Renal Cell Carcinoma

Question 1

Define RCC and give the 2 subtypes

Answer 1

Malignancy arising from the renal parenchyma/cortex. 85% of kidney cancers

• Clear cell RCC accounts for the majority (over 80%) of primary renal malignancies.
• Papillary carcinoma (10%)

Question 2

State some risk factors for RCC

Answer 2

• smoking
• male sex
• age >55 years
• residence in developed countries
• black/American-Indian ethnicity
• obesity
• hypertension
• positive family history of RCC
• history of hereditary syndromes- Von Hippel Lindau syndrome associated with clear cell RCC
• history of acquired renal cystic disease (eg PKD increases risk by 30-50x)

Question 3

Summarise the epidemiology of renal cell cancer

Answer 3

• UNCOMMON
• 4% of all adult malignancies
• Median age at diagnosis of 64 years
• Kidney cancer is the sixth and seventh most common diagnosed adult malignancy in men and women, respectively.

Question 4

Recognise the presenting symptoms of renal cell cancer

Answer 4

Presence of risk factors- smoking, male sex, age over 55 years, obesity, hypertension, positive family history of renal cancer, and history of hereditary syndrome.

Asymptomatic- >50% of RCCs are diagnosed incidentally

Triad of symptoms in locally advanced disease (10%):

1. Haematuria- microscopic or gross. Can occur on its own in less advanced disease. In TCC it occurs earlier
2. Flank pain
3. Palpable abdominal mass

Non-specific systemic symptoms of malignancy from paraneoplastic presentations of RCC occur in up to 20% of patients. May include:

• fever
• weight loss
• sweats
• pallor
• cachexia
• myoneuropathy

25% have metastases at presentation

Question 5

Recognise the signs of renal cell cancer on physical examination

Answer 5

• Palpable renal mass
• Hypertension
• Plethora- flushed complexion
• Anaemia
• A left-sided tumour can obstruct the left testicular vein as it joins the left renal vein, and cause a left-sided varicocoele

Question 6

Identify appropriate investigations for renal cell cancer

Answer 6

BLOODS

• FBC- paraneoplastic syndrome: reduced Hb, or elevated red blood cells
• LDH - advanced RCC: >1.5x upper normal
• corrected calcium
• liver function tests- poor liver function indicated metastases
• coagulation profile- paraneoplastic syndrome: elevated PT
• creatinine- Elevated due to chronic renal insufficiency either preceding or due to RCC.

URINE

• Neither sensitive nor specific
• But significant proteinuria/haematuria can indicate renal dysfunction from a variety of causes, including RCC.
• could also do culture

IMAGING

• abdominal/pelvic ultrasound-
  
  • best first-line investigation
  • can distinguish between solid masses and cystic structures
  • contrast-enhanced USS is much more accurate
• CT abdomen/pelvis
  • definitive test for diagnosis and staging of RCC.
  • contrast-enhanced CT has 100% specificity and ≥90% sensitivity for characterising a renal mass as malignant.
• MRI abdomen/pelvis
  
  • Modality of choice for diagnosis and staging in patients where contrast dye is contraindicated
  • (due to renal insufficiency or allergy).

Question 7

Staging system for RCC?

Answer 7

Robson staging system

stage I: limited to kidney

stage II: involvement of perinephric fat but remains limited to Gerota’s fascia

stage III

• IIIa: renal vein involvement
• IIIb: nodal involvement
• IIIc: both IIIa and IIIb

stage IV

• IVa: direct invasion of adjacent organs / structures
• IVb: distant metastases