Patient with renal tumors Flashcards
What’s the most common renal cancer?
Renal cell carcinoma - 85% of all renal cell malignancies
Presentation of renal cell carcinomas
Variety of symptoms including:
- haematuria (50%)
- loin pain (40%)
- mass (30%)
- 25% may have symptoms of metastasis
- less than 10% have the classic triad of haematuria, pain and mass
What’s the classic triad of renal cancer?
haematuria, pain and mass
*seen in <10% patients
Management of T1 renal cancers
T1 lesions may be managed by partial nephrectomy
*this gives equivalent oncological results to total radical nephrectomy (at the mass is limited at that stage)
Management of T2 renal cancer
For T2 lesions and above
- radical nephrectomy
(performed via a laparoscopic or open approach)
What do we need to at early stages of surgery for renal cancer?
During surgery early venous control is mandatory to avoid shedding of tumour cells into the circulation
What is the management of a patient with Transitional Cell cancer?
Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the bladder
Types of renal cancer (2) general devision
A. Renal Cells Ca
B. Urothelium-based cancers
Types of renal cell carcinoma
Renal Cell Ca:
- clear cell
- papillary
- collecting duct
- renal medullary
Types of urothelium - based cancers
Urothelium based cancers
- urothelial carcinoma
- squamous cell carcinoma
- adenocarcinoma
Why would we develop squamous cell carcinoma or adenocarcinoma in cell lining?
Chronic irritation/ inflammation -> dysplasia -> metaplasia -> completly different type of cell- line
*e.g. chronic pyelonephritis, untreated for years stones
Some of the uncommon types of renal cancers
What cancers tend to metastasise to the kidneys?
- breast
- thyroid
- lungs
- adjacent neoplasm (e.g. pancreas, stomach, adrenal) -> local invasion
Factors that increase the risk of renal cancer
- obesity
- smoking (20 a day will double the risk)
- hypertension
- chronic renal failure and dialysis (3-6 x risk)
- thyroid cancer
- previous radiotherapy
- familiar history (1st degree relative with kidney ca -> 2x risk)
- genetics (only 2% of renal cancers)
Some genes associated with kidney cancers (just look)
What renall Ca is von Hippel Lindau associated with?
- clear cell carcinoma
*VHL gene
What renal ca is Hereditary Papillary Renal Cancer associated with?
Papillary type 1 RCC
*MET gene
What renal cancer is Birt Hogg Dubé associated with?
Birt Hogg Dubé
- Chromophobe RCC / Oncocytoma
*Folliculin Gene
What renal cancer is Hereditary Leiomyomatosis Renal Cell Carcinoma (HLRCC) associated with?
Papillary type II RCC
*FH gene (Fumarate hydratase)
What may paraneoplastic syndrome present with?
Paraneoplastic syndrome
- Hypercalcaemia (PTHrP) – seen in approximately 25%
- Anaemia
- Hyponatraemia
- Raised ESR
- Polycythaemia (increased Hb)
What are the signs of obstruction to IVC from a renal tumour?
- bilateral limb oedema
- varicocele
When do the cachexia present in cancer?
Late signs - poor prognosis
How are the kidney cancers usually picked up?
Incidental finding on USS for various other, unrelated conditions
Why it is especially important to pick up kidney cancers early?
Options for Mx of kidney cancer is only surgery -> if not possible then palliative care
* similar is pancreatic cancer
What is a bone pain suggestive of ?
metastatic disease
General modes of Ix for renal Ca (4)
- Urine test
- Blood test
- Scans
- Cystoscopy
Blood Ix in renal Ca
- FBC
- U& E -> to look at kidney function
- Clotting -> if we want to operate we need to know
- Liver function
- calcium and ESR-> to look for paraneoplastic syndrome
(paraneoplastic: raised Ca, raised ESR)
What’s the primary aim of the Ix in renal Ca?
To see if metastasis are present -> need to stage in order to decide what Rx we can offer
(if not, then maybe able to operate; if yes, then palliative care)
What is there present in urine in renal Ca?
- blood
- associated infection
What is a gold standard scan used for evaluation of renal Ca?
CT scan
*those who cannot have CT, then MRI
Why do we do cystoscopy in Ix of renal Ca?
Cystoscopy = camera in the bladder
We do a cystoscopy, to look if a transitional cell carcinoma there (as if we may have transitional cell carcinoma in the renal pelvis -> then it may spread with the urine as its draining there)
*if transitional cell Ca in renal pelvis -> 30% chances of developing second tumour inside the bladder
What type of CT scan we do in renal Ca?
3 phase contrast CT staging scan
*3 phases = images taken at 3 different time points following contrast administration
What’s PET CT scan used for?
For detection of an active metastatic disease elsewhere
*little relevance in kidney cancer though
* more important for prostate, bladder
What’s DMSA scan?
Functional scan to find out about nephron function in each kidney (how much of function is left in each of the kidney)
*e.g. when we plan for the removal of the kidney of the tumour -> to see if other kidney could cope or if dialysis is needed
What staging is used to grade kidney cancer?
TNM staging
What are the main features T1, T2, T3 and T4?
Gerota’s facia - fat around the kidney
Nodal staging
- N0
- N1
N0 - no lymph node involved
N1 - regional lymph nodes involved
What are:
- M0
- M1
M0 - no distant metastasis
M1 - distant spread of cancer
What are the stages
Stage 1, 2, 3 and 4
(characterised by T- staging)
- Stage 1 - T1
- Stage 2 - T2
- Stage 3 - any N1 or T3
- Stage 4 - any T4 or M1
Do we need to worry about cysts in the kidney?
Generally not, but need to classify them (Bosniak classification)
*depends on the presence of septa inside the cyst
*pt may require follow up for few years with CT/USS - in stage II
Palliative modes of renal cancer management
- radiotherapy -> for pain in the bone, to shrink tumours there
- chemotherapy
- VGEF/ mTOR inhibitor
- immunotherapy
