Renal Cell Carcinoma

Question 1

What type of cancer is renal cell carcinoma?

Answer 1

Adenocarcinoma

Question 2

Where does RCC most commonly arise from?

Answer 2

Epithelium of the proximal convoluted tubule

Question 3

What are the subtypes of renal cell carcinoma?

Answer 3

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

Question 4

What are the risk factors for renal cell carcinoma?

Answer 4

Increasing age
Male
Black ethnicity
Smoking
Obesity
Hypertension
Haemodialysis
Von HIppel-Lindau disease

Question 5

What are the clinical features of renal cell carcinoma?

Answer 5

50% of patients are asymptomatic
Classic triad:
- Haematuria
- Flank pain
- Abdominal mass
Weight loss
Fatigue
Fever
Flank mass
Left-sided varicocele
Hypertension

Question 6

Why might RCC cause left-sided varicocele?

Answer 6

Left testicular vein drains into the left renal vein - a left RCC can invade the renal vein causing backpressure and varicocele formation
- The right testicular vein drains directly into the IVC

Question 7

Who should be referred for a two week wait?

Answer 7

Any patient aged over 45 with unexplained visible haematuria

Question 8

What stage of RCC are patients typically at on presentation?

Answer 8

Stage 4 (metastatic)

Question 9

What are the primary investigations for RCC?

Answer 9

FBC - anaemia of chronic disease
U&Es - renal dysfunction
LFTs and coagulation
Bone profile - elevated calcium is poor prognostic marker
LDH
Abdominal ultrasound

Question 10

What is the definitive test for diagnosis of RCC?

Answer 10

CT abdo/pelvis with contrast

Question 11

What is the management of localised RCC?

Answer 11

Partial nephrectomy (T1)
Radical nephrectomy (T2-T4) - may include lymph node dissection and adrenalectomy

Question 12

What is the management of metastatic RCC?

Answer 12

Molecular therapy (sunitinib and pazopanic)
Radiotherapy
Cytoreductive surgery

Question 13

What is the staging of RCC?

Answer 13

T1 - tumour <7cm and confined to kidney
T2 - tumour >7cm and confined to kidney
T3 - tumour extends into major veins and perinpehric tissues, but not ipsilateral adrenal or renal fascia
T4 - tumour invades beyond renal fascica (Gerota’s fascia)

Question 14

What are the complications of RCC?

Answer 14

Metastasis - adrenal, liver, bone, lung, brain
Paraneoplastic - EPO, PTH, ACTH
Stauffer syndrome

Question 15

What paraneoplastic syndromes is RCC associated with?

Answer 15

Polycythemia - excess EPO
Hypercalcaemia - secretion of hormoe that mimics PTH
Hypertension - increased renin, polycythaemia and physical compression
Stauffer’s syndrome - abnormal LFTs without liver mets

Question 16

What are cannonball metastases?

Answer 16

Metastases to the lungs that appear as clearly-defined circular opacities on CXR