Malignant renal tumours

Question 1

What are some types of malignant renal tumour?

Answer 1

• Renal cell carcinoma
• Transitional cell carcinoma
• Adenocarcinoma
• Wilm’s tumour - Nephroblastoma

Question 2

What is renal cell carcinoma?

Answer 2

Adenocarcinoma of the renal cortex; most common type of kidney tumour

Question 3

What are some risk factors for renal cell carcinoma?

Answer 3

• Smoking
• Renal failure and dialysis
• Obesity
• Hypertension
• Low socio-economic status
• Asbestos, cadmium exposure, phenacetin
• Genetic - VHL

Question 4

Where in the kidney does RCC occur?

Answer 4

Proximal convoluted tubule

Question 5

What is the function of the Bosniak score?

Answer 5

Used to predict cancer vs cystic kidney disease (10-25% of RCC contains cysts)

Question 6

What are the 5 main histological classes of renal cell carcinoma?

Answer 6

Conventional clear cell carcinoma - 80%
Papillary - 10-15%
Chromophobe - 5%
Collecting duct - Rare
Medullary cell - rare

Question 7

Characteristics of conventional clear cell carcinoma

Answer 7

• Loss of VHL
• Clear cells - Cytoplasm rich in lipids and glycogen 3p deletion

Question 8

Characteristics of papillary RCC

Answer 8

Elongated papillae often with foamy cells

Question 9

Characteristics of chromophobe RCC

Answer 9

• Large cells with defined cell borders
• Atypical nuclei resembling raisins - ‘raisinoid’
• Histologically similar to oncocytomas

Question 10

Characteristics of Collecting duct RCC

Answer 10

• Young patients
• Poor prognosis
• Most aggressive cancer
• High grade carcinoma of mixed cell type

Question 11

Characteristics of medullary cell RCC

Answer 11

• Young patients
• Sickle cell patients
• Very poor prognosis

Question 12

What are some places that RCC can invade?

Answer 12

Renal vein
Vena cava -> Heart

Question 13

How may RCC present?

Answer 13

• Haematuria
• Loin mass
• Loin pain
• Pyrexia of unknown origin
• Varicoele

Question 14

What are some paraneoplastic syndromes of RCC?

Answer 14

Polycythaemia - 5%
Hypertension - 25%
Hypercalcaemia
Anaemia - 30%

Question 15

What causes polycythaemia in RCC?

Answer 15

Renal cell carcinoma may produce excessive erythropoietin (EPO)

Question 16

What causes hypertension in RCC?

Answer 16

Increased renin production by the tumour
Renal artery compression

Question 17

What causes hypercalcaemia in RCC?

Answer 17

Parathyroid hormone-related peptide (PTHrP)produced by the tumour

Question 18

What are some investigations required in RCC

Answer 18

• USS
• CT chest abdomen, pelvis for staging
• FBC
• Renal and liver function

Question 19

What are the 4 T grades of RCC?

Answer 19

• T1 - Up to 7cm
• T2 - >7cm confined to the kidney
• T3 - Extends beyond the kidney into the renal vein, perinephric fat, renal sinus and IVC
• T4 - Beyond Gerotas fascia into the surrounding structures

Question 20

How are small (<3-4cm) RCC tumours managed?

Answer 20

• Surveillance in elderly unfit patients
• Ablation techniques in fit, elderly patients and selected younger patients
• Partial nephrectomy

Question 21

How are medium (>3-4cm) RCC tumours managed?

Answer 21

• Surveillance, ablative techniques
• Partial nephrectomy
• Radical nephrectomy

Question 22

How are large RCC tumours managed?

Answer 22

Radical nephrectomy

Question 23

How is small volume metastatic RCC managed (E.g. 1 lung module)?

Answer 23

Nephrectomy, which in some cases may cause regression of the met

Question 24

How is wide-spread metastatic RCC managed?

Answer 24

observation and systemic anti-cancer treatment with immunotherapy and tyrosine kinase inhibitors

Question 25

What follow-up investigations are required in RCC?

Answer 25

• FBC, renal and liver functions
• Imaging - CT/USS + CXR
• Duration 5-10 years

Question 26

What is Wilm’s tumour?

Answer 26

Nephroblastoma
Cancer of the kidneys that typically occurs in children

Question 27

How will Wilm’s tumour present?

Answer 27

• Painless, palpable abdominal mass
• Loss of appetite
• Abdominal pain
• Fever
• Nausea and vomiting
• Haematuria

Question 28

What investigations are required in Wilm’s tumour?

Answer 28

USS initially, CT/MRI for more detailed imaging

Question 29

How is Wilm’s tumour managed?

Answer 29

Resection +/- radiotherapy depending on stage

Question 30

What is transitional cell carcinoma?

Answer 30

This is a cancer of the lining of the kidneys and ureter and therefore is technically also a cancer of the bladder

Question 31

How is transitional cell carcinoma managed?

Answer 31

This is treated with nephro-uretectomy as the ureters are also removed