Renal cell carcinoma

Renal cancer (malignant renal tumors) is relatively low (1 to 2% of all malignant tumors). The most common is renal cell carcinoma (synonyms: hypernephroma, Grawitz tumor), which by the proximal tubule cells ( epithelial cells) emanates. It affects about nine out of every 100,000 inhabitants, where Men are affected three times more often than women. Mostly occurs renal cell carcinoma on the fifth and sixth decade of life.

Risk factors include advanced age, smoking, chronic renal failure, long-term analgesic therapy, exposure to trichlorethylene, cadmium and lead exposure and congenital kidney disease ( tuberous sclerosis, von Hippel- Lindau).

Classification

Renal cancer in the strict sense refers to malignancies that arise from the functional tissue of the kidney ( renal parenchyma ). In principle, malignant transformation can occur at each stage of a nephron.

These types of kidney tumors are also known as renal cell carcinomas ( NCC). A distinction is made according to the tissue of origin, the cytogenetic findings and the histological picture. Most often you will find the conventional renal cell carcinoma, which is often referred to as clear cell. Furthermore, find the chromophilic ( papillary ), the chromophobe and least often the ductus Bellini carcinoma ( collecting duct carcinoma). The latter is distinguished by special aggressiveness. The growth pattern of these tumors is mentioned. Tumorzytogenetisch chromosomal aberrations are described ( chromosome aberrations ). The cells of conventional renal cell carcinoma show, for example, early in the development process a fragment loss on chromosome 3

Type of cancer

Growth pattern

Origin

Cytogenetics

Clear cell carcinoma

Azinös, sarcomatoid

Proximal tubule

Papillary carcinoma basophil - type - eosinophilic type

Papillary, tubular design

Proximal tubule

7, 17 ,-Y

Chromophobe carcinoma

Solid, tubular design, sarcomatoid

Sammeltubulus ( cortical )

Hypodiploidie

Onkozytäres carcinoma

Tumor nests

Sammeltubulus ( cortical )

Ductus Bellini carcinoma

Papillary, sarcomatoid

Sammeltubulus ( medullary )

In a broader sense is meant by renal cancer and malignant diseases which, although arising in the kidney, but not spring from the function of the kidney tissue. These is the renal pelvis carcinoma ( transitional cell carcinoma of the renal pelvis ). This is a tumor that arises from the transitional tissues ( urothelium ) in the adjacent urinary tract. Of particular importance also is the nephroblastoma ( Wilms' tumor). This is an embryonic mixed tumor, which plays a significant role in pediatrics. Other malignant processes in the kidney may be caused by metastases (lung cancer, breast cancer, malignant melanoma) and separated by sarcomas.

Symptoms

The classic triad of blood in the urine ( hematuria), flank pain and a palpable tumor in the flank are found only rarely. If the tumor invades the left renal vein, a symptomatic varicocele can be the man in the left testicle form (1% of cases). Furthermore, paraneoplastic syndromes occur rarely ( formed by the tumor cells, hormones, such as renin, erythropoietin, parathyroid hormone or ACTH). As with most cancers can general symptoms such as fatigue, fever and weight loss may occur. 70 % of renal tumors are found by chance in the context of imaging studies ( ultrasonography, computed tomography, etc.). This has led in the past two decades, a so-called "stage shift": There are more and more frequently found small non-symptomatic tumors in the kidneys, which can thus be treated better.

Diagnosis

On clinical examination, only large, advanced tumors in the abdomen to fall. The laboratory examination may show a caused by the loss of blood in the urine anemia. Sonography is the first step to more accurate assessment of the kidney. With their help, also punctures suspicious lesions can be made in the kidney, which are then evaluated by the pathologist histologically. An intravenous urography is an x-ray with contrast medium nierengängigem, can provide insights about a disabled urine flow and can assess the function of the healthy kidney. To determine the spread of the tumor (staging), and thus the operability, a computed tomography of the abdomen is carried out. With radiographs of the chest (thorax ) and possibly a bone scan and a brain MRI ( magnetic resonance ) can be detected possible distant metastases. It is worth mentioning that by radiography can detect metastases from 1 cm in diameter, which computed a clear preference.

Therapy

The treatment of choice in case of a non-metastatic renal cell carcinoma is surgical removal of the tumor, which recent studies have shown that the long-term oncological results in kidney -preserving removal of the kidney tumor ( if operationally possible and useful) are just as good as the radical removal of the kidney.

For larger tumors ( stage T2 to T4 ), the whole kidney with adrenal gland, ureter, and the surrounding adipose tissue and capsule surgically removed. In the renal vein and inferior vena cava tumor grown pins must be resected, possibly with the use of a heart -lung machine during outgrowth into the right atrium. Other standards are by the latest findings in Talk: collection of laparoscopic radical nephrectomy and kidney -preserving partial resection; is the adrenalectomy always necessary? ; kidney -preserving surgery even with two healthy kidneys, minimally invasive treatment alternatives ( RITA - Radio Frequency interstitial tumor ablation, HIFU - High -intensity focused ultrasound, etc.).

In the case of renal cell carcinoma have in recent years in the relevant scientific studies approaches to adjuvant therapy, eg cytokine -based immunotherapy, often disappointed. Due to strong side effects kompliante a systemic immunotherapy is very stressful for the patient and thus restricted to a small, reasonably physically robust patient circuit and accordingly experienced treatment centers. In the U.S. there approved high- dose bolus interleukin -2 therapy nevertheless still regarded as the treatment of choice for eligible patients when a potential cure is the goal, as a long-term tumor response can be achieved.

A study published in autumn 2007 review article describes the adjuvant administration of an autologous tumor vaccine. The vaccine produced from the body's own tumor cells of the patient has improved statistically clearly the period of progression- free survival and overall survival in renal cancer patients in phase III studies. The innovative method of therapy was introduced in 2004 in the journal The Lancet as promising.

In the treatment of metastatic renal cell carcinoma has occurred since the 2007 ASCO meeting, a paradigm shift. Six new substances are now approved for the therapy: sunitinib, pazopanib, sorafenib, temsirolimus, bevacizumab and everolimus. They act anti-angiogenesis, that is, they prevent disturbance in the signal transduction of growth factors, the growth of blood vessels that feed the tumor.

The approved angiogenesis inhibitors have indeed shown in randomized controlled trials for the European approval generally a statistically significant prolongation of progression-free survival, only in individual cases, but this has translated into an increase in overall survival. Curative potential, for example in the form of long-lasting complete remissions of metastases, as they have been reported with high-dose immunotherapy in appropriate patients, has not yet confirmed for these new agents.

For more substances from the group of tyrosine kinase inhibitors are currently in clinical trials ( Cediranib ).

Forecast

The 5- year survival rate of renal cell carcinoma is a total of about 50%.

Depending stages:

Localized (T1 -T2, N0, M0): 70-80 %
Locally advanced ( T3, N0 -N2, M0): 20-60 %
Distant metastases ( any T, any N, M1): <10 %

Paul Grawitz Epithelium Tobacco smoking Wilms' tumor Adrenocorticotropic hormone Digital Object Identifier

405190