Renal Cell Carcinoma

Renal cell carcinoma (RCC) is the most common type of kidney tumour. It is a type of adenocarcinoma that arises from the renal tubules. The classic triad of presentation is haematuria, flank pain and a palpable mass.

 

Types of Renal Cell Carcinoma

There are several subtypes of renal cell adenocarcinoma, the three most common being:

  • Clear cell (around 80%)
  • Papillary (around 15%)
  • Chromophobe (around 5%)

 

Wilms’ tumour is a specific type of tumour affecting the kidney in children, typically under 5 years.

 

Risk Factors

  • Smoking
  • Obesity
  • Hypertension
  • End-stage renal failure
  • Von Hippel-Lindau Disease
  • Tuberous sclerosis

 

Presentation

Renal cell carcinoma may be asymptomatic, but may present with:

  • Haematuria
  • Vague loin pain
  • Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
  • Palpable renal mass on examination

 

The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for those:

  • Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

 

Spread

Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava. 

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.

TOM TIP: Remember cannonball metastases as originating from a renal cell carcinoma. It is worth looking at some images of cannonball metastases. They are an exam favourite and an easy question to get right if you know the answer. They can also appear with choriocarcinoma (cancer in the placenta) and, less commonly, with prostate, bladder and endometrial cancer.

 

Paraneoplastic Features

Renal cell carcinoma is associated with several paraneoplastic syndromes:

  • Polycythaemia – due to secretion of unregulated erythropoietin
  • Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
  • Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression 
  • Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis

 

Hypercalcaemia can also be caused by bony metastases.

 

Staging

A CT thorax, abdomen and pelvis are used to stage the cancer.

The TNM staging system is the most common staging system for renal cell carcinoma, rating the T (tumour), N (lymph node) and M (metastasis) stages.

There is also a number staging system specific to renal cell carcinoma:

  • Stage 1: Less than 7cm and confined to the kidney
  • Stage 2: Bigger than 7cm but confined to the kidney
  • Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia
  • Stage 4: Spread beyond Gerota’s fascia, including metastasis

 

Management

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

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)

 

Where patients are not suitable for surgery, less invasive procedures can be used to treat the cancer:

  • Arterial embolisation, cutting off the blood supply to the affected kidney
  • Percutaneous cryotherapy, injecting liquid nitrogen to freeze and kill the tumour cells
  • Radiofrequency ablation, putting a needle in the tumour and using an electrical current to kill the tumour cells

 

Chemotherapy and radiotherapy may also be used.

 

Last updated May 2021
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