Diagnosis and Modern Treatment
Semir A. S. Al Samarrai
Epidemiology and Etiology:
Kidney Cancer represents 2-3% of cancers with an age-standardized rate incidence of cancer with an age standardized rate incidence of 5.8 and mortality of 1.4 per 100,000, respectively, in more developed areas (1). The highest incidence all over the world is in the Czech Republic, when in 2010 the incidence rate was 14.62 and mortality 5.17 (age-standardized rate/world per 100,000) (2).
Renal Cell Carcinoma is the commonest solid lesion in the kidney and account for approximately 90% of all kidney malignancies. It includes different types, with specific histopathological and genetic characteristics (3). There is a 1.5:1.0 predominance of men over women, with the peak incidence occurring between the ages of 60 and 70. Etiological factors include lifestyle factors such as smoking, obesity, and hypertension (4-8). Obesity is controversial issue, as there have been reports showing a better prognosis for obese patients suffering from renal cell cancer (9). Having a first-degree relative with kidney cancer is also associated with an increased risk of RCC (10,11).
The most effective prophylaxis is to avoid cigarette smoking and obesity.
Diagnosis and Staging:
A) Symptoms: Many renal masses remain asymptomatic until the late stages of the disease. Currently, more than 50% of RCC are detected incidentally when non-invasive imaging is used to investigate a variety of nonspecific symptoms and other abdominal disease (12,13).
2) The classic triad of flank pain, gross hematuria, palpable abdominal mass is now rare (6-10%) and correlates with aggressive histology and advanced disease (14,15). Paraneoplastic syndrome are found in approximately 30% of patients with symptomatic RCCs.: Hypertension, Cachexia, Weightloss, Pyrexia, Neuromyopathy, Amyloidosis, Elevated erythrocyte sedimentation rate (ESR), Anemia, Abnormal Liver function, Hypercalcemia and Polycythemia. A few symptomatic patients present with symptoms caused by metastatic disease, such as bone pain or persist cough (16).
B) Physical Examination:
Physical examination has only a limited role in the diagnosis of RCC. However, the following findings should prompt radiological examinations.
- Palpable abdominal mass
- Palpable cervical lymphadenopathy
- Nonreducing varicocele and bilateral lower extremity edema, that suggests venous involvement
C) Laboratory findings:
The most commonly assessed laboratory parameters are serum creatinine, glomerular filtration rate (GFR), complete blood count (CBC), erythrocyte sedimentation rate (ESR), liver function study, alkaline phosphatase, lactate dehydrogenase (LDH), serum calcium (17,18), coagulation study and urinalysis. If there are central renal masses abutting or invading the collecting system, urinary cytology and possibly endoscopic assessment of the upper urinary tract should be considered in order to rule out the preference of urothelial cancer.
Split renal function should be estimated using renal scintigraphy in the following situations (19,20).
- When renal function is compromised, as indicated by an increased concentration of serum creatinine or a significantly decreased GFR.
- When renal function is clinically important e.g. in patients with a solitary kidney or multiple or bilateral tumours.
Renal scintigraphy is an additional diagnosis option in patients who are at risk of future renal impairment due to comorbid disorders e.g, diabetes, severe hypertension, chronic pyelonephritis, renovascular disease, urinary stones, or renal polycystic disease.
D) Imaging Investigations:
Most renal tumours are diagnosed when abdominal ultrasonography (US) or computed tomography (CT) are carried out for other medical reasons (11). Renal masses can be classified as solid or cystic on the basis of the imaging findings.
E) CT or MRI
computed tomography or MRI are used to characterize a renal mass. Imaging must be performed both before and after administration of intravenous contrast material in order to demonstrate enhancement.
Three Dimensional Image of Kidney Cancer Left
F) Radiographic Investigations for metastatic RCC chest CT is the most accurate investigation for chest staging. (21-25)
However, at the very least, routine chest radiography must be performed for metastatic evaluation, as less accurate alternative to the chest CT.
Treatment of Localized Kidney Cancer or RCC and local treatment of Metabolic Kidney Cancer or RCC.
Based on the available oncological and Qol outcomes, the current evidence suggest that localized renal cancers are best managed by nephron-sparing surgery (Partial Nephrectomy) rather than by radical nephrectomy, irrespective of the surgical approach. When open partial nephrectomy was compared to open radical nephrectomy the estimated cancer-specific survival rates (CSS) at 5 years were comparable (26-29).
The Recommendations of the European Association of Urology Guidelines-Edition 2014 are as follow:
1) Surgery for Localized Kidney Cancer to achieve cure.
2) Nephron-sparing surgery is recommended in patients with T1a Cancer.
3) Ipsilateral adrenalectomy is not recommended where there is no clinical evidence of invasion of the adrenal gland.
4) Lymph node dissection is not recommended in Localized Kidney Cancer without clinical evidence of lymph node invasion.
5) Laparoscopic radical nephrectomy is recommended for patients with T2 Cancer of the kidney and localized renal masses not treatable by nephron-sparing surgery.
6) Laparoscopic radical nephrectomy should not be performed in patients with T1 Cancer of the kidney for whom partial nephrectomy is indicated.
7) In the elderly and / or comorbid patients with small renal masses and limited life expectancy, active surveillance, radiofrequency ablation and cryoablation can be offered.
8) Excision of the kidney cancer and caval thrombus is recommended in patients with non-metastatic Renal Cell Carcinoma.
9) For most patients with metastatic disease, cytoreductive nephrectomy is palliative and systemic treatments are necessary.
This cytoreductive procedure combined with targeting agents, such sunitinib, sorafenib and others.
The recommendation for cytoreductive nephrectomy is only in appropriately selected patients with metastatic renal cell carcinoma.
10) In individual cases can stereotactic radiotherapy for bone metastases, and stereotactic radiosurgery for brain metastases be offered for relief.
11) Monotheraphy with IFN- ? or high-dose bolus IL-2 should not routinely be recommended as first-line therapy in metastatic renal cancer.
12) Systemic therapy for metastatic renal cancer should be based on targeted agents like, sunitinib and pazopanib as first-line therapy for advanced/metastatic clear-cell renal carcinoma and sequencing of targeted agents is recommended.
Tersirolimus is recommended as a first-line treatment in poor-risk renal cell carcinoma patients.
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Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576