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RENAL CELL CARCINOMA

What is the prevalence of renal cell carcinoma (RCC)?
In the United States, approximately 27,000 new cases of RCC are detected each year. It accounts for 3% of all adult malignancies and 85% of all primary malignant renal tumors.
 
What is the etiology of RCC?
The etiology of RCC is unknown, with cigarette smoking being the only known risk factor. There is an increased incidence of RCC in patients with von Hippel-Lindau disease, horseshoe kidneys, adult polycystic kidney disease, and acquired renal cystic disease from uremia.
 

Explain the staging systems for patients with RCC.

There are two primary staging systems for renal cell carcinoma. The Robson system is simple and easy to use, but the staging categories do not always relate directly to prognosis; for example, stage 3 disease includes isolated renal vein involvement, which carries a good prognosis, as well as lymph node involvement, which is associated with poor survival. The tumor-node-metastasis (TNM) system is more detailed in classifying the extent of tumor involvement.
 
What are the signs and symptoms of RCC?
The most common presenting signs and symptoms are gross or microscopic hematuria, abdominal or flank pain, and a palpable abdominal mass. These findings, the classic triad, will be present in 10-15~ of patients. Patients with metastatic disease may present with symptoms of lung or bone metastasis, ~uch as dyspnea, cough, or bone pain. RCC may also be associated with paraneoplastic syndromes such as erythrocytosis, hypercalcemia, hypertension, and nonmetastatic hepatic dysfunction.
 
If the diagnostic evaluation of a renal mass indicates RCC, how do you proceed?
Studies are necessary for clinical staging of the tumor and in preparation for surgery. Routine clinical staging studies include a history and physical examination, complete blood count, renal and hepatic function tests, urinalysis, chest x-ray, and a cr scan of the abdomen and pelvis. A radionuclide bone scan is indicated in patients with bone pain or an elevated serum alkaline phosphatase level. When abdominal cr scanning suggests inferior vena caval involvement, additional imaging with either MRI or contrast inferior venacavography is necessary to establish the presence and extent of vena caval involvement. Renal arteriography is indicated in patients undergoing a complicated partial nephrectomy and in patients with a known vena caval tumor thrombus; in the latter group, if arteriography demonstrates an arterialized tumor thrombus, preoperative angioinfarction can facilitate extraction of the thrombus at surgery.

 
How is a localized unilateral RCC treated?
Surgical excision is the only curative form of treatment for RCC. Radical nephrectomy is the treatment of choice for patients with a localized unilateral RCC and a normal-functioning opposite kidney. Radical nephrectomy involves removal of the entire kidney outside Gerotas fascia. The adrenal gland also must be removed if the upper portion of the kidney is involved with malignancy. The benefit of performing a regional lymphadenectomy is controversial. The 5-year survival rate following radical nephrectomy for Robson stage I RCC is 70-80%. This rate is reduced in the presence of perinephric fat involvement (60-70%), renal vein involvement (5Q-{)0%), vena caval involvement (40-50%), extension to regional lymph nodes (5-20%), invasion of adjacent organs (0-5%), and distant metastases (0-5%).
 

When should a nephron-sparing operation (partial nephrectomy) be done for localized RCC?
Nephron-sparing surgery is indicated in patients with localized RCC present bilaterally or in a solitary kidney, since radical nephrectomy would necessitate immediate renal replacement therapy. In recent years, the indications for this surgery have expanded to include other patients in whom preservation of renal function is clinically relevant. Examples of this are patients with unilateral RCC and a functioning but impaired contralateral kidney or patients with unilateral RCC and a contralateral kidney whose function is potentially threatened by a concomitant urologic or systemic disorder. For patients with low-stage RCC, the long-term results of nephron-sparing surgery are comparable to those of radical nephrectomy. The major disadvantage is the risk of postoperative local tumor recurrence, which is seen in 6-10% of patients.
 
What is the approach to RCC involving the inferior vena cava?
For patients with nonmetastatic RCC and inferior vena cava (IVC) involvement, 5-year survival rates of 47-68% have been reported following complete surgical excision. The presence oflymph node or distant metastases in such patients carries a dismal prognosis that is not appreci~bly altered by radical surgical extirpation. There is a palliative role for surgery in some patients with metastasis who experience severe disability from intractable edema, ascites, cardiac dysfunction, or associated local symptoms such as abdominal pain or hematuria. When performing radical nephrectomy with removal of an IVC thrombus, it is essential to obtain control of the lYC above the thrombus to prevent intraoperative embolization of a tumor fragment. When the thrombus extends above the diaphragm, a combined thoracic and abdominal surgical approach is necessary. In such cases, adjunctive cardiopulmonary bypass with deep hypothermic circulatory arrest allows extensive IVC thrombi to be completely and safely removed.
 

What are the indications for nephrectomy in patients with metastatic RCC?
Nephrectomy has a palliative role in patients with metastatic RCC who experience severe disability from associated local symptoms,although some patients in this category can be managed with percutaneous renal angioinfarction. In patients with RCC and a solitary resectable metastasis, surgical excision of the primary and metastatic lesion is warra.nted based on reported 5-year survival rates of 30-35%. Many biologic response modifier Protocols to treat metastatic RCC currently require preliminary removal of the primary tumor; however, the advantage of routine preliminary nephrectomy in this setting is not established.
 
 

How frequently do metastases OCcur in RCC? How are they treated?
Approximately one-third of patients with RCC have metastatic disease at the time of diagnosis, and an additional 30-50% develop metastatic disease within 5 years. Currently, approximately 11,000 patient deaths occur per year from metastatic RCC in the United States. Until recently, the treatment for metastatic RCC was relatively ineffective.

 
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