Renal cell carcinoma

A seminar on the epidemiology and evaluation of a patient with renal cell carcinoma.

1. RENAL CELL CARCINOMA
DR USIFOH .B . ITAMAN
surgery registrar
Presented 0n 7/10/2019 to the Urology Unit,
Department of Surgery, ISTH, as part of the requirements for the Part 1
Post-graduate Training Programme in Surgery

2. OUTLINE
•INTRODUCTION
•EPIDEMIOLOGY
•CLINICAL PRESENTATION
•MANAGEMENT
-Clinical Evaluation
-Investigation
-staging
•PROGNOSIS
•CONCLUSION
•REFERENCES

3. INTRODUCTION
•A group of malignant tumours arising from renal tubular
epithelium.
•First described by Konigin 1826 then in further details by
Grawitzin 1883.
•It is the most common renal tumour.
•It is still an uncommon cancer but incidence is rising (2 to
4% per yr).
•Incidental diagnosis with imaging increasing resulting in
stage migration.
•Classic clinical features seen in late cases.
•Commonly associated with paraneoplastic.

4. ANATOMY OF THE KIDNEYS

6. ANATOMY OF THE KIDNEYS
•Blood supply: 20% of cardiac output
•Lymphatic drainage: para-aortic nodes
•Nerve supply
Renal plexus

8. RENAL PHYSIOLOGY
•Functional unit is the nephron
Functions:
•Excretory
•Secretory
•Acid base homeostasis

9. EPIDEMIOLOGY
•Incidence = 0.6-14.7 per 100,000 population.
•8
th
most common adult malignancy.
•2% of all cancers
•Most common (80-85%) malignancy of urinary
tract.
•Important cause of cancer mortality
•Peak age 50 to 70yrs
•M:F = 2:1
•Highest incidence in the developed world. Least
common in Africa.

10. RISK FACTORS
•Majority are sporadic
•Genetic factors (VHL, HPRCC, BHD)
•Smoking
•Occupational exposure to cadmium, lead,
asbestos, petroleum
•Obesity
•Long term dialysis
•Acquired PKD
•Chronic phenacetin/aspirin use
•Others: hypertension,kidneytransplant, HIV

11. CLASSIFICATION
Hiedelberghistological classification
1.Clear cell (conventional) RC –70 to 80%
2.Papillary RCC –13 to 20%
3.Chromophobe RCC -5%
4.Collecting duct carcinoma -1%
5.Medullary carcinoma –rare

12. Natural history
•Incidental diagnosis in 7%
•Mostly asymptomatic till advanced stage
•Localiseddisease (45%),
•Locally advanced disease(25%)
•Metastatic disease (30%)
Lymph node metastasis (9-27%)
Renal vein (21%) and IVC (4%)
Distant metastasis :
lungs 75%, liver36%, bone20%. brain8%, and
skin8%

13. CLINICAL FEATURES
•Asymptomatic for most of its course (50%).
•Classic ‘too late’ triad seen in 5-10%
Flank pain 40%
Hematuria 40%
Palpable abdominal mass 25%
•Anemia, fatigue, cachexia, fever, malaise, night sweats,
hypertension, Varicocele.
•Features of metastasis
•Features related to paraneoplastic syndromes(20%):
hypertension, hypercalcemia, hepatic dysfunction.

14. PARA-NEOPLASTIC syndrome

15. MANAGEMENT
•DIAGNOSTIC WORKUP
1. Clinical Evaluation
-History
-Examination
2. Laboratory studies
-Urine
-Blood
-Biopsy
3. Radiographic studies
•TREATMENT

16. CLINICAL EVALUATION: History

17. CLINICAL EVALUATION :Examination
•May have no significant finding
•General examination
wasting, pallor, jaundice, pedal edema.
•Abdominal (loin) mass.
•Varicocele (espon the left).
•Features of metastasis

18. Laboratory studies
•Blood
FBC, LFT, ALP, EUCr, serum Ca,RBS
•URINE
Urinalysis, urine cytology, urine MCS
•Renal biopsy

19. Radiographic studies
•CTS
•Abdominal USS
•MRI
•IVU
•Plain xray KUB region
•Angiography

20. CT SCAN IVU

21. Metastasis workup
•Chest x-ray
•Abdominal USS
•Bone x-rays
•CT brain, chest, abdomen
•Bone scan

24. Differential diagnosis
•Renal cysts.
•Lymphomas
•Sarcomas
•Metastases
•Benign masses
•Renal adenomas
•Angiomyolipomas
•Oncocytomas
•Trauma (hematoma)

25. STAGING
•Robson
•TNM

26. ROBSON STAGING

27. TNM STAGING

28. PROGNOSTIC FACTORS
•Pathologic stage.
•Tumour size.
•Histologic type.
•Fuhrman histologic grade.
•Hereditary vs sporadic.
•Performance status.

29. CONCLUSION
•The incidence of RCC is on the rise. As such,
the urologist and any surgeon for that matter
must brace up to the challenge ahead.
•The importance of being adept in the clinical
evaluation and diagnosis cannot be over
stated as early diagnosis impacts greatly on
outcome.

30. REFERENCES
•McAninchJ.W.,LueT.F.SmithAndTanagho’sGeneral
Urology.2013:8
th
edn.Pg332-342.McGraw-HillPublisher,
USA.
•ReynardJ.,BreswsterS.,BiersS.OxfordHandbookof
Urology.2013:3
rd
edn.pg246-258.oxforduniversitypress,
london.
•UmbertoCapitanio,FrancescoMontorsi.Renalcancer.The
Lancet2015http://dx.doi.org/10.1016/S01406736(15)0004
6-X
•RichardE.Gray,GabrielT.H.RenalCellCarcinoma:
DiagnosisandManagement.AmericanFamilyPhysician.
2019:Vol.99(3)247-249.

31. THANKYOU