Renal Cell Carcinoma

Overview

• A 65-year-old man with a 40 pack-year history of smoking presents with right costovertebral angle pain, hematuria, fever, and a palpable mass in the right lower quadrant. CT of the abdomen demonstrates a contrast enhancing lesion on the kidney.

Introduction

• Overview
  • renal malignancy originating from the proximal renal tubular epithelium 
• Epidemiology
  • incidence
    • represents 2-3% of all adult cancers
    • accounts for ~85% of adult renal cancers
    • clear cell carinoma is the most common type and other types include
      • papillary carcinoma
      • chromophobe carcinoma
      • collecting duct carcinoma
  • demographics
    • more common in men
    • mean age is 60 years of age
  • risk factors
    • tobacco smoking (most significant)
    • obesity
    • hypertension
    • genetic factors
    • acquired cystic renal disease
• Pathogenesis
  • structural alterations in the short arm of chromosome 3 can result in sporadic or hereditary renal cell carcinoma in certain subtypes (e.g., clear cell)
• Associated conditions
  • von Hippel-Lindau
  • tuberous sclerosis
  • paraneoplastic syndromes
  • hereditary papillary renal carcinoma
  • familial renal oncocytoma
  • paraneoplastic syndromes 
    • ectopic EPO, ACTH, PTHrP, and prolactin
• Prognosis 
  • poorer prognosis
    • as the anatomic extent of the disease worsens
    • tumor grade
    • poor performance status
    • paraneoplastic syndrome
• obesity

Presentation

• Symptoms 
  • hematuria
    • occurs when the tumor invades the collecting system
  • flank pain
• Physical exam
  • palpable abdominal renal mass 
    • the mass is typically found to be
      • firm
      • nontender
      • homogeneous
  • scrotal varicoceles 
    • varicoceles do not empty with recumbancy
  • involvement of the inferior vena cava can result in
    • lower extremity edema
    • ascites
    • pulmonary emboli
• hepatic dysfunction

Imaging

• CT scan
  • indications
    • an essential initial radiographic test for the evaluation of renal cell carcinoma
    • for an accurate assessment of the extent of local and regional involvement
      • patients must be evaluated for metastasis prior to surgery
  • modality
    • CT scan of the abdomen and pelvis before and after contrast administration
  • findings
    • enhancing lesion with contrast
• thickened irregular walls or septa

Studies

• Serology 
  • polycythemia  
    • paraneoplastic syndrome due to EPO release
  • hypercalcemia
    • paraneoplastic syndrome due to PTH-related hormone
  • hypercortisolism
    • due to ACTH
  • hypertension
    • due to renin
• Histology
  • indication
• to make a tissue diagnosis of renal cell carcinoma

Differential

• Bladder cancer
  • differentiating factor
• evidence of bladder malignancy via cystoscopy

Treatment

• Medical
  • systemic therapy
    • indication
      • used in patients with unresectable disease (e.g., metastasis and localy advanced)
    • modality
      • immunotherapy (e.g., interleukin-2)
• Surgical
  • partial or radical nephrectomy
    • indication
      • considered definitive therapy in patients with localized renal cell carcinoma 
• partial versus radical nephrectomy is dependent on a number of factors

Complications

• Metastasis