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Tuesday, August 12, 2025

Kidney cancer


Definition

Kidney cancer, also known as renal cancer, refers to malignant tumors arising from the kidney tissues. The most common type in adults is renal cell carcinoma (RCC), accounting for approximately 85–90% of cases. Other types include urothelial carcinoma of the renal pelvis and rare tumors such as Wilms tumor in children.

Epidemiology

  • Accounts for 2–3% of all adult cancers.

  • Peak incidence: 60–70 years of age.

  • More common in males than females (ratio ~1.5–2:1).

Risk Factors

  • Smoking: Increases risk by ~50%.

  • Obesity.

  • Hypertension.

  • Chronic kidney disease and long-term dialysis.

  • Genetic syndromes: von Hippel–Lindau (VHL) disease, hereditary papillary RCC, Birt–Hogg–Dubé syndrome.

  • Occupational exposures: Asbestos, cadmium, trichloroethylene.

  • Family history of kidney cancer.

Types of Kidney Cancer

1. Renal Cell Carcinoma (RCC) – Subtypes

  • Clear cell RCC (most common, ~70–80%).

  • Papillary RCC (10–15%).

  • Chromophobe RCC (5%).

  • Collecting duct carcinoma (rare, aggressive).

2. Urothelial Carcinoma of the renal pelvis

  • Similar pathology to bladder cancer.

3. Wilms Tumor (Nephroblastoma)

  • Most common kidney cancer in children.

Pathophysiology

RCC often originates in the proximal tubular epithelium. Mutations in tumor suppressor genes (e.g., VHL gene in clear cell RCC) lead to dysregulated cell proliferation and angiogenesis, promoting tumor growth and metastasis.

Clinical Presentation

Classic Triad (rare, seen in ~10% of cases):

  • Gross hematuria.

  • Flank pain.

  • Palpable abdominal mass.

Other Symptoms

  • Microscopic hematuria.

  • Fatigue, weight loss.

  • Fever of unknown origin.

  • Hypertension (due to renin secretion).

  • Anemia or polycythemia (erythropoietin overproduction).

  • Varicocele (left-sided, due to renal vein compression).

Metastatic Symptoms

  • Bone pain, pathological fractures.

  • Cough or dyspnea (lung metastases).

  • Neurological deficits (brain metastases).

Diagnosis

Laboratory Investigations

  • Urinalysis: Hematuria.

  • CBC: Anemia or polycythemia.

  • Renal function tests: Serum creatinine, urea.

  • Liver function tests: May be altered in metastasis.

Imaging

  • Ultrasound: Initial assessment.

  • Contrast-enhanced CT scan: Gold standard for diagnosis and staging.

  • MRI: Useful for renal vein or IVC involvement.

  • Chest imaging: To detect lung metastases.

  • Bone scan: If bone pain or elevated alkaline phosphatase.

Histology

  • Percutaneous renal biopsy if diagnosis is uncertain or systemic therapy is planned without surgery.

Staging (TNM System – simplified)

  • Stage I: Tumor ≤7 cm, confined to kidney.

  • Stage II: Tumor >7 cm, confined to kidney.

  • Stage III: Tumor extends into major veins or perinephric tissue but not beyond Gerota’s fascia; may involve regional lymph nodes.

  • Stage IV: Tumor invades beyond Gerota’s fascia or has distant metastases.

Management

1. Localized Disease

  • Partial nephrectomy: Preferred for small tumors (<4 cm) to preserve renal function.

  • Radical nephrectomy: Removal of kidney, adrenal gland, perirenal fat, and regional lymph nodes.

  • Minimally invasive techniques: Laparoscopic or robotic-assisted surgery.

2. Locally Advanced Disease

  • Surgical resection with tumor thrombectomy if renal vein/IVC involvement.

3. Metastatic or Unresectable Disease

Systemic therapy options include:

Targeted Therapy (anti-angiogenic & tyrosine kinase inhibitors)

  • Sunitinib: 50 mg orally once daily for 4 weeks, then 2 weeks off.

  • Pazopanib: 800 mg orally once daily.

  • Axitinib: 5 mg orally twice daily.

  • Cabozantinib: 60 mg orally once daily.

mTOR Inhibitors

  • Everolimus: 10 mg orally once daily.

  • Temsirolimus: 25 mg IV once weekly.

Immunotherapy (Checkpoint Inhibitors)

  • Nivolumab: 240 mg IV every 2 weeks or 480 mg IV every 4 weeks.

  • Pembrolizumab: 200 mg IV every 3 weeks or 400 mg IV every 6 weeks.

  • Combination therapy: Pembrolizumab + axitinib for first-line treatment in advanced RCC.

4. Urothelial Carcinoma of the Renal Pelvis

  • Managed like bladder cancer: Nephroureterectomy + perioperative chemotherapy (cisplatin-based regimens).

5. Wilms Tumor

  • Combination of surgery, chemotherapy (vincristine, dactinomycin, doxorubicin), and radiotherapy depending on stage.

Supportive and Palliative Care

  • Pain management: Paracetamol, opioids as needed.

  • Bone metastases: Bisphosphonates (e.g., zoledronic acid 4 mg IV every 4 weeks) or denosumab.

  • Management of anemia: Iron therapy, erythropoiesis-stimulating agents.

Follow-Up

  • Surveillance schedule based on stage and risk of recurrence:

    • Imaging (CT or ultrasound) every 6–12 months for the first 3 years, then annually.

    • Regular monitoring of renal function.

Prognosis

  • Stage I: 5-year survival >90%.

  • Stage II: ~75–85%.

  • Stage III: 50–70%.

  • Stage IV: <15% (but improving with targeted and immunotherapies).




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