Renal Cell Carcinoma Flashcards
What is renal cell carcinoma (RCC) ?
Adenocarcinoma of renal cortex arising predominantly from the proximal convoluted tubules, most often appearing in the upper pole of the kidney.
How common is RCC?
- Most common form of renal tumour (accounting for 85% of all renal malignancies)
- 9th most common cancer worldwide
What are some other types of renal malignancies?
- Transitional cell carcinoma (urothelial tumours)
- Nephroblastoma in children (Wilm’s tumour)
- Squamous cell carcinomas
What are the risk factors?
- 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
How can RCC spread?
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.
What is tumour thrombosis in RCC?
Unique ability of RCC to invade through renal vein wall and into the lumen of the vessel.
What are the features of RCC?
- Classic triad = Present in 15% of patients
- Haematuria (Most common symptom)
- Visible/Non-visible
- Flanks/Loin pain
- Flank mass
- Haematuria (Most common symptom)
- Unspecific symptoms
- Weight loss, lethargy
- Left varicocoele
- Pararaneoplastic syndromes
- Features of metastasis (e.g. haemoptysis or pathological fractures)
What is the pathophysiology of paraneoplastic syndrome?
Ectopic secretion of hormones by RCC produce symptoms
What are paraneoplastic syndromes?
- Rare disorders that are triggered by an altered immune response to a neoplasm
- Non-metastatic systemic effects accompanying malignant disease
What are the different presentations of paraneoplastic syndromes?
- 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
Why can left varicoele occur as a feature of RCC?
Left-sided masses can cause compression of the left testicular vein as it joins the left renal vein.
Why do RCCs typically present late?
Kidneys are retroperitoneal so tumours often grow quite large before manifesting clinically
What percentage of RCCs are found on incidental abdo imaging?
50%
What are your differentials?
- Other urological malignancy
- Renal stones
- Urinary tract infection
What lab tests would you request for suspected RCC?
- 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.
Explain why you would do each lab test?
- 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
What imaging is useful in RCC?
- USS KUB
- CT abdo-pelvis pre & post IV contrast (GOLD STANDARD INVESTIGATION)
-
CT Chest
- For staging
How is RCC staged?
- 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
Is chemotherapy an effective treatment of RCC?
NO - It’s considered ineffective generally.
What is the management of localised RCC?
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
What is the management of metastasised RCC?
- Nephrectomy combined w/ immunotherapy
(e. g. IFN-α or IL-2 agents) - Biological agents (used in combination), such as:
* Sunitinib & Pazopanib (tyrosine kinase inhibitors) - Metastasectomy = Surgical resection of solitary metastases
What is the prognosis?
- 25% have metastases at presentation
- Survival for patients who have undergone nephrectomy = 70% at 3 years and 60% at 5 year