Renal Cell Carcinoma

Question 1

What is renal cell carcinoma (RCC) ?

Answer 1

Adenocarcinoma of renal cortex arising predominantly from the proximal convoluted tubules, most often appearing in the upper pole of the kidney.

Question 2

How common is RCC?

Answer 2

• Most common form of renal tumour (accounting for 85% of all renal malignancies)
• 9th most common cancer worldwide

Question 3

What are some other types of renal malignancies?

Answer 3

• Transitional cell carcinoma (urothelial tumours)
• Nephroblastoma in children (Wilm’s tumour)
• Squamous cell carcinomas

Question 4

What are the risk factors?

Answer 4

• Living in developed country
• Male (1.5x more common)
• Age 50-70 yrs
• Smoking (most common risk factor)
• Industrial exposure to carcinogens
  
  • Cadmium, lead, or aromatic hydrocarbons
• Dialysis
• Hypertension
• Obesity
• Anatomical abnormalities
  
  • Polycystic kidneys & Horseshoe kidneys
• Genetic disorders
  
  • von Hippel-Lindau syndrome

Question 5

How can RCC spread?

Answer 5

Can spread via:

• Direct invasion into perinephric tissues, adrenal gland, renal vein or the inferior vena cava.
• Lymphatic spread to pre-aortic and hilar nodes
• Haematogenous spread to the bones, liver, brain and lung.

Question 6

What is tumour thrombosis in RCC?

Answer 6

Unique ability of RCC to invade through renal vein wall and into the lumen of the vessel.

Question 7

What are the features of RCC?

Answer 7

• Classic triad = Present in 15% of patients
  
  • Haematuria (Most common symptom)
    
    • Visible/Non-visible
  • Flanks/Loin pain
  • Flank mass
• Unspecific symptoms
  
  • Weight loss, lethargy
• Left varicocoele
• Pararaneoplastic syndromes
• Features of metastasis (e.g. haemoptysis or pathological fractures)

Question 8

What is the pathophysiology of paraneoplastic syndrome?

Answer 8

Ectopic secretion of hormones by RCC produce symptoms

Question 9

What are paraneoplastic syndromes?

Answer 9

• Rare disorders that are triggered by an altered immune response to a neoplasm
• Non-metastatic systemic effects accompanying malignant disease

Question 10

What are the different presentations of paraneoplastic syndromes?

Answer 10

• Polycythaemia due to erythropoetin
• Hypercalcaemia due to parathyroid hormone
• Hypertension due to renin
• Pyrexia of unknown origin
• Stauffer syndrome – paraneoplastic hepatic dysfunction syndrome which presents with chloestasis and hepatosplenomegaly
• Pyrexia of unknown origin

Question 11

Why can left varicoele occur as a feature of RCC?

Answer 11

Left-sided masses can cause compression of the left testicular vein as it joins the left renal vein.

Question 12

Why do RCCs typically present late?

Answer 12

Kidneys are retroperitoneal so tumours often grow quite large before manifesting clinically

Question 13

What percentage of RCCs are found on incidental abdo imaging?

Answer 13

50%

Question 14

What are your differentials?

Answer 14

• Other urological malignancy
• Renal stones
• Urinary tract infection

Question 15

What lab tests would you request for suspected RCC?

Answer 15

• Initial routine bloods tests
  
  • FBC, U&Es, Calcium, LFTs, CRP
• Urinalysis & Cytology
• Biopsy of renal lesions (maybe)
  
  • Esp for small renal masses when surveillance or minimally invasive ablative therapies considered.

Question 16

Explain why you would do each lab test?

Answer 16

• FBC
  
  • Look for anaemia / erythrocytosis
• U&Es
  
  • Assess kidney function
• Calcium
  
  • Look for hypercalcaemia
• LFTs
  
  • Deranged LFT’s may indicate metastases
• Urinanalysis
  
  • Protein/blood in urine

Question 17

What imaging is useful in RCC?

Answer 17

• USS KUB
• CT abdo-pelvis pre & post IV contrast (GOLD STANDARD INVESTIGATION)
• CT Chest
  
  • For staging

Question 18

How is RCC staged?

Answer 18

• Stage 1 (T1N0M0)
  
  • Tumour ≤7 cm and confined to the renal capsule
• Stage 2 (T2N0M0)
  
  • Tumour >7 cm or invading the renal capsule (but confined to Gerota’s fascia)
• Stage 3 (T3 or N1M0)
  
  • Tumour extending into the renal vein, vena cava, or spread to 1 local lymph node
• Stage 4 (T4N2 or M1)
  
  • Tumour extending beyond Gerota’s fascia, >1 local lymph node, involvement of ipsilateral adrenal gland or perinephric fat, or distant metastases

Question 19

Is chemotherapy an effective treatment of RCC?

Answer 19

NO - It’s considered ineffective generally.

Question 20

What is the management of localised RCC?

Answer 20

For patients that can tolerate surgery (1st line approach):

• Partial nephrectomy (for small tumours)
• Radical nephrectomy (for large tumours)
  
  • To remove kidney, perinephric fat & associated lymph nodes

For patients that are not suitable / fit for surgery:

• Percutaneous radiofrequency ablation
• Cryotherapy
• Renal artery embolisation
  
  • For haemorrhaging disease / unresectable palliative case or prior to radiofrequency ablation

In patients unfit / unwilling to undergo surgery with a limited life expectancy:

• Surveillance of slow growing small renal masses

Question 21

What is the management of metastasised RCC?

Answer 21

1. Nephrectomy combined w/ immunotherapy
   (e. g. IFN-α or IL-2 agents)
2. Biological agents (used in combination), such as:
   * Sunitinib & Pazopanib (tyrosine kinase inhibitors)
3. Metastasectomy = Surgical resection of solitary metastases

Question 22

What is the prognosis?

Answer 22

• 25% have metastases at presentation
• Survival for patients who have undergone nephrectomy = 70% at 3 years and 60% at 5 year