renal%20cancer
RENAL CANCER

Renal cancer is the disease in which certain tissues of the kidney starts to grow uncontrollably and form a tumor.

It is also called as renal adenocarcinoma or hypernephroma.

Classic triad of symptoms are flank pain, palpable abdominal mass and gross hematuria.

Renal%20cancer Diagnosis

Staging

Robson staging system

  • Designed to correlate stage at presentation with prognosis and is as follows:
    Stage I Tumor is confined within the capsule of the kidney
    Stage II Tumor invades the perinephric fat but is still contained within the Gerota’s fascia
    Stage III Tumor invades the renal vein or inferior vena cava, regional lymph node involvement, or both
    Stage IV Tumor invades the adjacent viscera (excluding ipsilateral adrenal) or distant metastases

TNM Classification

  • Based on the 2017 American Joint Committee on Cancer (AJCC) TNM staging system for kidney cancer

Primary Tumor (T)

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 The tumor size is ≤7 cm and is limited to the kidney
T1a The tumor size is ≤4 cm and is limited to the kidney
T1b The tumor size is >4 cm but ≤7 cm and is limited to the kidney
T2 The tumor size is >7 cm and is limited to the kidney
T2a The tumor size is >7 cm but is ≤10 cm and is limited to the kidney
T2b The tumor size is >10 cm and is limited to the kidney
T3 Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia
T3a Tumor extends into the renal vein or its segmental (muscle containing) branches, or the tumor invades the perirenal and/or renal sinus fat (peri-pelvic) but not beyond the Gerota’s fascia
T3b Tumor extends into the vena cava below the diaphragm
T3c Tumor extends into the vena cava above the diaphragm or invades the wall of the vena cava
T4 Tumor invades beyond the Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Tumor has metastasized in the regional lymph node

Distant Metastasis (M)
M0 Clinically no distant metastasis
M1 Clinically distant metastasis

Clinical Staging

  • Based on the 2017 AJCC anatomic stage and prognostic groups

  • Stage I T1 N0 M0
    Stage II T2 N0 M0
    Stage III T1 or T2 N1 M0
    T3 NX, N0 or N1 M0
    Stage IV T4 Any N M0
    Any T Any N M1

Assessment

  • Management depends upon the disease's TNM classification, histologic subtype, and prognosis
Prognostic Risk Group
Memorial Sloan Kettering Cancer Center (MSKCC) Prognostic Model

  • Most widely used prognostic factor model
  • Prognostic factors include the following:
    • <1 year interval from diagnosis to treatment initiation
    • Karnofsky performance status of <80%
    • >1.5 x upper limit of normal (ULN) serum lactate dehydrogenase (LDH)
    • Corrected serum calcium > ULN
    • Serum hemoglobin (Hgb) less than lower limit of normal (LLN)
  • Based on above prognostic factors, identify the patient's prognostic risk group using the following parameters:
    • Low-risk: Prognostic factors absent
    • Intermediate-risk: 1-2 prognostic factors present
    • Poor-risk: ≥3 prognostic factors present
Predictors of Short Survival Used to Select Patients for Temsirolimus Therapy
  • Presence of ≥3 of the following represents the poor-prognosis group:
    • LDH of >1.5 x ULN
    • Hgb < LLN
    • Corrected serum calcium > 10 mg/dL (2.5 mmol/L)
    • <1 year interval from diagnosis to initiation of systemic therapy
    • Karnofsky performance score ≤70
    • ≥2 sites of metastasis
International Metastatic RCC Database Consortium (IMDC) Criteria (Heng's Model)
  • Derived from a study composed of patients with metastatic renal cancer given vascular endothelial growth factor(VEGF)-targeted therapy
  • Prognostic factors include the following:
    • <1 year interval from diagnosis to initiation of systemic therapy
    • Karnofsky performance status of <80%
    • Serum Hgb <120 g/L or 12 g/dL
    • Serum calcium >10.2 mg/dL
    • Neutrophil count >7.0 x 109/L
    • Platelet count >400,000
  • Based on above prognostic factors, identify the patient's prognostic risk group using the following parameters:
    • Favorable-risk: Prognostic factors absent
    • Intermediate-risk: 1-2 prognostic factors present
    • Poor-risk: 3-6 prognostic factors present

History

  • A detailed history should be elicited
  • Thorough review of medical records should include:
    • Number and frequency of episodes of symptoms
    • Previous imaging studies, interventions, evaluations and treatments
  • Family history with 1st or 2nd degree relative
  • It may also be appropriate to ask for the sexual and psychosexual history of the patient

Physical Examination

  • Since most of the patients presents with metastatic disease, physical examination of the lungs, bone, liver, cutaneous sites and central nervous system should be thoroughly evaluated
  • Check for hypertension, supraclavicular adenopathy and flank or abdominal mass with bruit
  • Presence of varicocele and paraneoplastic syndromes (eg hypercalcemia, erythrocytosis and Stauffer syndrome) should raise suspicion
  • If patients presents with gross hematuria with vermiform clots, consider upper urinary tract bleeding

Imaging

  • Essential for evaluating and staging renal masses, as well as for therapeutic planning

Bone Scan

  • Only indicated in patients with bone pain and/or an elevated serum alkaline phosphatase

Computed Tomography (CT) Scan

  • Can differentiate cystic masses from solid masses
  • Supplies information about the lymph node, renal vein and inferior vena cava involvement
  • Main modality for the assessment of renal masses, with pre- and post-contrast enhanced scanning of the abdomen, pelvis and chest
  • Abdominal CT scan primarily determines the extent of local and regional involvement
  • Chest CT scan evaluates the presence of pulmonary or mediastinal lymph node metastases

Intravenous Pyelogram (IVP)

  • Series of x-rays of the kidneys, ureters and bladder are taken to find out if cancer is present in these organs

Magnetic Resonance Imaging (MRI) Scan

  • Used to evaluate the inferior vena cava and right atrium for tumor involvement
  • Helpful in cases of renal insufficiency or contrast allergy preventing the use of IV contrast
  • May also be used in the assessment of inferior vena cava (IVC) thrombus or on clarifying the anatomy of individual renal lesions

Percutaneous Biopsy

  • Used in the evaluation of potentially malignant cystic renal lesions detected by ultrasound or CT scan
  • May also be used for small renal masses if there is a high index of suspicion for a metastatic lesion to the kidney, lymphoma or a focal kidney infection

Positron Emission Tomography (PET) Scan

  • Evaluation of lymph node involvement and to measure the area of metastasis
  • Has high sensitivity and specificity for primary lesion

Ultrasonography (UTZ)

  • Initially detects renal tumors and distinguishes a simple benign cyst from a complex cyst or a solid tumor
  • Detection of tumors depends on the size, location and echogenecity of the lesion

Ureteroscopy

  • May consider when a central renal mass is present and suggestive of urothelial carcinoma

Laboratory Tests

  • Complete blood cell (CBC) with differential
  • Electrolytes
  • Liver function tests (ALT and AST)
  • Renal profile
  • Urinalysis
  • Urine cytology or uteroscopy
  • Genetic evaluation (for patients with multiple tumors or <46 years of age)

Classification

Anatomic Classification Systems
  • The Preoperative Aspects, Dimensions Used for an Anatomical (PADUA) classification system, R.E.N.A.L. nephrometry score and the C-index are used to standardized the description of renal tumors
  • These includes assessment of the tumor size, exophytic/endophytic properties, nearness in the collecting system, renal sinus and in the anterior and/or posterior location
Histological Classification of Renal Cell Tumors
  • Based on the World Health Organization classification of 2016
  • More pertinent segregation is based whether the tumor histological subtype belongs to clear cell or non-clear cell
Clear Cell Subtypes
  • Clear cell RCC (ccRCC)
  • Clear cell papillary RCC
Non-clear Cell Subtypes
  • Multilocular cystic renal neoplasm of low malignant potential
  • Hereditary leiomyomatosis and RCC-associated RCC
  • Succinate dehydrogenase-deficient RCC
  • Acquired cystic disease-associated RCC
  • Papillary RCC
  • Chromophobe RCC
  • Collecting duct carcinoma
  • Renal medullary carcinoma
  • MiT family translocation RCC
  • Mucinous tubular and spindle cell carcinoma
  • Tubulocystic RCC
  • Unclassified RCC
  • Papillary adenoma
  • Oncocytoma
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