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Characteristically, patients with renal cell
carcinomas remain relatively asymptomatic through the early and intermediate stages of the
tumors natural history. The most
common clinical manifestations are hematuria, flank pain, anemia, fever, and other
constitutional symptoms, such as weight loss and anorexia. Laboratory findings may include
erythrocytosis and those related to metastatic disease. Radiologically, the tumor may be
detected by a CT scan and may require angiography to determine vascular patterns and the
presence of invasion (venography is frequently used to determine renal vein and vena caval
extension). Excretory urography may provide important information regarding the functional
status of the contralateral kidney. Depending on the appearance of the tumor in the
radiographic studies, a needle biopsy (CT-guided) may be necessary for diagnosis and
therapeutic planning. The TNM classification is usually used , which accounts for tumor
size, depending on the extent and size of the primary tumor (T0 to T4); nodal involvement,
including perinephric or hilar (N0 to N4); vascular invasion (renal vein or vena cava [V1
or V2]); and distant metastasis (M0, M1). Distant metastatic involvement includes lung
(75%), soft tissues (30%), bones (20%), liver (20%), and skin and brain (5% to 10%). |
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Treatment |
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The only curative treatment of renal cell
carcinoma is surgical; however, approximately 30% of patients present with evidence of
metastatic disease at the time of diagnosis. Radical nephrectomy, usually through a flank
incision, involves a complete removal of the kidney and adrenal gland. The prognosis
depends on TNM staging, varying from approximately 60% to 70% survival rates for localized
noninvasive tumors to 5% or less 5-year survival rates for those with M disease. The
indications for a nephrectomy for patients with M1 disease include intractable pain and
severe bleeding. Anecdotal, usually retrospective reviews have suggested a spontaneous
remission of metastatic disease after a nephrectomy for patients with M1 disease; however,
the incidence of such an event is probably lower than the rate of surgical morbidity and
mortality. |
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Various systemic treatments have been used for
this disease, including standard chemotherapy and biologic response modifiers. Clinical
benefits are uncommon, and the impact on disease control rates and survival is minimal at
best. This tumor is usually relatively radioresistant, and radiation therapy is mostly
used for palliative purposes (pain control, brain metastasis). |
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