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renal cell carcinoma - Nephrology

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									Nephrology Case Presentation




       Staci Smith DO
      November 20, 2009
    Case Presentation
n 55 yo CM with CKD 3 ( baseline Cr 1.5-1.8) presents to
  GVH ER with nausea , vomiting, and inability to keep
  liquids or any medicines down since surgery last Friday. Pt
  noticed that his abdomen has become progressively larger
  . He has not been passing flatus or had any recent BM.
n Pt has been hypotensive with sbp’s in the 90’s
n NG tube was placed in the ER with 1800 cc of green liquid
  output returned immediately.
    Pertinent Review of Systems

n Positive for fatigue, decreased appetite and po intake,
  increased abdominal girth as well as ab pain (now 10/10)
n Decreased BM’s and flatus
n Renal / Urinary specific
  ¡ Chronic foamy urine
  ¡ Positive bilateral renal carcinoma
  ¡ Decreased urinary output for past two days
  ¡ No recent OTC NAIDS
  ¡ No gross hematuria, known UTI’s, recent contrast or
      colonic prep, incontinence, bph, history of stones, need
      for any dialysis
    Outpatient Medications
n 1.Lisinopril / HCTZ 20 /12.5 one daily.
  2. Glyburide 5 mg twice a day.
  3. Neurontin 300 mg three times a day.
  4. Aspirin 81 mg daily.
  5. Multivitamin one p.o. daily.
  6. Lantus 50 units subcutaneous p.m plus sliding scale
  insulin
  7. Norvasc 10 mg daily.
  8. Coreg 25 mg twice a day.
  9. Plavix 75 mg daily.
  10.Crestor 20 mg p.o. every p.m.
  11.TriCor 145 mg daily
   Past Medical History
n 1. CKD 3 - baseline Cr 1.5-1.8
  2. Bilateral renal masses, worrisome for renal cell
  carcinoma
  3. Hypertension
  4. Coronary artery disease
  5. Hypercholesterolemia
  6. MI
  7. Peripheral vascular disease
  8. Diabetes mellitus, type 2, insulin requiring
  9. Tobacco abuse
    Patient History
n Past Surgical History
   ¡ 1. Right partial nephrectomy at OSU a week ago
      2. He has had heart catheterization with PTCA.
      3. Lipoma removal on the scalp.
      4. Left lower extremity angioplasty in 2006
n Allergies
   ¡ none
n SHx
   ¡ Only positive for tobacco abuse x 30yrs, but quit one week ago
n FHx
   ¡ No family members on HD or immediate family with cancers
   ¡ Positive family history of DM and HTN
    Important History
n Notably, the pt has a history of bilateral renal masses
  since April 2009
  ¡ Partial right nephrectomy at OSU last Monday
  ¡ Previous poor outpatient follow up since April 2009
      n Seen at Cassano Nephro only once in initial consult
      n Multiple phone calls to stress importance of timely follow up
    ER Physical Exam
n VS: BP 106/92- 92 HR, 96.7 F,15 RR, 95% on 2L oxygen
n Gen: Appears uncomfortable; no acute distress
n HEENT: Atraumatic, normocephalic. EOMI. Sclerae
  anicteric. Mucous membranes are dry
n CV: HRR without murmur, rub, click, or gallop. S1, S2
n Pulm: CTAB without wheezing,rhonchi, or crackles
n Ab: Distended. Positive bowel sounds. He does have lap
  trocar insertion site with mild erythema, and his belly has
  voluntary guarding.
n Ext: No clubbing, cyanosis, or edema. No calf tenderness
  bilaterally. Distal peripheral pulses are 2/4. No Lindsay’s
  nails
n Neuro: There is no asterixis. CN 2-12 GI
     ER Initial Labs
n   134        88      49       172
     3.5       34      6.1

n   No Ca, Mg, Phos, UA

n   20.5   15.0      474
           46.3

n   Cr back in Oct 2009 = 1.5
   ER Initial Labs

n CT scan – without contrast
  ¡ high-grade small bowel obstruction at the level
    of the ventral hernia
  ¡ large amount of subcutaneous emphysema,
    small amount of retroperitoneal and
    smaller amount of intraperitoneal gas regional
    to the right kidney where there
    has been recent surgical intervention
   Cause of the Patient’s Acute Kidney Injury ?

n Multifactorial
  ¡ hypovolemia
     n Secondary to GI loss with nausea and vomiting
     n Poor po intake with outpatient diuretics (HCTZ)
  ¡ hypotension in the prescence of OP ACE-I
     n Bp 90/46 in ER
  ¡ rule out urinary obstruction
     n nurses unable to place Foley
       ¡ can bladder scan
    What is Acute Kidney Injury?

n An abrupt reduction in kidney function within
  48 hours
   ¡ absolute increase in serum creatinine of > 0.3 mg/dl
   ¡ a percentage increase of 50%
   ¡ a reduction in urine output
      n documented oliguria of < 0.5 ml/kg/hr for > 6 hours
n realize that acute kidney injury may be a precursor to
  CKD, and CKD can also lead to AKI
Stages of AKI
 Stage       Cr Criteria            Urine Output
                                       Criteria
  1      ↑ Serum Cr of >0.3       <0.5ml/kg/hr for > 6hr
         mg/dl or increase to
         ≥150% - 200% from
         baseline
  2      Increase serum           <0.5ml/kg/hr for >12
         creatinine to > 200%-    hrs
         300% from baseline

         Increase serum creatinine <0.3ml/kg/hr x 24 hrs
  3      to >300% from baseline
         (or serum creatinine
                                     or anuria x 12 hr
         ≥4.0mg/dl with an acute
         rise of at least 0.5 mg/dl)
AKI – RIFLE Criteria
    Initial Renal US Report May 2009

n Right kidney measures 11.04 x 7.25 x 7.25 cm
  ¡ no hydronephrosis seen
  ¡ 5.92 x 4.99 x 4.3 cm hypoechoic solid-appearing mass
     within the cortex of the superior pole
     n lesion demonstrates mildly increased flow
  ¡ also a 2.26 x 1.95 x 2.70 cm either complex cyst with
     septation or two small adjacent cysts within the inferior
     pole of the right kidney
n Left kidney measures 11.42 x 5.06 x 5.82 cm
  ¡ exophytic 1.9 x 1.5 x 1.7 cm hypoechoic solid-
     appearing mass at the superior pole of the left kidney
     with vascular flow
  ¡ no hydronephrosis
    Initial CT Scan Report May 2009

n 5.8 x 4.2 cm partially exophytic mixed attenuation lesion
  arising from the superior pole of the right kidney
  ¡ most consistent with renal cell carcinoma until proven
      otherwise.
n Small exophytic lesion in upper pole of the left kidney
  ¡ 19 mm in diameter
  ¡ given its vascularity on the recent ultrasound a solid
      lesion is suspected
Renal cell carcinoma
    Renal cell carcinoma
n originate within the renal cortex
  ¡ 80 to 85 % of all primary renal neoplasms
n transitional cell carcinomas
  ¡ renal pelvis are the next most common – 8%
n in 2009, approximately 57,800 people will be diagnosed
  ¡ 13,000 will die from RCC in the United States
  ¡ worldwide mortality exceeds 100,000 per year
n eighth most common cancer
n typically fourth to sixth decade of life
  Incidence rates are rising three
  times faster than mortality rates




n Survival has improved over time
  Renal cell carcinoma

n Risk factors
  ¡ Smoking- two fold increase
  ¡ Occupational exposure
    n cadmium, asbestos, and petroleum by-products
  ¡ Acquired cystic diseases of the kidney
    n 30 times greater in dialysis patients with acquired
      polycystic disease
    n malignancy typically after at least 8 -10 yrs of
      dialysis
  ¡ After transplant
   Renal cell carcinoma

n Risk factors
  ¡   PCKD- RCC often bilateral
  ¡   Alcohol
  ¡   Cytotoxic chemotherapy/ prior radiation
  ¡   Unopposed estrogen
  ¡   Uncontrolled hypertension
      Genetic factors: Von Hippel Lindau

n Autosomal dominant
n abnormalities in chr 3pq
n increased formation of vascular
  tumours (mostly benign) called
  hemangioblastomas and risk
  for renal carcinomas and
  pheochromocytomas
    Reed syndrome

n Multiple cutaneous and uterine leiomyomatosis
  syndrome
n hereditary leiomyoma and renal cell cancer syndrome
  ¡ characterized by cutaneous leiomyomas, uterine
     fibroids, and renal carcinomas
  ¡ renal tumors are aggressive
     n metastasize and death in patients in their 30s
  Renal Cell Carcinoma

¡ History
  n Often zero point zero clues
    ¡ Twenty-five to thirty percent of patients are asymptomatic
    ¡ found on incidental radiologic studies
  n Classic triad is not common – only 10%
    ¡   flank pain
    ¡   hematuria
    ¡   flank mass
    ¡   indicative of advanced disease
  Renal Cell Carcinoma

n History
  ¡   Weight loss (33%)
  ¡   Fever (20%)
  ¡   Hypertension (20%)
  ¡   Hypercalcemia (5%)
  ¡   Night sweats
  ¡   Malaise
  ¡   Varicocele
      n usually left sided, due to obstruction of the
        testicular vein (2% of males)
   Renal Cell Carcinoma
n Physical
  ¡   Gross hematuria
  ¡   Hypertension
  ¡   Supraclavicular adenopathy
  ¡   flank or abdominal mass with bruit
n 30% present with metastatic disease
  ¡ evaluation for metastatic disease
      n lung (75%)
n Varicocele and findings of paraneoplastic
  syndromes raise clinical suspicion for this
  diagnosis.
    Differential Diagnosis of RCC
n NHL                   n Renal adenoma –
n Pyelonephritis          benign
n Abscess               n Renal cyst
n Angiomyolipoma -      n Renal infarct
  benign                n Sarcoma
n Oncocytoma -benign    n Transitional cell
n Metastasis from         carcinoma of renal
  distant primary         pelvis
n Metastatic melanoma
   Renal cell carcinoma
n challenging tumor because paraneoplastic
  syndromes
  ¡ hypercalcemia
  ¡ erythrocytosis
  ¡ nonmetastatic hepatic dysfunction (Stauffer
    syndrome)
  ¡ polyneuromyopathy
  ¡ amyloidosis
  ¡ dermatomyositis
  ¡ hypertension
    Labs to consider
n   Urine analysis
n   CBC count with differential
n   Renal profile
n   Liver function tests (AST and ALT)
n   Calcium
n   Erythrocyte sedimentation rate
n   Prothrombin time
n   Activated partial thromboplastin time
   Imaging – often incidentally discovered


n CT scan
  ¡ imaging procedure of choice for diagnosis and
    staging
n Ultrasonography
n MRI
n PET
  ¡ mets
n Bone Scan
  ¡ Especially high alk phos
   Procedures and Subtypes of RCC

n Percutaneous cyst puncture and fluid analysis
  ¡ 5 histologic subtypes of rcc
     n   clear cell (75%)
     n   chromophilic (15%)
     n   chromophobic (5%)
     n   oncocytoma (3%)
     n   collecting duct (2%)
         ¡ very aggressive,often younger pts
   Staging of RCC
n Robson modification of the Flocks and
  Kadesky system
  ¡ Stage I - Tumor confined within capsule of kidney
  ¡ Stage II - Tumor invading perinephric fat but still
    contained within the Gerota fascia
  ¡ Stage III - Tumor invading the renal vein or inferior
    vena cava (A), or regional lymph-node involvement
    (B), or both (C)
  ¡ Stage IV - Tumor invading adjacent viscera
    (excluding ipsilateral adrenal) or distant
    metastases
Robson staging system
   Treatment

n probability of cure is related directly to the
  stage
n more than 50% of patients with renal cell
  carcinoma are cured in early stages
    Surgical treatment of RCC
n Surgery is curative in the majority of patients
  without metastatic RCC
n Preferred treatment for patients with stages I, II,
  and III disease
n Also used for palliation in metastatic disease
n Radical nephrectomy
  ¡ most commonly performed standard surgical procedure
    today
  ¡ complete removal of the Gerota fascia and its contents,
    including a resection of kidney, perirenal fat, and
    ipsilateral adrenal gland, with or without ipsilateral
    lymph node dissection
  Surgical treatment of RCC

n Laparoscopic nephrectomy
  ¡ Advantages
    n less invasive procedure, incurs less morbidity, and
      is associated with shorter recovery time and less
      blood loss
  ¡ Disadvantages
    n concerns about spillage and technical difficulties in
      defining surgical margins
    Treatment of RCC
n no hormonal or chemotherapeutic regimen is accepted as
  a standard of care
n options are surgery, radiation therapy, chemotherapy,
  hormonal therapy, immunotherapy, or combinations of
  these
n IL-2-T-cell growth factor and activator and natural killer
  cells
n Interferon alpha
n Sutent-Sunitinib
   ¡ multi-kinase inhibitor
   ¡ high response rate (40% )
n Sorafenib –Nexavar
   ¡   kinase and vascular endothelial growth factor (VEGF)
       multireceptor kinase inhibitor
       n   advanced renal cell carcinoma
   Treatment

n For previously untreated patients
  ¡ low or intermediate risk
  ¡ sunitinib or the combination of bevacizumab
    and interferon alpha
   Treatment Recommendations
n Radical nephrectomy
  ¡ most widely used approach
  ¡ preferred procedure when there is evidence of invasion
    into the adrenal, renal vein, or perinephric fat
n Partial nephrectomy
  ¡ for smaller tumors
  ¡ particularly valuable in patients with bilateral or multiple
    lesions
  ¡ If renal dysfxn
n Elderly patients with significant comorbid disease
  ¡ increases the risk of surgery
  ¡ ablative techniques
     n cryoablation, radiofrequency ablation
   What happened to the patient?

n Ordered records from OSU
  ¡ Cr post op was 2.5
n Did not required sx for incercerated hernia
  ¡ Reduced at bedside
n Aggressive IVF hydration
n Cr improved daily
  ¡ Peak Cr 6.1 11/16
  ¡ 5.27        3.76          3.27      3.16
  Learning Points

n Stages of CKD
Renal Cell Carcinoma Learning Points

¡ History
  n Often zero point zero clues
    ¡ Twenty-five to thirty percent of patients are asymptomatic
    ¡ found on incidental radiologic studies
  n Classic triad is not common – only 10%
    ¡   flank pain
    ¡   hematuria
    ¡   flank mass
    ¡   indicative of advanced disease
   Learning Points: Renal Cell Carcinoma

n About 25-30% of patients have metastatic
  disease at diagnosis
n fewer than 5% have solitary metastasis
n surgical resection is recommended in
  selected patients with metastatic renal
  carcinoma
Thank You ;)
n Resources
  ¡ Up to date
  ¡ http://emedicine.medscape.com/article/281340-
    treatment

								
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