Urology: Renal Cell Carcinoma (RCC)

Renal Cell Carcinoma (RCC)

Basics

  • Most are Sporadic (4-6% Familial)
  • More Common in Older Adults (55-75 Years)
  • Most Common Mets: Lung
  • 1/3 Have Metastases at Diagnosis
  • 20-40% of Localized Disease at Diagnosis Eventually Develop Metastases
  • Strongest Predictors of Malignancy:
    • Male Sex
    • Increase in Tumor Size

Symptoms

  • Classic Triad (Rarely Seen):
    • Flank Pain
    • Palpable Mass
    • Hematuria
  • Most are Asymptomatic & Found Incidentally on Imaging
  • 10-20% Have an Associated Paraneoplastic Syndrome
    • More Common in Metastatic Disease

Risk Factors

  • Tobacco – Strongest Risk Factor
  • Obesity
  • Hypertension

Paraneoplastic Syndromes

  • Elevated Erythrocyte Sedimentation Rate (ESR) – The Most Common (50% of Paraneoplastic Syndromes)
  • Hypercalcemia – From PTH Related Peptide Release
  • Non-Metastatic Hepatic Dysfunction (Stauffer Syndrome)
  • Hypertension – From Renin Release
  • Erythrocytosis & Thrombocytosis
  • Fever
  • Cushing Syndrome
  • Hyperglycemia
  • Galactorrhea
  • Clotting Disorders

Renal Cell Carcinoma Gross Specimen, Invading IVC 1

TNM Staging – AJCC 8
  • TNM
  T N M
I Ia: ≤ 4.0 cm & Confined to Kidney Ib: > 4.0 cm, ≤ 7.0 cm & Confined to Kidney LN+ Mets+
II IIa: > 7.0 cm, ≤ 10.0 cm & Confined to Kidney IIb: > 10.0 cm & Confined to Kidney    
III IIIa: Extends into Renal Vein or its Segmental Branches, Invades Pelvicalyceal System or Invades Perirenal and/or Renal Sinus Fat but Not Beyond Gerota’s Fascia IIIb: Grossly Extends into the Vena Cava Below the Diaphragm IIIc: Grossly Extends into the Vena Cava Above the Diaphragm or Invades the Wall of the Vena Cava    
IV Invades Beyond Gerota’s Fascia    
  • Stage
  T N M
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1-3 N1 M0
IV T4 Any N M0
Any T Any N M1

Diagnosis

  • Primary Evaluation: CT or MRI
    • > 15-20 Hounsfield Units (HU) is Indicative of RCC
    • Unable to Reliably Diagnose RCC in Solitary Small Lesions – Generally Requires Resection
  • Renal Mass Biopsy (RMB) May Be Considered in Select Circumstances
    • Biopsy Often Avoided Due to Associated Risks:
      • High Nondiagnostic Rate
      • Occasional False-Negatives
      • Potential for Cystic Tumor Spillage

Treatment

  • Primary Treatment: Surgical Resection
    • Intermediate-High Risk Patients Should Be Offered Adjuvant Pembrolizumab (PD-1 Inhibitor)
    • Locally Advanced RCC (Invading IVC) is Still Primarily a Surgical Disease
  • Metastatic Disease:
    • Nephrectomy with Mastectomy May Be Considered for Limited Metastatic Disease
    • Factors Associated with Improved Outcomes After Metastasectomy:
      • Complete Resection
      • Solitary Metastatic Lesions
      • Age < 60 Years
      • Small Tumor Size
      • Pulmonary Metastasis
      • Metachronous Metastatic Disease
    • May Consider Cytoreductive Nephrectomy Alone in Select Patients

Extent of Surgical Resection

  • Indications for Partial Nephrectomy:
    • Small T1a Lesions (< 4 cm)
    • Solitary Kidney or Abnormal Contralateral Kidney
    • Bilateral Tumors
    • Preexisting Chronic Kidney Disease (CKD) or Proteinuria
    • Multifocal Masses
    • Other Comorbidities May Impact Future Renal Function
    • Known Familial RCC
  • Indications for Radical Nephrectomy:
    • Central Location in Kidney
    • Suspected Lymph Node Disease
    • Extension into Renal Vein, IVC or Adrenal Gland

Renal Cell Carcinoma on CT 2

References

  1. Parissis H, Akbar MT, Tolan M, Young V. Surgical resection of a renal cell carcinoma involving the inferior vena cava: the role of the cardiothoracic surgeon. J Cardiothorac Surg. 2010 Nov 5;5:103. (License: CC BY-2.0)
  2. Nguyen BD, Roarke MC. Renal Cell Carcinoma with Paraneoplastic Manifestations: Imaging with CT and F-18 FDG PET/CT. Radiol Case Rep. 2015 Dec 7;2(3):72. (License: CC BY-NC-ND-4.0)