Renal cell carcinoma

Cards (18)

  • 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