT
- Surgery
- clinical trials
- chemo - if all other avenues taken
- local radiate - pallative - for pain relief and symptom control.
- biphosphonate
(Zolendronic acid ) - bone matastases - can delay bone related symptoms.
Which cancers commonly spread to the bone ?
The five types of cancer that commonly spread to bone are breast, bronchus (lung), thyroid, kidney (renal cell carcinoma) and prostate.
Bowel cancer, testicular cancer and lymphoma less frequently spread to the bone.
Glioblastomas are primary brain tumours and locally invade and spread within the brain, they do not cause distant metastases
What are your differential for a 70 year old women presenting with :
Confusion of unknown cause - increasing worse over 2 weeks
- abdominal pain
- constipated
- not opened bowel in 10 days
History
- hypertension, mitral
- regurgitation
- breast cancer
- diverticular disease.
Drug history
- Rampril
- Aspirin
- Co- codamol
OE : HR - 95 bpm RR - 18 / min Temp ; 36 BP - 104/53 sp02 : 96% BM : 4.9 dry mucus membranes JVP down abdomen tender with fecal loading. GCS ; 14/15
0 Sepsis - always consider this in an older person with confusion
0 UTI - abdominal pain
0 Hypercalcemia - can be a reason for her non specific symptoms (confusion , abdominal pain , etc) stones , moans , abdominal groans & pyschic moans
(can cause constipation & constipation can cause urostatsis —————-> UTI )
Hypercalacemia of malignancy
(history of breast cancer which can spread to the bone & tumour can secrete PTHrH cause increased serum calcium etc. - there are other reasons. )
- can be found in people with advanced stage cancers.
- patient has high calcium levels and is
symptomatic. )
0 Opiod toxicity
(is taking Co- codamol - can cause confusion & conspitation )
What is hypercalcaemia of malignancy ?
- CAUSES
- RISK
FACTORS - SIGNS /
- SYMPTOMS
0 Humoral hypercalcaemia of malignancy : Tumour secretion of parathyroid hormone-related peptide [PTHrP])
0 Local osteolytic hypercalcaemia :
Local release of factors, including PTHrP, by bony metastases that promote osteoclast differentiation and function
0 Calcitriol (1,25-dihydroxyvitamin D)-mediated hypercalcaemia (characterised by autonomous production of calcitriol by lymphoma cells) —- ( increase Vitamin D synthesis more CA absorbed from the gut )
0 Ectopic hyperparathyroidism (characterised by tumour production of parathyroid hormone), which is very rare.
RISK FACTORS
- history of malingancy
(occurs in 20 -30 %)
e.g. spread to bone , Lymphoma or non spreading cancer.
- Use of hypercalcaemia inducing medications e.g
- thiazide diuretics - lithium
- calcium
- over the counter antiacids
- large doses of Vitamin D.
SIGNS / SYMPTOMS
- bones , stones , abdominal groans & physic moans
0 renal stones
(Hypercalcemia + Hypercaluria = renal stones )
- Polyuria
- Polydipisa (thirst - due to excessive urination 7 dehydration )
0 Abdominal pain - abdominal groans
- constipation
( too much calcium - slow muscle contraction - peristaltic movement affected. )
Psychic moans
- confusion
- depression
- nausea and vomiting
- fatigue
- ## bone pain
Investigation of Hypercalcaemia of malignancy ?
Serum : Total Calcium Ionised calcium (either one ) 0 Albumin 0 PTH 0 PTHrH (done if PTH levels are low despite known malignancy) 0 Calcitriol - (1 , 25 dihydroxyvitamin D - Vitamin D ) 0Phosphorus ( humoral hypercalcaemia of malignancy, PTHrP acts at the level of the kidney to reduce calcium clearance, as well as to reduce the renal phosphorus threshold, leading to hyperphosphaturia and hypophosphataemia. ) - results would show : low PH in blood but high CA.
0 Serum 25-hydroxyvitamin D
(Serum 25-hydroxyvitamin D should be checked if intravenous administration of bisphosphonate or subcutaneous denosumab is being considered, as vitamin D deficiency needs to be corrected prior to administration to avoid the risk of hypocalcaemia and, possibly, osteonecrosis of the jaw.)
25 - hydroxyvitamin D - major circulating form of Vitamin D in blood.
(biphosphonates, denosumab (monoconal antibody used to treat osteporosis ) increasease bone density )
TO CONSIDER
0 CXR
0 Skeletal survey.
Treatment of Hypercalcaemia of malignanacy ?
Mild / asymptomatic
- treat underlying cancer + supportive measures + monitoring.
MODERATE - SEVERE / SYMPTOMATIC + ADVANCED KIDNEY DISEASE
1st line
Saline + IV bisphonate (zondronic acid - ex ) or densumab
ADJUNCT
- Calcitonin
(only if Biphos doesnt work )
- Furosemide
(if fluid overload is present )
- avoid excaberating medicines
o thiazide
diuretics
o
Calcitriol [(1,25-dihydroxyvitamin D)]
o Calcium supplementation
o antacids
o lithium
(worsen hypercalcemia )
o sedatives o hypnotics o analgesics if possible (worsen symptoms of hypercalcemia )
- treat underlying malignancy
- Corticosteriod
MODERATE - SEVERE / SYMPTOMATIC + ADVANCED KIDNEY DISEASE
1st line
0 Renal dialysis + denosumab.
Serum levels
0 Mild - 2.6 to 2.9 mmol/L (10.5 to 11.9 mg/dL)
0 Moderate - 3.0 to 3.4 mmol/L (12.0 to 13.9 mg/dL), 0
0
Severe hypercalcaemi3.5 mmol/L (14.0 mg/dL) or greater.
Other causes of Hypercalcamia other than primary hyperparathyroidism and cancer ?
- – Sarcoidosis
- Thyrotoxicosis
- Thiazide diuretics.
- Renal failure causes secondary parathyroidism
( causing Hypocalcaemia
It is a consequence of failure of renal vitamin D hydroxylation and the retention of phosphate. This depresses serum Ca2+ and stimulates PTH release, leading to renal bone disease.)
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