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SOURCE

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Source: Walko CM, Crona DJ. Renal cell carcinoma. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146080440. Accessed March 7, 2017.

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DEFINITION

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  • Malignant tumor of kidney.

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ETIOLOGY

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  • Genetic factors contribute to 15% of cases of renal cell carcinoma (RCC); remaining 85% believed to be sporadic.

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PATHOPHYSIOLOGY

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  • Clear cell RCC

    • Predominant subtype responsible for most cases.

    • Affects proximal tubule.

    • Likely to metastasize.

    • Results from inactivation of von Hippel-Lindau (VHL) tumor suppressor gene on chromosome 3p24-25.

      • Leads to increased production of growth factors, including:

        • Vascular endothelial growth factor (VEGF)

        • Transforming growth factor (TGF)

        • Platelet-derived growth factor (PDGF), as well as others responsible for angiogenesis and cell growth.

  • Papillary RCC types 1 and 2

    • Occur in proximal tubule.

    • Account for 5–10% of RCC cases.

    • More favorable prognosis than clear cell.

      • Prognosis with type 1 better than type 2.

    • Associated with multiple genetic abnormalities.

  • Chromophore and oncocytoma subtypes.

    • Occur in intercalated cells of collecting system.

    • Account for 5–10% of RCC cases.

    • Associated with wide variety of chromosomal abnormalities.

    • Oncocytomas relatively benign and rarely metastasize.

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EPIDEMIOLOGY

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  • Fifth most common cancer in men; sixth most common in women.

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RISK FACTORS

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  • Smoking.

  • Obesity.

  • Hypertension.

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CLINICAL PRESENTATION

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  • Most cases diagnosed incidentally following computed tomography (CT) scans done for unrelated reasons.

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SIGNS AND SYMPTOMS
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  • Classic triad symptoms, seen in <10% of patients:

    • Flank pain.

    • Hematuria.

    • Palpable abdominal mass.

  • Other presenting symptoms are:

    • Fatigue.

    • Weight loss.

    • Anemia.

    • Hypertension.

    • Fever.

    • Lower extremity edema.

  • Metastatic disease symptoms:

    • Bone pain.

    • Adenopathy.

    • Pulmonary.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Results from biopsy.

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LABORATORY TESTS
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  • Complete blood count (CBC)

  • Metabolic panel.

  • Lactate dehydrogenase.

  • Coagulation profile.

  • Urinalysis.

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IMAGING
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  • CT: contrast and noncontrast of chest, abdomen, and pelvis or

  • MRI of chest, abdomen, and pelvis.

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DIAGNOSTIC PROCEDURES
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  • Biopsy of surgical specimen.

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STAGING
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  • Tumor staging utilizes TNM system.

  • Factors associated with prognosis include:

    • Positive surgical margins.

    • Metastatic spread.

    • Presence of sarcomatoid architecture.

    • Tumor subtype, grade, and stage.

      • Tumor stage most powerful prognostic indicator.

  • Memorial Sloan-Kettering Cancer Center (MSKCC) Prognostic Factors Model was developed for patients with metastatic disease.

    • Low risk: No poor prognostic risk factors present.

    • Intermediate risk: One or two factors.

    • High risk: ≥3 factors (Table 1)

  • These criteria used by clinicians to determine optimal therapy.

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Table Graphic Jump Location
TABLE 1.MSKCC Poor Prognostic Factors

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