1. Treatment Options for Renal Cell Carcinoma By: Anthony Jurayj

2. Outline Introduction Background Stages Studies Conclusion

3. What is Renal Cell Carcinoma Renal cell carcinoma (RCC) is usually a single mass or tumor found within one kidney or both kidneys, depending on the stage and severity. Often times RCC in one kidney is found before it can metastasize to both kidneys or nearby organs. Kidney cancer can be confirmed through several different tests including: abdominal CT, blood tests (CBC), as well as live imaging via ultrasound of abdomen and kidney. (Dugdale et al. 2012)

4. CT Abdomen and US

5. Risk Factors Although the exact cause is unknown, there are many risk factors that, when compounded, increase the likelihood of kidney cancer. Males between the ages of 50-70 Dialysis patient Any family history of the disease Hypertension Smoking Horseshoe kidney Polycystic kidney disease (Dugdale et al. 2012).

6. Symptoms Symptoms can include: abdominal pain and swelling back pain (CVA tenderness) blood in urine, which may appear pink, red or cola colored. swelling of veins around a testicle, flank pain weight loss Fatigue Intermittent fever Later, and more severe symptoms that can occur include excessive hair growth in females, pale skin, and vision problems.

7. Stages There are also four different stages of Renal Cell Cancer. In Stage I, the tumor is considered to be 7 centimeters or smaller and is found only in the kidney. In Stage II, the tumor is considered to be larger than 7 centimeters but is still only found in the kidney. In Stage III, the tumor can be any size and the cancer can be found in the kidney, in the main blood vessels or the layer of fatty tissue surrounding the kidney, or in 1 or more nearby lymph nodes. In Stage IV (the most severe stage) is where the cancer has spread beyond the layer of fatty tissue around the kidney and may be found in the adrenal gland above the kidney, the lymph nodes, in the lungs, liver, bones or even brain. (National Cancer Institute, 2012).

8. Stages (Cont.)

9. Treatment One of the more common treatment options for kidney cancer is a partial nephrectomy (PN) or radical nephrectomy (RN), which is the partial or entire removal of the kidney.

10. Treatment A study done by Zini et al. (2009) compared radical nephrectomy (RN) versus partial nephrectomy (PN) and its effect on overall and non-cancer mortality. They used a database which allowed them to compare 2198 PN patients and 7611 RN patients between 1988 and 2004. The study matched for age, year of surgery, tumor size and grade to address the effect of nephrectomy type on overall mortality and on non-cancer related mortality. They concluded that relative to PN, RN predisposed patients to an increase in overall mortality and non-cancer related death, and suggested PN whenever possible.

11. Treatment If a patient is able to undergo PN, there are two possible procedures: laparoscopic PN and the open PN. A study by Reifsnyder et al. (2012) compared complications between laparoscopic and open PN. The study analyzed 189 consecutive patients who had undergone PN for renal masses, and graded the 30- and 90-day complication rates. The author selected 107 patients that were subject to laparoscopic PN and 82 patients underwent open PN. The laparoscopic group indicated that surgical and hospitalization times were shorter, and estimated blood loss was lower. After 30 days, there were more overall complications in the open nephrectomy group, but more major complications in the laparoscopic group. The study concluded that laparoscopic partial nephrectomy has the advantage of decreased operative time, lower blood loss, and shorter hospital stay as compared to open nephrectomy, and complication rate in the laparoscopic group was similar to that of the open group. However, the study did indicate that a laparoscopic partial nephrectomy could only be conducted in favorable tumor characteristics, and is limited due to its specificity.

12. Treatment Sorafenib is a drug that has shown to prevents tumor spreading. A study conducted by Wang et al. (2012) demonstrated that high dose intermittent Sorafenib shows improved efficacy over conventional continuous dose in renal cell carcinoma. Renal cell carcinoma responds to agents that inhibit vascular endothelial growth factor pathway and Sorafenib is a multikinase inhibitor of vascular endothelial growth factor receptor. The vascular endothelial growth factor is effective at producing tumor responses and delaying free survival in patients with renal cell carcinoma. In this study, they gave Mice that were bearing xenographs derived from renal cell carcinoma different doses of Sorafenib. Groups received the conventional dose with both continuous therapy and intermittent therapy, and high dose with continuous therapy and intermittent therapy, totaling four different groups. The study resulted in tumors that were treated with high dose exhibited slowed tumor growth as compared to conventional dose, and high dose intermittent and continuous therapy proved to be more effective than conventional dose of intermittent or continuous therapy, reducing tumor size after MRI imaging. This study concluded that with modification of Sorafenib dosing, more specifically to a higher dosing, could improve protracted blood vessel growth activity.

13. Conclusion These studies indicate that there are many treatment options for patients with kidney cancer are safe and effective. Depending on the stage and type of kidney cancer, a PN is one of the more common treatment options with lower risks that still maintain good patient outcome and recovery. A variation of nephrectomy is also available, such as laparoscopic versus open, giving patients more options. Less evasive drugs like Sorafenib have the potential to help prevent the spread of malignant tumors, and eventually render the nephrectomy obsolete and outdated.

14. Cassie Hines Shoes Cancer Foundation

15. References Miller DC, Schonlau M, Litwin MS, et al. Renal and cardiovascular morbidity after partial and radical nephrectomy. Cancer. 2008. 1;112(3):511-20 National Cancer Institute. Renal Cancer Treatment. 2012. http://www.cancer.gov/cancertopics/pdq/treatment/renalcell/Patient/page2 http://www.cancer.gov/cancertopics/pdq/treatment/renalcell/Patient/page2 PubMed Health. A.D.A.M. Medical Encyclopedia. 2012 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001544/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001544/ Reifsnyder JE, Ramasamy R, Ng CK, et al. Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system. JSLS. 2012. 16(1): 38-44 Wang X, Zhang L, Goldberg SN, et al. High dose intermittent sorafenib shows improved efficacy over conventional continuous dose in renal cell carcinoma. J Transl Med. 2011. 9:220 Zini L, Perrotte P, Capitanio U, et al. Radical versus partial nephrectomy: effect on overall and noncancer mortality. Cancer. 2009. 1;115(7):1465-71.