Kidney cancer

Anatomy
Each kidney is surrounded by perinephric fat, then Gerota's fascia
Lymph drainage
 -Right kidney: paracaval/aortocava;l
 -Left kidney: para-aortic

Epidemiology
38,000 cases per year
Average age 55- 60

Risk factors
More common in men
Thorium, cadmium, petroleum exposure
Smoking
Obesity
Hypertension
Von Hippel-Lindau syndrome:
 -28-45% of patients get renal cell ca (typically clear cell)
 -Abnormality in short arm of chromosome 3 leads to uninhibited HIF
 -Also associated with cerebellar hemangioblastoma, pheochromocytoma, pancreatic tumors

Renal pelvis/ureteral CA
1/3 of patients will get bladder cancer
Risk factors: men, smoking, phenol exposure

Pathology
Most primary renal cancers are adenocarcinoma (90%)
Most common histology: clear cell; papillary is more favorable, sarcomatoid worse
Renal pelvis/ureter: most common histology is transitional cell (>90%), SCC 7-8%

Clinical
Classic triad: hematuria, flank mass, pain; only occurs in 5-10% of patients
Most frequent symptom is isolated hematuria
Incidental diagnosis carries a favorable prognosis (7% of pts)
Lymph nodes involved in 10-25%
Renal vein involved in 25%; IVC in 5%
Disease is bilateral in 2-3%
Mets may regress spontaneously after nephrectomy

Prognostic factors
T/N/M stage
Tumor grade/cell type
Incidental diagnosis
IVC involvement above diaphragm

Treatment
Definitive surgery = radical nephrectomy and lymph node dissection
Removes kidney, adrenal gland, perinephric fat, Gerota's fascia

2 preop trials testing preoperative XRT were negative as were 2 trials testing adjuvant RT
Modern indications: unresectable primary, positive margins (adding radiation in these situations increases local control with questionable impact on overall survival)

Adjuvant chemo includes IL-2, sorafenib, sunitinib (both tyrosine kinase inhibitors)

Radiation nephropathy
TD 5/5 = ~20Gy
Pathologic features: glomerular sclerosis/tuft obliteration, tubular degeneration
Lab: increased BUN/Cre; microhematuria, proteinuria, casts
Late effects: hypertension, complete renal failure, anemia