Renal cell carcinoma

Related Subjects: |Urothelial tumour s |Haematuria |Acute Urinary Retention |Anuria and Oliguria |Bladder cancer |Renal cell carcinoma |Benign Prostatic Hyperplasia |IgA nephropathy |Prostate Cancer |Henoch-Schonlein purpura |Glomerulonephritis

🔎 About

• 🧬 Renal cell carcinoma (RCC) is the most common renal tumour in adults.
• 👨‍🦳 Typically affects age 50+ and is 2–3x more common in males.

🧬 Aetiology

• Genetic Factors:
  • 🧩 Von Hippel-Lindau (VHL) syndrome: Mutation of VHL tumour suppressor gene.
  • 🧬 Hereditary Papillary RCC (HPRC): Autosomal dominant predisposition.
  • Other: Birt-Hogg-Dubé, hereditary leiomyomatosis.
• Lifestyle Factors:
  • 🚬 Smoking = major risk factor.
  • ⚖️ Obesity = increases RCC risk.
• Medical Conditions:
  • 📈 Hypertension = established risk.
  • 🩺 CKD + long-term dialysis predispose to RCC.
• Occupational Exposures:
  • 🏭 Cadmium, asbestos, industrial dyes (β-naphthylamine, benzidine).

🧫 Histology

• Originates in the renal tubular epithelium; ~10% bilateral.
• ➕ >10 histological and molecular subtypes.
• Clear cell RCC (ccRCC): ~75–80% of cases, most lethal, VHL gene mutations.

⚠️ Risk Factors

• 👨 Male gender.
• 🚬 Smoking, ⚖️ obesity, 📈 hypertension, CKD.
• 🩸 Haemodialysis, kidney transplant, acquired cystic kidney disease.
• 📜 Previous RCC diagnosis; ?diabetes link.

🩺 Clinical Features

• Symptoms: 🩸 Haematuria, flank pain, abdominal mass, weight loss, fever.
• Paraneoplastic: ectopic hormones → 🩸 polycythaemia (EPO), 🧾 hypercalcaemia (PTHrp), ACTH, renin, prolactin.
• 🍇 Left varicocele (compression of left testicular vein).
• 🌍 Metastases → lungs, liver, bones, brain.
• 🩸 May invade renal vein → IVC → right atrium (tumour thrombus).

🔍 Investigations

• 💉 Urinalysis: haematuria, malignant cells.
• 📊 FBC: anaemia or polycythaemia.
• Imaging:
  • 🖥️ USS: renal mass, venous extension.
  • 🖼️ CT: key for staging + operative planning.
  • 🧲 MRI: venous involvement, complex spread.
• 📷 CXR: “cannonball” lung metastases.
• 🧪 Biopsy: histology + subtype confirmation.

💡 RCC arises from renal tubule epithelium. Clear cell RCC = most common, VHL gene mutation, accounts for majority of deaths.

🛠️ Management

• General: 🚭 Stop smoking, ⚖️ weight management.
• Surgery:
  • 🔪 Partial nephrectomy (localized disease, nephron-sparing).
  • ⚡ Radical nephrectomy: kidney + adrenal + LN dissection.
• Local Therapies: RFA (heat), cryoablation (cold).
• Radiotherapy: 🎯 Mainly palliative for mets.
• Systemic Therapy:
  • 🛡️ Immunotherapy: checkpoint inhibitors (nivolumab, pembrolizumab).
  • 🎯 Targeted therapy: TKIs (sunitinib, pazopanib), mTOR inhibitors.
  • 💊 FGFR/VEGF inhibitors for selected genetic profiles.
• Prognosis:
  • 📍 Localized disease: ~60% 5-year survival.
  • 🌍 Metastatic disease: ~5% 5-year survival.

Case 1

58-year-old smoker with intermittent painless haematuria and dull right flank pain; renal US shows a solid cortical lesion and contrast CT (renal protocol) confirms a 5.2 cm enhancing upper pole mass without nodes or vein thrombus; labs reveal mild anaemia and ↑ALP; MDT plans nephron-sparing surgery with partial nephrectomy (T1b, favourable anatomy) to preserve renal function; no pre-op biopsy given classic imaging; pathology later shows clear cell RCC with negative margins—post-op plan: risk-adapted CT chest/abdomen surveillance, eGFR monitoring, and smoking cessation.

Case 2

72-year-old with weight loss, bone pain, and hypercalcaemia; staging CT demonstrates an 8 cm left renal mass with renal vein/IVC thrombus and pulmonary nodules; MRI maps thrombus extent; per MDT, tissue diagnosis obtained because systemic therapy precedes surgery; commence immunotherapy/VEGF-TKI combination per IMDC risk, treat hypercalcaemia (IV fluids + bisphosphonate/denosumab), and consider cytoreductive nephrectomy only if good performance status and response to systemic therapy; palliative radiotherapy for painful bone metastases as needed.

📚 References

• Renal Cell Carcinoma – ResearchGate
• Kidney Cancer – American Cancer Society