Renal cancer

Question 1

Most common type renal cancer

Answer 1

Renal cell carcinoma

Question 2

Other renal cancers

Answer 2

• Transitional cell carcinoma (urothelial tumour)
• Nephroblastoma in childrn (Wilms)
• Squamous cell carcinomas (chronic inflammation secondary to renal calculi, infection and schistosomiasis)

Question 3

RCC pathophys

Answer 3

• Adenocarcinoma of renal cortex
• Arises mostly from proximal convoluted tubules
• Most often appears in upper pole of kidney
• Microscopic - polyhedral clear cells, dark staining nuclei, cytoplasm rich with lipid and glycogen granules

Question 4

How can RCCs spread?

Answer 4

• Direct invasion - perinephric tissue, adrenal gland, renal vein or IVC
• Lymphatic system - pre aortic and hilar nodes
• Haematogenous - bones, liver, brain, lung

Question 5

What can RCCs do to the renal vein if spread?

Answer 5

• Distinct feature - can invade through renal vein wall and into lumen
• Condition called tumour thrombosis

Question 6

RF for RCC

Answer 6

• Smoking
• Industrial exposure to carcinogens - cadmium, lead, aromatic hydrocarbons
• Dialysis - 30x increase
• HTN
• Obesity
• Anatomical abnormalities eg PCKD or horseshoe kidney

Question 7

Genetic disorders pre-disposing to RCC

Answer 7

• Von Hippel-Lindau - bilateral multifocal tumours
• BAP1 mutation
• Birt-Hogg-Dube disease

Question 8

Symptoms of RCC

Answer 8

• Haematuria - non-visible or visible
• Flank pain
• Flank mass
• Non-specific - lethargy, weight loss
• Mets - haemoptysis, pathological #

Lots are diagnosed incidentally on abdominal imaging - lack symptoms

Question 9

Examination findings of RCC

Answer 9

• Large can be palpated in flank or hypochondrial region
• Left sided masses - left varicocele due to compression of left testicular vein as it drains into left renal vein

Retroperitoneal so takes time before signs and symptoms

Question 10

Paraneoplastic syndromes of RCC

Answer 10

• Polycythaemia due to EPO
• Hypercalcaemia due to PTHrP
• HTN due to renin
• Pyrexia of unknown origin

Question 11

Bedside and bloods for ?renal cancer

Answer 11

• FBC
• U&E
• LFT
• CRP
• Urinalysis for haematuria and send for cytology

Question 12

Imaging for ?renal cancer

Answer 12

• USS
• CT imaging abdomen pelvis pre and post IV contrast (then chest staging CT after confirmation)
• Biopsy esp if small when surveillance or minimally invasive ablation therapies are considered

Question 13

Staging for renal cancer

Answer 13

• American joint committee on cancer (AJCC) staging
• 4 stages

Question 14

Stages of renal cancer

Answer 14

• 1 - tumour 7cm or less, confined to renal capsule
• 2 - tumour >7cm, invading the renal capsule (but confined to Gerotas fascia)
• 3 - tumour extending into renal vein, vena cava or spread to 1 local LN
• 4 - extending beyond gerotas fascia, >1 local LN, involvement of ipsilateral adrenal gland or perinephric fat, or distant mets

Question 15

Management localised renal cancer

Answer 15

• Surgical - laparascopic or open
• Smaller tumour - partial nephrectomy
• Larger - radical nephrectomy (kidney, perinephric fat, local lymph nodes), sparing adrenal gland if possible

Question 16

Management localised renal cancer if unsuitable for surgery

Answer 16

• Percutaenous radiofrequency ablation
• Or laparascopic/percutaenous cryotherapy
• If slow growing and small- surveillance
• Renal artery embolisation for haemorrhaging disease prior to ablation and if unresectable palliative

Question 17

Management metastatic renal cancer

Answer 17

• Chemotherapy = INEFFECTIVE
• If otherwise fit, nephrectomy + immunotherapy (IL-2 or IFN-a agents
• Biological agents - Sunitinib, Pazopanib (tyrosine kinase inhibitors)
• Metastasectomy - surgical resection of solitary mets if resectable and pt well

Interferon alfa and interleukin 2