#Sorafenib D3

[garden-of-everything]

ABIM: Oncology

ABIM syllabus can be found here Let me know if you find any errors Sources: UWorld, MKSAP 16/17, Rizk Review Course, Louisville Lectures, Knowmedge (free version)

Lung cancer (clinical presentation and diagnosis)

Small cell:  associated with hyponatremia/SIADH, Lambert Eaton (like MG but fatiguable); Tx: chemotherapy + whole brain radiation if good response to chemo Non-small cell:  CT/PET, MRI brain –> Tx: stage I - surgical, stage II - surgery + chemo, stage III - chemo + XRT +/- surgery, stage IV - chemotherapy alone (1)  Squamous cell carcinoma:  associated with smoking, hypercalcemia, Pancoast tumors (cause Horner’s: ptosis, miosis, anhydrosis) (2)  Adenocarcinoma:  not associated with smoking (3)  Large cell carcinoma:  associated with SVC syndrome (4)  Bronchogenic carcinoma:  associated with cluster of painless, firm/hard cutaneous metastases *AE of chest XRT is CAD

Breast Cancer

- Screening:  mammogram >50yo or >35 with high risk * if palpable mass:  ALWAYS BIOPSY (even if not seen by mammo) * if in situ –> no need for LN biopsy * if positive LN –> axillary LN dissection (AE: UE lymphedema) *if >1cm or LN+: give adjuvant chemo * do NOT perform mastectomy if metastized * if mastectomy, add XRT if: (1) dermal invasion, (2) close margins, (3) 4+ LNs - Dx:  mammogram/US –> Bx –> ER/PR/Her2neu status - DCIS Tx: lumpectomy + local rads = simple mastectomy (for tumor >5cm) +/- if ER/PR+ –> 5 years of hormonal therapy (1) premenopausal: Tamoxifen (SERM; AE: clots, endometrial cancer), (2) postmenopausal: Anastrazole/Letrozole (AI) +/- if Her2neu+ –> get an ECHO to ensure good heart function, give Trastuzumab (- LCIS Tx: observe or b/l mastectomy (won’t be tested because controversial)

Neoplasm of the head and neck

Thyroid nodules and thyroid cancer: (1) Medullary thyroid cancer: associated with both MEN II syndromes, RET gene; elevated calcitonin –> hypercalcemia; Tx: surgical neck dissection (2) Papillary thyroid cancer:  aggressive, associated with BRAF (like melanoma); Tx: surgery + radioiodine (3) Follicular:  Tx: surgery + radioiodine (4) Anaplastic:  very poor prognosis

Gastrointestinal or hepatic cancer

Stomach cancer:   - Dx: upper endoscopy with ultrasound > CT scan - Tx: surgery, chemo, XRT - MALT lymphoma:  Tx: PPI and H.pylori Abx Colorectal cancer: - Tx: stage 1-2: resect, III: resect + chemo, IV: FOLFOX chemo +/- resect + Bevacizumab - f/u with CEA Q3-6mo for 2 years, then Q6months for 3 years - f/u with CT chest/ab/pelvis every year for 3 years - f/u with colonoscopy 1, 3, and 5 years post-treatment - Rectal cancer: Tx stage II-III: (1) chemo/XRT –> surgery or (2) surgery –> chemo Pancreatic carcinoma other than pancreatic endocrine tumors: - Trousseau venous thrombophlebitis (migratory VTEs), jaundice, palpable GB - stage I (pancreas) Tx: resection - stage II (duodenum) - stage III (LN) - stage IV (other mets) Tx: Gemcitabine *confused for autoimmune pancreatitis (because of mass); differentiate with biopsy; AIP has elevated IgG Hepatocellular carcinoma: - associated with Hep C > chronic Hep B - if nodule <1cm needs screening abdominal US Q6mo –> if >1cm: contrast CT/MRI liver (arterial phase enhancement) - if AFP>100, don’t have to biopsy –> Tx: resection / liver transplant > EtOH/radioablation > chemotherapy/Sorafenib Other CT abdomen findings: (1) Cavernous hemangioma: early peripheral nodular enhancement with delay in filling from periphery to center; don’t have to treat (2) Hepatic adenoma: associated with OCPs; early rapid loss of enhancement –> resect (3)  Focal nodular hyperplasia:  central stellate scar –> don’t have to treat

Urologic cancer

Renal clear cell carcinoma:   - presents as upper abdominal mass with hematuria; erythrocytosis (elevated Hb), hypercalcemia, and acute varicocele - associated with von-Hippel Lindau (retinal and cerebellar hemangioblastomas and RCC) - Dx: CT ab, pulmonary “cannonball” nodules/mets on CXR, if bone pain: elevated ALP - Tx: nephrectomy Transitional cell carcinoma: - painless hematuria - Dx: cystoscopy - Tx: TURBT –> intravesicular BCG; if muscle invasion: radical cystectomy Prostate cancer: - Dx: exam with elevated PSA –> transrectal US-guided prostate Bx - Gleason >7, PSA >15, large tumor or bone pain –> bone scan and CT ab/pelvis - penetrates prostate capsule Tx: XRT –> f/u PSA and rectal exam Q6-12mo - LN involvement/mets/elevated serum acid phosphatase Tx:  total hormonal ablation with 4-6mo Leuprolide (LHRH agonist to be given with antiandrogen Flutamide to prevent tumor flare)/Goserelin –> refractory: Docetaxel Testicular cancer: (1) Non-seminoma (embryonal, teratoma, choriocarcinoma): elevated AFP, hCG; Dx/Tx: inguinal orchiectomy (DO NOT BIOPSY) +/- chemo if spread (2) Seminoma: elevated hCG; Tx: radiation; if disseminated: platinum-chemo

Gynecologic cancer

Ovarian cancer: - may present with bleeding, dyspareunia, ascites (SAAG <1.1, ascites protein >2.5), peritoneal carcinomatosis - associated with HNPCC, infertility, early menarche, late menopause - Dx: pelvic U/S –> stage with ex-lap - Tx: stage I = surgery; stage II-IV: platinum-based chemo –> follow with pelvic exa, and CA-125 Q2-4mo for 2 years (do NOT need routine US) * if BRCA1 or 2+ –> offer oophorectomy at 35yo or after child-bearing * Dermatomyositis (anti-Jo1) is associated with ovarian cancer –> TVUS Endometrial cancer: - Dx: with biopsy - Tx: surgical resection of cervix/uterus/adnexa + XRT +/- chemotherapy; if high risk surgical patient, XRT only Cervical cancer: - Dx: punch bx or colposcopy bx - stage I Tx: LOOP/conization or if finished babies, hysterectomy WITHOUT dissection - stage II-IV Tx: XRT + cisplatin

CNS tumors

GBM: most common and aggressive adult intraparenchymal tumor - ring-enhancing with central necrosis and hemorrhage Meningioma: most common primary brain tumor (extraparenchymal, extradural) - insidious diffusely enhancing, partially calcified +/- dural tail; Tx: observe or surgery if symptomatic Oligodendroglioma:  rare, MRI = non-enhancing homogeneous intraparenchymal lesion Schwannoma: benign nerve sheath tumor ~CNVIII (hearing loss/tinnitus) - MRI shows enhancing lesion at cerebellopontine angle vs. Pseudotumor cerebri:  headaches worse in the morning + papilledema and visual changes in an obese person on Accutane - Dx: CT/MRI to r/o tumor and dural venous sinus, LP shows elevated ICP - Tx: Acetazolamide, repeat lumbar puncture –> if progressive visual loss: neurosurgery

Skin cancer

Squamous cell carcinoma:  preceded by actinic keratosis Basal cell carcinoma: raised pearlescent with telangiectasia Melanoma: Dx: wide excision + if >1mm deep, sentinel LN biopsy; additionally treat with IFN if >4mm or +LN

Hematologic malignancies (see ABIM: Hematology)

Assorted endocrine tumors and endocrine manifestations of tumors (see ABIM: Endocrine)

Malignancy associated hypercalcemia: (1) squamous cell (2) RCC (3) medullary thyroid cancer (elevated calcitonin)

Oncologic emergencies

SVC Syndrome :  associated with large cell NSCLC - Dx: biopsy tissue > mediastinoscopy/thoracotomy - if previously untreated: give chemo - if previously treated: XRT +/- chemo Fever and neutropenia: - Tx: with broad spec Pseudomonal abx (Cefepime) until PMN>500 - if no improvement in 2 days, add Vanc - if no improvement in 5 days, add Itraconazole Spinal cord tumors and compression: - Dx: Gad-enhanced MRI - Tx: steroids, surgery, XRT Cardiac tamponade from neoplastic pericarditis: - JVD, tachycardia, pulsus paradoxus - Tx: pericardiocentesis Tumor lysis syndrome: - elevated uric acid, potassium, phosphate - N/V/D, heart failure, seizures, syncope, death - PPx: Allopurinol, Rasburicase Hypercalcemia  - elevated Ca, decreased PTH, normal/decreased Vit D3 and Phos - Tx: NS Hyponatremia (SIADH): - associated with small cell - Tx: fluid restrict or if symptomatic, Na<120: 3% Saline + Lasix

Complications of cancer and its treatment

- give Morphine –> translate it to long-acting forms - Palliative O2 not helpful in absence of hypoxemia - Radiation toxicity: CAD, hypothyroidism, lung disease; breast, lung, esophageal cancer - Toxicity bear (borrowed from my Step 1 notes - Second Aid): –> Asparagine: neurotoxicityCisplatin:  ototoxic/nephrotoxic; Tx: Amifostine –> Vincristine/Vinblastine:  "Christ my nerves, Blast my bones" - Vincristine = peripheral neuropathy - Vinblastine = myelosuppression –> Bleomycin: pulmonary fibrosis –> Doxorubicin: cardiotoxic; Tx; Dexrozoxane (for cardiotoxicity), Dimethyl-sulphoxide (for ROS ulcers) –> Cyclophosphamide:  Acrolein = nephro/bladder toxic (Tx: Mesna); also SIADH effects (Tx: Demeclocycline) –> Methotrexate: nephrotoxic (Tx: Leucovorin), myelosuppression (Tx; Filgrastim)

Cancer of unknown primary

- axillary LN? –> biopsy comes back adenocarcinoma –> mammogram –>if neg: MRI breast - high cervical LN? –> PET/CT scan of head and neck - osteoblastic mets? –> PSA test for prostate adenocarcinoma - ascites, peritoneal carcinomatosis? –> ovarian cancer, Dx: ex-lap - young woman with retroperitoneal poorly differentiated mass? –> germ cell cancer; Tx: platinum chemo

Cancer screening (see ABIM: Screening)

[juniperpublishers-endocrinology]

Obesity, Insulin Resistance and Vitamin D Deficiency may be Reversible Risk Factors for Thyroid Cancer-JuniperPublishers

Abstract

Background: The incidence of thyroid cancer has been rising significantly over the past few decades; insulin resistance (IR), obesity and vitamin D deficiency (VDD) are found to be associated with many cancer types, this paper introduce a review for papers done in this field to show the association between IR, obesity, and VDD as reversible risk factors for thyroid cancer.

Methods: This paper was designed to review the previous studies in this field to evaluate the possible association between IR, obesity, VDD and thyroid cancer, possible mechanisms and the clinical applications.

Conclusion: Obesity, IR, and VDD are proved to be implicated in thyroid cancer incidence, but there relation to thyroid cancer aggressiveness still controversial, and whether vitamin D3 supplementation, physical activity, Drugs that decrease insulin resistance and diet may affect thyroid cancer prognosis and incidence still raw area for more researches.

Keywords: Thyroid nodules; Thyroid cancer; Vitamin D deficiency, Insulin resistance; Obesity

Abbreviations: IR: Insulin Resistance; VDD: Vitamin D Deficiency

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Introduction

Thyroid cancer is the comments endocrine malignancy, it’s incidence is rapidly increasing among all other malignancies, This rise may partly due to increase detection of thyroid cancers from enhanced usage of ultrasonography and fine-needle biopsies [1], and changes in exposure to environmental factors as ionizing radiation, and a family history of thyroid cancer. The aim of this paper is discuss if obesity, IR and Vitamin D deficiency (VDD) are possible risk factors for thyroid cancer and if so can we prevent thyroid cancer through weight control, Diet, Vitamin D supplementations, usage of metformin to decrease insulin resistance?

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Main Content

Obesity and thyroid cancer

Obesity is proved to be associated with the development and progression of many malignancies as endometrial cancer, breast cancer, esophageal cancer, colon, adenocarcinoma, liver cell carcinoma, prostate cancer, leukemia, melanoma, and non-Hodgkin lymphoma [2]. Recently, several studies have suggested a positive association between obesity and the prevalence of thyroid cancer [2-5], the underlying mechanism has not been confirmed. IGF-1, IR, cytokines, TSH, adiponectin, estrogens and leptin have been suggested as associated factors [6,7]. Obesity leads to a pro-inflammatory state, decrease adiponectin, and IR, which, leads to hyperinsulinemia and increase IGF1 levels, that may increase the risk for thyroid malignancies

Several studies have been done to show the relationships between obesity and clinical outcomes of thyroid cancer especially PTC [8-10]. There results remain still controversial. Some studies showed an association between obesity and more aggressive tumor stages [8,11,12], they suggested that overweight or obese patients with (PTC) more than 1cm in size had more risk of developing recurrent disease or loco-regional persistence [8]. However, other studies showed a higher body mass index (BMI) was not accompanied with more aggressive pathological features, or the recurrence or persistence of disease [9,13]. Other one reported that obesity might be associated with less aggressive tumor invasion [9].

So as these studies have not shown consistent results, and whether or not the severity of obesity influences the prognosis and the aggressiveness of pathological stages of thyroid cancer so we need more studies to uncover this issue.

Insulin resistance as a risk factor for thyroid cancer

IR is a characteristic finding of most patients with simple obesity, impaired glucose tolerance, type 2 diabetes mellitus, as well as other disorders [14]. Insulin stimulates proliferation of thyroid cells in culture. The presence of insulin resistance (IR) is associated with larger thyroid gland volume and an increased prevalence of thyroid nodules. [15,16] and may be involved in the pathogenesis of thyroid cancer development [17]. It was noticed that insulin receptors are overexpressed in most thyroid tumors as an early stage in thyroid carcinogenesis [18].

IR may be due to chronic activation of the pro-inflammatory pathway [19]. Chronic activation of the NF-kB pro-inflammatory pathway and/or JNK1 have been implicated [19]. IGF-IR is usually expressed at high levels in thyroid cancer cells [20], Vella et al. [18] showed that thyroid cancers overexpress IGF-I, IGF-IR, and IGF-II and IR [18]. The concomitant increase expression of IGF-IR and IR in thyroid cancer cells causes over expression of IR/IGF-IR hybrid receptors that, in most cases, exceed the IGFIR content so In cells with a high IR/IGF-IR content, blocking antibodies specific to these receptors inhibit IGF-I-induced cell growth [21].

So changes in the IGF system and the association with high circulating levels of insulin/IGFs have been reported in thyroid cancer, which may have important implications in endocrine cancer prevention and treatment [21].

TSH itself is a major regulator of growth and differentiation of thyroid cells, and plays a role in nodule formation. In the presence of insulin in cell cultures, TSH is a well-known mitogen and also suppresses apoptotic cell death in response to various stimuli [22], This effect, is mediated in part via IGF-I dependent pathway; therefore, IGF-1 might be expression of insulin receptor was increased in hypo functioning benign thyroid adenomas which lost differentiated functions such as iodine uptake. Therefore, over expression or activation of insulin receptor may be an early event in thyroid tumorigenesis and nodular formation [22]. So, hyperinsulinemia may act by enhancing thyroid proliferation, independently of the patient BMI

Metformin and thyroid cancer

Patients using Metformin had a lower risk for formation of thyroid nodules and a smaller thyroid volume [23-25]. Also Karimifar et al. [26] reported that metformin can reduce small solid thyroid nodules size and prevent an increase in the thyroid volume [26].

Metformin have complex effects that include not only lowering IR but also direct effects on cancer cells [27], Benveng et al. [28] noticed reduction in overall cancer incidence or mortality when metformin is used in the treatment of diabetes [28].

Metformin was found to antagonize the growth-stimulatory effect of insulin in vitro and inhibition of cell cycle progression and induction [29]. A recent cross-sectional study also reported a significant correlation between glycated hemoglobin and thyroid volume or the number of nodules [23].

Metformin also has indirect anticancer property as Rotondi et al. proved that metformin inhibit the TNF-α-induced CXCL8 secretion in primary cultures of human thyroid cells, Rotondi et al. In addition to in vitro study done by Chen et al. [29] showed that Rezzónico et al. [27] found that nodule size marked decreased in patients treated with both metformin and L-T4 compared to patients’ recieving metformin alone. The shrinkage of thyroid nodule was accompanied by decrease in TSH level and normalization of the homeostasis model assessment HOMA index [27].

Clinical trials showed that metformin therapy was associated with higher remission rate and survival in diabetic patients with thyroid cancer [28], and a favorable outcome in diabetic patients with cervical lymph node metastasis of DTC [13].

Another large observational study in Taiwanese patients with T2DM showed that metformin reduced thyroid cancer risk [30]. In a mouse model, metformin could block progression of obesityactivated thyroid cancer [31]. On the other hand Becker et al. [32] indicated neither use of metformin nor of other antidiabetic drugs was associated with a decreased risk of thyroid cancer [32].

Recently retrospective analysis found that metformin attenuated a 131I-induced decrease of peripheral blood cells in patients with DTC [33]. Chen et al. [29] reported that sorafenib, a multikinase inhibitor used as alternative therapy for radioiodineresistant DTC, combined with 2 metformin synergistically decreased the proliferation of anaplastic thyroid cancer cell lines and the outgrowth of derived cancer stem cells [29].

In papillary thyroid cancer the therapeutic potential of metformin has also been identified both in vitro and in vivo Cho et al. Another study on medullary thyroid carcinoma (MTC) cell lines showed that metformin inhibited growth in 2 MTC-derived cells, suggesting that metformin inhibits growth and prevents development of metastases in MTC [28]. In addition, 2 metformin may inhibit the growth, migration, and mesenchymal transition of thyroid cancer cell lines by the mTOR pathway beyond insulin/ IGF-1 pathway [34].

In conclusion several studies demonstrated that metformin was found to reduce the nodular volume and thyroid nodules size, inhibit the growth of thyroid carcinoma and potentiate the antimitogenic effect of chemotherapeutic agents and also may have a TSH-lowering effect. So these findings suggest a broader use of this drug not only for type 2 diabetics with or withoutproliferative thyroid disease but also for those with metabolic syndrome and obesity. However, more studies are required to show the effects of metformin in these patients.

Vitamin D and thyroid cancer

Recently the researchers give attention to the relationship between cancer and vitamin D levels, and the potential use of vitamin D receptor as a therapeutic target, a correlation between vitamin D and cancer prevention has been shown in breast, prostate, and colorectal cancer [35].

Several studies strongly suggest that vitamin D3 deficiency (VDD) increases the risk of developing malignancies [36- 38], while others studies reported that there is no association between VDD and thyroid cancer incidence [39,40], prognosis and aggressiveness [40,41]. However, Mawer et al. [42] suggest that adequate vitamin D3 levels may provide protection against cancer and may improve cancer prognosis [42]. Expression of the VDR gene and 25-hydroxyvitamin D3 1-α-hydroxylase, the rate limiting enzyme in the production of active vitamin D3, has been found in several tissues and tumor types [43]. The active form of vitamin D3, 1,25-dihydroxyvitamin D3 (1,25D), exerts antitumor activity by binding to the vitamin D receptor (VDR). The antitumor activities of 1,25D include inhibition of cancer cell proliferation and angiogenesis, promotion of cell differentiation and apoptosis [44,45].

Şahin et al. [46] discovered that increased risk of thyroid cancer in patients with more IR than with Vitamin D3 deficiency and Whether they are coexisting or contributing is controversial [46] but this study involved a small number of thyroid cancer patients. Low vitamin D levels have been observed in autoimmune thyroid diseases, [47] with no correlation of thyroid autoantibodies and vitamin D levels.

Izkhakov et al. [48] showed that VDR mRNA expressed much more in malignant thyroid tissues than in normal thyroid tissues, that indicates a possible correlation between thyroid cancer prognosis and VDR gene expression [48]; however, there were no clinic pathological differences between patients with low levels of gene expression and those with high levels of gene expression. Clinckspoor et al. [49] reported that lower vitamin D3 metabolism was associated with the progression of thyroid cancer of follicular [49].

The very recent study Choi et al. [50] showed that overexpression of VDR mRNA correlates with subtypes of papillary thyroid carcinoma that have the worse prognosis, classic and tall cell variant, and factors associated with poor prognosis such as extra thyroidal extension, lateral neck node metastasis, BRAF V600E mutation and tumor recurrence [50].

So VDD may be implicated in increasing thyroid cancer incidence but whether it affect aggressiveness of the cancer ornot still controversial, and its deficiency should be associated with IR to cause thyroid malignancy still also not known [51].

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Conclusion

Obesity, IR, and VDD are proved to be implicated in thyroid cancer incidence, but there relation to thyroid cancer aggressiveness still controversial, and whether vitamin D3 supplementation, physical activity, Drugs that decrease insulin resistance and diet may affect thyroid cancer prognosis and incidence still raw area for more researches

For more Journals in Juniper Publishers please click on https://juniperpublishers.com/journals.php

For more articles in Journal of Thyroid Research please click on: https://juniperpublishers.com/jetr/index.php

[homeremedynaturalcure]

Korean ginseng helps in preventing and treating kidney cancer

Korean ginseng helps in preventing and treating kidney cancer

Kidney cancer is also known as kidney tumor. This type of cancer can be found in one or both kidneys of the individual. People are getting this type of cancer when healthy cells in one or both kidneys are growing uncontrollably and they are forming a mass of cells. Tumor is exactly what we have said previously (small mass of cells). Based on the severity of this disease, the kidney cancer can be malignant or benign. The cure rate of this disease is generally increased with the help of some natural home remedies. When someone has a malignant kidney tumor, then it can grow and spread to other parts of the kidneys. When someone has a benign kidney tumor, then it grows in one or both kidneys but it does not spread to other parts of your body. Those people who have kidney cancer, suffer from one of these types. There are few cases when the benign tumor can be converted into malignant tumor as this disease is progressing. This type of cancer is classified into different types which are based on the presence of tumor in specific parts. The most common types of kidney cancer are Wilms tumor, Sarcoma, transitional cell carcinoma and Renal cell carcinoma. Men are having kidney cancer more often compared to women [1]. There are some studies in which are shown that the kidney cancer is the 7th most common cancer in men and 10th most common cancer in women all around the world. If you suffer from kidney cancer, then you must talk with your doctor about the best natural treatment for you.

Kidney cancer treatment

Increase fluid intake: You need to increase your fluid intake because it can help to cleanse the excess of toxins that are present in the body. In the most cases juices like organic honey in water and lemon juice can help to remove the heavy metals from the body. Juices can help to remove the toxins from your body and also they can provide essential minerals and nutrients which are required by our body for kidney cancer cure. Epsom salt: It is known that this natural cure can help to improve the overall functions of your kidneys by removing the waste and toxins from your kidneys. If you are suffering from diabetes and high blood pressure, then you should talk with your doctor before you start using the Epsom salt as your natural treatment for kidney cancer. Echinacea flower: The Echinacea flower has been used as a natural treatment for kidney cancer. It can help to cleanse the kidneys from the cadmium and it has anti – inflammatory effect on your body. You can use this herb in the form of tablets which are found in the medical shops for getting rid of the pain from the kidney cancer. [2] Baking soda: There are many people who do not believe that the simple baking soda can be very effective natural treatment for kidney cancer but in studies are believed that the baking soda can do it. Physicians are recommending the baking soda as a natural treatment for kidney cancer and the medical professionals are also saying that the baking soda can help to delay the need for dialysis treatment. Quit smoking: If you suffer from kidney cancer and you are smoker, then you should stop smoking [3]. Korean ginseng: For thousands of years, the roots of the Korean ginseng have been known as beneficial for health and longevity. There are many studies in which are said that the Korean ginseng is playing an important role in the prevention and treatment of kidney cancer. This natural cure can enhance the function of your immune system. There was a laboratory research in which is said that the Korean ginseng directly can inhibit the growth of kidney tumor and it can be considered as an effective home remedy for kidney cancer. Korean ginseng has a chemical component which can increase the blood pressure. People who are taking medications for blood pressure should talk with their doctor before they start using Korean ginseng as their natural treatment for kidney cancer. [4,5,6]

Natural cures for kidney cancer

Lowering blood pressure: Those people who suffer from kidney cancer and who have high blood pressure, should talk with their doctors about lowering the levels of blood pressure. [3] Vitamin D3: One of the most common risk factors for developing kidney cancer is the Vitamin D3 deficiency. It is known that the Vitamin D is required for the healthy immune function but there are many studies in which are shown that the deficiency in Vitamin D is on the rise, especially in older people. You can find the Vitamin D3 as a supplement form but also there are many foods which have it such as mushrooms, eggs, cod liver oil, fish oil, sardines, salmon and dairy products. There are rare cases when people have overdosed of Vitamin D3 but there are some cases which have occurred after taking doses upwards of 5,000 IU daily. Those people who are taking diuretic should talk with their doctors before they start using Vitamin D3 because this supplement can interfere with these medications. In the latest studies are said that the Vitamin D should be always taken with the Vitamin K for the best results. [7] Reishi: This is a very effective home remedy for kidney cancer. You can include 3 Reishi tablets per day which should be of 3 gm. There are some studies in which are said that this natural treatment can encourage the generation of protective immune system elements. [8] Goldenrod: This is an ancient herb which can be used as a natural treatment for kidney cancer. This herb is used for kidney cancer therapy by taking it with lots of fluids because this can increase the flow of urine in order to keep away kidney stone or diseases of the lower urinary tract [9]. Also it can help to reduce the size of kidney tumor and it can give a relief to patients from the unbearable pain in their kidneys due to tumor’s malignant growth. Maintaining a healthy body weight: It is very important  to maintain healthy body weight because it can help you to reduce your chances of getting kidney cancer. [3] Horsetail: This is one of the most common weeds which has diuretic properties. It can help to flush the kidneys are urinary tract by increasing the urine output. This natural cure has a positive impact on the renal system and kidneys. This natural cure is referred as an effective home remedy for kidney cancer because it is rich in silica. This is an essential component which is used to support the connective tissues and it can inhibit the growth of tumors in the body. You can consume horsetail in a form of tea or in a capsule form as your natural treatment for kidney cancer. [10] Astralagus: The astralagus is a very used home remedy for kidney cancer and it has been proven that it is useful to people who suffer from many different types of kidney cancer. This herb is well – known kidney restorer but also it is one of the best anti – tumor building herbs [11]. You can find astralagus in a form of tinctures, capsules and tablets. It is recommended to use 500 – 1000 mg of astralagus 3 times per day because it can help to prevent metastasizing. But also there are other doctors who are recommending 250 – 500 mg standardized extract, up to four times per day. This is a reason why you should always talk with your doctor for the proper dosage before you add astralagus as your natural treatment for kidney cancer. Cat’s claw: One of the most common natural cures which are used as a treatment for kidney cancer is the cat’s claw. This natural cure is mainly used to cure stomach ulcers, fever and inflammation. It can help to boost your immune system and also it can prevent kidney cancer and improve kidney health. You should make with cat’s claw and you should drink this tea two or three times a day. Also the cat’s claw tincture is very effective home remedy for kidney cancer. You should dilute the recommended cat’s claw dosage in half a cup of fresh water and you should add one teaspoon of lemon juice. This natural treatment for kidney cancer is effective and it is advisable for people who are not simultaneously taking insulin for the symptoms of diabetes. [12] Dahsen: This is a very popular antioxidant for the kidneys. It has antioxidants which can cause the cancer cells to self – terminate in laboratory animals [13]. The antioxidants are known as tanshinone IIA. Dahsen drug is not yet readily available but the dahsen extract can be found through herbal stockists and practitioners. This natural cure has side effects on the heart medications so this is a reason why you should talk with your doctor before you start using dahsen as your natural treatment for kidney cancer. References: [1] Shephard E, Neal R, Rose P, et al. Clinical features of kidney cancer in primary care: a case-control study using primary care records. British Journal of General Practice. 2013;63(609):e250-e255. [2] Bayramoglu G, Kabay S, Ozden H, et al. The effect of Echinacea on kidney and liver after experimental renal ischemia/reperfusion injury in the rats. African Journal of Pharmacy and Pharmacology. 2011;5(13):1561-66. [3] Chow WH, Dong LM, Devesa SS. Epidemiology and risk factors for kidney cancer. Nature Reviews Urology. 2010;7(5):245-57. [4] Lee YK, Chin YW, Choi YH. Effects of Korean red ginseng extract on acute renal failure induced by gentamicin and pharmacokinetic changes by metformin in rats. Food and Chemical Toxicology. 2013;59:153-159. [5] Chen S, Wang Z, Huang Y, et al. Ginseng and anticancer drug combination to improve cancer chemotherapy: A critical review. Evidence-based Complementary and Alternative Medicine. 2014;2014:168940. [6] Kim C, Lee JH, Baek SH, et al. Korean red ginseng extract enhances the anticancer effects of Sorafenib through abrogation of CREB and c-Jun activation in renal cell carcinoma. Phytotherapy Research. 2017;31(7):1078-1089. [7] Kim CS, Kim SW. Vitamin D and chronic kidney disease. The Korean Journal of Internal Medicine. 2014;29(4):416-427. [8] Zhong D, Wang H, Liu M, et al. Ganoderma lucidum polysaccharide peptide prevents renal ischemia reperfusion injury via counteracting oxidative stress. Scientific Reports. 2015;5:16910. [9] Melzig MF. Goldenrod--a classical exponent in the urological phytotherapy. Wiener Medizinische Wochenschrift. 2004;154(21-22):253-7. [10] Turker Y, Turkay M. Effects of Equisetumarvense Plant Extracts on the Kidney Stones and its Diuretic Action. Cell and Molecular Biology: Open Access. 2016;1(1). [11] Liao H, Hu L, Cheng X, et al. Are the therapeutic effects of Huangqi (Astragalus membranaceus) on diabetic nephropathy correlated with its regulation of macrophage iNOS activity? Journal of Immunology Research. 2017;2017:3780572. [12] Vattimo NFF, da Silva NO. Uncaria tomentosa and acute ischemic kidney injury in rats. Ravista da Escola de Enfermagem da USP. 2011;45(1). [13] Guan S, Ma J, Zhang Y, et al. Danshen (Salvia miltiorrhiza) injection suppresses kidney injury induced by iron overload in mice. PLoS One. 2013;8(9):e74318.