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Flashcards in Renal Neoplastic Disease Deck (57)
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1

1. Renal cell carcinoma (RCC) is cancer of the kidney that originates in the?

2. RCC represents____% of primary renal neoplasms

RCC represents __% of overall cancer incidence and mortality

1. renal cortex

2. 80-85%

3. 2

2

Epidemiology:
1. What gender is RCC more common in?
2. Highest incidence between age___ and ____?
3. Median age of diagnosis is ___ years
4. Median age of death___ years

1. Male predominance: RCC is approximately 50% more common in men than women

2. 60-80
3. 64
4. 70

3

Renal cell carcinoma risk factors?
4

1. Smoking 1/3 of cases
2. Hypertension
3. Obesity
4. Acquired cystic disease of the kidney

Usually an incidental finding

4

Renal Cell Carcinoma SubTypes
5

1. Clear Cell (75 to 85 %)
2. Papillary (chromophilic) (10 to 15%)
3. Chromophobe (5 to 10%)
4. Oncocytic (3 to 7%)
5. Collecting duct (Bellini's duct) (very rare)

5

Subtypes of renal cell carcinoma
Clear cell carcinomas (75-85%)
1. Arises from where?

2. Whats the genetic variation that is associated with this?

3. Macroscopic characteristics? 2

4. Tends to invade where?

1. arise from the proximal tubule

2. typically have a deletion of chromosome 3p

3. Macroscopically, they may be solid or less commonly cystic.

4. Tends to have a vascular invasion

6

Variants of renal cell carcinoma
Papillary (“chromophilic”) carcinoma (familial or sporadic) (10-15%)
1. Thought arise from where?

2. Genetic variation associated with this?

3. Divided into what?

4. How would you describe the prognosis?

1. Thought to arise from proximal convoluted tubule

2. Trisomy 7 common (also trisomy 16, 17, loss of Y)

3. Divided into Type 1 and Type 2

4. Recent study shows better prognosis than clear cell carcinoma

7

Chromophobe renal cell carcinoma
1. Compare this histologically with clear cell carcinoma

2. Arises from where?

3. Prognosis compared to clear cell carcinoma?

1. Histologically, composed of sheets of cells that are darker than clear cell carcinoma

2. Arises from intercalated cells of collecting ducts

3. lower risk of disease progression and death compared to clear cell carcinomas

8

Collecting duct carcinoma (Bellini duct carcinoma)
1. How prevelent is this?
2. Describe the clinical course?
3. In what demographics most often? 2

1. Approximately 1% of renal cell carcinomas
2. Aggressive clinical course
3. Affects younger adults and African American patients more frequently

9

Oncocytomas (3-7%)
1. Where do these orginiate?

2. What so they consist of?

3. Genetic variation associated with this?

4. Tends to be unilateral or bilateral? Single or multiple?

1. originate from the intercalated cells of the collecting ducts

2. consist of oncocytes, which are large well-differentiated neoplastic cells with intensely eosinophilic granular cytoplasm

3. Mutations in c-met oncogene associated with papillary RCC

4. Tends to be unilateral and single, but multiple and bilateral oncocytomas have been described

10

Renal Cell Carcinoma: Microscopic Appearances (1)
Clear Cell Carcinoma:
1. Describe the cytoplasm?

2. Describe the cells? 2

3. What do the cells form? 3

1. Clear cytoplasm due to lipid and glycogen;

2. cells may be
-bland or
-poorly differentiated;

3. cells form
-solid nests,
-tubules;
-fine vasculature

11

Renal Cell Carcinoma: Microscopic Appearances (2)
Papillary carcinoma:
1. Papillae are composed of what?

2. Papillary tips may undergo what?

Papillary carcinoma
1. delicate vascular cores with overlying layer of tumor cells

2. Papillary tips may undergo necrosis and calcification (“psammoma bodies”)

12

Renal Cell Carcinoma: Microscopic Appearances (3)
Chromophobe renal cell carcinoma?

Sheets of pink (eosinophilic) cells with perinuclear halos

13

Renal Cell Carcinoma: Clinical Features:
1. Presents when in the course of the disease?

2. Classic Presentation**** (classical triad)?

3. Nonspecific features? 2

4. Other features that could be associated? 3

1. Presents late in course and most commonly diagnosed incidentally

2.
-Flank pain (constant dull ache, back or abd)
-Gross hematuria
-Palpable renal mass

3.
-Sudden onset of a scrotal varicocele
-Paraneoplastic syndromes
due to ectopic production of various hormones


1. Anemia
2. Hepatic dysfunction
3. Anorexia

14

Renal Cell Carcinoma diagnostic evaluation?
3

Diagnostic Evaluation:
1. Ultrasound - initial
2. CT Scan - gold standard
3. MRI

15

Differential Diagnosis of Renal Masses

Cysts
-Simple
-Complex
-Multiple
Bosniak Scale

16

Ultrasound:
3 Major Criteria for simple cyst?

1. Mass is round and sharply demarcated with smooth walls
2. No echoes (anechoic) within the mass
3. Strong posterior wall echo indicating good transmission through the cyst

17

The primary reason to investigate a renal mass is to do what?

exclude a malignant neoplasm

18

Renal Cell Carcinoma
Assessing for Metastasis
Most common sites of metastatic disease include?
3

1. lung
2. lymph nodes (intra abdominal)
3. bone

19

Renal Cell Carcinoma
Assessing for Metastasis
3

1. Bone scan
2. CT of the chest
3. Positron Emission Tomography (PET)

20

What is the treatment of choice for renal cell carcinoma?

surgical removal

21

1. What is the surgery that we would do for renal cell carcinoma?
2. How often are the regional lymphnodes involed?
3. What else is involved in 5% of pts?

1. Nephrectomy
2. almost 25% of patients
3. inferior vena cava involvement

22

The role of radiotherapy remains controversial in the treatment of renal cell carcinoma. Why?

Renal cell carcinoma is a relatively radioresistant tumor
Chemotherapy, Immunotherapy have limited role in tx

23

SOOOO what is the gold standard for treatment of renal cell carcinoma?

Radical nephrectomy
-The "gold standard" therapy for RCC

24

A radical nephrectomy involves the ligation, dissection or removal of what structures?
5

Includes
1. early vascular ligation
2. extrafascial dissection of the kidney (outside Gerota's fascia),
3. en bloc resection of the adrenal gland
4. extensive lymphadenectomy from the crus of the diaphragm to the aortic bifurcation.
5. Resection of tumor extension into the Inferior Vena Cava

25

Nephron-Sparing Surgery (Partial Nephrectomy)
Recently, several long-term studies have shown equivalent survival of patients undergoing NSS versus radical nephrectomy for a unilateral renal tumor less than ___ cm in size

4

26

Nephron-Sparing Surgery (Partial Nephrectomy):
The risk of recurrence increases with what?
5

1. larger tumors
2. bilateral tumors
3. multifocality
4. symptoms
5. certain histologies such as papillary RCC

27

Stage I renal cysts are characterized how?

5 yr survival rate?

Tumor less than 7 in greatest dimension and limited to kidney.

5 yr survival 95%

28

Stage II renal cysts are characterized how?

5 yr survival rate?

Tumor greater than 7 cm in greatest dimension and limited to kidney.

5 yr survival - 88%

29

Stage II renal cysts are characterized how?

5 yr survival rate?

Tumor in major veins or adrenal gland, tumor with in Gerota's fascia or 1 regional lympth node involved

5 yr survival 59%

30

Stage III renal cysts are characterized how?

5 yr survival rate?

Tumor beyound Gerota's fascia or > 1 regional lymph node involved.

5 year survival 20%