Renal Cell Carcinoma

Today we talked about renal cell carcinoma presenting with anorexia, abdominal distension, hematuria, ascites and renal failure.

Here are links to two review articles, the first is from the Lancet in 2009 and the second is from NEJM in 2005.

Some key points about RCC:

1) RCC is the 7th most common cancer in men and the 9th most common in women. The peak incidence is in the 6th and 7th decades of life (mean age of 60). Men are affected twice as frequently as women.

2) Risk factors include: HTN, obesity, smoking, acquired cystic diseases of the kidney, ESRD and certain inherited conditions (e.g. von Hippel-Lindau). Regardless, most patients with RCC do not have an identifiable risk factor. Fruit and vegetable consumption may be protective!

3) This tumor was classically known as "The Internist's Tumor" due to its varied presentation, however with the widespread use of abdominal imaging and incidental diagnosis, some argue that RCC is now "The Radiologist's Tumor".

4) Signs and Symptoms at Presentation:
a) Local: The classic triad of abdominal pain, a palpable mass and hematuria is uncommonly seen today.
b) Systemic: Anorexia, fatigue, wasting and a variety of paraneoplastic phenomena including hypercalcemia (PTHrp), HTN (renin) and erythrocytosis (EPO).

5) Any patient over the age of 40 with hematuria should be assessed for RCC since prognosis is determined by stage.

6) Imaging: CT abdomen is the investigation of choice. However, abdominal U/S while less sensitive can help differentiate a simple cyst from a more complex structure. MRI can be useful if the U/S is non-diagnostic or contrast dye is contraindicated.

7) If a solid renal mass is identified with radiologic features consistent with RCC, biopsy is usually not performed due to low specificty and concern with seeding the peritoneum. Good surgical candidates often go directly for a partial or radical nephrectomy.

8) Surgical resection is the cornerstone of therapy as chemotherapy is minimally effective. Surgery can be curative in the majority of patients with Stage I, II and III disease. Resection of the primary tumor is recommended even in the setting of metastatic disease (in patients with good functional status).

9) Significant interest is currently focused on biologic agents including VEGF and mTOR inhibitors given the limited benefit and significant toxicity of Interleukin-2 immunotherapy.