RCC

Question 1

def of RCC

Answer 1

primary malignancy of the kidney

Question 2

pathology of RCC

Answer 2

Robson staging

arise from any portion of kidney (usually poles), from proximal reanl tubular epithelium

spherical mass composed of yellow-white tissue, may have necrosis, haemorrhage or calcification

90% adenocarcinomas with small nuclei and abundant clear cytoplasm, other granular cells, occasionally sarcomatoid

rarely, invasion of renal vein compresses L testicular vein = varicocoele

spread is often along the renal vein, with tumour emboli to the lungs

met to lymph nodes, bone liver and skin

Question 3

aetiology of rcc

Answer 3

renal clear cell carcinomas (80%) or papillary carcinomas (10%) are derived from proximal tubular cells of unknown aetiology

10% are transitional cell carcinomas that occur in renal pelvis

associated with inherited conditions: von hippel-lindau disease, tuberous sclerosis, polycystic kidneys and familial RCC

smoking

obesity

FH

chronic dialysis

chemical exposure (eg benzene, asbestos, trichloroethylene)

RCC can be associated with abnormal LFT in the absence of liver metastases, a phenomenon known as Stauffer’s syndrome

Question 4

epidemiology of rcc

Answer 4

uncommon approx 3% of all malignancies

M:F 2:1

peak incidence is 40-60yrs

90% of all renal cances

15% haemodialysis pts get RCC

Question 5

sx of rcc

Answer 5

usually present late (asymptomatic in 90%)

classic triad: haematuria, flank pain, abdo mass (only in 10%)

transitional cell carcinoma - usually present earlier with haematuria

systemic signs of malignancy - weight loss, anorexia, malaise, paraneoplastic syndromes: pyrexia of unknown origin, symptoms of hypercalcaemia or polycythamia

PUO?

Question 6

signs of rcc

Answer 6

palpable renal mass

hypertension, plethora or anaemia

L sided tumour extending into L renal vein can obstruct the L testicular vein causing L sided varicocele

raised BP because of renin secretion

Question 7

ix for rcc

Answer 7

• urine dipstick - haematuria, cytology
• Blood - FBC (polycythaemia from erythropoitin secretion), U&E, LFT, high ESR in 75%, ALP (bony mets)
• US abdo - 1st line, distinguish between solid mass and cystic
• KUB and IVU are limited - only detect large lesions that change renal contour or compress ureters
• CT with contrast of MRI more sensitive, staging - ‘cannonball mets’
• bone scan

Question 8

Management of early-stage RCC (T1 and T2)

Answer 8

surgery for localised
* partial nephrectomy up to 7cm / radical nephrectomy
ablative therapies if high surgical risk

Question 9

Management of locally advanced RCC (T3 and T4)

Answer 9

radical nephrectomy

Question 10

Management of metastatic RCC

Answer 10

surgery if good performance status and few isolated sites of disease
low risk: VEGF inhibitors eg sunitinib
immediate/high risk = dual immunotherapy: ipilimumab and nivolumab

Question 11

complications of renal cell carcinoma

Answer 11

Anaemia (up to 30%)
Hypercalcaemia
Polycythaemia
SIADH
Cushing’s syndrome
Stauffer’s syndrome (liver dysfunction due to paraneoplastic syndrome in the absence of liver metastases)
IVC obstruction due to malignant invasion
Limbic encephalitis: rare disorder characterised by personality changes,, depression, seizures and memory loss.

Question 12

adverse effects of systemic rx for RCC

Answer 12

Immunotherapy:
* rash,
* pneumonitis,
* colitis,
* thyroid dysfunction
* hypophysitis.

Complications can present over a year after treatment.

VEGF inhibitors:
* mucositis,
* leukopaenia,
* peripheral neuropathy,
* fever,
* arthralgia,
* electrolyte imbalance.

Question 13

px of renal cell cancer

Answer 13

5yr survival >68%