Renal%20cancer Diagnosis

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
May be considered when a central renal mass is present suggestive of urothelial carcinoma if with metastatic disease or if patient cannot tolerate ureteroscopy

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

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
Serum lactate dehydrogenase (LDH)
Liver function tests (ALT and AST)
Renal profile
Serum corrected calcium
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

Optimizing metastatic hormone-sensitive prostate cancer treatment in advanced prostate cancer

Assoc Prof. Darren Poon, Assoc Prof. Edmund Chiong, 14 Jan 2021

Metastatic hormone-sensitive prostate cancer (mHSPC) refers to the condition whereby patients have metastatic prostate cancer and no prior hormonal therapy or androgen deprivation therapy (ADT). Typically, patients with mHSPC have been treated with ADT alone, following which, the overwhelming majority develop castration resistance over time and head towards eventual mortality. In recent years, the publication of various landmark trials has prompted dramatic changes in the mHSPC treatment landscape, and had favourably impacted overall survival (OS) in these patients. At a recent webinar, A/Prof Darren Poon, Honorary Consultant in Clinical Oncology, Hong Kong Sanatorium & Hospital, and Honorary Clinical Associate Professor, Department of Clinical Oncology, The Chinese University of Hong Kong, reviewed treatment options in mHSPC, while A/Prof Edmund Chiong, Head and Senior Consultant, Department of Urology, National University Hospital, Singapore, presented a case which was discussed by an esteemed panel of experts. This webinar was jointly organized by the Singapore Society of Oncology and the Singapore Urological Association, and supported by Astellas.

Update on ADT: Degarelix shows promise in patients with advanced prostate cancer and CVD

26 Nov 2019

The incidence of prostate cancer (PC) and cardiovascular disease (CVD) typically increases with age; therefore, the choice of treatment for PC should take into account a patient’s underlying cardiovascular conditions. In this interview, Professor Laurence Klotz shared his take on androgen deprivation therapy (ADT) options for patients with prostate cancer who are at-risk of CV events.