Kidney

Question 1

Anatomy of kidneys

Answer 1

L kidney T12-L3 RT kidney 2-4cm lower than left
Adrenal gland on top
Ribs 11-12 covering structures
Three parts: Renal cortex, renal medulla, renal pelvis

Question 2

Physiology

Answer 2

1. Regulates volume of fluid in the body
2. Excretion of metabolic end products and foreign substances
3. Production and secretion of hormones and enzymes (renin-angiotensin)

Question 3

Epidemiology

Answer 3

Rare cancer
Incidence increased by 40% over past 30 years
More common in males than females

Question 4

Aetiology

Answer 4

Cigarette smoking - doubles likelihood
Obesity
Twice as common in men
Increasing age 
Family history 
Von Hippel Lindau (VHL) syndrome - blood vessel tumour of the brain, spinal cord and eye
Whites and african americans (highest in north america)
Asbestos, cadmium

Question 5

Prevention Of Kidney Cancer

Answer 5

• Cessation of cigarette smoking
• Reduction in weight
• Early diagnosis is challenging as it can be asymptomatic

Question 6

Diagnosis

Answer 6

Physical examination - abdominal mass
Complete blood test - blood count (abnormal), serum test (high level of calcium), High level of LDH
Urinalysis
Radiologic studies - chest radiography, CT tomography
Selected additional studies - MRI, sonography

Question 7

Patterns of spread

Answer 7

25% distant mets 
Local lymphatic and haematogenous spread common 
Direct invasion to perirenal tissue 
Local lymph node mets
Renal vein invasion common

Question 8

Histology

Answer 8

Renal Cell Carcinoma

Question 9

Staging (T)

Answer 9

Tx - Primary tumour cannot be assessed
T0 - no evidence of primary tumour
T1 - Tumour 7cm or less in greatest dimension, limited to kidney
T2 - more than 7cm in greatest dimension, limited to kidney
T3 - Extends to major veins or invades adrenal gland but not beyond Gerota’s fascia
T4 - Invades beyond Gerota’s fascia

Question 10

RT Treatment positioning

Answer 10

SBRT: Head first supine, VACBAG, Wingboard (Arms up), indexing devices (loc-bar, knee pillow), organ motion management device

Question 11

Clinical Management

Answer 11

Most common - surgical resection (nephrectomy/partial nephrectomy)
RT not used in primary management
SBRT has shown effective for small tumours or with multiple comorbidities and not good candidates for surgery
RT used for palliation

Question 12

CT simulation and scan parameters

Answer 12

1-3mm slices
Scan length - lower border T10 - inferior border of ischial tuberosities
Ant tattoo - ML and 2 Lateral tattoos

Question 13

OARs

Answer 13

• Contralateral Kidney and ureter • Spinal Cord • Small bowel • Large Bowel • Stomach • Heart • Liver

Question 14

Prognosis

Answer 14

Mets to bone 25%-50%

Brain mets are diagnosed in 10% - 4.4 month survival prognosis

Question 15

Simulation consideration

Answer 15

Use of IV contrast - requires good renal function

Organ motion management - 4DCT simulation with breath hold, abdominal compression

Question 16

Signs and symptoms

Answer 16

Abdominal pain, palpable mass, haematuria, hypertension, increased blood calcium, fatigue and weight loss, pyrexia - fever