HJNO Mar/Apr 2024

54 MAR / APR 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS ONCOLOGY DIAL GUE COLUMN ONCOLOGY Introduction Renal cell carcinomas (RCC), which originate within the renal cortex, constitute 80-85% of primary renal neoplasms. Other parenchy- mal epithelial tumors, such as oncocytomas, collecting duct tumors, and renal sarcomas, are rare. Nephroblastoma or Wilms tumor is common in children (5-6% of all primary renal tumors). Clinical manifestations Patients with RCC can present with a range of symptoms; unfortunately, many patients are asymptomatic until the disease is ad- vanced. At presentation, approximately 25% of individuals either have distant metastases or advanced locoregional disease. The clas- sic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in, at most, 9% of patients; when present, it strongly suggests locally advanced disease. Among patients with disseminated disease, signs or symptoms may be due to metastatic tumor; the most common sites of involve- ment include the lungs, lymph nodes, bone, liver, and brain. Hypercalcemia occurs in up to 15% of patients with advanced RCC. As with other tumors, patients with RCC may suffer from significant cachexia. Hepatic dysfunction is an uncommon occurrence in patients with RCC, which is called Stauffer syndrome when it occurs in the absence of liver metastases. Patients with RCC can present with or sub- sequently develop systemic symptoms or paraneoplastic syndromes. Special populations Patients with Von Hippel-Lindau (VHL) disease are at risk for developing RCC due to molecular alterations in the VHL gene. Other hereditary syndromes are also associated with development of RCC, such as polycystic kidney disease and hereditary leiomyomato- sis and renal cell carcinoma (HLRCC). Diagnostic evaluation Patients with unexplained hematuria or other symptoms, signs, or findings sugges- tive of possible RCC must undergo imaging evaluation for the presence of a renal mass. Incidental diagnosis of RCC is becoming more common due to the frequent use of abdominal computed tomography (CT) and/ or ultrasonography for evaluation of an unre- lated problem. The usual first test is abdomi- nal CT. Magnetic resonance imaging (MRI) may be useful when ultrasonography and/or CT are inconclusive or if iodinated contrast cannot be administered because of allergy or poor renal function. OVERV I EW OF Kidney Cancer Tissue diagnosis After the presumptive diagnosis has been made based upon imaging studies, the pa- tient must be evaluated for the extent of local involvement and the presence of metastatic disease prior to surgery. For patients with isolated solid renal masses, resection with either a partial or complete nephrectomy is preferred over biopsy because it provides the diagnosis, pathologic tumor (T) and nodal (N) staging, and definitive treatment. Preopera- tive needle biopsies are usually not used for resectable renal lesions because of their low specificity and concerns about tumor seeding of the peritoneum. Nephrectomy or partial nephrectomy is used in most cases to obtain tissue for diagnosis of RCC prior to treatment, although the diagnosis of RCC is occasion- ally established by a biopsy of a metastasis. Staging studies The extent of local and regional involve- ment is determined primarily by abdominal CT, which is extremely accurate in staging RCC. Other imaging studies that may be useful for assessing for distant metastases