Renal Cell Carcinoma

Question 1

Define Renal Cell Carcinoma

Answer 1

Renal malignancy arising from the renal parenchyma/cortex

Accounts for 85% of kidney cancer

Question 2

Aetiology of Renal Cell Carcinoma

Answer 2

Unknown
Genetics:
 - Von Hippel-Lindau (VHL) (autdom)
 - Folliculin (FLCN)
 - Mesenchymal-epithelial transition factor (MET)
 - Fumarate hydratase (FH)
 - Succinate dehydrogenase (SDH) 
 - BAP1 

Renal cell carcinoma can spread haematogenously (classically to the lungs, leading to ‘cannon ball metastases’), locally (into the renal vein and inferior vena cava for example), and via the lymphatic system.

Renal cell carcinomas often present late on in their course, and up to 30% of patients may have metastases and a poor prognosis by that time.

Question 3

Risk factors for Renal Cell Carcinoma

Answer 3

Smoking (20-30% in men, 10-20% in women)
Male
Obesity 
Hypertension
Renal transplantation and end-stage renal disease 
Age >55
Residence in developed countries
Black/american-indian ethnicity 
\+ve family history of RCC
History of hereditary syndromes of acquired renal cystic disease

Question 4

Epidemiology of Renal Cell carcinoma

Answer 4

• Accounts for 80-90% of all kidney cancers

Median age 64

Question 5

Symptoms of Renal Cell Carcinoma

Answer 5

Renal carcinoma is often detected incidentally while such investigations are being performed for other conditions.

Macroscopic haematuria 
Flank pain 
Systemic symptoms: weight loss, lethargy, fever, sweats, pallor
Lower Limb swelling
Scrotal Varicoele

Von Hippel Lindau: vision loss

Question 6

Signs of Renal Cell Carcinoma

Answer 6

Haematuria
Palpable abdominal mass
Lower limb oedema (inferior vena cava involvement)
Scrotal varicocoele
Paraneoplastic presentation:
- Hepatic dysfunction: ascites, hepatomegaly, spider angiomata
- Myoneuropathy

Question 7

Investigations for Renal Cell Carcinoma

Answer 7

CT abdomen/pelvis: Renal mass, regional lymphadenopathy, and/or visceral/bone metastases
Biopsy: malignancy (not required when imaging

Urinalysis: haematuria and/or proteinuria

FBC: Reduced Hb or elevated RBCs (paraneoplastic)
LDH: raised 1.5x in advanced RCC
Corrected calcium: Raised 2/5x in advanced RCC
LFTs: ?mets/paraneoplastic
Coagulation: prolonged PT (paraneoplastic)
U+Es: Cr elevated

USS: abnormal cyst/mass, lymphadenopathy
MRI: renal mass
CT CAP: staging