Renal Cell Carcinoma (RCC)
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Renal Cell Carcinoma (RCC) arises from the proximal tubular epithelium. It accounts for 85% of all kidney cancers. It is often found incidentally on scans for other reasons. It is radio-resistant and chemo-resistant, so surgery and immunotherapy are the mainstays of treatment.
Clinical Scenario: The Incidentaloma
A 60-year-old smoker has an ultrasound of his gallbladder for colic. The report notes a '4cm solid mass in the upper pole of the right kidney'. He feels entirely well.
Key Teaching Points
- **Diagnosis**: Likely **RCC** (specifically T1a disease).
- **Next Step**: Triphasic CT Kidneys (Pre-contrast, arterial, nephrogenic phases).
- **Management**: Partial Nephrectomy (Nephron-sparing surgery) is the gold standard for tumours <4cm.
Image Integration Plan
| Image Type | Source | Status |
|---|---|---|
| Management Algorithm | AI-generated | PENDING |
| CT (Enhancing Mass) | Web Source | PENDING |
| Diagram (VHL Pathway) | AI-generated | PENDING |
| CXR (Cannonball Mets) | Web Source | PENDING |
[!NOTE] Image Generation Status: Diagrams illustrating the Left Varicocele mechanism are queued.
Histological Subtypes
- Clear Cell (75-80%):
- Arises from Proximal Convoluted Tubule.
- Associated with deletion of 3p (VHL gene).
- Cells appear clear due to high glycogen/lipid.
- Papillary (10-15%): Type 1 (Slow) and Type 2 (Aggressive).
- Chromophobe (5%): Excellent prognosis.
- Incidence: Increasing (due to more imaging).
- Sex: Male > Female (2:1).
- Age: 60-70 years.
- Risk Factors:
- Smoking (2x risk).
- Obesity.
- Hypertension.
- Dialysis: Acquired Cystic Kidney Disease.
- Genetics: Von Hippel-Lindau (VHL) syndrome (Hemangioblastomas + RCC).
- VHL Gene: Normally acts as a tumour suppressor by degrading HIF (Hypoxia Inducible Factor).
- Mutation: Loss of VHL leads to accumulation of HIF -> Unchecked production of VEGF (Vascular Endothelial Growth Factor) and Erythropoietin.
- Result: Highly vascular tumours ("Angiogenesis") + Polycythaemia.
- Abdomen: Ballot the kidneys (bimanual). A mass moves with respiration.
- Scrotum: Check for varicocele (standing and supine).
- General: Plethora (polycythaemia)? Pallor (anaemia)?
- Urinalysis: Haematuria.
- Bloods:
- FBC (Hb high or low).
- Calcium (High).
- LFTs (Stauffer's syndrome).
- CT Kidneys (Triphasic Protocol):
- Gold Standard. RCC enhances avidly with contrast.
- Staging: Assess Renal Vein / IVC for thrombus.
- CT Chest: To exclude "Cannonball Metastases" (Haematogenous spread).
- Biopsy: Often NOT done if removing the whole kidney. Reserved for:
- Uncertain diagnosis (Lymphoma/Abscess?).
- Planned ablation/surveillance.
- Metastatic disease (to guide systemic therapy).
A. Localised Disease (Stage I-III)
- Partial Nephrectomy (Nephron Sparing Surgery):
- Gold Standard for T1 tumours (< 7cm, especially < 4cm).
- Preserves renal function.
- Radical Nephrectomy:
- Removal of kidney, fat, and fascia. For larger tumours or central location.
- Can include IVC Thrombectomy if tumour extends into vein.
- Active Surveillance:
- For small masses (<3cm) in elderly/frail patients. Many grow very slowly.
- Ablation: Radiofrequency (RFA) or Cryotherapy.
B. Metastatic Disease (Stage IV)
- RCC is Resistant to conventional Chemotherapy and Radiotherapy.
- Targeted Therapy:
- Tyrosine Kinase Inhibitors (TKIs): Sunitinib, Pazopanib. Block VEGF / Angiogenesis.
- Immunotherapy:
- Checkpoint Inhibitors: Nivolumab (PD-1 inhibitor) + Ipilimumab (CTLA-4 inhibitor). Now often first line.
- Cytoreductive Nephrectomy: Removing the primary kidney tumour even in metastatic disease (can improve survival in select fit patients).
- Metastasis: Lung, Bone, Brain, Liver.
- Hyperviscosity: From polycythaemia (Stroke/MI risk).
- CKD: Post-nephrectomy.
- Stage I: >90% 5-year survival.
- Stage IV: <15% 5-year survival.
- Leibovich Score used for prognosis.
- EAU Guidelines on RCC.
- NICE NG131: Renal cancer.
What is Kidney Cancer? It is a cancer starts in the tubes that filter blood. It accounts for most growths in the kidney.
Why did I get it? Smoking is the biggest cause. Being overweight also increases the risk. Sometimes it happens by chance as we age.
I feel fine, why do I need surgery? We often find these cancers "by accident" on a scan for something else. This is actually good news, as it means we caught it early before it caused symptoms like blood in the urine or pain. At this early stage, we can often just cut the lump out (Partial Nephrectomy) and save the rest of your kidney, which cures you completely.
Does it respond to Chemo? No, traditional chemotherapy doesn't work well on kidney cancer. If the cancer spreads, we use clever "Targeted Drugs" that starve the tumour of its blood supply, or "Immunotherapy" which teaches your immune system to eat the cancer cells.
- Ljungberg B, et al. EAU Guidelines on Renal Cell Carcinoma. Eur Urol. 2019.
- Motzer RJ, et al. Nivolumab plus Ipilimumab in Advanced Renal-Cell Carcinoma. N Engl J Med. 2018.
- Choueiri TK, Motzer RJ. Systemic Therapy for Metastatic Renal-Cell Carcinoma. N Engl J Med. 2017.