Renal cell carcinoma

Oncology

Clinicals - History

Fact Explanation
Haematuria Renal cell carcinoma is the commonest tumor of the kidney in adults. It is more common among men. Haematuria is the commonest presentation of renal cell carcinoma. Haematuria
Renal cell carcinoma is the commonest tumor of the kidney in adults. It is more common among men. Haematuria is the commonest presentation of renal cell carcinoma.
Clot colic Renal cell carcinoma may present with gross haematuria. Haematuria may result in clot formation which may obstruct the ureters. The patient develops severe abdominal pain which radiates to the groins. The pain is colicky in nature and mimics a ureteric colic due to ureteric stones. Clot colic
Renal cell carcinoma may present with gross haematuria. Haematuria may result in clot formation which may obstruct the ureters. The patient develops severe abdominal pain which radiates to the groins. The pain is colicky in nature and mimics a ureteric colic due to ureteric stones.
Abdominal mass/ Abdominal discomfort The tumor mass may be detected by the patient. A large tumor may cause abdominal heaviness. Abdominal mass/ Abdominal discomfort
The tumor mass may be detected by the patient. A large tumor may cause abdominal heaviness.
Lower limb swelling Renal cell carcinoma is characteristically known to grow along the renal vein into the vena cava. This may obstruct lower limb blood flow resulting in edema. Lower limb swelling
Renal cell carcinoma is characteristically known to grow along the renal vein into the vena cava. This may obstruct lower limb blood flow resulting in edema.
Bone pain/ Bone lump Presentation with features of distant metastases alone is common in renal cell carcinoma. Spread to bone may give rise to severe bone pain. The axial skeleton is most affected – Vertebrae, skull, upper femur, ribs. Bone pain/ Bone lump
Presentation with features of distant metastases alone is common in renal cell carcinoma. Spread to bone may give rise to severe bone pain. The axial skeleton is most affected – Vertebrae, skull, upper femur, ribs.
Chronic cough/ Haemoptysis/ Dyspnea Due to lung metastasis. Chronic cough/ Haemoptysis/ Dyspnea
Due to lung metastasis.
Features of anemia : Palpitations, exertional dyspnea Due to chronic blood loss via the urinary tract. Features of anemia : Palpitations, exertional dyspnea
Due to chronic blood loss via the urinary tract.
Hyperviscosity symptoms Presentation with hyperviscosity features such as confusion, spontaneous bleeding through gut or urinary tract, visual disturbances and CNS disturbance is due to ectopic erythropoietin production by the tumor cells. This leads to secondary polycythemia. Hyperviscosity symptoms
Presentation with hyperviscosity features such as confusion, spontaneous bleeding through gut or urinary tract, visual disturbances and CNS disturbance is due to ectopic erythropoietin production by the tumor cells. This leads to secondary polycythemia.
Prolonged fever/ Constitutional symptoms Renal cell carcinoma is well known to present with atypical features. Pyrexia of unknown origin is one such presentation. Prolonged fever/ Constitutional symptoms
Renal cell carcinoma is well known to present with atypical features. Pyrexia of unknown origin is one such presentation.
Presentation due to ectopic hormone production Renal cell carcinoma has being associated with ectopic hormone production – Calcitonin, Renin, Androgens and Sex hormones. The patient may be diagnosed with hypercalcaemia. Features of Cushing’s syndrome such as central obesity, hypertension, acne, hirsutism, easy bruising, osteoporosis etc may occur rarely. Feminization and musculinization are rare presentations. Presentation due to ectopic hormone production
Renal cell carcinoma has being associated with ectopic hormone production – Calcitonin, Renin, Androgens and Sex hormones. The patient may be diagnosed with hypercalcaemia. Features of Cushing’s syndrome such as central obesity, hypertension, acne, hirsutism, easy bruising, osteoporosis etc may occur rarely. Feminization and musculinization are rare presentations.

Clinicals - Examination

Fact Explanation
General examination : Anemia Due to chronic blood loss. General examination : Anemia
Due to chronic blood loss.
General examination : Polycythemia The conjunctiva may appear flushed. Palmer erythema may be present. Erythropoiesis is stimulated due to excess erythropoietin production. General examination : Polycythemia
The conjunctiva may appear flushed. Palmer erythema may be present. Erythropoiesis is stimulated due to excess erythropoietin production.
General examination : Lower limb pitting edema Due to vena caval blood flow obstruction from tumor growth. General examination : Lower limb pitting edema
Due to vena caval blood flow obstruction from tumor growth.
General examination : Bone tenderness or bone lumps Bone deposits may present as a definite lump if a superficial bone is affected. Renal cell carcinoma is characteristically associated with highly vascular bone deposits which may be soft in consistency or even be pulsatile. General examination : Bone tenderness or bone lumps
Bone deposits may present as a definite lump if a superficial bone is affected. Renal cell carcinoma is characteristically associated with highly vascular bone deposits which may be soft in consistency or even be pulsatile.
Respiratory system examination : Features of pleural effusion Metastatic deposits in the lung may cause pleural effusions. The affected side shows reduced chest movement, reduced tactile fremitus, stony dull percussion note and reduced breath sounds. Pleural deposits may also lead to effusion formation. Respiratory system examination : Features of pleural effusion
Metastatic deposits in the lung may cause pleural effusions. The affected side shows reduced chest movement, reduced tactile fremitus, stony dull percussion note and reduced breath sounds. Pleural deposits may also lead to effusion formation.
Abdominal examination : Abdominal mass The tumor mass is felt in the lumbar regions of the abdomen. The mass can be felt as a separate mass from the liver and spleen. It will be hard in consistency and have an irregular surface. The mass is usually ballotable. The mobility of the mass may be limited due to fixation to surrounding structures. Abdominal examination : Abdominal mass
The tumor mass is felt in the lumbar regions of the abdomen. The mass can be felt as a separate mass from the liver and spleen. It will be hard in consistency and have an irregular surface. The mass is usually ballotable. The mobility of the mass may be limited due to fixation to surrounding structures.
Genital examination : Varicocele The left gonadal vein drains directly into the left renal vein. Varicocele, particularly on the left side may develop due to tumor growth along the renal vein. Genital examination : Varicocele
The left gonadal vein drains directly into the left renal vein. Varicocele, particularly on the left side may develop due to tumor growth along the renal vein.

Investigations - Diagnosis

Fact Explanation
Ultrasound scan of the abdomen USS is usually the first imaging modality when an abdominal mass is detected. Information that can be gathered are the origin of the mass, nature of the mass (solid or cystic) and may help in excluding hepatomegaly/ ascites. Ultrasound scan of the abdomen
USS is usually the first imaging modality when an abdominal mass is detected. Information that can be gathered are the origin of the mass, nature of the mass (solid or cystic) and may help in excluding hepatomegaly/ ascites.
Intravenous urogram (IVU) Traditionally IVU has being the main mode of imaging in patients suspected of renal cell carcinoma. The plain radiograph may show distortion of the renal outline and calcification within the tumor. Subsequent films following dye administration may highlight the distorted renal calyceal system and the tumor may appear as a filling defect. The function of the contra-lateral kidney may also be assessed. Intravenous urogram (IVU)
Traditionally IVU has being the main mode of imaging in patients suspected of renal cell carcinoma. The plain radiograph may show distortion of the renal outline and calcification within the tumor. Subsequent films following dye administration may highlight the distorted renal calyceal system and the tumor may appear as a filling defect. The function of the contra-lateral kidney may also be assessed.
CT scan – abdomen Contrast enhanced CT is considered the investigation of choice in diagnosing and staging renal cell carcinoma due to the high sensitivity and specificity. An abdominal mass detected should be first assessed for benign or malignant properties. Assess loco-regional spread of the tumor, growth along the renal vein and lymphadenopathy for staging of the tumor. Assess the anatomy of the opposite kidney. CT scan – abdomen
Contrast enhanced CT is considered the investigation of choice in diagnosing and staging renal cell carcinoma due to the high sensitivity and specificity. An abdominal mass detected should be first assessed for benign or malignant properties. Assess loco-regional spread of the tumor, growth along the renal vein and lymphadenopathy for staging of the tumor. Assess the anatomy of the opposite kidney.
MRI Provides similar results to CT scan. Lack of availability and high cost limits its routine use in diagnosing renal cell carcinoma. MRI is accurate in determining local tumor spread, growth along the inferior vena cava and is used as the primary diagnostic investigation in certain settings. MRI
Provides similar results to CT scan. Lack of availability and high cost limits its routine use in diagnosing renal cell carcinoma. MRI is accurate in determining local tumor spread, growth along the inferior vena cava and is used as the primary diagnostic investigation in certain settings.
Abdominal X-ray Plain radiographs have limited diagnostic value. Distortion of the renal outline and calcifications within the tumor may be seen. Abdominal X-ray
Plain radiographs have limited diagnostic value. Distortion of the renal outline and calcifications within the tumor may be seen.
Urinalysis Red blood cells can be seen. Urinalysis
Red blood cells can be seen.

Investigations - Management

Fact Explanation
Full blood count Look for anemia or polycythemia. The hemoglobin level and platelet level are important parameters to consider prior to surgery. Full blood count
Look for anemia or polycythemia. The hemoglobin level and platelet level are important parameters to consider prior to surgery.
Renal function tests Assess renal functions in preparation of surgery as a baseline investigation. Renal function tests
Assess renal functions in preparation of surgery as a baseline investigation.
Serum electrolytes Serum calcium level may be elevated as part of a paraneoplastic syndrome. Serum electrolytes
Serum calcium level may be elevated as part of a paraneoplastic syndrome.
Liver function tests : AST/ALT/Serum protein Assess liver function prior to surgery. A low serum protein level is a risk factor for poor wound healing. Liver function tests : AST/ALT/Serum protein
Assess liver function prior to surgery. A low serum protein level is a risk factor for poor wound healing.
Blood group and save Radical nephrectomy carries the risk of severe bleeding if aberrant arteries are not secured. Reserve blood for replacement of blood loss during surgery. Blood group and save
Radical nephrectomy carries the risk of severe bleeding if aberrant arteries are not secured. Reserve blood for replacement of blood loss during surgery.
Chest X-ray To rule out lung deposits which appear as cannon ball secondaries. Chest X-ray
To rule out lung deposits which appear as cannon ball secondaries.
Bone scan To investigate for bone deposits. Bone scan
To investigate for bone deposits.
Inferior venacavography/ Magnetic resonance angiography Prior to surgery it is important to determine the presence of cancer growth along the renal vein into the inferior vena cava. Inferior venacavography/ Magnetic resonance angiography
Prior to surgery it is important to determine the presence of cancer growth along the renal vein into the inferior vena cava.

Management - Supportive

Fact Explanation
Patient counseling and education The diagnosis of renal cancer should be informed to the patient and relatives sensitively. Provide psychological support during the initial stages. Provide information regarding the natural course, aetiology, complications of the tumor and investigations required. Counsel the patient regarding the stage o f the cancer and treatment options available. Renal cell carcinoma nomograms are used to predict the future progression and accurate prognostication. Patient counseling and education
The diagnosis of renal cancer should be informed to the patient and relatives sensitively. Provide psychological support during the initial stages. Provide information regarding the natural course, aetiology, complications of the tumor and investigations required. Counsel the patient regarding the stage o f the cancer and treatment options available. Renal cell carcinoma nomograms are used to predict the future progression and accurate prognostication.
Preparation for surgery Optimize pre-existing medical conditions prior to radical surgery. Achieve control of blood pressure and blood glucose level. If present anemia should be corrected. Blood transfusions may be required if the hemoglobin level is very low. Preparation for surgery
Optimize pre-existing medical conditions prior to radical surgery. Achieve control of blood pressure and blood glucose level. If present anemia should be corrected. Blood transfusions may be required if the hemoglobin level is very low.

Management - Specific

Fact Explanation
Treatment options The main treatment options available for renal cell carcinoma are surgery, immunotherapy, chemotherapy and radiotherapy. The most appropriate measure should be selected based on the stage of the tumor, patient fitness and preferences. Majority of patients are diagnosed in the early stages of disease and are suitable for curative surgery. Renal cell carcinoma has good prognosis if the tumor can be excised completely. The survival rate after 5 years is approximately 60%. Treatment options
The main treatment options available for renal cell carcinoma are surgery, immunotherapy, chemotherapy and radiotherapy. The most appropriate measure should be selected based on the stage of the tumor, patient fitness and preferences. Majority of patients are diagnosed in the early stages of disease and are suitable for curative surgery. Renal cell carcinoma has good prognosis if the tumor can be excised completely. The survival rate after 5 years is approximately 60%.
Surgery : Nephrectomy Tumors confined to the kidney are treated with nephrectomy and removal of the perinephric fat. Complete removal of even large tumors by radical surgery carries a good prognosis. The kidney can be approached by either an abdominal or loin incision. Achieving control of the renal pedicle is the initial step. The renal artery is identified and ligated. Next the renal vein is identified and palpated along its length to look for tumor growth along the vein. If no growth is detected the renal vein followed by the artery can be ligated and dissected. By careful dissection of the vascular pedicle, the risk of bleeding and tumor cell embolization can be minimized. The ureter is identified and traced downwards and divided. The kidney is then mobilized with its coverings. It is important to exclude the presence of aberrant renal arteries and tumor extension into the inferior vena cava. Cytoreductive nephrectomy is used for treating metastatic renal cell carcinoma. Patients with resectable metastatic deposits are treated with radical nephrectomy and metastasectomy. Surgery : Nephrectomy
Tumors confined to the kidney are treated with nephrectomy and removal of the perinephric fat. Complete removal of even large tumors by radical surgery carries a good prognosis. The kidney can be approached by either an abdominal or loin incision. Achieving control of the renal pedicle is the initial step. The renal artery is identified and ligated. Next the renal vein is identified and palpated along its length to look for tumor growth along the vein. If no growth is detected the renal vein followed by the artery can be ligated and dissected. By careful dissection of the vascular pedicle, the risk of bleeding and tumor cell embolization can be minimized. The ureter is identified and traced downwards and divided. The kidney is then mobilized with its coverings. It is important to exclude the presence of aberrant renal arteries and tumor extension into the inferior vena cava. Cytoreductive nephrectomy is used for treating metastatic renal cell carcinoma. Patients with resectable metastatic deposits are treated with radical nephrectomy and metastasectomy.
Immunotherapy Immunotherapy is being increasingly used for treatment of renal cell carcinoma. Interleukin 2 and interferons are used for this purpose. These agents have also shown to be effective as an adjuvant treatment option to surgery. In combination molecular agents such as everolimus, sorafenib, pazopanib, temsirolimus, axitinib, sunitinib etc can be used. Further evaluation is required to determine its optimum role in the management of renal cell carcinoma. Immunotherapy
Immunotherapy is being increasingly used for treatment of renal cell carcinoma. Interleukin 2 and interferons are used for this purpose. These agents have also shown to be effective as an adjuvant treatment option to surgery. In combination molecular agents such as everolimus, sorafenib, pazopanib, temsirolimus, axitinib, sunitinib etc can be used. Further evaluation is required to determine its optimum role in the management of renal cell carcinoma.
Chemotherapy Adenocarcinoma of the kidney has poor response to conventional chemotherapeutic agents. Trials have being conducted with gemcitabine, fluorouracil, floxuridine, vinblastine, paclitaxel etc in varies combinations and the response rate has being poor. Chemotherapy
Adenocarcinoma of the kidney has poor response to conventional chemotherapeutic agents. Trials have being conducted with gemcitabine, fluorouracil, floxuridine, vinblastine, paclitaxel etc in varies combinations and the response rate has being poor.
Radiotherapy Radiotherapy can be used as a primary treatment option in inoperable disease and as an adjuvant following surgery. It is useful to treat locally infiltrative malignancy where there is tumor infiltration into surrounding structures. Radiotherapy can used to treat bone and brain deposits for palliation of troublesome symptoms. Radiotherapy
Radiotherapy can be used as a primary treatment option in inoperable disease and as an adjuvant following surgery. It is useful to treat locally infiltrative malignancy where there is tumor infiltration into surrounding structures. Radiotherapy can used to treat bone and brain deposits for palliation of troublesome symptoms.
Renal artery embolization Renal artery embolization is reserved for patients with disseminated malignancy. Further studies are required to determine its role in management of renal cell carcinoma. Renal artery embolization
Renal artery embolization is reserved for patients with disseminated malignancy. Further studies are required to determine its role in management of renal cell carcinoma.
Management of widely metastatic disease Immunotherapy is considered the first line treatment for metastatic malignancy. Treatment with agents such as Sunitinib has shown success for treating metastatic renal carcinoma. Further evaluation is required to determine the appropriate regimes and duration of therapy required. Surgery to de-bulk the tumor can be used as a palliative treatment option. Surgery and radiotherapy can be used as a local measure for bone deposits and brain netastases. Management of widely metastatic disease
Immunotherapy is considered the first line treatment for metastatic malignancy. Treatment with agents such as Sunitinib has shown success for treating metastatic renal carcinoma. Further evaluation is required to determine the appropriate regimes and duration of therapy required. Surgery to de-bulk the tumor can be used as a palliative treatment option. Surgery and radiotherapy can be used as a local measure for bone deposits and brain netastases.

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