Renal Cell Carcinoma

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    Introduction

    • Arise from renal cortex - most common kidney tumor.
    • Metastatic Sites:
      • BONE
      • Lung

    Symptoms

    • Generally asymptomatic until advanced
    • Classic Triad (9% of pts)
      • Hematuria
      • Flank Pain
      • Abdominal Mass
    • Other Symptoms:
      • Unexplained Weight Loss
      • Abdominal Pain
    • Many paraneoplastic syndromes:
      • Erythrocytosis
      • AA amyloidosis
      • PMR
      • Hepatic Dysfunction

     

    Investigations

    • Abdo Ultrasound or CT
      • Solid mass or complex cyst require further intervention
      • Biopsy small lesions if possible.
      • Large masses suspicious for cancer can be removed without biopsy.  (still do CT to assess local/metastatic disease)

     

    Management

    • Large massess suspicious for malignancy on imaging --> remove without biopsy.
    • Non-metastatic:
      • Radical or partial nephrectomy
      • If not candidates for surgery:
        • Active Surveillance
        • Ablative Treatment (if small tumor)
    • Metastatic
      • Poor outcomes.
      • Often cytoreductive nephrectomy is done for metastatic disease (improves survival!!)
      • For spinal compression: if single-level compression can refer to neurosurg followed by radiation (if multi-level, do radiation only) (RCT done showing benefit of neurosx+rads vs. rads alone)
        • Often needs to be embolized before any surgery (highly vascular, bleeds a lot)
    • NO ADJUVANT Therapy established (poor outcomes)  (studies with targeted agents ongoing).
    • No cytotoxic therapy available.
    • Specific Therapies:
      • Interleukin-2: can result in long-term remission in 10% (highly toxic and expensive)
      • VEGF Inhibitors
        • Bevacizumab
        • Sunitinib (tyrosine kinase inh.)
        • Sorafenib
        • Pazopanib
        • Axitinib
      • mTOR Inhibitors
        • Temsirolimus
        • Everolimus
    • VEGF inhibitors are often first-line, but poor evidence.
    • High Risk Features:  LDH, performance status, lactate, calcium, anemia, 
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