Kidney Tumors

Epidemiology

General

  • 95% are in the parenchyma and 5 % in the pelvis
  • 28800 new cases/year
  • 50-60 years is peak
  • 18% bilateral

Risk Factors

Patient

  • smoking
  • obesity
  • leather tanning
  • asbestos
  • dialysis

Other Disesases

  • retinal angiomas
  • hemangioblastomas

Genetics

  • deleted tumor suppressor gene on chromosome 3
  • Von Hipple Lindau disease with t(3:11)

Presentation and Evaluation

Anatomy

Pathology

Clinical Presentation

Routes of Spread

Diagnostic Studies

Staging

Treatment

Outcome

Prognostic Factors

Summary

Studies

RENAL CELL CARCINOMA
General

Anatomy
∑ Gerotia fascia encompasses the kidney, adrenal gland, and perirenal fat.
∑ Nodal drainage to the para-aortics nodes.

Pathology
∑ Renal cell occur in three types: clear cell (most common), granular, and spindle cell.
∑ Others include Wilms’s tumor and transitional cell of the pelvis.

Presentation
∑ Gross hematuria, flank pain, mass (classic triad).
∑ Also varocele, anemia or increased Hct (can produce erythropoetin), wt loss, HTN, and fever.
∑ Route of spread: Locally through the capsule and into the renal vein or pelvis. DM to lung, brain or bone in 1/3 of the cases.

Staging see index

Work-up
∑ H/P
∑ CBC, CHEM20, LFT, UA
∑ IVP, CXR, CT of abdomen and pelvis, and bone scan.
∑ Biopsy

Prognostic Factors
∑ Perinepheric or renal vein extension
∑ Nodal disease
∑ DM
∑ Tumor grade
∑ Histological type
Treatment
∑ Surgery: the standard of care with LF about 5-15% and DM 10-30%.
∑ Radical Nephrectomy: remove Gerotia’s fascia, remove RV involvement and also go into VC if that is involved. The 5 year survivals are as follows:
T1, T2 90% N+ 10-25%
T3a 60-70% M+ 0-10%
T3b 50-60%
T3c 30%
T4 0-20%
∑ Partial Nephrectomy: Done if need to preserve the parenchyma such as in bilateral tumors, DM nephropathy, unilateral agenesis of the kidney, horse shoe kidney, nephrosclerosis, and hydronephrosis where there may be impaired renal function. 5 year survival at ~80%.
∑ Nodal dissection: often done with nephrectomy.
∑ Adjuvant RT: no role for RT in an adjuvant setting
∑ 3 randomized trials (Vander Werf, Jursela, and Finny) showed no advantage with RT in the pre-CT era.
∑ 1 trial (Kjaer) during CT era showed no advantage with post-operative RT.
∑ Chemotherapy: 5 FU has been beneficial in combination with immunotherapy based on UCLA data.
∑ Immunotherapy: Interferon and Interleukin 2 have been used.
Renal Tolerance
∑ The problems seen with nephritis are HTN, anemia, increased BUN and albumin, edema.
∑ The glomeruli show fibrosis, endothelial swelling, edema, and BM thickening.
∑ Doses to BOTH kidneys:
∑ T5/5 for clinical renal damage is 2000cgy
∑ T50/5 is 2500cgy.

Bibliography
1. Cox J, Ang K. Radiation Oncology: rationale Technique Results. 8th ed. New York: Mosby, 2003.
2. Gunderson L, Tepper J: Clinical Radiation Oncology. 2nd ed. China: Elsevier 2007.
3. Devita V, Hellman S, Rsenberg S: Cancer: Principles and practice of Oncology. 7th ed. Philadelphia: Lippincott, 2005.
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