Renal cell carcinoma

Last reviewed: March 2019

Last updated: November 2017

Summary

Renal malignancy arising from the renal parenchyma/cortex. Clear cell renal cell carcinoma accounts for majority (>80%) of primary renal malignancies.

Sixth to eighth most common malignancy in males; risk in general North American population is 1 in 10,000. Incidence increasing along with stage migration to more early-stage diagnosis due to the frequent use of sensitive imaging.

Most cases are sporadic, although positive family history increases risk 4-fold.

Often asymptomatic and diagnosed incidentally.

TNM assessment of primary tumour (T), regional lymph nodes (N), and distant metastasis (M) is made by pathology and imaging studies.

Surgery for early/local disease can be curative in up to 90% of patients; potential increasing role for surveillance and/or biopsy of small renal masses. Risk of distant relapse remains 30% for curatively resected renal cell carcinoma.

Metastatic disease has traditionally had poor 5-year survival (10%). However, targeted systemic therapies have revolutionised treatment for metastatic disease, with median overall survivals improving across all risk groups. Ongoing strategies on combinations of therapies and optimal sequencing of therapies will likely further improve outcomes.

Future directions in management include integrating molecular biomarkers into prognostic models, evaluating the role of targeted treatments in the adjuvant and neoadjuvant settings, examining the sequencing and combinations of targeted treatments in advanced disease, and evaluating new imaging modalities for assessing treatment response.

Definition

Renal cell carcinoma (RCC) is renal malignancy arising from the renal parenchyma/cortex, and accounts for about 85% of renal cancers.

History and exam

Key diagnostic factors

presence of risk factors
asymptomatic (incidental finding)
haematuria
flank pain
palpable abdominal mass

Full details

Other diagnostic factors

non-specific systemic symptoms
signs of hepatic dysfunction
myoneuropathy
lower limb oedema
scrotal varicocele
dermatological manifestation (hereditary syndromes)
dental pits (tuberous sclerosis)
nail manifestations (tuberous sclerosis)
vision loss (von Hippel Lindau)

Full details

Risk factors

smoking
male sex
age 55 to 84 years
residence in developed countries
black/American-Indian ethnicity
obesity
hypertension
positive family history (FHx) of RCC
history of hereditary syndromes
history of acquired renal cystic disease
asbestos/cadmium/petroleum exposure
obstetric history/oestrogen exposure
pelvic radiation

Full details

Diagnostic investigations

1st investigations to order

FBC
LDH
corrected calcium
liver function tests (LFTs)
coagulation profile
creatinine
urinalysis
abdominal/pelvic ultrasound
CT abdomen/pelvis
MRI abdomen/pelvis

Full details

Investigations to consider

CT chest
MRI brain/spine
bone scan
biopsy
surgical pathology

Full details

Emerging tests

PET scan

Full details

Treatment algorithm

ONGOING

small renal mass or RCC stage 1 or 2

RCC stage 3

RCC stage 4 (metastatic disease)

Contributors

Authors VIEW ALL 

Amishi Y. Shah, MD

Assistant Professor

Genitourinary Medical Oncology

MD Anderson Cancer Center

Houston

Disclosures

AYS has an unpaid advisory role for Merck pharmaceuticals.

Acknowledgements

Dr Amishi Y. Shah would like to gratefully acknowledge Dr Sonal Gandhi and Jennifer J. Knox, previous contributors to this topic. SG and JJK declare that they have no competing interests.

Peer reviewers VIEW ALL 

Stephen A. Boorjian, MD

Assistant Professor

Fox Chase Cancer Center

Philadelphia

Disclosures

SAB has been reimbursed by Pfizer for serving on its speakers bureau. SAB is co-author of a reference cited in the monograph.

Thomas J. Guzzo, MD, MPH

Assistant Professor of Urology and Surgery

The Hospital of the University of Pennsylvania

Philadelphia

Disclosures

TJG declares that he has no competing interests.

Jonathan Waxman, BSc, MBBS, MD, FRCP

Professor of Oncology

Imperial College

London

Disclosures

JW declares that he has no competing interests.

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Renal cell carcinoma

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

small renal mass or RCC stage 1 or 2

RCC stage 3

RCC stage 4 (metastatic disease)

Contributors

Authors VIEW ALL 

Amishi Y. Shah, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Stephen A. Boorjian, MD

Disclosures

Thomas J. Guzzo, MD, MPH

Disclosures

Jonathan Waxman, BSc, MBBS, MD, FRCP

Disclosures

Differentials

Guidelines

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