hey guys it's medicosa's perfect status where medicine makes perfect sense welcome back to my Nephrology playlist in previous videos we talked about nephritic syndrome when I'm losing blood in the urine we talked about nephrotic syndrome when I'm losing proteins in the urine we talked about acute kidney failure and chronic kidney failure both of which will give me azotemia azut means nitrogen because we're talking about blood urea nitrogen nitrogen that's in diarrhea why do we call nitrogen azote because it literally means no life because you cannot survive only on nitrogen you need oxygen for sure after that we talked about kidney infections like pyelonephritis we also talked about cystic kidney diseases today we continue our discussion on kidney tumors the last video was about angiomyolipoma today's video is on renal cell carcinoma if it ends in Oma it's a tumor please watch the videos in this playlist in order kidney diseases could be diseases of inflammation diseases of infection disease of the vessels disease of the kidney interstitium cystic diseases of the kidney obstructive disease of the kidney we talked about all of these before today we're talking about an Oma a malignant Oma which is renal cell carcinoma it's a cancer Urological tumors include kidney cancers ureter Cancers and bladder cancers all of them can give me blood in the urine and by the way any adult patient with hematuria unless it's after trauma has cancer until proven otherwise how do you work up the cancer try to visualize it but before you visualize it feel it on physical exam then visualize it Imaging such as ultrasound CT scan MRI what's the most accurate test biopsy the mass but how do I obtain the sample my papa drives a Rolls-Royce you can obtain your sample via a needle through the skin percutaneously or good old open surgery if it's bladder cancer cystoscopy with biopsy kidney cancer can be divided into two categories if the cancer started in the kidney we call this primary such as today's topic renal cell carcinoma but if the cancer started somewhere else and then metastasized to the kidney for example the cancer started in the adrenal gland then went to the kidney or in the liver and then went to the kidney or the colon and then went to the kidney we call these secondaries or metastases remember the structure of the kidney I bet you do what's that called proximal convoluted tubule the tubule has a lumen but of course the tubule is lined by epithelium I mean any cavity in your body is lined by epithelium this epithelium is probably the origin of the renal cell cause Sonoma tubular epithelial cells in the proximal convoluted tubule look at this proximal renal tubular cells there is something important to understand about renal cancer let's suppose that we have cancer in this kidney which is the left kidney and cancer in this kidney the right kid and then we will metastasize both of them the cancer on the left side metastasized here to this left renal vein and the cancer on the right side also metastasized to this right renal vein what's going on look at my right testicle I should not have said it that way testicular organelle vein look at this we're draining into the inferior vena cava and I'm draining to the heart I am not affected by this cancer whatsoever but look at my left testy spermatic vein testicular vein call it whatever you want to call it even call it left gonadal vein drains to the left renal vein and look I am obstructed by the the metastasis of this renal cancer so what do you think is going to happen all of that venous blood will be unable to drain therefore all of the Venus blood will accumulate and pile up and pile up back up here until I end up with Left sided varicocele with a bag of worms sensation in my left testy not the right testy how do you remember this Miracles is easy look at the left renal vein it goes from the left kidney all the way until it reaches the inferior in a cave it's a very long distance however the right renal vein has a very short distance mnemonic time that left renal vein is very long it is so long it has lots of space that it agreed to accept drainage from the left gonadal vein and from the left adrenal vein as well one from above one from below now on to today's topic renal cell carcinoma where does it come from where does it arise from it arises from proximal renal tubular cells as we have discussed what is the pathological type the most common subtype is clear cell adenocarcinoma when you look under the microscope the cells are very clear there is no Gunk inside and this is called clear cell adenocarcinoma when you hear the word adrenal you remember what gland what do glands do they secrete something oh I got you so this cancer can secrete erythropoietin and before you know it I have increased red blood cell count increased hemoglobin and hematocrit this is secondary polycythemia what do you call this rise in IPO appropriate or inappropriate well it's not secondary to hypoxia indeed it is secondary to cancer so it is inappropriate that's correct so it is over 18 just like the patient's age the typical patient of renal sulcus Sonoma is usually older not just older than 18. in his 60s risk factors for renal cell carcinoma old age being male indeed it's twice as likely in males as in females smoking cigarettes being obese being on dialysis for a long time being exposed to lead or asbestos or petroleum products including gasoline or A congenital disease known as Von hippol Lindor which is a translocation usually it involves chromosome number three remember you have three letters vhl chromosome 3 and more three there is RCC renal cell carcinoma in one kidney right no this disease is brutal two kidneys that's it right no and other tumors where are they in my retina of the eyes oopsie and cerebellum I can't walk I can't see I can't pee normally because my pee has hematuria what are the types of renal cell carcinoma sporadic and hereditary what the flip is the difference hereditary is a genetic cancer which means it runs in my family for example my Daddy has it my grandpa has it etc etc that's a heretic hair here in also carcinoma or sporadic my dad was fine my grandpa was fine my mom was fine my aunt everyone in the family is I am the first person in this family to develop prenatal carcinoma I.E it developed sporadically de novo out of the blue should I blame my parents or should I blame the Stars on physical exam and history renal cell carcinoma is a classic Triad of flank pain cost to vertebral angle pain and tenderness flank mass that can be palpable on physical exam as well as hematuria blood in the urea blood in the urine does every case of renal cell carcinoma have to have these three things no many of them remain called hidden no symptoms whatsoever discovered incidentally on Imaging and in some cases RCC is symptomatic can we have other symptoms sure if the renal cell carcinoma on the left kidney metastasized to the left renal vein male patients can develop left-sided varicoceles and don't forget the perineoplastic syndrome I can get symptoms of polycythemia or symptoms of hypercalcemia you remember the classic symptoms of primary hyperparathyroidism we can see similar symptoms bones groans Thrones moans psychiatric overtones and phones call the Emergency Medical Services because the hypercalcemia gave me acute pancreatitis not just pancreatitis but transaminitis elevated levels of liver transaminases or amino transferases if you want to be Gentile about it can also have more complications like any cancer renal cell carcinoma can give me weight loss and cachexia and don't forget the crazy Stouffer syndrome what's that this is renal silk carcinoma causing liver cell dysfunction even without metastasizing to the liver what in the world yeah boy metabolic organs can affect one another even without metastasis and it goes the other way around as well does anyone remember hepato renal syndrome that's a liver disease causing kidney disease even without metastasis medicine makes so much sense once you understand what the flip you're talking about prognosis well it depends on the metastasis most patients will have no metastasis if metastasis happens it's usually late but if it does happen it decreases my survivability or the five-year survival rate to about 45 which means half of the patients with RCC with metastasis will not make it past five years this is just sad if the cancer extends to the capsule if the cancer extends to the left renal vein it carries poor prognosis because it means it is metastasizing ESR is elevated as if we care ESR is very non-specific tells you there is something going on but it never specifies what exactly is going on and given the fact that there are more than 10 000 conditions in medicine it is not that stinking helpful maybe in the exception of temporal or giant cell arteritis when ESR is super duper High you give steroids right away otherwise the patient can go blind but other than this ESR is a piece of garbage test how about IPO well it depends sometimes IPO is high if it's a perineoplastic syndrome but remember that this cancer is growing growing growing and encroaching on the kidney itself maybe it encroaches on the cells that make IPO and IPO can go down giving me anemia this can be called enemy of malignancy you can also so-called enemy of chronic disease and in most cases it will be a normal setting but how many courses I studied that anemia of chronic disease is micro acidic yes indeed but it starts at normalcytic however on your exam when they ask about RCC anemia go with normalcytic in most cases you will be correct how can we diagnose this tumor good history meticulous physical exam and then go to the labs and go to Imaging stuff what do I expect from the labs we just talked about them right here and then Imaging ultrasound of the abdomen CT scan of the abdomen MRI Etc then you biopsy the mass usually looks bright yellow and it's usually larger than 3 centimeters in diameter the mass is usually at the upper pole not the lower pole of the kidney lots of cysts lots of bleeding lots of necrosis like any cancer Hemorrhage and necrosis are criteria of malignancy when you see Hemorrhage and necrosis that's not benign baby baby for the most part clear cell adenocarcinoma is the most likely subtype to be encountered under the microscope and it's clear it has lipid it has glycogen besides clear silk adenocarcinoma what else could it be it could be papillary chromophilic adenocarcinoma chromophilic I love colors what's the opposite of that chromophobic renal cell carcinoma there is also uncocetic renal cell carcinoma and there is the biliniduct carcinoma or the collecting duct carcinoma and not just oncocetic renostal carcinoma there is another one called oncosytoma just remember it's benign it's brown it is rich in mitochondria and that's why if you have too many mitochondria you will stay in pink Under the microscope acidophilic is it made from the proximal tubular cells no oncocytoma is made from the intercalated cells which are part of the late distal and collecting ducts around the nucleus there is usual really no clearing no perinuclear clearing unlike the chromophobic RCC which has peritubular clearing on an exam question if they describe a kidney tumor as benign brown with Central radial Scar and rich in mitochondria the answer is oncosytoma back to clear cell adenocarcinoma okay it has lipid it has glycogen and has clear cells what else how do you grade it and how do you stage it remember gray ding it has letter G and D gray ding is the degree of differentiation what do you mean you could be well differentiated as a tumor or poorly differentiated which one is worse of course the poorly differentiated is worse if you are well differentiated it means that you are low grade but if you are poorly differentiated it means high grade which is awful how about staging then staging is not grading state aging is that size and the spread of the tumor how do I establish grading in order to see the degree of differentiation you need histopathology you need to look at the cells under the microscope but for staging for the size and the spread of the cancer you need the following song physical exam and CT scan physical exam and CT scan for example if you can palpate a tumor in my kidney and a tumor in my liver and a tumor in my whatever then it means it has spread all over the place if you can palpate a bigger tumor it's getting bigger and bigger and bigger every time you see the patient that's a bad sign it means it is spreading and growing and of course CT scan will show you where in the body is the tumor how many masses how many sites Etc management surgical resection of course if you have to remove the entire kidney will be called total nephrectomy how do I remove the tumor you can do this through good old open surgery or the newer laparoscopic surgery or the even newer robotic surgery oh by the way just because something is fancy and new and modern and more expensive doesn't necessarily mean that the patient's outcome will be better because that is an empirical question not a foregone conclusion the outcome could be better could be worse could be the same besides surgery do we have other options yup immunotherapy or targeted therapy such as interferon Alpha and look into or tyrosine kinase Inhibitors tki do you remember the tenebs for CML it was called imeteneba here it's called sonetaneb or soraphene or posappen who name these things when renal cell carcinoma the primary cancer metastasizes it can go to many organs it can go to my lungs and it's not going to be one mess it's going to be multiple masses because it goes with the blood take this tumor tumor tumor this will be Cannonball appearance in my lungs if it goes to Bones it will give me lytic not plastic bone lesions if it metastasizes the lymph node they will be painless remember cancer is painless infection is painful for the most part and then it can also meet pesticides to the skin recall that this tumor has Hemorrhage it is vascular and when it goes to the skin it will give me vascular hemorrhagic nodules so we just talked about RCC let's compare this with bladder cancer the most common type of renal cell carcinoma is the clear cell Adeno the most common type of bladder cancer is the transitional cell carcinoma also known as urothelioma or urothelial cancer because the transitional epithelium that is normally in the bladder is also known as urothelium the epithelium of the urinary tract such as the ureter and the bladder transitional cell carcinoma has the classic papillary appearance this was an old male smoker same thing here this patient was obese and on dialysis exposed to lead arsenic or gasoline this is also an old male smoker but exposed to other things such as aniline dyes aromatic amines or a worker in the rubber industry such as manufacturing tires or a patient taking cyclophosphamide how about hematuria I can see himaturia with either one besides clear cell adenocarcinoma what else did we have we had the chromophobic the chromophilic the oncosidic the oncocytoma and the Bellini here we can also have squamous cell carcinoma after chronic infections such as the Egyptian guy like me with chronic schistosoma hematobium not treated unresolved it is notorious for causing squamous cell carcinoma of the bladder it is such an ugly parasite the late famous Egyptian singer known as Abdel halim hafez died from schistosoma but it was the other sister Soma schistosoma mansoni but that's a story for another time The Chronic infection of the bladder does not have to be schistosoma it could be any cystitis that is chronic and unresolved smoking is also a risk factor of course diagnosis of these cancers history physical exam and imaging such as CT scan ultrasound MRI Etc staging is always physical examined CT scan management is surgery and others speaking of surgery do you want to learn about trauma surgery the different types of shock how about orthopedic surgery how about Urological surgery ophthalmological surgery and much more download my surgery high yields course at medicosisperfect status.com and speaking of cancers I have a course on anti-cancer pharmacology on my website maricosisperfectsnetis.com if you do not want to download my courses but would rather watch them right here on YouTube click the join button choose the highest tier to gain instant access to More Than 3 300 premium videos please subscribe and hit the Bell support my channel here or here go to my website to download my courses notes and cases be safe stay happy study hard this is medicosa's perfect snail is where medicine makes perfect sense