Renal Cell Carcinoma

Question 1

What is RCC? [1]

What are the major types of malignant RCC? [2]

Answer 1

Renal Adenocarinoma
Tumor of the epithelial cells in PCT

85% - Clear Cell
10% - Papillary

Question 2

What are the risk factors for renal cell carcinoma? [6]

Answer 2

FH 
Smoking
Obesity
Anti-hypertensive treatment
ESRD
Acquired renal cystic disease

Question 3

Family history as a risk factor for RCC [3]

How does a RCC present? [4]

Answer 3

Von Hippel Lindau disease
Familial clear cell RCC
Hereditary papillary RCC

Mostly asymptomatically, incidental finding

10% show the classic triad of flank pain, mass and haematuria.

30% can have paraneoplastic syndromes

30% can have metastatic disease

Question 4

Where does RCC metastasize to? [4]

Signs of RCC on examination [4]

Answer 4

Bone
Brain
Lungs
Liver

OE:
palpable abdo mass, scrotal varicocele lower limb, oedema (IVC obstruction), hepatic dysfunction

Question 5

Describe some paraneoplastic syndrome resulting from RCC? [4]

Answer 5

• Cachexia & Pyrexia
• Hypertension, hypercalcaemia & deranged LFTs
• Anaemia, Polycythaemia & raised ESR (EPO)
• Myoneuropathy

Question 6

How does renal cell carcinoma tend to spread? [4]

Describe in terms of direct, venous, hematogenous and lymphatic invasion

Answer 6

o Direct invasion: through renal capsule
o Venous invasion: renal vein and IVC
o Haematogenous: to lungs, bone, brain and liver
o Lymphatic: to paracaval nodes

Question 7

What tests would you do to diagnose and stage renal cancer? [4]

Answer 7

Urinalysis showing both microscopic + macroscopic hematuria, proteinuria
FBC - anaemia, polycythemia
U&E, Cr, Ca, ESR, LFT, clotting profile
CT triple phase abdo & chest

Question 8

What other tests can be done to assess the contralateral kidneys function? [2]

Answer 8

DMSA or MAG-3 isotope testing

Question 9

How is RCC treated? [3]

Answer 9

Mainly Laparoscopic Radical Nephrectomy

Patients with small no of metastases can get palliative Cytoreductive Nephrectomy to prolong life

Some immunotherapy (e.g. with interferon-alpha) or Tyrosine Kinase Inhibitors (e.g. Sorafenib)

Question 10

Why isnt RT / Chemo used in RCC?

Answer 10

RCC is largely chemo and RT resistant

Question 11

How is RCC staged? [7]

Name 7 stages of ‘T’

Answer 11

T1 - in capsule <7cm
T2 - In capsule >7cm
T3 - Outside capsule
T3a - In fat
T3b - Renal Vein or IVC below diaphragm
T3C - IVC above diaphragm
T4 - Beyond Gerota's Fascia

Question 12

Prognosis for RCC?

Answer 12

Depends on stage:
T1 - very good 95% 5 yr survival
T4 - Very bad 20% 5 yr survival
M1 - 12-18months

Question 13

Von Hippel Lindau Disease

Answer 13

Autosomal dominant predisposing to neoplasia

Ch3p25 deletion mutation

Features:

• Cerebellar and retinal haemangiomas
• Renal cysts, RCC
• Phaeochromocytoma