Renal cell carcinoma, RCC

Notes
  • This is an adenocarcinoma that constitute more than 80% of all cancers of the kidney.
  • RCC is categorized into the following subtypes: clear cell (75-85%), papillary (10-15%), chromophobe (<5%), oncocytic (<5%), collecting duct (rare) and unclassified (<5%).
  • Risk factors associated with RCC: smoking, obesity, chronic renal disease, hypertension, sickle cell disease, drugs such as paracetamol and aspirin, exposure to toxic reagents and hereditary traits such as von Hippel-Lindau
  • Statistics: Gender distribution of the prevalence of RCC – 60% men and 40% women.
Symptoms
  • Mostly asymptomatic
  • Hematuria
  • Flank pain
  • Excruciating, sharp, bandlike back pain
  • Palpable mass
  • Weight loss
  • Fever of unknown origin (FUO)
  • Scrotal swelling in men
  • Leg edema
  • Anemia
  • Hypercalcemia
  • Amyloidosis
  • Thrombocytosis
  • Erythrocytosis (excessive RBC due to overproduction of erythropoietin)
  • Elevated levels of alkaline phosphatase.
  • Paraneoplastic syndromes (which are isorders that are triggered by an altered immune system response to a neoplasm) occur in 20% of RCC cases and it is manifested as dermatomyositis-polymyositis, Cushing syndrome, CNS involvement
Diagnosis
  • CT scan (chest, abdominal and pelvis)
  • MRI (chest, abdominal and pelvis)
  • Sometimes bone scan and brain imaging
  • Urinalysis
  • Biopsy, histology and staging
Differential
  • Acute or chronic pyelonephritis
  • Abscess
  • Bladder cancer
  • Metastatic cancer
  • Non-Hodgkin lymphoma
  • Renal cyst
  • Wilms Tumor
Prevention
  • Weight management
  • Avoid smoking
  • Prudent use of NSAIDS
Management
  • Partial or radical nephrectomy (especially in stage 1- III)
  • Metastectomy (especially with metastatic growth in the lymph nodes and the lungs) where the tumor has metastasized and the removal of the mass will give some relief.
  • Traditional adjuvant therapy has not been successful with RCC but the following treatment has been promising:

_Interferon-alpha in combination with bevacizumab (anti-vascular endothelial growth factor, anti-VEGF)

_Interleukin-2 (administered in the ICU)

_Tyrosine Kinase Inhibitors (TKIs) such as sunitinib and sorafenib.

_Mechanistic target of rapamycin (mTOR) protein kinases such as sirolimus, everolimus and temsirolimus

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