KIDNEY CANCER P 1144 1145 Arise from the cortex or pelvis and calyces o Tumors can be benign or malignant malignant are more common Adenocarcinoma renal cell carcinoma is the most common type men 50 70 o Higher risk with cigarette smoking family history obesity HTN exposure to asbestos cadmium and gasoline and ESRD CLINICAL MANIFESTATIONS No early signs usually undiagnosed until progressed 30 have mets at diagnosis o Common metastases sites ungs liver long bones renal vein and vena cava Symptoms from compressing stretching or invading near by structures o Hematuria flank pain and palpable mass Weight loss fever HTN and anemia CT scan used for diagnosis o Ultrasound determines if it is a solid mass tumor or cyst 90 are cysts o Angiography percutaneous needle aspiration MRI and IVP are also used Increased use of CT and MRIs have increased early diagnosis Radionuclide isotope scanning to detect metastases NURSING AND COLLABORATIVE MANGEMENT Robson s system of staging renal carcinoma o I limited to kidney small tumor 7 cm o II soreading to perirenal fat but confined with fascia o III tumor invades renal vein or vena cava or regional lymph nodes or both o IV presence of metastases Radical nephrectomy for stages I II and some III o Removal of kidney adrenal gland surrounding fascia part of the ureter and draining lymph nodes Metastatic treatments or when surgery is not an option o Radiation therapy is used palliatively when inoperable or stage IV o Cryoablation freezing and radiofrequency ablation heat o Chemotherapy adenocarcinoma is refractory to most chemo 5 fluorouracil 5 FU floxuridine FUDR and gemcitabine Gemzar o Biologic therapy o Target therapy A interferon and interleukin 2 IL 2 Sunitnib Sutent Sorafenib Nexavar temsirolimus Torisel everolimus Afinitor ofatumumab Arzerra bevacizumab avastin and pazopanib Votrient o Survival rate is low however do remain stable for a prolonged period of time BLADDER CANCER P 1145 1146 Most frequent malignant tumor of the urinary tract is transitional cell carcinoma of the bladder o Usually papillomatous growths within the bladder o Men 60 70 smoking rubber and cable industry dyes chronic abuse of phenacetin containing analgesics not on the market now cervical radiation and cyclophosphamide Squamous cell cancer of the bladder chronic renal calculi chronic lower UTIs long term indwelling catheters have increased risk CLINICAL MANIFESTATIONS Microscopic gross painless hematuria chronic or intermittent Bladder irritability with dysuria frequency and urgency DIAGNOSITC STUDIES Urine specimen neoplastic atypical and exfoliated cells o Bladder tumor antigens CT ultrasound MRI for detection Cystoscopy most reliable for detection and biopsy to confirm Jewett Strong Marshall classification system o Based on depth of invasion or bladder wall and surrounding tissues o Superficial carcinoma in situ CIS O A 80 do not invade bladder wall Although more easily cured 95 reoccurrence rate in 15 years o Invasive B1 B2 C o Metastatic D1 D4 NURSING INTERVENTIONS Encourage patient to increase fluid intake and to quit smoking Assess for secondary UTI Stress need for routine follow up Address fears and concerns about sexual activity and bladder function COLLABORATIVE MANAGEMENT Low stage low grade bladder cancers respond to instillation of intravesical chemotherapy and transurethral resection of the bladder tumor TURBT Surgical therapy o Transurethral resection with fulguration Diagnosis and treatment of superficial lesions Used to control bleeding if poor operative risk or with advanced tumors Tumor mass is excised through cysoscope then cauterized o Laser photocoagulation Used to treat superficial bladder cancer can be repeated a number of times Benefits bloodless destruction of lesions minimal risk of perforation and lack of need for a urinary catheter Disadvantages staging cannot be completed o Open loop resection with fulguration Snaring of polyp types of lesion Used to control bleeding for large superficial tumors and multiple lesions o Cystectomy segmental partial or radical For large lesions and no metastasis and create urinary diversion Partial resection of portion of the bladder wall with margin of normal tissue Radical removal of bladder prostate seminal vesicles uterus cervix urethra and ovaries o Postoperative management Drink large volumes of fluids for first week no alcohol Self monitor urine Pink for first several days not bright red or with clots 7 10 days dark red or rust colored flecks in urine scabs Opioid analgesics with stool softener 15 20 minute sitz bath 2 3 times a day Promote relaxation and reduce urine retention Follow up cystoscopies every 3 6 months for three years then yearly Radiation therapy o Primary therapy when inoperable or surgery is refused o Often combined with systemic chemotherapy Intravesical immunotherapy o Intravesical delivered directly into the bladder via urethral catheter Therapy usually weekly intervals for 6 12 weeks o Bacille Calmette Guerin BCG Treatment of choice for carcinoma in situ May cause flu like symptoms frequency hematuria systemic infection N V and hair loss NOT experienced o A interferon Roferon A Intron A When BCG fails Intravesical chemotherapy o Thiotepa Thioplex o Valrubicin Valstar Systemic chemotherapy o Empty bladder instill retained for about 2 hours change position every 15 minutes to coat all surfaces of bladder drain