Renal cell carcinoma (RCC) is a malignancy arising from the renal parenchyma/cortex. Clear cell RCC accounts for the majority (over 80%) of primary renal malignancies.
Incidence is increasing along with stage migration to more early-stage diagnosis due to the frequent use of sensitive imaging. Often asymptomatic and diagnosed incidentally.
Most cases are sporadic, although at least four hereditary clinical kidney cancer syndromes have been identified.
Assessment of primary tumour, regional lymph nodes, distant metastasis, and classification of histological subtypes are of paramount importance for making treatment decisions.
Surgery for early/local disease can be curative in over 90% of patients; surveillance and/or biopsy may be the most appropriate strategy in some patients with small renal masses. Risk of distant relapse remains 30% for curatively resected RCC.
Metastatic disease has traditionally had poor 5-year survival (10%). However, targeted systemic therapies have revolutionised treatment for metastatic disease, with median overall survival improving across all risk groups. Combination therapy (dual immune checkpoint inhibitors or an immune checkpoint inhibitor plus a tyrosine kinase inhibitor) is now recommended as first-line therapy.
Future directions in management include integrating molecular biomarkers into prognostic models, evaluating the role of targeted treatments in the adjuvant and neoadjuvant settings, and evaluating new imaging modalities for assessing treatment response.
Renal cell carcinoma (RCC) is a renal malignancy arising from the renal parenchyma/cortex, and accounts for about 90% of kidney cancers.
History and exam
Key diagnostic factors
- presence of risk factors
- asymptomatic (incidental finding)
- flank pain
- palpable abdominal mass
Other diagnostic factors
- non-specific systemic symptoms
- signs of hepatic dysfunction
- lower limb oedema
- scrotal varicocele
- dermatological manifestation (hereditary syndromes)
- vision loss (von Hippel Lindau)
- male sex
- age over 55 years
- residence in developed countries
- black/American-Indian ethnicity
- positive family history of RCC
- history of hereditary syndromes
- history of acquired renal cystic disease
- obstetric history/oestrogen exposure
- pelvic radiation
1st investigations to order
- corrected calcium
- liver function tests
- coagulation profile
- estimated GFR
- abdominal/pelvic ultrasound
- CT abdomen/pelvis
- MRI abdomen/pelvis
Investigations to consider
- CT chest
- MRI brain/spine
- bone scan
- surgical pathology
- PET scan
small renal mass or RCC stage 1 or 2
RCC stage 3
RCC stage 4 (metastatic disease)
Rodrigo R. Pessoa, MD, PhD
Anshutz Medical Campus
University of Colorado
UCASOM Division of Urology
RRP declares that he has no competing interests.
Simon Kim, MD, MPH
Associate Professor of Surgery
Associate Program Director
Anschutz Medical Campus
University of Colorado
UCSOM Division of Urology
SK declares that he has no competing interests.
Dr Rodrigo R. Pessoa and Dr Simon Kim would like to gratefully acknowledge Dr Amishi Y. Shah, Dr Sonal Gandhi, and Jennifer J. Knox, previous contributors to this topic.
AYS has an unpaid advisory role for Merck pharmaceuticals. SG and JJK declare that they have no competing interests.
Stephen A. Boorjian, MD
Fox Chase Cancer Center
SAB has been reimbursed by Pfizer for serving on its speakers bureau. SAB is co-author of a reference cited in this topic.
Thomas J. Guzzo, MD, MPH
Assistant Professor of Urology and Surgery
The Hospital of the University of Pennsylvania
TJG declares that he has no competing interests.
Jonathan Waxman, BSc, MBBS, MD, FRCP
Professor of Oncology
JW declares that he has no competing interests.
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