Renal - Renal cancers

Question 1

what is the most common type of renal malignancy in adults? what cells do these arise from?

Answer 1

Renal cell carcinoma arising from PCT epithelial cells

Question 2

what is the most common type of renal malignancy in children? what cells do these arise from?

Answer 2

Wilm’s tumour (nephroblastoma) arising from metanephric blastemal cells

Question 3

what is the most common subtype of RCC? describe the cytopmorphology

Answer 3

Clear cell RCC: epithelial cells with clear cytoplasm due to glycogen accumulation and a well defined membrane, separated by delicate branching network of vascular tissue.

Question 4

describe an example of an inherited renal cancer

Answer 4

Von Hippel-Lindau Disease

• often involves both kidneys in younger men and women
• autosomal dominant mutation in VHL gene (tumour suppressor) on chromo. 3

Question 5

suggest risk factors for sporadic RCC

Answer 5

• male
• smoker
• obesity
• HTN
• long-term dialysis or renal transplant
• acquired renal cystic disease

Question 6

where do RCCs tend to spread?

Answer 6

1. Can extend into:
   - adjacent organs: adrenal glands, liver, spleen, colon, pancreas
   - local retroperitoneal LNs
   - renal vein and then IVC (increased risk of metastasis)
2. Can metastasise to:
   - lungs (most common) - cannon ball secondaries is almost diagnostic
   - bones - produce osteolytic lesions
   - brain

Question 7

how do RCC pts usually present

Answer 7

> 50% adult renal tumours detected using USS to investigate non-specific features.

Classic triad:

1. loin pain
2. haematuria
3. loin mass

+/- fatigue, weight loss, fever

Question 8

Suggest possible paraneoplastic syndromes that can occur as result of RCCs

Answer 8

1. EPO - polycythaemia
2. Renin - HTN
3. PTHrP - hypercalcaemia
4. ACTH - Cushing’s syndrome

Question 9

Why might a male pt with RCC present with a varicocoele?

Answer 9

Obstruction of L renal vein due to cancer spread or metastasis

Question 10

which investigations would you perform to diagnose someone with suspected RCC?

Answer 10

1. Bedside tests
   - urine dipstick: exclude UTI
   - urine MCandS: exclude UTI, +/- malignant cells
2. Bloods
   - FBC: ?iron-deficiency anaemia (haematuria), ?polycythaemia (EPO production)
   - UandE, creatinine, eGFR: should be normal if other kidney ok
   - calcium: ?hypercalcaemia (PTHrP production)
   - LFTs: ?liver mets
   - LDH: indication of RCC prognosis
3. Imaging
   - kidney contrast CT scan: best initial Ix
   - MRI or USS: if CT results equivocal
   - renal angiography: may be needed to assess blood supply
4. Other
   - renal biopsy: cytology

Question 11

which investigations would you perform to stage a RCC?

Answer 11

1. CXR or CT: may show classical cannon ball secondaries
2. bone scan: may be required for bone mets
3. brain CT: indicated if neuro Sx

Question 12

describe management for a pt with localised RCC

Answer 12

1. partial nephrectomy (1st line) if tumour <7cm diameter

2. +/- radiotherapy/ chemotherapy (poor response)

Question 13

describe management for a pt with advanced/metastatic RCC

Answer 13

1. nephrectomy
2. immunotherapy, e.g. IFNa
3. molecular therapy, e.g. sunitinib or pazopanib (tyrosine kinase inhibitors),