Renal cellcarcinoma 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)