Renal Cell Carcinoma

Question 1

Risk Factors

Answer 1

1. Smoking
2. Industrial Exposure
3. Prior Kidney Radiation
4. Von Hippel Lindau Syndrome
5. Hereditary Papillary RCC
6. Acquired Polycystic Kidney 2’ chronic dialysis (needs yearly ultrasound

Question 2

Types of RCC: Location, Pathogenesis, Prognosis

Answer 2

Question 3

What are some differentials

Answer 3

Benign:
1. Angiomyolipomas
2. Renal Cyst (Bosniak Classification to assess risk)
3. Renal Adenoma/Abscess
4. Pyelonephritis
5. Renal Oncocytoma

Malignant:
1. RCC
2. Wilms Tumour
3. Mets
4. Sarcoma

Question 4

What is the Bosniak Classification of Renal Cysts

Answer 4

Question 5

Clinical Presentation

Answer 5

1. Local Symptoms
   - Painless gross hematuria
   - flank pain
   - flank mass (firm, homogenous, moves with respiration)
2. Regional Symptoms
   - Left varicocele
   - extension into IVC = lower limb edema, ascites, liver dysfunction and PE
3. Systemic Symptoms
   - Retroperitoneal LN
   - Lungs, Liver, Bones, Brain
4. Paraneoplastic Syndromes
   - Hypertension
   - Liver Dysfunction (Stauffer Syndrome)
   - Hypercalcemia
   - Polycythaemia
   - Cushing Syndrome
   - Feminization or Masculinization

Question 6

Investigations

Answer 6

DIAGNOSIS
1. US Kidney: to differentiate cystic from solid renal masses, there are 3 major criteria: classical cyst will be (i) round and sharply demarcated with smooth walls, (ii) anechoic, and (iii) strong posterior acoustic enhancement (indicating good transmission through a cyst). If all 3 criteria are fulfilled, there is no need
for further evaluation. Otherwise, go for CT with contrast.

2. CT Kidney: a renal parenchymal mass with thickened irregular walls and enhancement after contrast injection suggests malignancy
3. IVU - mottled central calcification
4. Pathological Diagnosis
   - Perc biopsy/partial or total nephrectomy
   - in mets, biopsy met site

STAGING
1. CT TAP
2. Bone Scan\
3. MRI

OTHERS
1. Bloods Tests (FBC, RP, CRP/ESR, Ca/Mg/PO4, LFT)

Question 7

Staging for RCC

Answer 7

Question 8

What is the management?

Answer 8

-Resectable-
1. Surgery + Adjuvant + Surveillance

Surgery
- Partial Nephrectomy: T1 Disease
- Total Nephrectomy: T2 and above
- Radical Nephrectomy: Ligation of renal artery & vein (impt to prevent tumour dissemination at surgery), removal of kidney + Gerota’s fascia, and occasionally the adrenal gland as well (only if high risk of local invasion of adrenal) (Gold standard for T2 and above)

Adjuvant Chemo
- no established role

-Nonresectable-
- Most small tumours grow slowly and do not become symptomatic or metastasise – reasonable to manage conservatively with
periodic re-evaluation
- Alternatives: (heat) radiofrequency ablation, (freezing) cryotherapy of lesions

-Advanced Tumours-
1. Immunotherapy
▪ High dose interleukin-2
▪ Cytoreductive nephrectomy performed prior to starting immunotherapy can improve survival (primary tumour acts as an
‘immunologic sink’ of activated immune cells)
2. Molecular targeted therapy
▪ Sorafenib – an inhibitor of tyrosine kinase → blocks intracellular domain of the vascular endothelial growth factor (VEGF) receptor
▪ Bevacizumab – monoclonal antibody against VEGF

Question 9

Complications of Nephrectomy

Answer 9

• General anaesthesia – atelectasis, AMI, pulmonary embolism, CVA, pneumonia and thrombophlebitis
• Operative mortality rate is approximately 2%.
  ▪ Bleeding / Infections
  ▪ Pleural injuries can result in pneumothorax
  ▪ Injury neighbouring organs – gastrointestinal organs / major blood vessels
  ▪ Temporary or permanent renal failure

Question 10

Quick talk through the risk factors, clinical features, compliations, investigations and management of renal angiomyolipoma

Answer 10