renal cancer

Question 1

what is the most common types of renal cancer?

Answer 1

adenocarcinoma most commonly arising from the epithelium of the proximal convoluted tubule

Clear cell carcinoma is the most common histological variant

Question 2

which genes plays a role in renal cancer?

Answer 2

The vast majority are sporadic and due to a deletion in the VHL tumour suppressor gene

A small minority are hereditary and associated with Von Hippel-Lindau (RCC, pheochromocytoma, and cerebellar hemangioblastoma) and tuberous sclerosis.

Question 3

what are the risk factors for renal cell carcinoma?

Answer 3

Increasing age: peak age between 60 and 70 years of age
Male: 3:2 ratio of men to women
Black ethnicity
Hereditary e.g. Von Hippel-Lindau
Smoking: the single greatest modifiable risk factor
Obesity 
Hypertension
Haemodialysis

Question 4

what is the classic triad for renal cancer?

Answer 4

• flank pain
• haematuria
• abdominal mass
• weightloss, fatigue, fever

Question 5

what may you see on examination of a patient with renal cancer?

Answer 5

• flank mass
• left sided variocele- left testicular vein drains into the left renal vein, a renal carcinoma can invade the renal vein and cause backpressure leading to varioecle formation
• may have hypertention as this is a risk facote for disease

may have evidence of mets: SOB, liver disease, bone pain

Question 6

which primary investigations would you do when suspecting a renal cancer?

Answer 6

bedside:
- urinalysis

bloods:
FBC: anaemia of chronic disease or polycythemia because of EPO production from cancerous cells

UandE= renal function

LFT and coagulation profile: derrangement suggests liver mets

LDH: if elevated is a poor prognostic marker

imaging:
- abdominal USS= a sesnsitive initial modality
CT abdo pelvis= definative diagnosis

Question 7

apart form primary USS and CT which other investigations would you consider for RCC?

Answer 7

CT chest: if initial imaging suggests malignancy, a CT chest is needed to complete staging and assess for pulmonary metastasis

Bone scan: if there is evidence of bony metastases, e.g. pain or hypercalcaemia

Renal biopsy: there is a risk of tumour seeding to surrounding structures so not generally performed, but may be considered after MDT discussion

Question 8

what is the management for localised disease?

Answer 8

Partial nephrectomy: standard for T1 tumours (i.e. ≤ 7cm) and performed with curative intent

Radical nephrectomy: standard for T2-T4 tumours (i.e. > 7cm). Local lymph node dissection and adrenalectomy may be considered if these structures are involved

Minimally-invasive procedures: reserved for patients unfit for surgery, e.g. radiofrequency ablation or embolisation

Question 9

what is the managment for metastatic disease

Answer 9

Molecular therapy: Sunitinib and Pazopanib (receptor tyrosine kinase inhibitors) are first-line agents

Radiotherapy: some patients are suitable for palliative radiotherapy

Cytoreductive surgery: some patients are suitable for a debulking, non-curative nephrectomy as there is evidence for a slight improvement in survival

Question 10

what are the complications of renal cancer?

Answer 10

Metastasis: adrenal, liver, bone, lung, brain

Paraneoplastic: polycythaemia (EPO), hypercalcaemia (PTHrP), Cushing’s syndrome (ACTH)

Stauffer syndrome: also known as paraneoplastic nephrogenic hepatomegaly. RCC results in hepatomegaly, cholestasis and cholestatic jaundice, possibly secondary to increased IL-6 concentrations

Question 11

what is stauffer syndrome?

Answer 11

paraneoplastic nephrogenic hepatomegaly.

RCC results in hepatomegaly, cholestasis and cholestatic jaundice, possibly secondary to increased IL-6 concentrations