Renal Cancer

Question 1

What is the most common form of adult renal cancer?

Answer 1

Renal cell carcinoma RCC

It is the 9th most common cancer worldwide

Question 2

Epidemiology of RCC

Answer 2

High incidence in developed countries

M 1.5:1 F

Peak incidence in 50-70 years

Question 3

Other renal cancers

Answer 3

TCC (urothelial tumours)

Nephroblastoma in children (Wilm’s tumour)

Squamous cell carcinoma (chronic inflammation secondary to renal calculi, infection and schistosomiasis)

These flashcards will however focus on RCC

Question 4

Pathophysiology of RCC

Answer 4

Adenocarcinoma of the renal cortex, usually arise from the proximal convoluted tubules.

Most often appearing in the upper pole of the kidney.

They can spread through direct invasion to perinephric tissues, adrenal gland, renal vein or IVC.

RCC can also spread via lympathics to pre-aortic and hilar nodes or via blood to bones, liver, brain and lung.

Question 5

What is tumour thrombosis?

Answer 5

RCCs have a distinct features where they can invade through the renal vein wall and into the lumen.

Question 6

Microscopic findings

Answer 6

Polyhedral clear cells

Dark staining nuclei and cytoplasm rich with lipid and glycogen granules

Question 7

Risk factors

Answer 7

Smoking

Industrial exposures like cadmium, lead or aromatic hydrocarbons

Dialysis (30x increase)

HTN

Obesity

Anatomical abnormalities like polycystic kidney or horseshoe kidney

von Hippel-Lindau

BAP1 mutant disease

Birt-Hogg-Dube syndrome

Question 8

Clinical features

Answer 8

Haematuria visible or non-visible

Flank pain

Flank mass

Non-specific symptoms like lethargy or weight loss.

Around 50% are detected incidentally on abdo imaging.

Classic triad is supposed to be haematuria, mass and flank pain but only present in 15% of cases.

Question 9

Examination findings

Answer 9

Large RCC can be palpated in the flank or hypochondrial regions

Left-sided masses may also present with a left varicocoela.

Question 10

Paraneoplastic syndromes of RCC

Answer 10

Polycythaemia (EPO)

Hypercalcaemia

Hypertension (renin)

Pyrexia of unknown origin

Question 11

Dx

Answer 11

Urological malignancy

Renal stones

UTI

Question 12

Lab tests

Answer 12

Routine bloods with FBC, U&Es, calcium, LFTs and CRP

Urinalysis + cytology

There are no serum tumour markers avaiable to aid in diagnosis of RCC

Question 13

Imaging

Answer 13

As for most cases of haematuria -> USS or CT is done first

CT abdo-pelvis pre and post IV contrast is gold standard for suspected cases

Additional CT abdo-chest-pelvis is done for staging.

Biopsy of renal lesions, particularly small masses can be done.

Question 14

When is renal biopsy done

Answer 14

In small renal masses when surveillance or minimally invasive ablative therapies are being considered.

Question 15

Staging of RCC

Answer 15

American Joint Committe on Cancer AJCC

Question 16

Explain AJCC

Answer 16

TNM staging

S1 - T1N0M0 with tumour 7cm or less and confined to renal capsule

S2 - T2N0M0 with tumour >7cm or invading the renal capsule but confined to Garota’s fascia

S3 - T3 or N1M0 with tumour extending into renal vein, vena cava or spread to 1 local LN

S4 - T4N2 or M1 with tumour extending beyond Garota’s fascia, >1 LN, involvement of ipsilateral adrenal gland or perinephric fat or distant metastases.

Question 17

Management of localised disease

Answer 17

Surgical management either through laparoscopy or open approach.

Question 18

Management of localised small tumours

Answer 18

Partial nephrectomy may be suitable

Question 19

Management of localised large tumours

Answer 19

Radical nephrectomy with removing the kidney, perinephric fat and local LN

Question 20

If the patient isn’t suitable or fit for surgical management in localised disease, what can be done?

Answer 20

Percutaneous radiofrequency ablation or laparoscopic/percutaneous cryotherapy.

Renal artery embolisation can also be done prior.

Surveillance of slow growing small renal masses can be employed in patients unfit or unwilling to undergo surgery with a limited life expectancy.

Question 21

Management of metastatic disease

Answer 21

Nephrectomy + immunotherapy with IFN-alpha or IL-2 agents is often recommended

Biological agents like Sunitinib and pazopanib can be used

Metastasectomy is recommended where it can be done

Chemotherapy is considered ineffective.

Question 22

Prognosis

Answer 22

25% have metastases at presentation

Survival underogone nephrectomy is around 70% at 3 years and 60% at 5 years.