Renal Cancer + Renal Cysts

Question 1

What are the different types of renal cancer?

Answer 1

Renal cell carcinoma (adenocarcinoma) - 85%
Transitional cell
Nephroblastoma (Wilm’s tumour) - children
SCC - secondary to calculi, infection + schistosomiasis

Question 2

How does RCC spread?

Answer 2

Direct invasion:
- perinephric tissues
- adrenal gland
- renal vein (tumour thrombosis)
Lymphatic:
- pre-aortic + hilar nodes
Haematological:
- bones
- liver
- brain
- lungs

Question 3

What are the risk factors for RCC?

Answer 3

Smoking
Industrial exposure to carcinogens:
- cadmium, lead, aromatic hydrocarbons
Dialysis (30x increase)
Hypertension
Obesity
Anatomical abnormalities:
- polycystic kidneys
- horseshoe kidneys
Von Hippel-Lindau disease

Question 4

What are the clinical features of RCC?

Answer 4

Haematuria (most common PC)
Flank pain
Flank mass
Lethargy, weight loss
Left mass --> left varicocele (compression left testicular vein)
Paraneoplastic syndrome

Question 5

What paraneoplastic syndrome may be caused by RCC?

Answer 5

Epo –> polycythaemia
Parathyroid hormone –> hypercalcaemia
Renin –> hypertension
Pyrexia of unknown origin

Question 6

Which investigations should be done for suspected RCC?

Answer 6

Routine bloods
Urinalysis (blood) + send for cytology
Initially USS or CT as for any haematuria

Question 7

What is the gold standard for diagnosis of RCC?

Answer 7

CT abdo pelvis - pre and post IV contrast

Additional chest CT once diagnosis confirmed

Question 8

How is RCC staged?

Answer 8

Stage 1:
- < 7cm and confined to renal capsule
Stage 2:
- > 7cm or invading renal capsule (but confined to Gerota's fascia)
Stage 3:
- extending into renal vein, vena cava or spread to 1 lymph node
Stage 4:
- beyond Gerota's fascia
- >1 local lymph node
- adrenal gland or perinephric fat
- distant mets

Question 9

How is localised RCC managed?

Answer 9

Surgery:

• partial nephrectomy
• or radical nephrectomy

If not fit for surgery:

• percutaneous radio frequency ablation
• or cryotherapy

Question 10

How is metastatic RCC managed?

Answer 10

Nephrectomy + immunotherapy (IFN alpha or IL-2 agents)

Chemo not effective for RCC

Question 11

How are renal cysts classified?

Answer 11

Simple (well defined, homogenous)

Complex (thick walls, septations, calcification, heterogenous enhancement) –> risk of malignancy

Question 12

Which genetic conditions cause renal cysts?

Answer 12

Polycystic kidney disease
Tuberous sclerosis
Von Hippel-Lindau disease

Question 13

What are the types and features of polycystic kidney disease (PKD)?

Answer 13

Autosomal dominant PKD:
- mutations in PKD1 or PKD2 –> multiple renal cysts

Autosomal recessive PKD –> diagnosed in utero, most don’t survive first month of life

Question 14

What are the clinical features of autosomal dominant PKD?

Answer 14

Associated with:

• berry aneurysms
• mitral valve disease
• liver cysts

May present with uncontrolled hypertension or a flank mass

Patients eventually develop end stage renal failure –> dialysis or transplant

Question 15

What are the clinical features of renal cysts?

Answer 15

Usually asymptomatic - found incidentally on imaging

Flank pain if cyst ruptures or becomes infected
Haematuria

Question 16

Which investigations should be done for a suspected renal cyst?

Answer 16

Usually picked up on USS

But definitive diagnosis
–> CT or MRI with pre- and post- IV contrast images

Question 17

Which system is used to classify renal cysts and guide management?

Answer 17

Bosniak Scoring system
based on CT scan
- stage 1 is simple cyst
- stage 2-4 are complex

Question 18

What is the management of each stage of renal cyst?

Answer 18

1 --> no follow up
2 --> no follow up
2F --> CT at 3, 6 + 12 months
3 --> surveillance or surgical
4 --> surgical

Question 19

How can a symptomatic simple cyst be managed?

Answer 19

Simple analgesia initially
If significantly impacting patient:
- needle aspiration or cyst deroofing