Renal cell carcinoma

Question 1

What is it?

Answer 1

Renal cell carcinoma (RCC) is the most common type of kidney tumour. It is a type of adenocarcinoma that arises from the renal tubules. The classic triad of presentation is haematuria, flank pain and a palpable mass.

Question 2

Types of Renal Cell Carcinoma

Answer 2

There are several subtypes of renal cell adenocarcinoma, the three most common being:

Clear cell (around 80%)
Papillary (around 15%)
Chromophobe (around 5%)

Wilms’ tumour is a specific type of tumour affecting the kidney in children, typically under 5 years.

Question 3

Risk Factors

Answer 3

Smoking
Obesity
Hypertension
End-stage renal failure
Von Hippel-Lindau Disease
Tuberous sclerosis

Question 4

Presentation

Answer 4

Renal cell carcinoma may be asymptomatic, but may present with:

Haematuria
Vague loin pain
Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
Palpable renal mass on examination

The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for those:

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

Question 5

Where does it spread?

Answer 5

Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava.

“Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.

Polycythaemia – due to secretion of unregulated erythropoietin
Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis

Question 6

Staging

Answer 6

A CT thorax, abdomen and pelvis are used to stage the cancer.

The TNM staging system is the most common staging system for renal cell carcinoma, rating the T (tumour), N (lymph node) and M (metastasis) stages.

There is also a number staging system specific to renal cell carcinoma:

Stage 1: Less than 7cm and confined to the kidney
Stage 2: Bigger than 7cm but confined to the kidney
Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia
Stage 4: Spread beyond Gerota’s fascia, including metastasis

Question 7

Management

Answer 7

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

Surgery to remove the tumour is the first-line, where possible. This may involve:

Partial nephrectomy (removing part of the kidney)
Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland)

Where patients are not suitable for surgery, less invasive procedures can be used to treat the cancer:

Arterial embolisation, cutting off the blood supply to the affected kidney
Percutaneous cryotherapy, injecting liquid nitrogen to freeze and kill the tumour cells
Radiofrequency ablation, putting a needle in the tumour and using an electrical current to kill the tumour cells

Chemotherapy and radiotherapy may also be used.