Cancer of a kidney unites various options of malignant neoplastic transformation of renal fabric in the histologic plan. Renalny symptoms (pain, a gematuriya, opukholevidny education) and ekstrarenalny (general) manifestations are clinical signs of cancer of kidney. Diagnosis of cancer of kidney demands a careful all-clinical, laboratory, ultrasonic, radiological, tomographic, radio isotope trial of an urinary system. At cancer of a kidney the radical or expanded nefrektomiya is shown; immunotherapy, chemotherapy, targetny therapy.
Cancer of a kidney makes 2-3% of all oncological diseases, and in adult urology takes the 3rd place after a prostate cancer and cancer of a bladder. Mainly cancer of a kidney comes to light at patients of 40-60 years, at the same time at men statistically by 2-3 times more often than at women. According to modern views, cancer of a kidney is a polietiologichesky disease; its development can be caused by the most various factors and influences: genetic, hormonal, chemical, immunological, beam etc.
Kidney cancer reasons
According to modern data, cancer cases of a kidney are influenced by a number of factors. At kidney and cellular cancer at patients a certain type of mutations - a translocation of the 3rd and 11th chromosomes is revealed, and also the possibility of inheritance of predisposition to emergence of tumoral process (Gippelya-Lindau's disease) is proved. The reason of growth of all malignant tumors including kidney cancer, insufficiency of antineoplastic immune protection is (including DNA reparation enzymes, antioncogenes, natural killerny cages).
Tobacco smoking, abuse of greasy food, uncontrollable reception of analgetics, diuretichesky and hormonal medicines considerably increase risk of cancer cases of kidneys. The chronic renal failure and regular carrying out a hemodialysis, kidneys can lead nephrosclerosis developing against the background of diabetes, arterial hypertension, a nefrolitiaz, chronic pyelonephritis to developing of cancer of kidney.
Cancer of kidneys can be provoked by chemical impact on an organism (at contact with carcinogens - nitrosamines, cyclic hydrocarbons, asbestos, etc.), and also radiation. Development of cancer of kidney after earlier postponed trauma of body is possible.
Classification of cancer of kidney
Morphological options of cancer of kidney are extremely variable that explains existence of several histologic classifications. According to the histologic classification accepted by WHO carry to main types of malignant tumors of a kidney:
- Pochechnokletochny tumors (light-cellular carcinoma, tubulyarny carcinoma, medullary carcinoma, papillary carcinoma, granular and cellular carcinoma, etc.)
- Nefroblastichesky tumors (nefroblasty or Vilms's tumor)
- Mesenchymal tumors (leyomiosarky, angiosarky, rabdomiosarky, fibrous gistiotsitoma, osteosarcoma)
- Neuroendocrine tumors (, neuroblastoma)
- Germinogenny tumors (horiokartsiny)
The international TNM classification of 1997 is the general for different types of cancer of kidney (T - the size of primary tumor; N – prevalence on lymph nodes; M – metastasises in target organs).
- T1 – tumoral knot less than 7 cm, localization is limited to a kidney
- T1a – the size of tumoral knot is up to 4 cm
- T1b – the size of tumoral knot is from 4 to 7 cm
- T2 – tumoral knot more than 7 cm, localization is limited to a kidney
- The t3 – tumoral knot sprouts in okolopochechny cellulose, an adrenal gland, veins, however the invasion is limited to Gerot's fastion
- T3a – an invasion of paranefralny cellulose or an adrenal gland in borders of a fastion of Gerot
- T3b – germination of a renal or lower hollow vein is lower than a diaphragm
- T3c – germination of the lower hollow vein is higher than a diaphragm
- T4 – spread of a tumor out of limits of the kidney capsule with defeat of adjacent structures and target organs.
On existence/lack of metastatic knots at cancer the kidney can distinguish stages:
- N0 — signs of damage of lymph nodes do not come to light
- N1 — comes to light a kidney cancer metastasis in a single regionarny lymph node
- N2 — come to light kidney cancer metastasises in several regionarny lymph nodes
On existence/lack of the remote metastasises of cancer allocate to a kidney stages:
- M0 — the remote metastasises in bodies targets do not come to light
- M1 — the remote metastasises, as a rule, in lungs, a liver or bones come to light.
Kidney cancer symptoms
Kidney cancer at the small sizes of a tumor can proceed asymptomatically. The displays of cancer of kidney arising at patients differ in a variety, distinguish renalny and ekstrarenalny symptoms from them. The triad belongs to renalny symptoms of cancer of kidney: availability of blood in urine (gematuriya), pain in a waist and palpatorno the defined education on the party of defeat. Simultaneous emergence of all symptoms is characteristic of big tumors at the started process; at earlier stages two signs come to light one or more rare.
Gematuriya is a patognomonichny symptom of cancer of kidney, can appear once or periodically already at early stages of a disease. Gematuriya at cancer of a kidney can begin unexpectedly, without serious consequences at satisfactory general health, can be insignificant (mikrogematuriya) and total (makrogematuriya). Makrogematuriya results from injury of blood vessels at germination of a tumor in a kidney parenchyma, sdavleniya it intra renal veins. Allocation with urine of worm-shaped blood clots is followed by renal gripes. The expressed gematuriya at the started cancer of a kidney can lead to anemia, an obturation of a mochetochnik, a bladder tamponada blood clots and a sharp delay of urine.
Pains from defeat are a late symptom of cancer of kidney. They have the stupid, aching character and are caused by a sdavleniye of the nervous terminations at an internal invasion of a tumor and stretching of the kidney capsule. Cancer of a kidney is palpated generally at the third or fourth stages as dense, hilly education.
Carry to ekstrarenalny symptoms of cancer of kidney: paraneoplastic syndrome (weakness, loss of appetite and weight, perspiration, temperature increase, arterial hypertension), syndrome of a sdavleniye of the lower hollow vein (symptomatic to a varikotsela, hypostases of legs, expansion of hypodermic veins of a belly wall, thrombosis of deep veins of the lower extremities), Shtauffer's syndrome (liver dysfunction).
Temperature increase of a body at kidney cancer long, values more often subfebrilny, but sometimes – high febrilny, can fluctuate from normal amounts to raised. At early stages of cancer of kidney the hyperthermia is caused by immune reaction of an organism to tumoral anti-genes, on late – processes of a necrosis and inflammation.
Diverse clinical symptoms of cancer of kidney can be manifestation of metastasises of a tumor in surrounding fabrics and various bodies. Can be signs of metastasis of cancer of kidney: cough, a blood spitting (at damage of lungs), a pain syndrome, pathological changes (at bone metastasises), a severe headache, strengthening of neurologic symptomatology, constant neuralgia and radiculitises (damage of a brain), jaundice (at metastasises in a liver). Cancer of kidneys at children (Vilms's disease) is shown by increase in the size of body, increased fatigue, leanness, and also pains of various character.
Diagnosis of cancer of kidney
In diagnosis of cancer of kidney all-clinical, laboratory, ultrasonic, radiological and radio isotope trials are applied. Inspection at the doctor-urologist at cancer of a kidney includes collecting the anamnesis, the general survey, a palpation and percussion (Pasternatsky's symptom). By results of all-clinical inspection laboratory diagnostics of blood and urine (the general and biochemical analyses, a cytologic research) is appointed.
At cancer of a kidney changes of laboratory indicators of blood and urine come to light: anemia, increase in SOE, secondary , proteinuria and leykotsituriya, giperkaltsiyemiya, enzymatic shifts (increase in secretion of alkaline phosphatase, laktatdegidrogenaza). The increased secretion by a tumor of various biologically active agents (prostaglandins, tromboksan, an active form of vitamin D), hormones is observed (a renin, a paratgormon, insulin, HGCh).
At suspicion of cancer of a kidney the tool research is carried out: Ultrasonography of kidneys and abdominal organs, radio nuclide scanning, X-ray contrast urography, renalny angiography, KT of kidneys and MRT. Examination of a thorax and bones for identification of metastasis of cancer of kidney in lungs and bones of a basin is surely conducted.
Paramount value at the initial stage of diagnosis of cancer of kidney has ultrasonography which in the presence of a tumor reveals deformation of contours of body, heterogeneity of an echo signal because of presence of zones of a necrosis and hemorrhages, sharp absorption of ultrasound tumoral education. Under control of ultrasonography carry out the closed chreskozhny punktsionny biopsy of a kidney for an intake of tumoral material for a morphological research.
Radio nuclide scanning and nefrostsintigrafiya allow to find the focal changes characteristic of kidney cancer. Because of various absorption of gamma particles the normal kidney parenchyma and fabric of a tumor creates partial defect of the image of renal fabric or its total absence at total defeat.
The excretory urography and renalny angiography are carried out at the final stage of diagnosis of cancer of kidney. Signs of cancer defeat of a kidney parenchyma at urography is increase in the sizes of a kidney, deformation of its contours, defect of filling cup systems, a deviation of the top ureteralny department; according to the angiogram of kidneys - increase in diameter and shift of the main renal artery, a chaotic excess vaskulyarization of tumoral fabric, heterogeneity of a shadow of a tumor at its necrosis. The kidney angiography at cancer of a kidney helps to differentiate a true new growth from a cyst, to reveal a small tumor in a cortical layer, existence of metastasises in the next bodies and the second kidney, tumoral blood clot in a renal vein.
X-ray KT or MPT with contrast strengthening allows to find cancer of a kidney no more than 2 cm in size, to establish its structure and localization, depth of germination of a parenchyma, infiltration of paranefralny cellulose, tumoral thrombosis kidney and lower hollow veins. In the presence of the corresponding symptoms KT of abdominal organs, zabryushinny space, bones, lungs and a brain for the purpose of identification of the regionarny and remote metastasises of cancer of kidney is carried out. Cancer of a kidney is differentiated with a solitary cyst of a kidney, an urolithic disease, gidronefrozy, nefrolitiazy, abscess and tuberculosis of a kidney, with tumors of an adrenal gland and extra organ zabryushinny tumors.
Cancer therapy of a kidney
Expeditious treatment is the main and most effective method in most cases of kidney cancer, is applied even at the regionarny and remote metastasises and allows to increase the term of survival and quality of life of patients. At cancer removal of a kidney (a radical and expanded nefrektomiya) and a kidney resection are carried out. The choice of medical approach is defined by kidney cancer option, the size and localization of the tumor predicted by survival of the patient.
The resection of a kidney is carried out for the purpose of preservation of body at patients with a local form of cancer and tumor less than 4 cm in size in a case: only kidney, bilateral tumoral process, dysfunction of the second kidney. During a resection of a kidney carry out an intraoperative histologic research of fabric from edges of an operational wound regarding depth of a tumoral invasion. After a resection there is higher risk of a local recurrence of cancer of kidney.
The radical nefrektomiya is a choice method at all stages of cancer of kidney. The radical nefrektomiya assumes surgical excision by one block of a kidney and all next educations: okolopochechny fatty cellulose, kidney fastion, adrenal gland and regionarny lymph nodes. Removal of an adrenal gland is carried out at a tumor arrangement in the top pole of a kidney or detection in it pathological changes. Limfadenektomiya with a histologic research of remote knots helps to establish a stage of cancer of kidney and to define its forecast. In the absence of kidney cancer metastasises in lymph nodes (according to ultrasonography, KT) the limfadenektomiya can not be carried out. Performance of a radical nefrektomiya at cancer of the only kidney demands carrying out a hemodialysis and the subsequent transplantation of a kidney.
At an expanded nefrektomiya fabrics of the tumor which extended to surrounding bodies are excised. When growing a tumor into a gleam kidney or lower hollow veins the trombektomiya is carried out; at defeat the tumor of a vascular wall carries out a regional resection of the site of the lower hollow vein. In case of widespread cancer of a kidney, except a nefrektomiya, the surgical resection of metastasises in other bodies, a limfadenektomiya is obligatory.
The arterial himioembolization of a tumor can be carried out as preoperative preparation for reduction of blood loss at a nefrektomiya as a palliative method of cancer therapy of a kidney at inoperable patients or for a bleeding stop at a massive gematuriya. As additional to surgical (and at inoperable patients - the basic) cancer therapies of a kidney are used conservative methods: immunochemotherapy, chemotherapy, targetny therapy.
The immunotherapy is appointed for stimulation of antineoplastic immunity at widespread and recurrent cancer of a kidney. Usually apply monotherapy interleykinom-2 or alpha interferon, and also the combined immunotherapy these medicines that allows to achieve partial regression of a tumor (approximately in 20% of cases), long full remission (in 6% of cases) at patients with kidney cancer. Effectiveness of an immunotherapy depends on a gistotip of cancer of kidney: it is higher at the light-cellular and mixed cancer and is extremely low at sarkomatoidny tumors. The immunotherapy is inefficient in the presence of kidney cancer metastasises in a brain.
Targetny therapy of cancer of kidney medicines , , , , allows to block growth factor an endoteliya of vessels of a tumor (VEGF) that leads to violation of angiogenesis, blood supply and growth of tumoral fabric. The immunotherapy and targetny therapy at widespread cancer of a kidney can be appointed to or after a nefrektomiya and a resection of metastasises depending on a trudnoudalimost of a tumor and the general state of health of the patient.
The chemotherapy (medicines , 5-ftoruratsit) at metastatic and recurrent cancer of a kidney yields the minimum result because of cross medicinal resistance, is carried out usually in combination with an immunotherapy. Radiation therapy in cancer therapy of a kidney does not give necessary effect, is applied only at metastasises in other bodies. At widespread cancer of a kidney with the germination of surrounding structures, extensive metastasises in lymph nodes of zabryushinny space remote by metastasises in lungs and bones performing only palliative or symptomatic treatment is possible.
Forecast of cancer of kidney
After the carried-out cancer therapy of a kidney regular observation and inspection at an onkourolog is shown. The forecast of cancer of kidney is defined generally by a stage of tumoral process. At early detection of a tumor and metastasises of cancer of kidney it is possible to hope for favorable result of treatment: 5-year survival of patients with T1 with a kidney cancer stage after a nefrektomiya makes 80-90%, at T2 of a stage of 40-50%, at stage T3-T4 the forecast extremely adverse – 5-20%.
Prevention of cancer of kidney consists in observance of a healthy lifestyle, refusal of addictions, timely treatment of urological and other diseases.