This is a slide which shows a medullary carcinoma
This is a slide which shows a medullary carcinoma of the kidney. I think you can appreciate that the organization of this tumor and the appearance of the slides is much less differentiated than in the run-of-the-mill renal cell carcinoma. These do tend to appear much more like adenocarcinomas on histologic section. I’ve tended to treat these people also with chemotherapy rather than immunotherapy, and I tend to treat these as an adenocarcinoma of unknown primary. Although I don’t think there is very much data one way or another about how to treat these patients.
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Now when renal cell carcinoma presents, the classic triad is hematuria, abdominal mass and pain, but only 9% of the patients have the classic triad. About 50% of the patients will have at least one of these three findings. There is also a syndrome which I’m going to talk about in a little bit, where some patients will present with constitutional symptoms; weight loss, anemia, and fever. These constitutional symptoms are probably related to cytokine production by either the tumor or the tumor infiltrating lymphocytes. I’ll be talking a little bit more about this later.
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Now this slide doesn’t project very well, but fortunately the important information is summarized here. With respect to staging of renal cell carcinoma, the staging for renal cell carcinoma changed in 2006, so some of the tables that are in the textbooks are out of date. I was looking at the Lippincott table in the staging manual that they have there, it doesn’t include this up-to-date staging system. It’s simplified in many respects. The T1 tumors are less than 7 centimeters and the T2 tumors are greater than 7 centimeters. These represent then stage I and stage II disease respectively. The T3 tumors invade into the major veins, the adrenal gland or the perinephric tissues and are one of the subgroups that constitute your stage III disease, the T3 tumors. If you have lymph node involvement in a single lymph node, that is considered N1 disease. If you have involvement in more than one lymph node – not a lymph node grouping, but a lymph node – that’s considered to be N2 disease. In other words, involvement of more than one lymph node, is considered to be stage IV disease.