Kidney Cancer

1. Kidney Cancer Presented by: Trisha Allen Sonya Derakhshan Amy Hedrick Roya Momtazzadeh

2. INCIDENCE • In the United States it will be estimated that over 54,390 new cases of kidney cancer will be diagnosed in the year 2008 with about 13, 010 people dying from kidney cancer. • The most common type is the kidney cancer is called renal cell carcinoma (adenocarcinoma). It accounts for more than 9 out of 10 cases. • Renal cell carcinoma (adenocarcinoma) occurs twice as often in men as in women typically from 50 to 70 years old.

3. Types of Kidney Cancer Like all cancers, kidney cancer begins small and grows larger over time. It usually grows as a single mass within the kidney. But a kidney can have more than one tumor. Sometimes tumors are found in both kidneys at the same time. The cancer might be found only after it has become very large. Most of the time it is found before it has spread to other organs through the bloodstream. This is good because like most cancers, kidney cancer can be hard to treat after it has spread (metastasized). There are several subtypes of RCC, based mainly on how the cancer cells look under a microscope: • Clear Cell RCCThis is the most common form of renal cell carcinoma. About 8 out of 10 people with RCC have this kind of cancer. When seen under a microscope, the cells that make up clear cell RCC look very pale or clear. • Papillary RCCThis is the second most common subtype -- about 10% to 15% of people have this kind. These cancers form little finger-like projections (called papillae) in some, if not most, of the tumor. Some doctors call these cancers chromophilic because the cells take up certain dyes used to prepare the tissue to be looked at under the microscope. The dyes make them look pink.

4. Types of Kidney CancerCont’d. • Chromophobe RCCThis subtype accounts for about 5% of RCCs. The cells of these cancers are also pale, like the clear cells, but are much larger and differ in other ways, too. • Collecting Duct RCCThis subtype is very rare. The major feature is that the cancer cells can form irregular tubes. Unclassified RCC In rare cases, renal cell cancers are labeled as "unclassified" because they don't fit into any of the other categories or because more than one type of cell is present.

5. RISK FACTORS • Age Your risk of renal cell carcinoma increases as you age. Renal cell carcinoma occurs most commonly in people 60 and older • Sex Men are more likely to develop renal cell carcinoma than women are. • SmokingSmokers have a greater risk of renal cell carcinoma than nonsmokers do. The risk increases the longer you smoke and decreases after you quit. • Obesity People who are obese have a higher risk of renal cell carcinoma than do people who are considered average weight. • High blood pressure (hypertension)High blood pressure increases your risk of renal cell carcinoma, but it isn't clear why. Some research in animals has linked high blood pressure medications to an increased risk of kidney cancer, but studies in people have had conflicting results.

6. RISK FACTORSCont’d. • Chemicals in your workplace Workers who are exposed to certain chemicals on the job may have a higher risk of renal cell carcinoma. People who work with chemicals such as asbestos, cadmium and trichloroethylene may have an increased risk of kidney cancer. • Treatment for kidney failure People who receive long-term dialysis to treat chronic kidney failure have a greater risk of developing kidney cancer. People who have a kidney transplant and receive immunosuppressant drugs also are more likely to develop kidney cancer. • Von Hippel-Lindau disease People with this inherited disorder are likely to develop several kinds of tumors, including, in some cases, renal cell carcinoma. • Hereditary papillary renal cell carcinoma Having this inherited condition makes it more likely you'll develop one or more renal cell carcinomas. • Transitional cell carcinoma risk factors

7. CLINICAL MANIFESTATIONS • Kidney cancer rarely causes signs or symptoms in its early stages. In the later stages, kidney cancer signs and symptoms may include: • Blood in your urine, which may appear pink, red or cola-colored • Back pain just below the ribs that doesn't go away • Weight loss • Fatigue • Intermittent fever • A palpable mass in the flank or abdomen • Hypertension • Anemia • 30% of patients have metastasis at the time of diagnosis. Common sites include lungs, liver, long bones.

8. Diagnosis • Physical exam: The doctor checks general signs of health and tests for fever and high blood pressure. The doctor also feels the abdomen and side for tumors. • Urine tests: Urine is checked for blood and other signs of disease. • Blood tests: The lab checks the blood to see how well the kidneys are working. The lab may check the level of several substances, such as creatinine. A high level of creatinine may mean the kidneys are not doing their job. • Intravebous Pyelogram(IVP): The doctor injects dye into a vein in the arm. The dye travels through the body and collects in the kidneys. The dye makes them show up on x-rays. A series of x-rays then tracks the dye as it moves through the kidneys to the ureters and bladder. The x-rays can show a kidney tumor or other problems.

9. DiagnosisCont’d. • CT scan (CAT scan): An x-ray machine linked to a computer takes a series of detailed pictures of the kidneys. The patient may receive an injection of dye so the kidneys show up clearly in the pictures. A CT Scan can show a kidney tumor. • Ultrasound test: The ultra sound device uses sound waves that people cannot hear. The waves bounce off the kidneys, and a computer uses the echoes to create a picture called a sonogram. A solid tumor or cyst shows up on a sonogram. • Biopsy: In some cases, the doctor may do a biopsy. A biopsy is the removal of tissue to look for cancer cells. The doctor inserts a thin needle through the skin into the kidney to remove a small amount of tissue. The doctor may use ultrasound or x-rays to guide the needle. A pathologist uses a microscope to look for cancer cells in the tissue. • Surgery: In most cases, based on the results of the CT scan, ultrasound, and x-rays, the doctor has enough information to recommend surgery to remove part or all of the kidney. A pathologist makes the final diagnosis by examining the tissue under a microscope.

10. Robson’s System of Staging Renal Carcinoma StageDescription I Limitation to renal capsule II Spreading to perirenal fat but confined within fascia; includes metastasis to adrenal gland III Regional lymph node involvement of renal vein or vena cava IV Presence of distant metastases

11. MEDICAL TREATMENTS Treatment is tailored to the circumstances of the patient's condition after thorough evaluation and discussion. Surgical removal of the entire kidney (radical nephrectomy) or a portion of the kidney (partial nephrectomy), or freeze-killing (cryoablation) or heat-killing (radiofrequency ablation) procedures are the more frequently recommended treatments. Surgery Partial Nephrectomy (Kidney-Sparing Surgery) Most kidney tumors today are detected by chance when a physician studies an MRI, CT scan, or abdominal ultrasound to investigate some other condition. Treatment of choice for stage I or II tumors and selected stage III tumors Radical NephrectomyThe traditional renal cell cancer treatment is the surgical removal of the diseased kidney and its neighboring adrenal gland (radical nephrectomy). The procedure became the standard when kidney cancer was rarely detected until it was relatively advanced. Diagnosis then usually came only after the development of symptoms such as flank pain, blood in the urine, or a mass or lump in the abdomen or flank.

12. MEDICAL TREATMENTS Cont’d. • Percutaneous Radiofrequency AblationIn radiofrequency ablation, ultrasound or CT imaging is used to guide a needle-like electrode through the skin into the tumor. Radiofrequency energy is then passed into the tip of the electrode, resulting in very high temperatures in the surrounding tumor. The tumor is destroyed over the course of 5 to 15 minutes, depending on the tumor's size and location. • Radiation Therapy • Radiation therapy is reserved for patients in whom the goal of therapy is only to relieve or diminish the symptoms of the disease, as it is not an effective alternative to surgery. • Experimental Drug Therapies • Experts still consider bone marrow transplant for kidney cancer to be experimental. • Treatment of Metastatic Disease • Treatment options may include immotherapy agents such as interferon or interleukin-2. Chemotherapy using 5-fluorouracil (5-FU0, flosuridine (FUDR), and gemcitbine (Gemzar) is used. However, renal cell carcinoma is refractory to most chemotherapy drugs. Target therapy, including sunitinib (Sutent) and sorafenib (Nexavar) work at multiple targets to deprive tumor cells of the blood and nutrients needed for growth. Physicians develop individualized treatment plan that treats the cancer, manages pain and promotes quality of life.

13. Laparoscopic Nephrectomy A laparoscopic nephrectomy is perfomed using five puncture sites. One incision is to view the kidney and another is to dissect it. The laparoscope contains a miniature camera so that the surgeons can watch what they are doing on a video monitor. Once dissected, the kidney is maneuvered in a nylon impermeable sack, and its contents can then be safely removed from the patient. This procedure is less painful and requires no sutures or staples which has a faster recovery and shorter hospital stay.

14. Nursing Management Assessment Subjective data – Patient history of blood in urine – when occurs, any pain Advanced stages – any wgt. Loss, fatigue, dull flank pain Objective data – PE – mass in pt’s flank area, hematuria, Nursing Diagnoses Acute painrt invading structures near or within the kidney – repositition for comfort, admin pain meds Ineffective coping rt powerlessness – encourage pts to express feelings Impaired physical mobility rt pain/discomfort – admin pain meds before activity, encourage active/passive ROM exercises Tons more

15. Treatment of choice - Radical Nephrectomy Nursing Intervention – Preoperative care • Adequate fluid intake and a normal electrolyte balance • Educate pt. there will be a flank incision on the affected side and that during surgery the pt will be put in a hyperextended , side-lying position which will cause the pt to experience muscle aches after surgery. • Assure pt that one working kidney is sufficient to maintain normal renal function

16. Treatment of choice - Radical Nephrectomy Postoperative care • Urine output should be monitored every 1 to 2 hrs. Total urine output should be at least 0.5 ml/kg/hr. Observe color/consistency – increased amounts of mucus, blood, or sediment may occlude the drainage tubing or catheter. Important to assess dressing for urine drainage and to estimate amount. Do not clamp catheter or tubing without specific order • Respiratory - Incision is just below diaphragm and often involves removing 12th rib. Promote adequate ventilation - Admin pain med before breathing exercises, Turn, cough, deep breath, IS q 2hrs, early ambulation. • Abdominal Distention – usually present. Oral intake is restricted until bowel sounds are present (usually 24 to 48 hrs after surgery). IV fluids continued till oral fluids are taken. Progress to a regular diet