Renal Cell Carcinoma

Question 1

What are the types of renal cell carcinoma?

Answer 1

Adenocarcinoma of the renal parenchyma or Nephroblastoma (Wilm’s) which can occur in children and is very rare. Clear cell is the most common 70%, associated with Von-Hippel Lindau syndrome. Also Papillary, Chromophobe (less aggressive), Collecting duct (rare highly aggressive) and Medullary (rare associated with sickle cell and aggressive).

Question 2

Where does renal cell carcinoma spread to?

Answer 2

Usually spread to bone liver and lung.

Question 3

What causes renal cell carcinoma?

Answer 3

Heavy Smoking
Obesity
Family history and genetic syndromes 
Middle aged men 
Tuberous sclerosis

Question 4

What are the signs and symptoms of renal cell carcinoma?

Answer 4

Usually incidental findings
Haematuria
Triad of (loin pain, haematuria, palpable mass seen in 10%)
Anorexia
Malaise
Weight loss
Rarely varicocele due to occlusion of left testicular vein

Question 5

What paraneoplastic syndrome occurs from renal cell carcinoma?

Answer 5

Paraneoplastic syndromes
Stauffer’s syndrome (abnormal LFTs) thought to be due to IL6
Hypercalcaemia
Hypertension
Increase or decrease in erythropoietin causing Polycythaemia or anaemia
Pyrexia of unknown origin

Question 6

What investigations should be done in suspected renal cell carcinoma?

Answer 6

Urinalysis and culture

USS picks up most
CT with contrast needed to confirm/stage
CXR may show cannon ball metastasis

Should check BP due to increase renin release
FBC, Us and Es, LFT and ALP (bony mets)

Question 7

What are the Bosniak classification of renal cysts?

Answer 7

Bosniak classification of renal cysts 
I benign simple
II mildly complex but benign
IIF very likely benign but needs follow up
III 60% chance of cancer
IV definite RCC

Question 8

Describe the TNM staging criteria for renal cell criteria?

Answer 8

TNM staging 
T1 – 1-7cm split into T1a and T1b
T2 – >7cm - split into T2a and T2b 
T3 – perinephric fat and renal vein invasion 
T4 into adjacent structures

Question 9

How is renal cell carcinoma managed?

Answer 9

RCC generally radio and chemo resistant so surgery is the main treatment but must assess function of contralateral kidney first.
Partial or full Nephrectomy (robotic or open radical)
Surveillance (elderly or co-morbidity)
Ablation (cryotherapy or radiofrequency) but must have biopsy first

Question 10

How is renal cell carcinoma managed palliatively?

Answer 10

In palliative patients
Tyrosine Kinase inhibitors such as Sunitinib – interferes with VEGEF pathway
Immune Checkpoint inhibitors – Nivolumab and Atezolizumab

Question 11

Describe upper tract TCC?

Answer 11

Uncommon
Present with haematuria
CT urogram investigation of choice
Biopsy may be needed to confirm diagnosis
Small tumours can sometimes be treated with laser ablation
Majority treated with Nephro-ureterectomy