Kidney

Adenocarcinomas(renal cell carcinoma [RCC]) make up approximately 85% of malignant kidney tumors. The incidence of RCC is higher in developed countries. Rates in the United States have increased by about 2% a year since the 1970. It most commonly occurs in the age range of 50 to 70. 2 || Table 1.1 Diagnostic Work-up for Renal Cell Carcinoma 10  || GX: Grade of differentiation cannot be assessed G1: Well differentiated G2: Moderately differentiated G3: Poorly differentiated or undifferentiated G4: Poorly differentiated or undifferentiated
 * ​ Epidemiology: || For the year 2009, the American Cancer Society estimated 57,760 new cases of kidney cancer and 12.980 deaths from kidney cancer. Their numbers included both adults and children. According to them, the overall lifetime risk of getting kidney cancer is approximately 1 in 75. The risk is higher for men than women. 1 
 * Etiology: || The cause of RCC is not known but there are identified risk factors. A major risk factor is smoking. According to the American Cancer Society, the risk appears to be linked to the amount one smokes and the risk drops with smoking cessation. Obese people have a higher risk of acquiring the disease. Job hazards that have been linked to the disease are exposure to certain chemicals such as asbestos, cadmium, some herbicides, benzene, and organic solvents such as trichloroethylene. Some risk factors that deal with hereditary conditions are those who have von Hippel-Lindau disease, hereditary papillary renal cell carcinoma, hereditary leiomyomatosis and renal cell carcinoma, Birt-Hogg-Dube syndrome, and hereditary renal oncocytoma. Anyone who has family members with kidney cancer, especially brother or sisters, have a much higher probability of getting the disease. High blood pressure has also been associated with Kidney cancer although it is unknow if the increased risk is from the medications taken, the high blood pressure itself, or the two together. A pain reliever (phenacetin) that was used in the U.S. previously (more than 20 years ago) has been linked to kidney cancer but is not thought to be much of a risk anymore because of it nonuse. Those who have advanced kidney disease and are one dialysis appear to have a higher risk. Kidney cancer is seen in twice as many men than women although the reason is unknown. African Americans have a slightly higher rate of RCC than Caucasians, although the reason for that too is unknown. 3 ||
 * Signs & Symptoms: || Hematuria ( blood in the urine) is the most common symptom associated with renal cell carcinoma. It can present as gross hematuria or be found microscopically. Other symptoms can include: unexplained weight loss, fatigue, back pain, palpable mass, night sweats, unexplained fever, hypertension, and paraneoplastic syndromes. 7  Historically, Kidney cancer was diagnosed when patients presented with the classic traid symptoms .The classic triad characteristics include; hematuria, flank pain, and palpable mass. Thanks to modern imaging, only 5-10% of patients commonly present with these advanced symptoms. 4  A better prognosis is expected in the 7% of renal cell cancer patients that are accidentally diagnosed during radiographic imaging studies .<span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">7 ||
 * Diagnostic Procedures: || <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">The diagnostic workup for renal cell cancer should include a complete history and physical examination. Radiographic studies should include CT or MRI of abdomen and pelvis. Lab work should include a complete blood count including liver and kidney function tests. A bone scan can be obtained to rule out bony metastases. Usually the pathologic confirmation of renal cell cancer is made at the time of nephrectomy. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">4 <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> A complete diagnostic work-up is listed in table 1.1. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">10 <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">
 * Histology: || <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;">Adenocarcinoma is the predominant histopathologic type of cancer that arises in the renal parenchyma. Other types include clear cell carcinoma, granular cell carcinoma, and a sarcomatoid variant. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;"> 10 ||
 * Lymph Node Drainage: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">The lymphatics of the kidney and renal pelvis drain along the renal vessels. The right kidney drains mostly into the paracaval and interaortacaval lymph nodes. The left kidney, on the other hand, drains solely into the paraaortic lymph nodes. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">4 ||
 * Metastatic Spread: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Close to 50% of patients with renal cell carcinoma will develop metastasis. The most common places of metastatic spread include the lung (75%), soft tissue (36%), bone (20%), liver (18%), cutaneous areas (8%), and CNS (8%). <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">6 ||
 * Grading: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Histopathologic grading (G)

Grade is an important prognostic factor for those patients with papillary and clear-cell renal cell carcinoma. 5 ||
 * Staging: || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">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. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">

The **Robson system** classifies tumors in the following stages: Stage I: The tumor is confined to the kidney and does not involve the capsule of tissues that surround the kidney Stage II: The tumor extends through the capsule of the kidney Stage III: The tumor involves lymph node(s) or extends into the renal vein or the inferior vena cava Stage IV: The tumor has invaded organs adjacent to the kidney or shows evidence of distant spread to other organs. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%; vertical-align: super;">8 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">

The American Joint Committee uses the following staging system for Renal cell Carcinoma: <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%; vertical-align: super;"> 4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">“This system appears to be superior to the Robson system because of it delineates more clearly the local tumor extent and quantifies the lymph node involvement." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%; vertical-align: super;">9 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> ||
 * Radiation Side Effects: || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Carcinomas of the kidneys radiation sequelae are similar to upper abdomen and pelvis irradiation: including nausea, vomiting, diarrhea, and abdominal cramping. Patients with right sided tumors may be in danger of radiation induced liver damage because of the significant portion of the liver is irradiated. The contralateral kidney dose should not exceed 20 Gy in 2 to three weeks. The spinal cord should be kept below 45 Gy. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> ||
 * Prognosis: || <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">The most important prognostic factor is the tumor stage at the time of initial presentation. The significance of renal vein invasion and vena cava invasion on prognosis has been debated. A worse prognosis with lower survival and increased metasasis was reported by one study while the opposite was reported by another study. Lymph node metastasis have been associated with an increase in local recurrence and distant metastasis. "Higher pathologic grade or spindle cell or sarcomatoid variant lead to poor 5-year disease-free survival. High nuclear grade is associated with an increased incidence of advanced tumor stage, lymph node involvement, distant metastases, renal vein involvement, tumor size, and perirenal fat involvement." <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 89%; vertical-align: super;">4 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">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. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">6<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;"> ||
 * Treatments: || For localized T1 and T2 renal cell carcinomas radical nephrectomy is the standard treatment. Regional lymphadenectomy is often performed at the time of the radical nephrectomy. Definitive radiation 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 recieved postoperative irradiation, but no survival benefit has been noted. Chemotherapy and immunotherapy, such as interferon and interleukin, are used although survival gains are marginal.

Patients with a solitary bony metastasis are at risk of developing multiple metastases, but these patients also have a 30%-40% chance of surviving for 5 years. Thus high dose palliative radiation therapy to metastatic bony lesions should be performed to ensure a long symptom-free survival time for these patients.

Renal Pelvic and Ureteral Carcinoma Management consists of nephroureterectomy with the excision of a cuff of bladder and bladder mucosa. Less agressive surgery, such as nephrectomy and partial ureterectomy, is accompanied by a ureteral stump recurrence rate of 30%. Combination chemotherapy consisting of methotrexate, vinblastine, doxorubicin, and cis-platinum (MVAC) produces an objective response of more than 70% in limited groups of patients who have metastatic transitional cell carcinoma of the bladder, ureter, or renal pelvis. Combination of chemotherapy and radiation are prefered for patients with high-stage and high-grade tumors with local extension or patients with regional lymph node metastases.

Renal Cell Carcinoma Radiation is most commonly delivered in the postoperative setting when tumor is left behind or for recurrence following surgery. The treatment volume includes the renal fossa and site of gross recurrence, if present, along with the paraaortic nodal drainage site in the adjuvent setting. Postoperative radiation doses range from 4500 to 5500 cGy; the usual recommended dose that can be safely given to the upper abdomen with an acceptable complication rate is 5040 cGy at 180 cGy per fraction over 5 to 6 weeks. A boost of 540 cGy in three fractions to a smaller volume may be added for a total tumor dose of 5580 cGy. The remaining kidney should not recieve doses above 1800 cGy. The patient is usually treated via isocentric, parallel opposed AP/Pa fields. CT planning is often used to define the area at risk and normal structures. Treatment plans include (1) equal weighting or parallel-opposed AP/Pa fields, (2) bias loading (i.e., 3:1 or 2:1 posterior loading), and (3) other wedge pair techniques. A shrinking-field technique should be used to reduce exposure to dose-limiting adjacent structures. Radiation can also be used to pappiate a symptomatic renal mass that is unresectable or the patient who is inoperable.

Renal Pelvic and Ureteral Carcinoma Postoperative radiation portals for renal pelvic and ureteral carcinoma usually includes the entire renal fossa, ureteral bed, and ipsilateral bladder trigone. The extent is dictated by clinical information obtained at the time of surgery and a pathologic analysis of the resected specimen. The portals should also include the paraaortic and paracaval areas because of the high incidence of lymph node involvement. The usual dose is 5040 cGy in 180 cGy fractions, with a possible boost of an additional 540 cGy in three fractions to a reduced volume. The technique is usually AP/Pa parallel opposed for the large field with the same technique or oblique beams for the boost. 6

<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Figure 1. Treatment plan for treating kidney tumor bed. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 99%; vertical-align: super;">4 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Figure 2. Radiation portal for renal cancer. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 99%; vertical-align: super;">4 || Liver - 2500 cGy Kidney - 2000 cGy Spinal Cord - 4500 (10 cm 2 ) 6 || Holly is royal blue Stacy is Green Shae is red Kristy is pink || <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">References: <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> 1. American Cancer Society//.// //How Many People Get Kidney Cancer?// Available at: [] <span style="color: #008000; font-family: 'Times New Roman',Times,serif;">Accessed January 26, 2010. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">2. Rubin P. //Clinical Oncology: A Multidisciplinary Approach for Physicians and Students.// 8th edition. P. 421, 427. Philadelphia, PA: W.B. Saunders Company. 2001. 3. American Cancer Society//. What Causes Kidney Cancer? Can it be Prevented?// Available at: [] <span style="color: #008000; font-family: 'Times New Roman',Times,serif;">Accessed January 26, 2010.<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">4. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 90%;">Chao KS, Perez CA, Brady LW. //Radiation Oncology Management Decisions. 2nd edition.// Philadelphia, PA: Lippincott Williams & Wilkins. 1999, 2002; 422-423, <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 99%;">426-428. <span style="color: #008080; font-family: 'Times New Roman',Times,serif;">5. Lenhard RE, Osteen RT, Gansler T. The American Cancer Society's Clinical Oncology. 1st edition. Atlanta, GA: The American Cancer Society, Inc. 2001: 417-418. 6. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 2nd ed. St. Louis, MI: Mosby. 2004: 832 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">, 80-81, 833-836 , <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">831. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;">7. The Kidney Cancer Institute signs and symptoms of Kidney cancer. Available at []. Accessed Jan. 28, 2010. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">8. Urology Channel. (2010) //Kidney Cancer: Staging//. Retrieved January 27, 2010, from []. <span style="color: fuchsia; font-family: 'Times New Roman',Times,serif; font-size: 12pt;">9. Gunderson, LL & Tepper, JE. (Eds.) //<span style="font-family: 'Calibri','sans-serif';">Clinical Radiation Oncology //. 2nd edition. Philadelphia, PA: Elsevier, Churchill & Livingstone. 2007: 1290-1291. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;">10. Halperin EC, Perez CA, Brady LW. //Principles and Practice of Radiation Oncology.//fifth edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2008; 1399-1400.
 * TD5/5: || Bladder - 6000 cGy
 * || Kim is teal