Kidney

1 to 6 percent of renal cancers are a sarcomatiod variant that accompanies a poor prognosis.2 ||
 * **Epidemiology:** || ** Cancer of the Kidney ** 1
 * Seventh most common cancer in men, and ninth most common in women
 * More than 85% of kidney tumors are renal cell carcinomas (RCCs)
 * 30% of patients present with metastatic disease
 * RCC accounts for 3% of all adult malignancies
 * Demonstrates a slight male predominance with 60% of the diagnoses and deaths occurring in men
 * Peak incidence is in ages 60-80, but presentation is not uncommon at any age
 * Incidence of RCC is increasing due to computed tomography (CT) scans being able to capture small renal masses
 * Despite aggressive treatment methods, mortality rates are increasing ||
 * **Etiology:** || ** Risk Factors for Cancer of the Kidney ** 1
 * Cigarette smoking
 * Obesity
 * Phenacetin abuse
 * Asbestos exposure
 * Leather tanning
 * Shoe repair
 * Chronic hemodialysis
 * Von Hippel-Lidau disease ||
 * **Signs & Symptoms:** || ** Signs and Symptoms ** 1
 * Flank pain
 * Flank mass
 * Hematuria
 * Classic triad
 * Anemia
 * Erythrocytosis
 * Weight loss
 * Hypercalcemia
 * Hypertension
 * Fever
 * Varicocele ||
 * **Diagnostic Procedures:** || RENAL CELL CARCINOMA2
 * After radiographic evaluation, in most cases, pathologic confirmation is often made at the time of nephrectomy
 * Staging evaluation should include a complete a complete history and physical examination, complete blood cell count, and liver and kidney function test. A metastatic workup includes a chest x-ray and computed tomography (CT) or magnetic resonance imaging (MRI) scan of the abdomen and pelvis
 * A bone scan should be obtained in patients with symptoms suggestive of bony metastases or an elevated alkaline phosphatase level
 * PET scanning may be useful in the detection of LN or distant metastasis ||
 * **Histology:** || Adenocarcinoma is the predominant histology for renal cancers; sub types include clear cell carcinoma and granular cell carcinoma, clear cell is the more predominant of the two subtypes.2
 * **Lymph node drainage:** || The right kidney(B) drains into the paracaval and the interaortocaval lymphnodes, while the left kindey(A) drains into the para-aortic lymph nodes.2

|| G1: Well differentiated G2: Moderately differentiated G3: Poorly differentiated or undifferentiated G4: Poorly differentiated or undifferentiated
 * **Metastatic spread:** || * Renal cell can spread via:3
 * Local infiltration through renal capsule
 * Direct extension in the venous channels
 * Retrograde venous drainage to the testis
 * Lymphatic drainage to the renal hilar, paraaortic, and paracaval nodes
 * hematogenous route to any part of the body including
 * lung, liver, central nervous system, skeleton, and other organs
 * Close to 50% of patients with renal cell carcinoma will develop metastasis. 3
 * The most common places of metastatic spread include the lung (75%), soft tissue (36%), bone (20%), liver (18%), cutaneous areas (8%), and CNS (8%). 3 ||
 * **Grading:** || Histopathologic grading (G)GX: Grade of differentiation cannot be assessed

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Grade is an important prognostic factor for those patients with papillary and clear-cell renal cell carcinoma. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">3,2 ||
 * **Staging:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Robson's modification of the Flock's and Kadesky system is the most common Renal Cell Carcinoma staging system used by clinicians in the United States.2

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The Robson system classifies tumors in the following stages: <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Stage I: The tumor is confined to the kidney and does not involve the capsule of tissues that surround the kidney <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Stage II: The tumor extends through the capsule of the kidney <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Stage III: The tumor involves lymph node(s) or extends into the renal vein or the inferior vena cava <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Stage IV: The tumor has invaded organs adjacent to the kidney or shows evidence of distant spread to other organs. 2

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The American Joint Committee uses the following staging system for Renal cell Carcinoma: 2

|| Kidney: (1/3)5000 cGy, (2/3)3000 cGy, (3/3)2300 cGy Spinal Cord: (1/3) 5cm-5000 cGy, (2/3) 10cm- 5000 cGy, (3/3) 20cm- 4700 cGy Bladder: (1/3)N/A, (2/3)8000 cGy, (3/3)6500 cGy Liver: (1/3)5000 cGy, (2/3)3500 cGy, (3/3)3000 cGy ||  ||   ||   ||   ||   ||
 * **Radiation side effects:** || Radiation therapy side effects are comparable to upper abdomen and pelvis irradiation. They include nausea, vomiting, diarrhea, and abdominal cramping. Patients with tumors of the right kidney may be in danger of radiation induced liver damage because of the significant portion of the liver being irradiated. The contralateral kidney dose should not exceed 20 Gy. The spinal cord dose should be kept below 45 Gy.3 Following morbidities for the above structures were noted:
 * Stomach – perforation, ulceration
 * Liver – failure
 * Duodenum – perforation, ulceration
 * Kidney – clinical nephritis ||
 * **Prognosis:** || The most defining factor in the prognosis for renal cancers is its initial stage at diagnosis. The significance of renal vein or vena cava involvement has been associated with perinephric primary tumor spread. Such involvement has been debated as a prognostic factor with no clear association positive or negative. Lymph node metastasis has been associated with an increase in local recurrence and distant metastasis. Reported 5-yr survival rates for stage I is 88%, stage II is 67%, stage III is 40%, and stage IV is 2%. If a patient has metastatic disease at the time of diagnosis, the mean survival time is about 4 months and only approximately 10% survive 1 year.4 ||
 * **Treatments:** || Primary therapy for renal cell cancer is a surgical resection. Resectable tumors may undergo a partial or radical nephrectomy. At the time of the radical nephrectomy regional lymphadenectomy is often performed. Radiation therapy treatment may be indicated if the patient is not a candidate for surgical resection. Tumor shrinkage and increased resectability have been reported in patients who received postoperative irradiation, but no survival benefit has been noted. Chemotherapy and immunotherapy, such as interferon and interleukin, are used although survival gains are marginal. For patients with metastatic symptoms high dose palliative radiation therapy to metastatic bony lesions should be performed to ensure a long symptom-free survival time for these patients.5 ||
 * **TD 5/5:** || TD 5/5 is a statistical guideline to consider which states that there has been a five percent probability of complication in five years. These values are based on a 200cGy 5 fraction a week treatment schedule.6


 * **References:** || # <span style="background-color: #ffffff; color: #800080; font-family: Arial,Helvetica,sans-serif;">Hoppe RT, Phillips TL, Mack III M. Leibel and Phillips Textbook of Radiation Oncology. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010.
 * 1) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3nd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2011; 469-474
 * 2) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MI: Mosby. 2011: 854-861.
 * 3) Chao KS, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2002; 422-428.
 * 4) Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. 3th ed. St. Louis, MI: Mosby. 2004: 854-861.
 * 5) Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: []. Accessed: June 12, 2012. ||

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