Term
| where is the highest rate of renal cell carcinoma? what is the median age of contracting it? |
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Definition
| north america - lowest rate is SE asia. the median age is 64 yrs |
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Term
| what are risk factors for renal cell carcinoma? |
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Definition
| smoking (esp non filtered cigarettes), high body mass index, inactivity, HTN, male gender, and CKD w/renal hemodialysis |
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Term
| what a part of the kidney is more likely to develop a tumor? |
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Definition
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Term
| what percent of tumors in the kidney are malignant? |
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Definition
| 85%, 15% are transitional cell carcinomas from the pelvis |
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Term
| what are pediatric renal tumors to consider? |
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Definition
| predominately wilm's tumors and nephroblastomas |
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Term
| does acquired cystic kidney disease with chronic renal failure and tuberous sclerosis increase the risk of renal cell carcinoma? |
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Definition
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Term
| what is the most common type of renal cell carcinoma? |
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Definition
| clear cell renal cell carcinoma at 68% prevalance. |
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Term
| what is the classic clincal triad for renal cell carcinoma? how many people with renal cell carcinoma will present with this? |
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Definition
| hematuria (most common - ask if urine is iced tea colored), flank pain, and palpable mass. only 40% of pts will have one of these at presentation, and 10% have all 3. |
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Term
| what is the prevalence of incidental renal cell carcinoma dx? |
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Definition
| 40% of renal cell carcinomas are discovered incidentally w/ultrasound |
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Term
| what are symptoms of renal cell carcinoma? |
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Definition
| weight loss (>10% of body weight), fever (of unknown origin), metastatic symptoms (bone pain, hemoptysis, SOB, chest pain - often 1st presentation of the disease), paraneoplastic syndromes (due to hormone secretion): hypercalcemia (confusion, mental status changes, nausea, vomiting), stauffers syndrome (elevation of liver enzymes do to cholestasis), polycythaemia (if erythropoietin is secreted by the tumor), amyloidosis. if it is small: usually no symptoms. |
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Term
| what are ddxs for hematuria? |
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Definition
| UTI (by far the most common - need to do a urinalysis w/this), renal calculi (kidney stones, generally painful), STD, renal hematoma (seen easily w/ultrasound), drug induced (cytoxan is the classic chemo agent for this, also NSAIDs and blood thinners), and renal CA |
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Term
| how are renal cell carcinomas diagnosed? |
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Definition
| renal ultrasound (classic, cheap, non-invasive), CT scan/MRI (no evidence that MRI is better), PET scan only detects 50% of the time |
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Term
| what is the next step after a positive CT scan? |
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Definition
| tissue bx - need this to confirm 100% renal cell CA dx |
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Term
| why do people with renal cell CA need to get a CXR? |
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Definition
| b/c the lung is a common site of metastasis |
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Term
| what blood work needs to be done for renal cell CA pts? |
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Definition
| CBC (check for very high/low blood count - could get anemia or viscosity), CMP (look at electrolytes, BUN, creatinine to check kidney function), Ca++ (hyper/hypocalcemia can be lethal), LDH (prognostic factor), UA (make sure nothing else is going on), and transaminases (ALT, AST - stouffer) |
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Term
| should a CT of the abdomen and pelvis be done for pts with renal cell CA? |
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Definition
| yes, if the CMP is ok (contrast may cause kidney failure) |
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Term
| if you think there may be venous thrombosis involved with the renal cell carcinoma, which is better CT or MRI? |
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Definition
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Term
| why do a bone scan for pts with renal cell CA? |
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Definition
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Term
| should you do a CT of the brain for pts with renal cell CA? |
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Definition
| only if you think there may be something occuring there, for example if the pt has hypercalcemia |
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Term
| how does primary lung CA differ from metastatic lung CA on a CXR? |
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Definition
| primary lung CA is usually a single solitary lesion - metastatic is more diffuse |
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Term
| if the tumor is solitary and < 3 cm, what is the course of tx? |
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Definition
| 20% of solitary and < 3 cm kidney tumors are oncocytomas - low grade tumors that rarely metastasize. in elderly pts, the dr may choose to just monitor the tumor for changes rather than perform sx - where if a small tumor is found in a younger pt, it would still probably need to be removed |
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Term
| can bilateral tumors occur? |
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Definition
| yes, this is rare, but possible - think of multiple angiomyolipomas, renal lymphoma, one a metastasis of the other, oncocytomas or 2 renal cell carcinomas |
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Term
| what is the median survival for advanced renal cell CA? |
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Definition
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Term
| what are positive prognostic factors for RCC? |
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Definition
| performance status, lack of constitutional symptoms, no weight loss, low ESR (erythrocyte sedimentation rate), 0-1 metastatic site, hemoglobin, non-elevated LDH, and normal serum Ca++ |
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Term
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Definition
| yes, but its really rough |
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Term
| what are the general prognostic projections for pts with 0 risk factors, 1-2 risk factor, and 3-5 risk factors? |
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Definition
| 0 risk factors – favorable group, 26 mos, 1-2 risk factors - intermediate group, 14 mos, and 3-5 risk factors - poor group, 5 mos |
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Term
| how is a radical nephrectomy performed? how are metastatic sites affected by this? |
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Definition
| ant approach, the renal vascular pedicle was ligated, en block excision (kidney, adrenal gland, perirenal fat), and the systemic adrenelectomy is optional. mortality from this is <1% and morbidity is 10%. *there should be some regression of metastatic sites after this sx.* |
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Term
| are lymph nodes taken out with RCC sx? |
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Definition
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|
Term
| what is the preferred approach for RCC at this point? |
|
Definition
| partial nephrectomy (as much as you need to take - no more) |
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|
Term
| are the ureters removed with transitional cell CA? |
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Definition
|
|
Term
| is radiation therapy beneficial for RCC? |
|
Definition
| no, only a proportion may respond |
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Term
| what is the effect of IFN alpha for RCC? |
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Definition
| makes pts miserable, no survival advantage |
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|
Term
| what is the effect of medroxyprogesterone-acetate for RCC? |
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Definition
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Term
| what is the problem with refractory RCC chemo tx? |
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Definition
| the MDR (multi-drug resistance) gene, which encodes for P-glycoprotein, a transmembranous protein serves as a pump that pumps out toxins - and CA cells may not see chemo drugs b/c they get pumped back out so quickly |
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Term
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Definition
| yes, it can increase survival (not curative), and is a "bear to give" |
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Term
| can bevicizimab help w/RCC? |
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Definition
| yes, it can extend survival given IV and enacts anti-VEGF therapy. it is a relatively easy drug to give. |
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Term
| what kind of immunotherapy revolutionized the way RCCs are treated? |
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Definition
| TKIs (tyrosine kinase inhibitors) such as *sunitinib malate* which inhibits phosphorylation in the PY3 kinase pathway. TKs are involved in tumor growth, angiogenesis, and metastatic sites. this is an oral therapy = good pt compliance, and is now considered the DOC for RCC. (sunitinib malate doesn't affect overall survival, just increases quality of life = better progression-free survival benefit than IFN-alpha) |
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Term
| what are the ADRs associated with sunitib malate? |
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Definition
| fatigue (pretty bad after 3 wks), HTN (managable side effect of all TKIs), heart failure (will go away if you cease adm), hand-foot syndrome, N/V, and diarrhea |
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Term
| what is pazopanib? possible benefits over sunitib? |
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Definition
| a recent TKI that also affects VEGF and PDGF receptors. it is currently indicated for metastatic RCC. it shows a doubled rate of progression-free survival vs placebo. it doesn't have the same fatigue ADRs as sunitib, but can incur liver toxicity |
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Term
| what are mTOR inhibitors? |
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Definition
| these inhibit the Mammalian Target of Raptomycin - a kinase protein found in the cytoplasm of cells and associated with cell proliferation, angiogenesis and cell metabolism. *temsirolimus* is one that dramatically improves OS (overall survival) over IFN, though b/c it has poor ADRs (rash, asthenia, mucositis, diarrhea, anorexia, edema), it is generally prescribed for pts that have already failed TKIs |
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Term
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Definition
| an oral temsirolimus mTOR inhibitor generally given if pts fail sunitib/other TKIs. it has ADRs including: stomatitis, asthenia, infection, diarrhea, cough |
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