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Updated: Nov 4 2021

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
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