Renal Cell Carcinoma: (RCC)

- Adenocarcinoma of the kidney (most often used term)- It is also known as hypernephroma and clear cell carcinoma of the kidney- In 2000 an estimated 36,000 new cases were diagnosed with 12,000 resulting in death- RCC comprises about 3% of adult tumors - RCC makes up about 85% of all primary malignant renal tumors

Who gets RCC?- most commonly occurs in the 5th and 6th decades of life- male:female ratio- 2:1- the incidence is equivalent between whites and blacks- Hispanics have rates more than 1/3 higher than white Americans

Etiology of RCC:

- the cause of RCC is unknown- cigarette smoking is only risk factor consistent linked to RCC- roles of cellular oncogenes and tumor suppressor genes is still up for discussion- in patients with acquired cystic disease of the kidneys in uremic states, 4-9% develop RCC

Pathology of RCC:

- RCC originates from the proximal renal tubular epithelium- RCC originates in the cortex- Average diameter is 7-8 cm- There is equal frequency of RCC in either kidney- It is randomly distributed in the upper and lower poles- Types of RCC and prevalence-

- clear cell type- 25%- granular cell type- 25%- mixed cell types- 50%

- sarcomatoid variety- 2% Pathogenesis of RCC:

- most common site of metastasis is the lung- liver, bone, ipsilateral adjacent lymph nodes, adrenal gland, and the opposite kidney are the

sites of disease spread- few patients today have evidence of metastases at presentation

Clinical findings of RCC:

- classic triad of gross hematuria, flank pain, and a palpable mass occurs in 10% of patients- 60% of patients present with gross or microscopic hematuria- 20% may present with pain or an abdominal mass- dyspnea, cough, and pain secondary to metastatic disease are not common- 30% detected incidentally

Paraneoplastic Syndromes:- erythrocytosis- hypercalcemia- hypertension- nonmetastatic hepatic dysfunction

RCC may produce other biologically active products that result in syndromes-

- ACTH→ Cushings syndrome- enteroglucagon→ protein enteropathy- prolactic→ galactorrhea- insulin→ hypoglycemia- gonadotropins→ gynecomastia and decreased libido

Work up for RCC:

- UA, C&S, CBC, SMA-20- IVP- when patient presents with hematuria- Renal US- 98% accurate in defining simple cysts- CT abdomen- the mass becomes enhanced with the use of IV contrast- MRI- if suspicion of renal vein or venal caval tumor- CXR- PA or lateral- Fine needle aspiration (FNA)-

- has a limited role- used to differentiate primary RCC from metastases- used to diagnose masses in patients with solitary kidneys- used when a histologic diagnosis is needed prior to nonsurgical rx- used to distinguish complicated cyst vs RCC

Tumor Staging:

Size-T1: tumor 2.5 cm or lessT2: tumor more than 2.5 cmT3: tumor extends into major veins, adrenal, and perinephric tissues

- T3a: invades adrenal but not beyoned Gerota’s fascia- T3b: extends into renal vein or vein cava

T4: tumor invades beyond Gerota’s fascia

Regional lymph nodes (N)-N1: metastases in single lymph node 2 cm or lessN2: metastases in single or multiple lymph nodes- none > 5 cmN3: metastases in lymph node > 5 cm

Distant metastases (M)-M0: No distant metastasesM1: Distant metastases

Treatment- Localized disease:

- Radical nephrectomy is the standard:- Involves the removal of the kidney and its enveloping fascia (Gerota’s), including the

ipsilateral adrenal and proximal ureter

Alternative treatments:

- Nephron sparing surgery- partial nephrectomy- Laprascopic nephrectomy

Treatment for metastatic disease:

- radical nephrectomy for palliation- spontaneous regression of RCC mets after nephrectomy reported in less than 1%- solitary metastases may be candidates for combined nephrectomy and resection of metastases- hormonal therapy- often gives poor response- chemotherapy- often gives poor response- immunotherapy- interferons, IL-2, monoclonal antibiotics

Follow up care:

- H&P- CXR- CBC- Serum chemistries- US, CT and bone scans when clinically indicated

Prognosis:

5 year survival rates:T1- 90%T2- 70%T3a- 70%T3b- 30%T4- <20%

Tumors of the Testis:

- the lifetime probability of deverloping testicular cancer is 0.2% for a white male in the USA- overall 5-year survival rates: 95%

Etiology of testicular cancer:

- cause is unknown - the strongest association has been in cryptorchid testis

- 7-10% of testis tumors in patients with a history of cryptorchidism- risk of malignancy

- intra-abdominal testes: 1 in 20- inguinal testes: 1 in 80

- exogenous estrogen administration to the mother during pregnancy associated with increased risk

- acquired factors- trauma

- infection

Classification:

- Semimoma- 35%- Nonaseminomatous germ cell tumors (NSGCT)

- embryonal (20%)