Renal Tumors Flashcards
- Describe the epidemiology of renal tumors, which are the most common?
Renal cell carcinoma: clear cell 85% papillary type 1 10% chromophobe 2% (other rare: papillary type 2, collecting duct, renal medullary-Sickle, uncategorized)
- Describe the epidemiology of renal tumors, what are risk factors for getting RCC?
more common in males, 60+, the obese (hormonal and metabolic changes), smoking (chronic inflammation/HTN), African Americans, chronic HTN (inflammation)
(ESRD and Familial RCC)
incidence has been increasing since the 70s with 68,000 cases in 2013
- Describe the detection of renal tumors.
incidental finding on imaging for another indication
Discuss the classifications of TNM Staging kidney cancer.
T1A <4cm, T1b 4-7cm, T2 7+cm (limited to the kidney)
T3a extension T3b extension to VC, T3c VC above the diaphragm, T4 invades the fascia
N & M nodes and metastatic spread
- Describe the appropriate radiographic and pathologic evaluation of renal masses.
confirmatory imaging is an enhancing mass of CT (with contrast), non enhancing renal masses <4 are debatable
some patients with cysts that are complex and enhanced have malignant changes- Category I and II have no enhancement, III and IV do, IIF can go either way
- Give examples of clinical syndromes associated with renal cell carcinoma.
“classic triad” hematuria, flank pain, palpable mass
abrupt development of varicocele in men (backed up testicular veins),
spontaneous bleeding around kidney
- Give examples of (paraneoplastic) clinical syndromes associated with renal cell carcinoma.
excess or lacking of normal products: Vit D, renin, EPO and various prostaglandins
abnormal products: PTH-like hormones, lupus-type anticoagulant, hCG, insulin, cytokines and inflammatory mediators
these lead to: elevated sed rate, HTN, cachexia and weight loss, anemia/polycythemia, hypercalcemia (bad)
What is Stauffer Syndrome?
non-metastatic hepatic dysfunction due to renal carcinoma: elevated alk. phos, prothrombin time, serum bilirubin, transaminase or hypoalbuminemia (IL-6 and other cytokines implicated
- Describe the pathology of clear cell renal cell carcinoma.
(most common type) originates in the cells of the PCT
grossly is bright yellow, microscopic appearance of chicken wire
Von Hippel-Lindau genes at 3P in some cases, most are sporadic mutation
Describe the characteristics of Von Hippel Lindau disease.
(autosomal dominant) hemangioblastomas (spine and cerebellum), pheochromocytomas, angioatosis (retinal), ccRCC, renal cysts, other cysts
results form a mutation of VHL the prevents hypoxia inducible factor (HIF) inactivation which can then drive VEGF and PDGF production and cancer
Describe Birt, Hogg and Dube Syndrome.
mutation in foliculin gene (AD), a tumor suppressor gene found in the skin, distal nephron and type 1 pneumocytes
associated with renal cancer (chromophobe RCC), pneumothorax, and skin findings (fibrofolliculomas, trichodiscomas, achrochordons)
- Discuss appropriate therapies, both surgical and medical, for small and large renal masses, with or without metastasis.
cytoreductive nephrectomy with immunotherapy +3mo survival
metastectomy is very effective when feasible
new neo-adjuvant therapy is being evaluated
- Discuss appropriate therapies, focusing on small molecule interactions.
mutant VHL does not inhibit HIF so medical interventions can inhibit other factors that encourage HIF ie. mTOR inhibitors: everolimus or temserolimus
PDGF and VEGF inhibitors can decrease the products of HIF: bevacizumab (anti VEGF), sorefenib and sunitinib are kinase inhibitors
these lead to longer lives, not necessarily cures
- Discuss appropriate therapies, describing the latest improvements in surgical interventions.
RCC is a surgical disease, can remove the whole kidney but reducing morbidity by taking only parts (arthroscopically or robotic assist)
other approaches for older more high risk patients is a percutaneous approach that destroys part of the kidney via cytogenesis or ablation
