Kidney

Renal cell cancer is typically a disease that affects adults. Several factors have been identified as possible causes of renal cell cancer. The incidence is approximately 13 per 100,000 cases in the general population and accounts for 2% to 3% of all cancers diagnosed in the United States. Of the 49,000 cases of renal cell cancer affecting individuals this year, the estimated number of deaths will be 11,000. The disease peaks between the ages of 50 to 80 years old. The male to female ration is 5:1. Race does not seem to play an important role in its diagnosis, but data suggests that the Asian population has a slightly lower incidence that whites and blacks. Data also shows that there is a higher incidence of renal cell cancer in two regions, the United States and the Scandinavian peninsula. 1 || Environmental and genetic factors that are possible causes are: The most frequent symptom of a renal cell carcinoma is gross or microscopic hematuria. 3 Other symptoms include pain and a palpable mass, which can indicate advanced disease, as well as paraneoplastic syndromes. However, oftentimes patients may be asymptomatic. 3 ||
 * **Epidemiolgy:** || Pablo
 * **Etiology:** || Becky
 * Smoking
 * Obesity
 * Hypertension
 * Phenacetin-containing analgesia
 * Cystic disease of the kidney
 * Tuberous Sclerosis
 * Von Hippel-Lindau disease
 * Long duration of nonaspirin nosteroidal anti-inflammatory drugs (NSAID) 2 ||
 * **Signs & Symptoms:** || Adam
 * **Diagnostic Procedures:** || Megan

For healthy individuals undergoing a normal medical exam, there is currently no screening test such as a blood or urine test, available for kidney cancer. For first-time diagnosis of kidney cancer and for follow-up tests for kidney cancer patients, radiological tests are required. Biopsies of tumors in the kidney are usually not performed because the biopsy may miss the tumor and for fear that the cancer cells may be spread by the procedure. An ultrasound test is an inexpensive, non-invasive, diagnostic measure using no radiation and efficiently diagnoses locally controlled kidney cancers. Since ultrasound can help diagnose primary tumors in other internal organs as well as kidney, in some countries ultrasounds are part of the regular annual check-ups. For primary diagnosis, to establish a definitive diagnosis, practitioners usually follow up an ultrasound with a CT scan. A CT scan can be given with or without contrast, but the CT scan with contrast is the more efficient procedure. The gold standard of diagnostic tools is the MRI, which gives a more extensive view of not only the kidney but also the surrounding areas including the renal artery and vein, the ureter, etc, but requires a radiologist for proper interpretation. 4 ||
 * **Histology:** || Kevin T
 * The predominant histopathologic type of renal cancer is adenocarcinoma; subtypes include clear cell carcinoma (most predominant type) and granular cell carcinoma. 5
 * A sarcomatoid variant represents 1% to 6% of RCCs; these tumors are associated with a significantly poorer prognosis. ||
 * **Lymph node drainage:** || Erin

The lymphatics of the kidney drain along the renal vessels. The right kidney mainly drains into the paracaval and interaortacaval lymph nodes. The left kidney drains exclusively to the paraaortic lymph nodes. 6

|| Although renal cancers are relatively low in comparison to other forms, it can still have a high chance to metastasize to other areas. Sites: 3 The staging system mostly used in the United States is the Robson modification of the Flocks and Kadesky sytem. The following stages are used to describe renal cell carcinoma. 7 __Stage I__ – The tumor is 7 centimeters (cm) or smaller and is confined to the kidney. __Stage II__ – The tumor measures more than 7 cm and is also found only in the kidney. __Stage III__ – In this stage: 1) The tumor is of any size, found in the kidney and in one or more nearby lymph nodes. 2) Tumor is present in one of the main blood vessels of the kidney or in the fatty tissue in the kidney. Cancer may also be present in one or more nearby lymph nodes. __Stage IV__ – The cancer has spread in one of the following ways: 1) Beyond the fatty tissue in the kidney, it may also be preset in the adrenal gland and or nearby lymph nodes. 2) To distant organs, such as the liver, bones, lungs or brain. Disease may have also spread to distant lymph nodes. 7
 * **Metastatic spread:** || Spencer
 * The renal vein can be invaded by the tumor in 21% of cases, while the inferior vena cava at only 4% of cases. 3
 * Renal cancers can spread to the lymphatic’s in about 9-27% of cases, most frequently towards the renal hilar, para-aortic, and paracaval lymph nodes. 3
 * Almost one half of patients with renal cell carcinoma will develop metastatic disease somewhere in the body. 3
 * Lung – 75%
 * Bone – 20%
 * Liver – 18*
 * Skin – 8%
 * CNS (Central Nervous System) – 8% ||
 * **Grading:** || Pablo

8 || 9 || Common side effects of radiation therapy to a kidney cancer include: 3
 * **Staging:** || Becky
 * **Radiation side effects:** || Adam
 * Nausea
 * Vomiting
 * Diarrhea
 * Abdominal Cramping
 * Possible liver damage for tumors on the right side ||
 * **Prognosis:** || Megan

If the cancer is limited to the kidney, the 5-year survival rate is estimated as 90%. If it is found in a local lymph node, the survival rate drops to 60%. If it has spread to a distant organ, the 5-year survival rate is 9%. The overall survival rate for someone with kidney cancer averages 63%.

Another factor in survival prediction is the grade of the tumor, or what the cells’ nuclei look like. Grade varies from 1 to 4, with grade 4 being the most aggressive. 4 || Liver - 3000cGy (Liver failure) Stomach - 5000cGy (Ulceration/perforation) Spinal Cord - 4500cGy (Myelitis, necrosis, paralysis) Bladder - 6500cGy (Contracture) Small Bowel - 4000cGy (Obstruction/perforation) Colon - 4500cGy (Obstruction/perforation) 10 || <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">1. Clinical Key. Website. []. Accessed Jun 17, 2013. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">2. Curti B. Renal cell carcinoma. Medscape Web Site. [] 2013. Accessed June 11, 2013. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">3. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">4. Action to Cure Kidney Cancer website. 2010.[]. Accessed June 19, 2013. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">5. Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. PA: Lippincott Williams and Wilkins; 2011:469-479. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">6. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:419. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">7. Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 2rd ed. PA: Lippincott Williams and Wilkins; 2002. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">8. National Cancer Institute. Website. <span style="font-family: Arial,Helvetica,sans-serif;">[|http://www.cancer.gov/cancertopics/pdq/treatment/renalcell/Patient/page2#Keypoint9] <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">. Accessed Jun 17, 2013. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">9. Chao KSC, Perez CA, Brady LW. Upper urinary tract. In: Chao KSC, PerezCA, Brady LW, eds. Radiation Oncology Management Decisions. Philadelphia, PA: Lippincott, Williams and Wilkins; 2011: 469-481. <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">10. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby Inc; 2010:82. || Back to Week 4
 * **Treatments:** || Kevin T
 * Radical nephrectomy – nonmetastatic RCC 5
 * Only curative option for patients at risk – elective removal of lymphatics that may contain microscopic disease
 * Partial nephrectomy – early-stage tumors with poor renal reserve or absence of a normal functioning contralateral kidney
 * Preoperative irradiation – increase tumor resectability and local tumor control
 * Postoperative irradiation – should be considered (a) unresectable nonmetastatic tumors and (b) incomplete resection with gross or microscopically positive margins
 * Chemotherapy – has little to no role in treatment of metastatic RCC ||
 * **TD 5/5:** || Erin
 * **References** || <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Spencer