Renal Cancer

Introduction

Kidney (kidney) cancer is cancer that develops in the tissues of the kidneys.

Renal cancer includes:

1. Renal Cell Carcinoma – Renal cell carcinoma (RCC), a primary malignant adenocarcinoma derived from renal tubular epithelial cells, is the most common malignant renal tumor [1].
2. Renal pelvis cancer – Cancer of the renal pelvis develops in the center of the kidney, where urine collects.
3. Wilms tumor – a childhood cancer that usually develops before the age of five. [2]

Kidney cancer is one of the most important cancers, due in part to the enormous economic burden of metastatic kidney cancer, estimated at US$ 1.6 billion (2006 US$) in selected countries and causing more than 131,000 deaths each worldwide and 342,000 event-case-years [3].

• The etiology of RCC is largely unknown but appears to be multifactorial in nature. [3]
• The burden of kidney cancer has seen little or no improvement over the past 28 years. Renewed efforts are needed to reduce exposure to risk factors and improve prevention and early detection of the disease [3].

Epidemiology

Kidney cancer is responsible for more than 131,000 deaths and 342,000 new cases worldwide each year [3], with renal cell carcinoma accounting for 80-90%.

Renal cell carcinomas

• Considered the 8th most common adult malignancy
• Represent 2% of all cancers
• Accounts for 80-90% of primary malignant renal tumors in adults
• Patients are typically 50-70 years old at presentation 12 Moderate male preference 2:1 2.[1].

The most common kidney tumor in adults is renal cell carcinoma. RCC accounts for nearly 90% of all kidney tumors and about 3% of all cancers. [4]

Risk Factors

Many different risk factors have been studied, some of which are modifiable (creating opportunities for primary prevention).

Risk factors for kidney cancer are categorized as:

• Lifestyle risk factors – smoking, overweight, alcohol consumption, physical activity and diet
• Medical history – high blood pressure, chronic kidney disease, kidney stones, use of cyclophosphamide (chemotherapy drug) for dialysis-associated cystic disease [1] and diabetes mellitus after kidney transplantation [3]
• Environmental and Occupational Exposures – Trichlorethylene and Aristolochic Acid
• Genetic risk factors and others

Characteristics/Clinical Presentation

Presentations are usually described as the following three parts:

1. Macroscopic haematuria: 60%
2. Flank pain: 40%
3. Palpable flank mass: 30-40%[1]

However, this triad is present in only 10-15% of patients

• Increasingly, the diagnosis is made by CT evaluation of hematuria alone or as an incidental finding.
• The majority of cases are sporadic.
• In modern medicine, almost half of all identified renal cell carcinomas are discovered incidentally during imaging studies performed for other purposes [1].

Approximately 25-30% of patients have metastases at diagnosis. Kidney cancer most commonly spreads to the lungs (75%), regional lymph nodes (65%), bones (40%), and liver (40%). [5] Patients may complain of cough or bone pain secondary to pulmonary or skeletal metastases.

The 1 minute video below outlines the presentation

[6]

Pathology

Renal cell carcinoma (RCC), or kidney cancer, is divided into four main types based on the cell of origin:

• Clear cells : 70-80% from the proximal convoluted tubule
• Papillary : 13-20% from distal convoluted tubules
• Chromophobe : 5% interlaminar cells from collecting duct[1]
•  Collecting duct : 1% of cases [5]

Grading

Histological nuclear grading

• The most widely used and predictive grading system for renal cell carcinoma is the Fuhrman nuclear grade, which has grades I-IV, with grade I having the best prognosis and grade IV the worst.

Diagnostic Tests

The following tests and procedures are available:

• Physical Exam and Health History
• Ultrasound exam
• Blood test: An abnormal (higher or lower than normal) amount of a substance may be a sign of a disease.
• Urinalysis
• CT scan (CAT scan): Dye may be injected into a vein or swallowed to help organs or tissues show up more clearly. The procedure is also known as computed tomography computerized tomography or computerized axial tomography.
• MRI (Magnetic Resonance Imaging) – This procedure is also known as Nuclear Magnetic Resonance Imaging (NMRI).
• Biopsy – a thin needle is inserted into the tumor and a sample of tissue is removed [7].

Treatment Overview

People with renal cell carcinoma can work with a team of healthcare professionals to coordinate their care. For example, urologists, surgeons, urologic oncologists, medical oncologists, radiation oncologists, oncology nurses, registered dietitians [8]

People with renal cell carcinoma have different types of treatment. Five types of standard treatments are used:

1. Surgery
2. Radiation therapy
3. Chemotherapy
4. Immunotherapy
5. Targeted therapy[7]

RCC is mainly treated surgically. Although aggressive radical nephrectomy is the treatment of choice for localized and metastatic disease. This includes removing:

• Kidney
• Gerota’s fascia: fibrous areolar tissue surrounding the kidney and perinephric fat
• Adrenal gland
• Regional lymph nodes

Kidney cancer is very difficult to cure once it has spread to other organs at the time of diagnosis. Targeted drugs are currently considered the standard of care for advanced kidney cancer that has spread to other organs. [9]

• Targeted therapies that work by targeting the cancer at the cellular level expand the options for treating kidney cancer. Targeted therapy blocks specific abnormal signals present in kidney cancer cells that allow them to grow. These drugs show promise in treating the kidneys Cancer that has spread to other parts of the body. The targeted drugs Axitinib (Inlyta) Bevacizumab (Avastin) Pazopanib (Votrient) Sorafenib (Nexavar) and Sunitinib (Sutent) block the signals that play a role in the growth of blood vessels that feed cancer cells and allow cancer cell spread. Tamsirolimus (Torisel) and everolimus (Afinitor) are targeted drugs that block the signals that allow cancer cells to grow and survive. Targeted therapy medicines can cause serious side effects such as: Severe rash Diarrhea and fatigue
• Whereas targeted therapy specifically stops the growth and spread of kidney cancer cells, immunotherapy works in a more general way by using the body’s immune system to fight cancer. Immunotherapy drugs include interferon and aldesleukin (Proleukin), which are synthetic versions Chemicals made in your body. Side effects of these drugs include: chills, fever, nausea, vomiting, and loss of appetite.

Physical Therapy Management

Maintaining strength while undergoing kidney cancer treatment is important, and a physical therapist will be able to provide an exercise program designed specifically for the patient’s needs.

• If a patient has had surgery to remove a tumor, moderate exercise can help restore muscle tone and help rebuild severed muscles Increase your range of motion and help prevent complications that may occur after surgery, such as: Respiratory infections Pressure sores and these Formation of deep vein thrombosis (DVT). [10]
• Exercise has the added benefit of reducing stress and depression, which are common among patients undergoing cancer treatment.
• Physiotherapy can also be used to combat fatigue, which is not only a common symptom of kidney cancer but can also be a side effect of treatment (e.g. chemotherapy) [10]. Building endurance can reduce the incidence and severity of fatigue. This will be an important factor in increasing a Patient independence and ability to maintain a high quality of life.
• Educating patients about diet will play an important role throughout treatment.
• A systematic review and meta-analysis of randomized clinical trials demonstrated that in-dialysis exercise regimens have positive effects in CKD patients with poor cardiorespiratory fitness, exercise tolerance, and ventilatory efficiency [11].

Case Reports/ Case Studies

• Sciatica leads to discovery of renal cell carcinoma
• Atypical presentation and rare metastatic sites in renal cell carcinoma: a review of case reports
• Hereditary leiomyomatosis and renal cell carcinoma presenting with metastatic kidney cancer at age 18: implications for surveillance
• Renal carcinoma and Wegener’s granulomatosis: a case report