Renal Cell Carcinoma

1
Renal Cell Carcinoma

• Christopher D. Gran, M.D.
• Department of Urology

2
Incidence

• 28,000 new cases/year in the U.S.
• 19,100 in men
• (2-31 malefemale)
• 3 of diagnosed cancers
• 7th most common cancer
• 8,900 in women
• Peak occurrence in 5th-7th decade
• 2-3 bilateral

3
Mortality

• 7,200 Deaths/year (male)
• 3 of all cancer-related deaths
• 10th most frequent cause of cancer mortality
• Approximately 12,000 deaths/year total

4
Risk Factors

• Tobacco use Smokers are twice as likely to
  develop kidney cancer as nonsmokers. The longer
  a person smokes, the higher the risk. Decreased
  for those who quit
• Obesity
• Occupational exposures
• Radiation Women treated with radiation uterine
  CA may have a slightly increased risk of
  developing kidney cancer.
• Phenacetin drug no longer sold in the United
  States
• Dialysis ESRD patients on dialysis have an
  increased risk of developing renal cysts and
  renal cancer
• Von Hippel-Lindau (VHL) disease, Tuberous
  Schlerosis

5
Presenting Symptoms

• Common symptoms
• 1. Hematuria/blood in the urine. Blood may be
  present one day and not the next. In some cases,
  a person can actually see the blood, or traces of
  it may be found by urinalysis
• 2. A lump or mass in the kidney area
• 3. Pain
• Classic Triad present in 10 of patients with RCC

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Presenting Symptoms

• Less common symptoms
• Fatigue
• Loss of appetite
• Weight loss
• Recurrent fevers
• Persistent flank pain
• Lethargy
• High blood pressure
• Anemia

7
Incidental Findings

• A large number of RCCs will be discovered as an
  incidental finding of a solid kidney mass upon
  testing for abdominal pain, trauma, or in the
  work-up for other medical problems

8
Differential Diagnosis

• VITAMIN
• Vascular
• Infectious
• Toxic
• Autoimmune
• Metabolic
• Iatrogenic
• Neoplasm (Cancer)

9
Differential Diagnosis of a Renal Mass

• Cyst
• Infection/Abscess
• Aneurysm
• Renal Cell Cancer (smokers)
• Transitional Cell Cancer (history of kidney
  stones)
• Benign Lesion

10
Anatomy
11
Pathology

• 85 of renal cell cancers are adenocarcinomas,
  90 of which are of proximal convoluted tubular
  origin
• Clear Cell Carcinoma (70-80)
• Papillary (10-15) - slower growing
• Chromophobe, Sarcomatoid
• Transitional cell carcinomas - renal pelvis

12
Gross specimen of RCC
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Evaluation/Workup

• History
• Physical Exam
• Lab Studies
• urinalysis
• Radiological Evaluation
• KUB (x-ray of Kidneys, Ureter and Bladder)
• IVP (intravenous pyelogram)
• Cystoscopy

14
History

• Flank Pain (41)
• Hematuria (36)
• Weight loss (36)
• Flank Mass (24)
• HTN (20)
• Hypercalcemia (6)
• Erythrocitosis (3)

15
Past Medical History

• Smoking History
• Environmental Exposures
• Asbestos, Cadmium, dyes, benzene
• Family History
• ESRD and Hemodialysis
• Von Hippel Lindau
• Tuberous Schlerosis

16
Physical Exam

• Abdominal mass
• Flank pain
• Bruit
• Varicocele
• Hypertension

17
Laboratory Studies

• Urinalysis
• Urine culture with sensitivities
• CBC (anemia)
• BMP (Cr and Ca)

18
Radiological Studies

• Ultrasound
• KUB
• IVP
• CT scan
• MRI
• RPG (retrograde pyelogram)
• Angiography

19
Ultrasound
20
IVP
21
CT scan
22
MRI
23
Retrograde Pyelogram
24
Angiogram
25
Metastatic Work-up

• Chest X-ray
• CT
• Abdomen and Pelvis lymphadenopathy or elevated
  liver function tests
• Head/Chest (mental status changes, lung lesions)
• Bone scan
• with bone pain

26
Metastatic Work-up

• Laboratory Tests
• Liver Function Tests (LFTs)
• Serum Calcium
• Sites of metastases include
• Lung (69) Bone (43) Liver (34) Lymph Nodes
  (22) Adrenal gland(s) (19) Brain (7)

27
Treatment

• Radical Nephrectomy
• Partial Nephrectomy (nephron sparing)
• Laparoscopic Nephrectomy
• Radiation
• Chemotherapy
• Immunologic Therapy

28
Laparoscopic Nephrectomy
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Survival

• Based on Tumor Stage
• Robsons Classifications
• Stage 1 - contained within renal capsule
• Stage 2 - outside capsule but within Gerotas
  fascia
• Stage 3 - regional lymph node, renal vein or vena
  cava involvement
• Stage 4 - metastatic

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Survival

• 5 year survival according to stage at nephrectomy
• Stage 1 65-93
• Stage 2 47-68
• Stage 3 34-51
• Stage 4 2-20
• Spontaneous regression in lt1 of RCC

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Survival

• With metastatic disease
• 30 with metastatic RCC at time of diagnosis
• Average survival of 4 months
• 10 survive 1 year

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Recurrence

• The prognosis is poor
• Surgical resection in select patients
• 15 objective response rate in patients with
  non-bulky pulmonary and/or soft tissue metastases
  with excellent performance status (ECOG 0,1) and
  no weight loss
• 5 of durable complete remissions
• Treatment options Interleukin-2 with or without
  lymphokine-activated killer (LAK) lymphocytes
  Interferon alpha External-beam irradiation
  (palliative) Vinblastine Non-myeloablative
  allogeneic stem cell transplantation

33
Rare Malignant Renal Tumors

• Sarcoma (60 leiomyosarcomas)
• Hemangiopericytoma
• Lymphoblastomas
• Metastatic Renal Tumors

34
Benign Tumors

• Oncocytoma
• Angiomyolipoma (Hamartoma)
• Adenoma
• Lipoma
• Fibroma
• Leiomyoma
• Angioma