Renal cell carcinoma Flashcards
Define renal cell carcinoma.
Malignancy arising from the renal parenchyma/cortex, and accounts for about 85% of renal cancers.
How common is RCC? Who is most affected?
- M:F 2:1
- 50% found incidentally
- 85% of all renal cancers
What cells does renal cell carcinoma arise from? What is it also known as?
- Also known as von Grawitz tumour, hypernephroma
- Arising from the renal parenchyma/cortex
What is one biggest environmental and genetic risk factor for RCC?
Environmental:
- Smoking is most well established RF (implicated in 20-30%).
Genetics:
- In von Hippel-Lindau syndrome up to 30% develop RCC - germline inactivation of VHL allele on Chr 3p
What are the risk factors for RCC?
- Age 55-84yrs
- Smoking
- Male sex 2:1
- Obesity
- HTN
- FH
- Hx of renal cystic disease
- Dialysis (15%) - cysts commonly develop in patients with ESRF on dialysis –> high risk of developing RCC.
- Inherited syndromes - von Hippel-Lindau, tuberous sclerosis, familial papillary renal cell carcinoma
TCC risk factors - smokers, aniline dye workers and analgesic abusers (phenacetin).
SCC risk factors - chronic urinary stones
What are the signs and symptoms of RCC?
CLASSIC TRIAD: haematuria, loin pain, palpable abdominal mass
Other:
- Asymptomatic - 50% found incidentally - most cases sporadic, silent, solitary
- PUO (pyrexia of unknown origin)
- Night sweats
- Rarely polycythaemia
- Flank pain - <10%, usually in invasive disease
- Hepatic dysfunction - ascites, hepatomegaly, spider angiomata
- Varicocele in males - invasion of left renal vein compresses left testicular vein
- Underlying disease manifestations:
- Brit-Hogg-Dube syndrome- derm papules
- Hereditary leiomyomatous - skin fibromas
- Tuberous sclerosis - hypopigmented macules (ash leaf spots) or facial angiofibromas, dental pits, nail angiofibromas
- vHL - vision loss, retinal angiomatosis
What investigations would you do for RCC?
- BP - increased due to renin
- FBC - paraneoplastic syndrome; low Hb or elevated RBC (polycythaemia or iron deficiency anaemia (due to bleeding cyst))
- AlkPhos - raised ALP (bone mets)
- Urinalysis - RBCs in urine
- LDH - advanced RCC: >1.5 times the upper limit of normal
- Corrected calcium -poor prognosis if high
- LFTs - abnormal in paraneoplastic syndrome/metastatic disease: raised AST/ALT and poor function = metastasis; cholestasis (high bil, alkphos and GGT) with raised PT, thrombocytosis and hepatosplenomegaly = Stauffer’s syndrome (paraneoplastic presentation)
- Creatinine - elevated if reduced clearance
- Coagulation profile - eleated PT in paraneoplastic syndrome
Imaging:
- US abso/pelvis - abnormal renal cyst/mass, lymphadenopathy, visceral metastatic lesions
- CXR - cannon ball metastases
- CT/MRI
- IV urogram - filling defect +/- calcification
- Bone scan/PET scan
- Biopsy
What are 2 differentials for a patient presenting with loin discomfort and macroscopic haematuria?
What 3 further investigations would you do?
- MSU for culture and sensitivities
- Ultrasound renal tract
- Local Anesthetic Cystoscopy- checks fir LUT bladder/transitional cell cancer
- Renal carcinoma
- Transitional cell carcinoma renal tract
What is shown? What further investigations are needed? What is the most likely diagnosis?
An irregular defect is seen in the lower pole calyces of the left kidney. The right kidney appears normal, but CT urogram could miss a small lesion.
Investigations: biopsy and staging by ureteroscopy. CT chest for lung staging.
Why do patients with TCCs need to be followed up?
Most TCC’s occur in the bladder and synchronous (occuring at the same time) and metachronous (occuring later) lesions are common within the bladder, so cystoscopic follow up is needed for several years in moderately or poorly differentiated tumours.
What cancer do chronic stones predispose to?
SQUAMOUS carcinoma of the urinary tract (not TCC)
What is shown in relation to RCC?
Secondary lung metastases (lesions are rounded and there are 2 suggesting that it is not a primary malignancy)
Might get cannon ball metastases
What is shown here in relation to RCC?
Lytic lesions in the bone
What are the stages of RCC?
I and II - Early-stage confined to kidney without regional lymph node or distant mets.
III - extend into major veins, or invade the adrenal gland or perinephric tissue, but do not invade beyond the Gerota fascia. May be metastasis in single node.
IV - extend beyond the Gerota fascia or have distant metastasis.
What is the Gerota fascia?
Fibrous tissue around the kidney
