What is the most common form of adult renal cancer?
Renal cell carcinoma RCC
It is the 9th most common cancer worldwide
Epidemiology of RCC
High incidence in developed countries
M 1.5:1 F
Peak incidence in 50-70 years
Other renal cancers
TCC (urothelial tumours)
Nephroblastoma in children (Wilm's tumour)
Squamous cell carcinoma (chronic inflammation secondary to renal calculi, infection and schistosomiasis)
These flashcards will however focus on RCC
Pathophysiology of RCC
Adenocarcinoma of the renal cortex, usually arise from the proximal convoluted tubules.
Most often appearing in the upper pole of the kidney.
They can spread through direct invasion to perinephric tissues, adrenal gland, renal vein or IVC.
RCC can also spread via lympathics to pre-aortic and hilar nodes or via blood to bones, liver, brain and lung.
What is tumour thrombosis?
RCCs have a distinct features where they can invade through the renal vein wall and into the lumen.
Polyhedral clear cells
Dark staining nuclei and cytoplasm rich with lipid and glycogen granules
Industrial exposures like cadmium, lead or aromatic hydrocarbons
Dialysis (30x increase)
Anatomical abnormalities like polycystic kidney or horseshoe kidney
BAP1 mutant disease
Haematuria visible or non-visible
Non-specific symptoms like lethargy or weight loss.
Around 50% are detected incidentally on abdo imaging.
Classic triad is supposed to be haematuria, mass and flank pain but only present in 15% of cases.
Large RCC can be palpated in the flank or hypochondrial regions
Left-sided masses may also present with a left varicocoela.
Paraneoplastic syndromes of RCC
Pyrexia of unknown origin
Routine bloods with FBC, U&Es, calcium, LFTs and CRP
Urinalysis + cytology
There are no serum tumour markers avaiable to aid in diagnosis of RCC
As for most cases of haematuria -> USS or CT is done first
CT abdo-pelvis pre and post IV contrast is gold standard for suspected cases
Additional CT abdo-chest-pelvis is done for staging.
Biopsy of renal lesions, particularly small masses can be done.
When is renal biopsy done
In small renal masses when surveillance or minimally invasive ablative therapies are being considered.
Staging of RCC
American Joint Committe on Cancer AJCC
S1 - T1N0M0 with tumour 7cm or less and confined to renal capsule
S2 - T2N0M0 with tumour >7cm or invading the renal capsule but confined to Garota's fascia
S3 - T3 or N1M0 with tumour extending into renal vein, vena cava or spread to 1 local LN
S4 - T4N2 or M1 with tumour extending beyond Garota's fascia, >1 LN, involvement of ipsilateral adrenal gland or perinephric fat or distant metastases.
Management of localised disease
Surgical management either through laparoscopy or open approach.
Management of localised small tumours
Partial nephrectomy may be suitable
Management of localised large tumours
Radical nephrectomy with removing the kidney, perinephric fat and local LN
If the patient isn't suitable or fit for surgical management in localised disease, what can be done?
Percutaneous radiofrequency ablation or laparoscopic/percutaneous cryotherapy.
Renal artery embolisation can also be done prior.
Surveillance of slow growing small renal masses can be employed in patients unfit or unwilling to undergo surgery with a limited life expectancy.
Management of metastatic disease
Nephrectomy + immunotherapy with IFN-alpha or IL-2 agents is often recommended
Biological agents like Sunitinib and pazopanib can be used
Metastasectomy is recommended where it can be done
Chemotherapy is considered ineffective.
25% have metastases at presentation
Survival underogone nephrectomy is around 70% at 3 years and 60% at 5 years.