Renal Carcinoma

Question 1

What is the MC primary renal malignancy?

Answer 1

RCC

Question 2

Epidemiology of RCC?

Answer 2

M > W

6-8th decades

73% 5 yr survival

Question 3

What are some risk factors for RCC

Answer 3

SMOKING

others: HTN
Obesity
Chronic dialysis 
Toxic exposures
Heavy aspirin, NSAIDS, or acetaminophen use
Genetics

Question 4

Path of RCC?

Answer 4

MC: clear cell- deletion of chromosome 3p, proximal tubule

papillary: proximal tubule

Less common:

Question 5

Classic triad for presentation of RCC?

Answer 5

usually asxs until late disease

HEMATURIA

ABDOMINAL PAIN

FLANK PAIN

Question 6

Other S/S of RCC?

Answer 6

Weight loss

Scrotal varicocele (left-sided)

IVC involvement: lower extremity edema, ascites, hepatic dysfunction, pulmonary emboli

Metastasis: common sites are lungs, lymph nodes, bone, liver, brain

Paraneoplastic syndromes:

Question 7

Work up for RCC?

Answer 7

Abdominal CT w/wout contrast***

MRI

tissue bx - for ANY solid renal mass

To eval for mets: bone scan, CT chest, MRI, PET

Question 8

Tx for RCC?

Answer 8

localized > resection

Advanced: options

• systemic therapy
• surg
• radiation

Question 9

What are some predictors of malignancy for small renal mass?

Answer 9

male sex

increasing tumor, greater than 4cm is higher risk, less than 2 cm more likely to be benign

Question 10

Management of small renal mass?

Answer 10

consult nephrology

dedicated renal CT/MRI

if s/s of paraneoplastic syndrome- CMP/CBC

renal func.

+/- chest imaging

+/- biopsy

Question 11

Management options for small renal mass?

Answer 11

surg

thermal ablation if <3cm

surveillance if <2cm (every 3-6 mo 1st yr, then every 6-12 mos)

Question 12

Epidemiology of wilms tumor?

Answer 12

makes up small number of renal tumors but makes up 95% of renal malignancies in KIDS!

2/3 dx under 5, 95% before 10

sporadic

Question 13

Path of wilms tumor

Answer 13

abn. renal development
assoc. with loss of func. of tumor suppressor genes

usually solitary lesion surrounded by pseduocapsule

Question 14

Clinical presentation of wilms tumor?

Answer 14

ABDOMINAL MASS
-usually smooth and nontender and doesn’t midline

less common: abd pain, hematuria, fever, HTN

Question 15

Work up for wilms tumor?

Answer 15

Definitive: histologic (excision or biopsy)

initial study: Abd US

others: CT/MRI with contrast

Labs: renal func., UA, liver function, Ca, CBC, coag studies

Question 16

Tx for wilms tumor?

Answer 16

refer to peds CA center

Chest imaging to r/o mets

chemo/surg

Question 17

Px for wilms tumor?

Answer 17

5 yr survival 90%

but increased risk of premature death in adulthood due to secondary neoplasms and other late comp.

Question 18

Surveillance after tx of wilms tumor?

Answer 18

Includes CXR, abd u/s, chest/abd/pelvic CT

Q 6-8 weeks during therapy, q 3 months x 2 years, q 6 months x 2 years

Question 19

What 2 things cause renovascular disease?

Answer 19

renal artery stenosis

fibromuscular dysplasia

Question 20

Renovascular disease can be a cause of…

it is assoc. with…

Answer 20

secondary HTN

accelerated target organ injury: LVH, renal fibrosis

Question 21

When should we consider renovascular disease as cause for secondary HTN?

Answer 21

younger

severe or resistant

acute rise over stable value

Question 22

What else can be seen in renovascular disease?

Answer 22

Sr Cr rises >30% after ACE or ARB

mod severe HTN in pt with recurrent episodes of flash pulmonary edema

stage II HTN onset after age 55

mod/severe HTN in pt who have artherosclerosis or small kidney

abd bruit

Question 23

Work up for renovascular disease?

Answer 23

Labs: may have BUN/Cr

Gold standard: Renal arteriography- looks for signs of fibromuscular dysplasia

Duplex Doppler US- but not always done (tech error, takes long)

CTA- usually start with this!!

MRA

Question 24

Describe Atherosclerotic renal artery stenosis, etiology?

Answer 24

aka ischemic nerphropathy

usually > 45y/o

reduced blood flow to kidney; usually involves aortic orifice or proximal main renal artery

Question 25

RF for atherosclerotic renal artery stenosis?

Answer 25

Hyperlipidemia
Cigarette smoking
Age > 50 y/o

Question 26

atherosclerotic renal artery stenosis is a….

Answer 26

cardiac risk equivalent

-so start on Statin

Question 27

Dx of atherosclerotic renal artery stenosis

Answer 27

luminal occulsion of at least 60-70%

Question 28

Tx for atherosclerotic renal artery stenosis

Answer 28

Tx the HTN; monitor CKD; CV secondary prevention; revascularization (angioplasty w/ or w/o stenting or bypass)

Question 29

Who usually gets fibromuscular dysplasia

Answer 29

younger women, Less than 50 y/o

Question 30

Etiology of fibromuscular dysplasia?

Answer 30

noninflammatory, nonatherosclerotic disorder leading to arterial stenosis, occlusion, aneurysm, dissection, and arterial tortuosity – can effect nearly every arterial bed

Question 31

What can you see on angiography with fibromuscular dysplasia?

Answer 31

multifocal (string of beads) vs. focal (circumferential or tubular stenosis)

Question 32

Clinical presentation of fibromuscular dysplasia?

Answer 32

H/a, pulsatile tinnitus, neck pain, flank or abdominal pain

HTN, cervical or abdominal bruit, TIA, stroke

Question 33

Management of fibromuscular dysplasia?

Answer 33

ACE or ARB, f/o with serum Cr

Surg: angioplasty

Question 34

How do ace/arbs work in renovascular disease?

Answer 34

renal perfusion is decreased due to the stenosis

so,

Medical blockade of angiotensin II formation blunts the effect of autoregulation > reduced GFR > possible AKI (hemodynamically induced)

Question 35

Comps of surg. for renovascular disease?

Answer 35

Renal artery dissection
Capsular perforation
Hemorrhage
Atheroembolic disease – accelerates HTN and kidney failure

Question 36

Who is most likely to benefit for surg. tx for renovascular disease?

Answer 36

Short duration of BP elevation prior to dx

Failure of med therapy to control BP

Intolerance to med therapy

Recurrent flash pulmonary edema and/or refractory heart failure