Renal Carcinoma Flashcards
What is the MC primary renal malignancy?
RCC
Epidemiology of RCC?
M > W
6-8th decades
73% 5 yr survival
What are some risk factors for RCC
SMOKING
others: HTN Obesity Chronic dialysis Toxic exposures Heavy aspirin, NSAIDS, or acetaminophen use Genetics
Path of RCC?
MC: clear cell- deletion of chromosome 3p, proximal tubule
papillary: proximal tubule
Less common:
Classic triad for presentation of RCC?
usually asxs until late disease
HEMATURIA
ABDOMINAL PAIN
FLANK PAIN
Other S/S of RCC?
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:
Work up for RCC?
Abdominal CT w/wout contrast***
MRI
tissue bx - for ANY solid renal mass
To eval for mets: bone scan, CT chest, MRI, PET
Tx for RCC?
localized > resection
Advanced: options
- systemic therapy
- surg
- radiation
What are some predictors of malignancy for small renal mass?
male sex
increasing tumor, greater than 4cm is higher risk, less than 2 cm more likely to be benign
Management of small renal mass?
consult nephrology
dedicated renal CT/MRI
if s/s of paraneoplastic syndrome- CMP/CBC
renal func.
+/- chest imaging
+/- biopsy
Management options for small renal mass?
surg
thermal ablation if <3cm
surveillance if <2cm (every 3-6 mo 1st yr, then every 6-12 mos)
Epidemiology of wilms tumor?
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
Path of wilms tumor
abn. renal development
assoc. with loss of func. of tumor suppressor genes
usually solitary lesion surrounded by pseduocapsule
Clinical presentation of wilms tumor?
ABDOMINAL MASS
-usually smooth and nontender and doesn’t midline
less common: abd pain, hematuria, fever, HTN
Work up for wilms tumor?
Definitive: histologic (excision or biopsy)
initial study: Abd US
others: CT/MRI with contrast
Labs: renal func., UA, liver function, Ca, CBC, coag studies
Tx for wilms tumor?
refer to peds CA center
Chest imaging to r/o mets
chemo/surg
Px for wilms tumor?
5 yr survival 90%
but increased risk of premature death in adulthood due to secondary neoplasms and other late comp.
Surveillance after tx of wilms tumor?
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
What 2 things cause renovascular disease?
renal artery stenosis
fibromuscular dysplasia
Renovascular disease can be a cause of…
it is assoc. with…
secondary HTN
accelerated target organ injury: LVH, renal fibrosis
When should we consider renovascular disease as cause for secondary HTN?
younger
severe or resistant
acute rise over stable value
What else can be seen in renovascular disease?
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
Work up for renovascular disease?
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
Describe Atherosclerotic renal artery stenosis, etiology?
aka ischemic nerphropathy
usually > 45y/o
reduced blood flow to kidney; usually involves aortic orifice or proximal main renal artery
RF for atherosclerotic renal artery stenosis?
Hyperlipidemia
Cigarette smoking
Age > 50 y/o
atherosclerotic renal artery stenosis is a….
cardiac risk equivalent
-so start on Statin
Dx of atherosclerotic renal artery stenosis
luminal occulsion of at least 60-70%
Tx for atherosclerotic renal artery stenosis
Tx the HTN; monitor CKD; CV secondary prevention; revascularization (angioplasty w/ or w/o stenting or bypass)
Who usually gets fibromuscular dysplasia
younger women, Less than 50 y/o
Etiology of fibromuscular dysplasia?
noninflammatory, nonatherosclerotic disorder leading to arterial stenosis, occlusion, aneurysm, dissection, and arterial tortuosity – can effect nearly every arterial bed
What can you see on angiography with fibromuscular dysplasia?
multifocal (string of beads) vs. focal (circumferential or tubular stenosis)
Clinical presentation of fibromuscular dysplasia?
H/a, pulsatile tinnitus, neck pain, flank or abdominal pain
HTN, cervical or abdominal bruit, TIA, stroke
Management of fibromuscular dysplasia?
ACE or ARB, f/o with serum Cr
Surg: angioplasty
How do ace/arbs work in renovascular disease?
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)
Comps of surg. for renovascular disease?
Renal artery dissection
Capsular perforation
Hemorrhage
Atheroembolic disease – accelerates HTN and kidney failure
Who is most likely to benefit for surg. tx for renovascular disease?
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