Renal Cancer (Renal Cell Carcinoma) Flashcards
What is the pathophysiology of renal cancer?
Renal cell carcinoma (RCC) or adenocarcinoma of the kidney is the most common type of kidney cancer and occurs as a result of impaired cellular regulation. Healthy kidney tissue is damaged and replaced by cancer cells, which impairs urine elimination for that kidney.
- RCC has five distinct carcinoma cell types: clear cell, papillary cell, chromophobe cell, collecting duct carcinoma, and unclassified type. Kidney tumors are classified into four stages.
What systematic effects occur with renal cancer?
Systemic effects occurring with this cancer type are called paraneoplastic syndromes and include anemia, erythrocytosis, hypercalcemia, liver dysfunction with elevated liver enzymes, hormonal effects, increased sedimentation rate, and hypertension.
Why does a patient with renal cancer develop anemia or erythrocytosis?
Anemia and erythrocytosis may seem confusing; however, most patients with this cancer have either anemia or erythrocytosis, not both at the same time. There is some blood loss from hematuria, but the small amount lost does not cause anemia. The cause of the anemia and the erythrocytosis is related to kidney cell production of erythropoietin. At times, the tumor cells produce large amounts of erythropoietin, causing erythrocytosis. At other times, the tumor cells destroy the erythropoietin-producing kidney cells and anemia results.
What risk factors are associated with renal cancer?
- Slightly higher for adults who use tobacco
- Exposure to cadmium and other heavy metals
- Asbestos, benzene, and trichloroethylene
- Men are slightly more likely to acquire RCC
- Obesity
- Hypertension
- African Americans
What are possible complications?
- Metastasis
- Urinary tract obstruction
Where does the cancer usually spread?
The cancer usually spreads to the adrenal gland, liver, lungs, long bones, or the other kidney. When the cancer surrounds a ureter, hydroureter and obstruction may result.
What is the average age of diagnosis and what age group is it not common in?
The average age at diagnosis is 64 years old. Kidney cancer is not common in people younger than 45.
How can hormones produced by the cancer cells affect the body?
Parathyroid hormone produced by tumor cells can cause hypercalcemia. Other hormone changes include increased renin levels (causing hypertension) and increased human chorionic gonadotropin (hCG) levels, which decrease libido and change secondary sex features.
What should the nurse ask the patient during the assessment?
- Ask the patient about his or her age
- Ask about known risk factors (e.g., smoking or chemical exposures)
- Ask about weight loss
- Ask about changes in urine color
- Ask about abdominal or flank discomfort, and fever
- Ask whether any other family member has ever been diagnosed with cancer of the kidney, bladder, ureter, prostate gland, uterus, or ovary.
What are physical assessment / signs and symptoms associated with renal cancer?
- Flank pain
- Obvious blood in the urine
- A kidney mass that can be palpated
- Ask about the nature of the flank or abdominal discomfort. Patients often describe the pain as dull and aching. Pain may be more intense if bleeding into the tumor or kidney occurs.
- Inspect the flank area, checking for asymmetry or an obvious bulge. An abdominal mass may be felt with gentle palpation. A renal bruit may be heard on auscultation.
- Bloody urine is a late common sign
- Blood may be visible as bright red flecks or clots, or the urine may appear smoky or cola-colored
- Without gross hematuria, microscopic examination may or may not reveal red blood cells (RBCs).
- Inspect the skin for pallor, darkening of the nipples, and, in men, breast enlargement (gynecomastia) caused by changing hormone levels.
- Other findings may include muscle wasting, weakness, and weight loss.
What diagnostics can be done for a patient?
- Urinalysis may show RBCs. Hematologic studies show decreased hemoglobin and hematocrit values, hypercalcemia, increased erythrocyte sedimentation rate, and increased levels of adrenocorticotropic hormone, human chorionic gonadotropin (hCG), cortisol, renin, and parathyroid hormone. Elevated serum creatinine and blood urea nitrogen (BUN) levels indicate impaired kidney function.
- CT scan or MRI may detect kidney masses.
- Ultrasound is also used to detect masses or for initial screening.
- Kidney biopsy may be considered to help target therapy.
What are some nonsurgical interventions that can be done?
- Microwave ablation (MWA) or cryoablation can slow tumor growth. It is a minimally invasive procedure carried out after MRI has precisely located the tumor. MWA is used most commonly for patients who have only one kidney or who are not surgical candidates.
- Traditional chemotherapy has limited effectiveness against this cancer type.
- Use of biologic response modifiers (BRMs) such as interleukin-2 (IL-2), interferon (IFN), and tumor necrosis factor (TNF) has increased survival time
What are some surgical interventions that can be done?
Renal cell carcinoma (RCC) is usually treated surgically by nephrectomy (kidney removal). Renal cell tumors are highly vascular, and blood loss during surgery is a major concern. Before surgery, the arteries supplying the kidney may be occluded (embolized) by the interventional radiologist to reduce bleeding during nephrectomy.
What preoperative care is done prior to surgical intervention?
- Instruct the patient about surgical routines.
- Explain the probable site of incision and the presence of dressings, drains, or other equipment after surgery.
- Reassure the patient about pain relief.
- Care before surgery may include giving blood and fluids IV to prevent shock.
What postoperative care is done after surgical intervention?
- Monitoring includes assessing for hemorrhage and adrenal insufficiency. Inspect the patient’s abdomen for distention from bleeding. Check the bed linens under the patient because blood may pool there. Hemorrhage or adrenal insufficiency causes hypotension, decreased urine output, and an altered level of consciousness.
- A decrease in blood pressure is an early sign of both hemorrhage and adrenal insufficiency. With hypotension, urine output also decreases immediately. Large water and sodium losses in the urine occur in patients with adrenal insufficiency, leading to impaired fluid and electrolyte balance. As a result, a large urine output is followed by hypotension and oliguria (less than 400 mL/24 hr or less than 25 mL/hr). IV replacement of fluids and packed RBCs may be needed.
- The second kidney is expected to provide adequate function, but this may take days or weeks. Assess urine output hourly for the first 24 hours after surgery (urine output of 0.5 mL/kg/hr or about 30 to 50 mL/hr is acceptable). A low urine output of less than 25 to 30 mL/hr suggests decreased blood flow to the remaining kidney and potential for acute kidney injury (AKI). The hemoglobin level, hematocrit values, and white blood cell count may be measured every 6 to 12 hours for the first day or two after surgery.
Monitor the patient’s temperature, pulse rate, and respiratory rate at least every 4 hours. Accurately measure and record fluid intake and output. Weigh the patient daily. - The patient may be in a special care unit for 24 to 48 hours after surgery for monitoring of bleeding and adrenal insufficiency. A drain placed near the site of incision removes residual fluid. Because of the discomfort of deep breathing, the patient is at risk for atelectasis. Fever, chills, thick sputum, or decreased breath sounds suggest pneumonia.
- Managing pain after surgery usually requires opioid analgesics given IV. The incision was made through major muscle groups used with breathing and movement. Liberal use of analgesics is needed for 3 to 5 days after surgery to manage pain. Oral agents may be tried when the patient can eat and drink.
- Preventing complications focuses on infection and management of adrenal insufficiency. Antibiotics may be prescribed during and after surgery to prevent infection. The need for additional antibiotics is based on evidence of infection. Assess the patient at least every 8 hours for indications of systemic infection or local wound infection.
- Adrenal insufficiency is possible as a complication of kidney and adrenal gland removal. Although only one adrenal gland may be affected, the remaining gland may not be able to secrete sufficient glucocorticoids immediately after surgery. Steroid replacements may be needed in some patients.
