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02.17 Kidney Cancer

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Overview

  1. Kidney A & P
    1. Pair of bean-shaped organs at the back of the abdomen
    2. Adrenal glands sit on top of the kidneys
    3. Function
      1. Get rids of excess salt, water, and waste
      2. BP control → Renin release → RAAS system
      3. Erythropoietin release → RBC creation
    4. We can live with only one kidney
    5. If both kidneys fail → dialysis
  2. Cancer of the kidney
    1. Detected from imaging → sometimes accidentally
    2. Renal cell carcinoma (RCC) is the most common
      1. Multiple types of RCC
      2. Clear-cell RCC is most often seen
      3. Non-Clear Cell RCC being studied extensively
    3. Other types of kidney cancer
      1. Urothelial Carcinoma
      2. Squamous cell carcinoma
      3. Adenocarcinomas
      4. Renal sarcomas
      5. Wilms’ Tumor or nephroblastoma
        1. Occurs in children
        2. See Nursing.com lesson- Nephroblastoma
    4. Staged with TNM → tumor size, lymph node involvement, and metastasis
    5. Graded based on cell differentiation
      1. Grade 1
        1. Cells similar to kidney cells
        2. Better outcomes
      2. Grade 4
        1. Cells not differentiated
        2. Worse outcomes
    6. Good outcomes if caught early
      1. 92% 5-year survival with local disease
      2. 12% 5- year survival with distant spread

Nursing Points

General

  1. Etiology and risk factors
    1. Non-modifiable → patients cannot change
      1. Age → average age 64
      2. Gender → Males get RCC twice as much as females
      3. Race → African Americans more susceptible
      4. Genetics → related to family history and some genetic disorders → these patients might be screened periodically but there is no routine screening for others
      5. Hemodialysis → risk of acquired cystic disease that is linked to RCC
    2. Modifiable → patients can change
      1. SMOKING → like bladder cancer, this has a direct link and the more you smoke the higher your risk is
      2. Obesity → this is thought to be linked to a hormone imbalance with obesity
      3. Chemical exposure → trichloroethylene (TCE), uranium, and cadmium has shown to lead to cellular changes leading to RCC

Assessment

  1. Symptoms of RCC
    1. No symptoms early in disease → often accidentally found in other imaging studies
    2. The classic triad of symptoms in later stages only about 25% of cases see this → related to damaged kidney cells and tumor growth
      1. Hematuria → Blood in the urine
      2. Flank pain
      3. Palpable flank mass
    3. With advanced disease
      1. Fever
        1. Body’s immune activation
      2. Loss of appetite and weight loss
        1. From cancer cells competing for nutrients
      3. Anemia and fatigue
        1. From the failure of erythropoietin production or bleeding
      4. Bone pain
        1. If cancer has spread to the bones
      5. Lymphadenopathy
        1. Enlarged lymph nodes if it has spread to the lymph system
      6. Varicocele → enlarged veins of the scrotum from obstruction of testicular vein

Therapeutic Management

  1. Surgery →  #1 treatment for local disease → can cure cancer alone
    1. Nephrectomy- removal of a kidney or part of a kidney
      1. Radical nephrectomy → open, laparoscopic, or robot-guided
        1. Removed kidney, lymph nodes, adrenal gland, and fatty tissue around the kidney
      2. Partial nephrectomy → nephron-sparing
        1. Removed part of the kidney and tumor
        2. Favorable but not an option in advanced disease or if the tumor is in the center
      3. After the loss of a kidney I/O and lab monitoring very important
    2. Metastasectomy → remove the tumor from the area it has metastasized to
    3. Ablative treatment → If stage 1 but not a surgical candidate
      1. Cryotherapy → freezes the tumor to kill the cells
      2. Radiofrequency ablation → high energy to burn the cells
  2. Immunotherapy → Used to boost the patient’s own immune system
    1. Checkpoint inhibitors
      1. Block proteins on tumors that protect the cancer cells from being destroyed
      2. Example → Pembrolizumab → Keytruda → tons of commercials about this right now
    2. Cytokines
      1. Interleukin-2
        1. Activates functions of the immune system including natural killer cells and T-cells
        2. High dose is given in ICU because of extreme side effects → capillary leak syndrome → fluid rapidly escaping from the vasculature
        3. Lose dose given as injections in the clinic
      2. Interferon → is given in combination to enhance immune system activation
  3. Targeted therapy → Many options
    1. Tyrosine kinase inhibitors
      1. Block a protein that cancer cells need to survive
    2. Anti-VEGF antibodies
      1. Block the ability for cancer cells to grow new blood supply
    3. A common side effect is high BP → linked to good tumor response
  4. Radiation → mostly is given to treat areas of metastasis
  5. Chemotherapy
    1. Not a typical treatment because RCC doesn’t typically respond well
    2. Given if other treatments fail or in conjunction with other treatments

Nursing Concepts

  1. Cellular regulation
    1. Disruption in DNA
  2. Elimination
    1. Hematuria
  3. Fluid and electrolyte balance
    1. Strict I/Os after nephrectomy

Patient Education

  1. Smoking cessation
    1. Directly linked to kidney cancer
  2. Know risks for self and family
  3. Treatment specific
    1. Surgery
    2. Immunotherapy
    3. Targeted therapy
  4. Renal precautions after nephrectomy
    1. Monitor BP
    2. Monitor urine protein
    3. Healthy lifestyle

Reference Links

Study Tools

Video Transcript

Hi guys today, we’re going to be talking about kidney cancer and we’ll dive right in first talk about some normal function of the kidneys and what they are. So we all know we have two kidneys right there. These bean shaped organs, they have the adrenal glands on top of them and important about the kidneys is we can function with just one of them. Right? I have some friends or a friend rather who actually has only one kidney. Cause she donated one to someone who actually had kidney cancer. And she’s doing just fine with one kidney. Now, if both kidneys fail, then we’re going to end up with hemo dialysis, right? H D and it that’s important talking about kidney cancer because that can actually end up leading to kidney cancer. It’s a risk factor anyway, so that’s an important thing to mention there. 

Okay. And normal function. What does our kidney do for us? It filters it filters. So it gets rid of water, excess waste. And that’s why it’s really hard to treat kidney cancer with things like chemotherapy, because it just wants to filter out those toxins. Right. It doesn’t want to let them work in the kidneys. It just wants to get rid of them. Okay. Other normal function, blood pressure control and then red blood cell creation, red blood cell without erythropoietin. And then let’s talk about kidney cancer, some important things about kidney cancer. There’s a lot of facts and information in the outline. I’m just gonna highlight some of the most important things. Kidney cancer is often diagnosed with imaging. That’s actually for something else. So if you have like a really bad stomach ache or something, they might do an ultrasound, they might do a CT scan. 

And then they find out that there is a lesion or tumor on the kidney because there’s not really a lot of symptoms in early kidney cancer. So that’s kind of why we’ve seen an increase in kidney cancer because of the increase in imaging that we’re doing, especially in this country. Okay. And then also important things about kidney cancer, kidney cancer, conform in any of the cells within the kidney. The most common one is in the renal cell renal cell carcinoma. And that’s mostly what we’re going to be talking about here today in children, they can get a nefro blastoma or a wilms’ tumor, and there is a whole, there’s some.com lecture about that. Wilms tumor. So you can check that out. Now, if it is caught early, if we find this accidentally on a CT scan or an ultrasound, if, and if it’s caught early, we have a great prognosis of kidney cancer, because we can just remove the kidney, right? 

Because we can function with only one kidney. Now, if it has spread and we find it in later stages, kidney cancer is very hard to treat because it likes to filter everything out. Okay. Let’s talk about some risk factors of kidney cancer. Smoking is a huge risk factor for kidney cancer, and it actually matters how much you smoke. So it’s related. The more you smoke, the higher your risk is of kidney cancer. Obesity is related to kidney cancer, and they think that’s because of the change in hormone production with obesity, chemical exposure is also linked to kidney cancer. And these are heavy metals, specifically try Clore, ethylene, or TC. He has been linked to kidney cancer, and that’s mostly exposure to different jobs. Non-modifiable risk factors are ones that can not be changed. The average age of diagnosis of renal cell carcinoma is 64. 

Gender males actually get kidney cancers twice. As much as females race, African Americans are more susceptible to kidney cancer. So education about their risk is important. Genetics. If there are certain genetic mutations those have been linked to kidney cancers. So if people have these mutations, they can actually get screened with imaging, but there’s no typical screening routine screening for others just if they have certain genetic mutations. And then I mentioned before, dialysis can actually lead to renal cell carcinoma. First, acquired cystic disease happens, and then that leads to renal cell carcinoma. So there’s some talk about doing more screening for cancer with these haemodialysis patients symptoms. I talked about the fact that there’s none in early disease, so that’s why it’s caught accidentally often. Now, if we start to have symptoms, they have this classic triad, or we say there’s a classic triad, and that would be blood in the urine or hematuria flank pain.

Which would be in the right and the sides towards the back, and then a palpable flank mass. So we call this the classic triad of kidney cancer, but that actually only happens in 21st, 25% of patients often. There’s no, there’s no symptoms, especially in early disease, right? In advanced disease. We’re looking more at metastasis, the signs that we’ll see, but specific to kidney cancer, there can be a fever and that’s, if we’re activating our immune response  and then anemia is one specific to kidney cancer. And that’s because of that decreased red blood cell production, right? Cause our kidneys not making a Ray through a point and then one another one specific to kidney cancer, it’s called varicose seal this night, I knew of varicose veins, which it should  because it is related to the veins. We’re actually talking about a specific in large veins in the scrotum. 

And that is, I mean, obviously that’s in males that happens if we’re getting blood flow to the scrotum, but a tumor is impeding the flow back to the heart. So that’s specific to kidney cancer. The number one treatment for kidney cancer is to remove it. And that can be done by a nephrectomy or removal of the kidney. It can be partial, certainly in taking out a portion of the kidney  now would obviously be favorable, but it’s not an option always. Or it can be a radical nephrectomy. And that would be not only removal of the kidney, but also the adrenal gland in area around the kidney. And that’s  with more distant spread to the lymph nodes, lymph nodes are also removed here. Metastatic to me just means removal of metastatic sites. And then if someone is not a candidate for surgery, they might get an ablation of the tumor. 

And that can be done with cold through cryotherapy, which freezes the tumor to kill the cells or with heat. And that would be with radio frequency ablation. And that would burn the cells of the tumor. Now I mentioned that chemotherapy is very hard to use to treat kidney cancer because our body just wants to filter out those toxins, right? So immunotherapy is a big one for kidney cancer and that’s using our body’s own immune system or components of our own immune system. Checkpoint inhibitors can be used. Um, that’s a type of immune therapy and that would block proteins on tumors that usually protect the cancer cells from being destroyed or we’ll have cytokines. This is what I’m most familiar with.  Those can be interleukin or interferon. Interleukin two is a big one for kidney cancer. I L two, and this is a very high risk chemotherapy administration. 

These patients end up with an ICU admission to get this medication because there’s such a high risk of our immune system. It’s working really hard to kill the cancer, but then it’s also just hyperactive and it can damage our regular tissues also, and create this cytokine storm. So that’s what the risk would be with activating our immune system too much. Basically other treatments would be targeted therapy if they have certain genetic changes or for looking at targeting the blood cells that these cancers are growing radiation treatment. Usually that’s used for areas of metastasis and then chemotherapy I’ve mentioned before that that’s not a doesn’t typically respond well to chemo, but if nothing else is working, they’ll try chemo with other treatments. Also educating our patients. We need to talk to them about smoking cessation. Always. We need to talk to our patients about smoking cessation, right, but as directly linked to kidney cancer and then treatment specific, depending on what treatments they’re getting, we need to educate them about that. 

What are the risk factors that they have and then renal precautions. If they’ve had the kidney removed, they need to make sure they understand the precautions for the rest of their life concepts. We’re talking about here, cellular regulation, always right. Something went wrong in our cellular regulation to form cancer elimination. There’s going to be changes with elimination and also fluid and electrolyte balance. If our kidneys are not functioning. Okay. So some key points about kidney cancer, renal cell carcinoma is the most common type of kidney cancer and adults wilms’ tumor or nefro blastoma occurs in children. And you can check out the lesson about that. One surgery is the number one treatment for kidney cancer, and it can be a cure. And then immunotherapy works better than chemo because our kidneys like to filter out those toxins. All right, guys, we love you go out and be your best self today. And as always happy nursing.

 

 

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