Renal cell carcinoma

• Renal cell carcinoma is the most common kidney cancer in adults. It accounts for 80-85% of kidney cancers.
• Classic triad of symptoms:

  • Haematuria
  • Flank pain
  • Palpable mass
• Three main types:

  • Clear cell (most common - worst prognosis) - originates in renal tubules
  • Papillary
  • Chromophobe
• The lungs are the most common site of distant spread
• Risk factors:

  • Advancing age
  • Smoking
  • Obesity
  • Family history
  • Hypertension
• Renal cell carcinoma may also be associated with a number of hereditary syndromes:

  • Von Hippel-Lindau syndrome
  • Tuberous sclerosis
  • Birt–Hogg–Dubé syndrome
  • Hereditary papillary renal carcinoma
• Clinical features:

  • Haematuria (usually painless)
  • Flank pain
  • Flank mass
  • Fever
  • Night sweats
  • Malaise
  • Weight loss
  • Varicocele (classically left sided)
  • Hypertension
  • Hypercalcaemia
  • Bone pain
• Varicoceles usually form in the left testes, as the left gonadal vein tends to drain at a sharp angle into the left renal vein. Tumours can compress venous return. A solitary right sided varicocele is a red flag for renal cancer
• “Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.
• Associated with several paraneoplastic syndromes:

  • Polycythaemia - secretion of unregulated erythropoietin
  • Hypercalcaemia - secretion of hormone that mimics PTH
  • Hypertension - Increased renin, polycythaemia and physical compression
  • Staffer's syndrome - abnormal LFTs without liver mets
  • Hypercalcaemia can also be caused by bony metastases
  • Cushing's syndrome
• 2WW referral:

  • Over 45 with unexplained haematuria either without a UTI or persisting after treatment of a UTI
• Urine investigations:

  • Urine dip and MSU
  • Cytology
• Blood tests:

  • FBC - raised WCC often seen
  • U&Es - may be hypercalcaemia
  • LFTs
  • ESR - typically raised
  • Bone profile
• Ultrasound scan used initially to distinguish simple cysts from solid masses

  CT or MRI usually used to confirm diagnosis and stage disease
• Surgery to remove the tumour is the first-line, where possible. This may involve:

  • Partial nephrectomy (removing part of the kidney)
  • Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland)
• There are a number of systemic therapies are available:

  • Sunitinib: inhibitor of tyrosine kinase receptors
  • Pazopanib: inhibitor of tyrosine kinase receptors
  • Temsirolimus: inhibitor of the mammalian target of rapamycin (mTOR)
  • Everolimus: inhibitor of the mammalian target of rapamycin (mTOR)
• Common presentations:

  • Frank haematuria
  • Microscopic haematuria
  • Loin pain
  • Renal mass
  • Incidental finding on imaging
• Uncommon presentations:

  • Iron deficiency anaemia
  • Polycythaemia causes by erythropoietin production
  • Hypertension caused by renin production
  • Hypercalcaemia
  • Elevated ESR
  • Symptoms of metastatic disease (bone pain, weight loss, night sweats)
  • Secondary lesions (e.g. cannonball lesions on CXR)
  • Acute varicocoele