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.

Staging

Robson staging system

  • Designed to correlate stage at presentation w/ prognosis & is as follows:
    Stage I Tumor is confined w/in the capsule of the kidney
    Stage II Tumor invades the perinephric fat but is still contained w/in 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 2010 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 & is limited to the kidney
T1a The tumor size is ≤4 cm & is limited to the kidney
T1b The tumor size is >4 cm but not >7 cm & is limited to the kidney
T2 The tumor size is >7 cm & is limited to the kidney
T2a The tumor size is >7 cm but is ≤10 cm & is limited to the kidney
T2b The tumor size is >10 cm & is limited to the kidney
T3 Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland & not beyond Gerota’s fascia
T3a Tumor extends into the renal vein or its segmental (muscle containing) branches, or the tumor invades the perirenal &/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 2010 American Joint Committee on Cancer Anatomic Stage & Prognostic Groups

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

Assessment

Anatomic Classification Systems

  • The Preoperative Aspects, Dimensions Used for an Anatomical (PADUA) classification system, R.E.N.A.L. nephrometry score & 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 & in the anterior &/or posterior location

History

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

Physical Examination

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

Imaging

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

Bone Scan

  • Only indicated in patients w/ bone pain &/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 & inferior vena cava involvement
  • Main modality for the assessment of renal masses, w/ pre- & post-contrast enhanced scanning of the abdomen, pelvis & chest
  • Abdominal CT scan primarily determines the extent of local & 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 & 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 & 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 & to measure the area of metastasis
  • Has high sensitivity & specificity for primary lesion

Ultrasonography (UTZ)

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

Laboratory Tests

  • Complete blood cell (CBC) w/ differential
  • Electrolytes
  • Liver function tests (ALT & AST)
  • Renal profile
  • Urinalysis
  • Urine cytology or uteroscopy
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