Urological Malignancy - Renal Cell Carcinoma Flashcards
What is a Renal Cell Carcinoma?
Hypernephroma; Adenocarcinomas that account for 85% of primary renal neoplasms, arising from the proximal renal tubular epithelium.
Give 9 risk factors for RCC development.
- Male Sex (4:1).
- Increasing Age (Above 50).
- Smoking.
- Obesity.
- Genetic Conditions e.g. von-hippel Lindau Syndrome.
- Hypertension.
- End-Stage Renal Failure.
- Tuberous Sclerosis.
- North American and European Ethnicity.
What is von-Hippel Lindau Syndrome?
A rare autosomal dominant genetic disorder that predisposes individuals to certain tumours e.g. RCC and phaeochromocytomas.
What are the commonest types of RCCs?
- Clear-Cell (80%).
- Papillary (15%).
- Chromophobe (5%).
Clinical Features of RCC (6).
- Asymptomatic (50%).
- Triad : Loin Pain, Loin Mass, Haematuria.
- Constitutional Symptoms.
- Pyrexia of Unknown Origin.
- Varicocoele.
- Paraneoplastic Syndromes.
Aetiology of Varicocoele from RCC.
Invasion of the left renal vein by the tumour compresses the left testicular vein.
What is the Urothelium?
Epithelium that lines the urinary tract - it rests on a basement membrane; previously known as the Transitional Epithelium.
What are the layers of the urinary tract wall? (4).
- Urothelium.
- Lamina Propria.
- Muscularis Propria (Detrusor - Bladder).
- Adventitia (Perivesical Fat - Bladder).
What is the macroscopic appearance of RCC?
Well-circumscribed with a yellowish appearance (high content of fat and glycogen) with areas of necrosis and haemorrhage.
What is the microscopic appearance of RCC?
Cytoplasm appears clear as the large content of fat and glycogen contained in the cytoplasm dissolves.
Spread of RCC (3).
- Tissues Around Kidney within Gerato’s Fascia.
- Renal Vein.
- Inferior Vena Cava.
Metastatic RCC (2).
- 25% metastasised at presentation.
2. Typical Feature : Cannon-Ball Metastases in Lungs.
Cannon-Ball Metastases (2).
- Clearly-defined circular opacities scattered throughout the lung fields on a CXR.
- Other Causes : Choriocarcinoma and Prostate, Bladder, Endometrial Cancer (less commonly).
Paraneoplastic Syndromes of RCC (4).
- Polycythaemia (Increased EPO Secretion).
- Hypercalcaemia (PTHrP Secretion).
- Hypertension (Increased Renin, Polycythaemia, Physical Compression).
- Stauffer Syndrome.
What is Stauffer Syndrome? (3).
- Abnormal LFTs demonstrate obstructive jaundice without any localised liver/biliary metastasis.
- Paraneoplastic Hepatic Dysfunction Syndrome - presenting as Cholestasis or Hepatosplenomegaly.
- Secondary to increased levels of IL-6.
2-Week Wait Rule in RCC.
Anyone above the age of 45 with unexplained visible haematuria without a UTI or after treatment for a UTI.
Staging of RCC (4).
TNM - CT (TAP).
- Less than 7cm (confined to kidney).
- More than 7cm (confined to kidney).
- Local Spread to Tissues/Veins (Not Beyond Gerato’s Fascia).
- Spread Beyond Gerato’s Fascia.
Grading of RCC.
Fuhrman Grading System (1-4) - Grade I - least aggressive; Grade IV - most aggressive.
Management of RCC (4).
- 1st Line - Nephrectomy (Surgery).
- Adjuvant - Radiotherapy and Chemotherapy (a-INF, IL-2, Tyrosine Kinase Receptor Inhibitors e.g. Sorafenib, Sunitinib).
- T1 - Partial/Radical Nephrectomy.
- T2+ - Radical Nephrectomy (removal of adrenal gland, lymph nodes, perinephric fat).
What is an important consideration during surgery?
Early venous control - avoid shedding of tumour cells into the circulation.
Non-Surgical Methods of Management of RCC (3).
- Arterial Embolisation (cutting off blood supply to affected kidney).
- Percutaneous Cryotherapy (injecting liquid nitrogen to freeze and kill tumour cells).
- Radiofrequency Ablation (needle into tumour and electric current to kill tumour cells).
