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Renal Cell Carcinoma

RCC

Renal cell carcinoma (RCC) is the most common type of kidney cancer in adults.

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Presentation

Typically, twenty-five to thirty percent of patients are asymptomatic and the carcinoma is detected accidentally. Some of the symptoms that patients might complain about, although not common and usually indicative of advanced stages are:

Less common symptoms may include:

Weight Loss
  • Most paraneoplastic signs and symptoms correlated with poor survival, although on multivariate analysis hypoalbuminemia, weight loss, anorexia and malaise predicted shorter survival.[ncbi.nlm.nih.gov]
  • The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n 17) with 8 having lung metastases at presentation.[ncbi.nlm.nih.gov]
  • Kidney cancer symptoms may include hematuria, back pain, and weight loss. Localized renal cell carcinoma is highly curable, and standard kidney cancer treatment is partial or radical nephrectomy.[medscape.org]
  • Lifestyle measures such as exercise, weight loss and diet changes can help. Some people may need to add medications to lower their blood pressure. Discuss your options with your doctor.[mayoclinic.org]
Fever
  • A 58-year-old Chinese male presented with general fatigue and intermittent-remittent fever, accompanied by palpitations and dizziness.[ncbi.nlm.nih.gov]
  • The patient was a 62-year-old male who had visited a physician with the chief complaint of fever. After IVP and CT scanning, left real carcinoma was suspected and he was transferred to our hospital on March 2, 1982.[ncbi.nlm.nih.gov]
  • […] side effects of OPDIVO when used alone include: feeling tired; rash; pain in muscles, bones, and joints; itchy skin; diarrhea; nausea; weakness; cough; shortness of breath; constipation; decreased appetite; back pain; upper respiratory tract infection; fever[opdivo.com]
  • Tell your doctor or nurse right away if you have any trouble breathing, or develop a cough or fever. TORISEL may cause bowel perforation. Fatal cases have been reported.[web.archive.org]
Anemia
  • Of several adverse events, only anemia and fatigue were significantly more frequently observed in older than younger patients.[ncbi.nlm.nih.gov]
  • Symptoms include blood in the urine, unexplained pain in the side or lower back, anemia, fever, and unexplained weight loss.[britannica.com]
  • In fact, the most common presenting sign of kidney cancer is a low red blood cell count ( anemia ).[cancer.about.com]
  • […] the symptoms that patients might complain about, although not common and usually indicative of advanced stages are: Hematuria Flank pain A palpable mass in the abdomen or flank Abdominal pain Less common symptoms may include: Hypertension Weight loss Anemia[symptoma.com]
  • The Memorial Sloan Kettering Cancer Center (MSKCC) prognostic risk groups are based on the presence of 0 (favorable), 1 (intermediate), or 2 or 3 (poor) of the following prognostic factors: anemia, hypercalcemia, and poor performance status.[nejm.org]
Malaise
  • Cachexia did not predict a higher recurrence rate in patients with localized disease and only malaise correlated with a decreased likelihood of responding to immunotherapy.[ncbi.nlm.nih.gov]
  • […] that patients might complain about, although not common and usually indicative of advanced stages are: Hematuria Flank pain A palpable mass in the abdomen or flank Abdominal pain Less common symptoms may include: Hypertension Weight loss Anemia Fever Malaise[symptoma.com]
  • […] may include the following: Hematuria ( blood in the urine ) Lower back pain or pain in the flank (side or back above the waist) that will not go away Noticeable lump in the flank Weight loss Fatigue (feeling tired) Loss of appetite Fever Night sweats Malaise[emedicinehealth.com]
  • […] the individual components of the classic triad is as follows: Hematuria – 40% Flank pain – 40% A palpable mass in the flank or abdomen –25% Other signs and symptoms include the following: Weight loss (33%) Fever (20%) Hypertension (20%) Night sweats Malaise[emedicine.medscape.com]
Flank Mass
  • This study also found that the classic triad of pain, hematuria and flank mass was present in only six of 109 patients (5.5 percent). Tumors found incidentally will usually be of lower pathological stage and may carry a better prognosis.[ncbi.nlm.nih.gov]
  • History Part I: Pattern Recognition: Solid renal mass Hematuria Flank pain Flank mass Weight loss Anemia or polycythemia B.[clinicaladvisor.com]
  • mass: 30-40% This triad is however only found in 10-15% of patients 1,2 , and increasingly the diagnosis is being made on CT for assessment of haematuria alone or as an incidental finding.[radiopaedia.org]
  • mass: 30-40% This triad is however only found in 10-15% of patients 1,2, and increasingly the diagnosis is being made on CT for assessment of hematuria alone or as an incidental finding.[radiopaedia.org]
  • The classic triad of flank pain, hematuria, and flank mass is uncommon (10%) and is indicative of advanced disease. Twenty-five to thirty percent of patients are asymptomatic, and their renal cell carcinomas are found on incidental radiologic study.[emedicine.medscape.com]
Hyposmia
  • We report a case of 79 year old woman with recurrent episodes of rhinorrhea, headache, hyposmia and monolateral right epistaxis, with a history of RCC.[ncbi.nlm.nih.gov]
Abdominal Mass
  • Clinical Presentation • Most asymptomatic • Hematuria present 40% of patients • Classic triad: flank pain, hematuria, palpable abdominal mass occur in 9% of patients • 45% present with localized disease, • 25% with locally advanced disease, • 30% with[slideshare.net]
  • The symptoms of RCC may include, but are not limited to: 3 Blood in urine Pain in side Abdominal mass Fatigue and loss of appetite Weight loss Early diagnosis of RCC is crucial Like all forms of cancer, the stage at which an RCC diagnosis is made has[roche.com]
  • Historically, symptoms of flank pain (pain on the side and lower back), an abdominal mass, and blood in the urine were the most common presenting signs, but today it's often suspected when a person develops anemia (a low red blood cell count), or as an[cancer.about.com]
  • Other signs may include flank pain and an abdominal mass that can be felt by the examining doctor. Other symptoms of renal cell carcinoma may include high blood pressure (hypertension), anemia, abnormal liver function and fever.[rarediseases.org]
  • This classic triad is 1: haematuria, which is when there is blood present in the urine, 2: flank pain, which is pain on the side of the body between the hip and ribs, and 3: an abdominal mass, similar to bloating but larger.[en.wikipedia.org]
Abdominal Pain
  • A 56-year-old female with past medical history of thrombotic microangiopathy presented to her physician with nonspecific abdominal pain.[ncbi.nlm.nih.gov]
  • Other symptoms, such as backache or abdominal pain tend to be non-specific. As a result, RCC is often discovered by chance during routine imaging examinations for unrelated complaints.[pharma.bayer.com]
  • Some of the symptoms that patients might complain about, although not common and usually indicative of advanced stages are: Hematuria Flank pain A palpable mass in the abdomen or flank Abdominal pain Less common symptoms may include: Hypertension Weight[symptoma.com]
  • When symptoms are present, they may include blood in the urine; urine that is brown or rusty-colored; abdominal pain; weight loss; enlargement of one testicle or varicose veins of the testis (varicocele) in a male patient; fever; a thin, malnourished[rarediseases.org]
Abdominal Fullness
  • She was also found to have vague abdominal fullness, although it was only after biopsy of a clivus lesion identified on brain scanning that its true nature became apparent, prompting abdominal scans, which revealed a renal mass with hepatic metastases[ncbi.nlm.nih.gov]
Hypertension
  • Renin-dependent hypertension was relieved soon after nephrectomy. It is an uncommon cause of positive captopril renography.[ncbi.nlm.nih.gov]
  • Age, male gender, body mass index, diabetes, and hypertension were all significant associated with renal cancer in bivariate analysis (P CONCLUSIONS: Obesity, hypertension, and smoking are the 3 modifiable risk factors that could aggressively be targeted[ncbi.nlm.nih.gov]
  • The established determinants of renal cell cancer, cigarette smoking, obesity, and hypertension, account for less than half of these cancers.[ncbi.nlm.nih.gov]
  • Role of diuretics, other anti-hypertensive medications and hypertension. Int J Cancer. 1995;63(2):216–21. PubMed CrossRef Google Scholar 82. Choi MY, Jee SH, Sull JW, Nam CM. The effect of hypertension on the risk for kidney cancer in Korean men.[doi.org]
  • During the treatment, angiotensin II type 1 receptor blockers and Ca antagonists were used to strictly control the axitinib-induced hypertension and proteinuria. Aortic dissection and cardiac dysfunction occurred coincidentally.[ncbi.nlm.nih.gov]
Back Pain
  • A 86-year-old man with a chief complaint of continuous back pain for 3 months and discovery of a cutaneous nodule on the nose for a month visited the oncology department of our hospital.[ncbi.nlm.nih.gov]
  • Kidney cancer symptoms may include hematuria, back pain, and weight loss. Localized renal cell carcinoma is highly curable, and standard kidney cancer treatment is partial or radical nephrectomy.[medscape.org]
  • The most common side effects of OPDIVO when used alone include: feeling tired; rash; pain in muscles, bones, and joints; itchy skin; diarrhea; nausea; weakness; cough; shortness of breath; constipation; decreased appetite; back pain; upper respiratory[opdivo.com]
  • pain Pallor Vision problems Renal cell carcinoma is a challenging and unique tumor because of the occurrence of paraneoplastic syndromes.[symptoma.com]
  • How to Treat Renal Cell Carcinoma Renal cell carcinoma can produce numerous symptoms including blood in urine, abdominal and back pain, swelling, weight loss, problems with vision and pale skin.[newhealthadvisor.com]
Slurred Speech
  • CASE REPORT We present the case of a patient who was brought to the Emergency Department with right-sided extremity weakness and slurred speech consistent with acute ischemic stroke.[ncbi.nlm.nih.gov]
Hematuria
  • This study also found that the classic triad of pain, hematuria and flank mass was present in only six of 109 patients (5.5 percent). Tumors found incidentally will usually be of lower pathological stage and may carry a better prognosis.[ncbi.nlm.nih.gov]
  • TAE can potentially palliate symptoms of RCC such as pain and hematuria. Trans-arterial chemoembolization and trans-arterial radioembolization are emerging concepts for RCC.[ncbi.nlm.nih.gov]
  • Abstract A 67-year-old man consulted our department with gross hematuria. Computed tomography (CT) revealed a huge renal tumor with a paracaval metastatic lymph node (mLN).[ncbi.nlm.nih.gov]
  • A 45-year-old male patient presented a nine day history of gross hematuria without any other symptoms.[ncbi.nlm.nih.gov]
  • KEYWORDS: genetics; hematuria; surgical oncology; urological cancer; urological surgery Publication type, MeSH terms Publication type Case Reports MeSH terms Adult Carcinoma, Renal Cell/diagnosis* Carcinoma, Renal Cell/diagnostic imaging Carcinoma, Renal[ncbi.nlm.nih.gov]
Flank Pain
  • Symptoms Patients at risk should be precautious and report unusual symptoms such as blood in the urine, flank pain or a palpable mass in the abdomen or flank.[symptoma.com]
  • Symptoms can include hematuria, flank pain, a palpable mass, and FUO. However, symptoms are often absent, so the diagnosis is usually suspected based on incidental findings. Diagnosis is confirmed by CT or MRI and occasionally by biopsy.[msdmanuals.com]
  • Clinical Presentation • Most asymptomatic • Hematuria present 40% of patients • Classic triad: flank pain, hematuria, palpable abdominal mass occur in 9% of patients • 45% present with localized disease, • 25% with locally advanced disease, • 30% with[slideshare.net]
Macroscopic Hematuria
  • They usually occur in 50-70-year old patients and macroscopic hematuria occurs in 60% of the cases.[radiopaedia.org]
  • Urinalysis - micro- or macroscopic hematuria occurs in 60% of patients Complete blood count (CBC) - patients may have anemia of chronic inflammation (normo- or microcytic), some have erythrocytosis from paraneoplastic erythropoietin (Epo) production,[clinicaladvisor.com]

Workup

Renal cell carcinoma is a challenging and unique tumor because of the occurrence of paraneoplastic syndromes. The workup for RCC should also include laboratory tests for these paraneoplastic syndromes [5].

The use of imaging modalities is helpful in the evaluation of the renal mass. These include:

  • Computed tomography
  • Ultrasoundography
  • Venography
  • Arteriography
  • Magnetic resonance imaging
  • Positron-emission tomography [5]

Differentiating a non-malignant and malignant renal mass can be difficult. Typically, when a patient presents for a physical examination for possible RCC it is most likely in the metastatic stage. The physical exam should pay close attention to the:

  • Lungs
  • Bones
  • Liver
  • Soft tissue
  • Central nervous system
  • Cutaneous sites

Some of the laboratory testing should include, but not limited to:

  • Urinalysis
  • Complete blood count (CBC)
  • Liver function test
  • Renal profile
  • Chemistry profile (electrolytes) with serum calcium

Treatment

More than 50% of patients who are diagnosed with RCC in the early stages are cured. The approach of treatment is determined by the size and stage of the tumor. The primary care physician should review the patient’s current health status, renal function, oncologic issues and complication risks [5].

The main treatments available for renal cell carcinoma are:

  • Surgery: Surgical resection is the only effective treatment for a localized tumor, but has also been used for metastatic disease as a palliative therapy.
  • Immunotherapy: Used as a standard of care in metastatic disease.
  • Radiation therapy: Used as a standard of care in metastatic disease as a palliative therapy for patients who clinically are not surgical candidates.
  • Molecular-targeted therapy: Used as a standard of care in metastatic disease

Experimental therapies include:

There are studies available for those patients who may qualify. One such study ARGOS, ADAPT Phase 3, is a worldwide randomized study to examine their product to extend the survival rate of early diagnosed renal cell carcinoma patients [8].

Prognosis

RCC is the tenth leading cause of death in males. The rate of complications, transfusions, and in-hospital mortality is higher in patients treated with cytoreductive nephrectomy than in those who underwent nephrectomy. Risk is further increased in patients who are older, have higher comorbidity, or need secondary surgical procedures. A study by Heng et al found that progression-free survival at 3 and 6 months predicted overall survival among patients with metastatic renal cell carcinoma. The survival rate depends on if the cancer has already metastasized outside of the kidney and how well the patient tolerates the course of treatment. If RCC is diagnosed in the early stages the prognosis is good.

The following are factors associated with increased survival in patients with metastatic disease:

  • A long disease-free interval between initial nephrectomy and the appearance of metastases
  • The presence of only pulmonary metastases
  • Good performance status
  • Removal of the primary tumor

Etiology

The exact cause of RCC is unclear at this time. It is known that many predisposing factors play a major role in the causation of RCC. Cigarette smoking, obesity, occupational exposure to chemicals, chronic use of NSAIDS, and few genetic disorders are the major causative factors.

Epidemiology

Incidence

Renal cell carcinoma varies widely globally with the highest rates being in the North America and the Czech Republic [2]. In the United States alone, there are 64,000 new cases and approximately 14,000 deaths per year [3]. RCC is the seventh most common cancer in males. Statistics show that 50% of those with RCC die within 5 years after diagnosis [3] [4].

Gender and age

Renal cell carcinoma is 50% more prevalent in males than females. RCC most often occurs between 60 to 80 years of age with the median age being 64 [5].

Sex distribution
Age distribution

Pathophysiology

The origin of renal cell carcinoma is in the proximal renal tubular epithelium. There are four hereditary syndromes that are associated with renal cell carcinoma [7]:

  • Von Hippel-Lindau disease (VHL)
  • Hereditary papillary renal carcinoma (HPRC)
  • Hereditary renal carcinoma (HRC)
  • Familial renal oncocytoma associated with Birt-Hogg-Dube syndrome (BHDS)

Prevention

Although there are no set prevention methods, avoiding causative factors can be helpful. Some of these factors include smoking, obesity, occupational and environmental exposures to toxic chemicals. Patients with acquired renal cystic disease undergoing long term dialysis or renal transplant, and patients with chronic hepatitis C should take precautions and report unusual symptoms such as blood in the urine, pain on urination or any of the other mentioned symptoms.

Summary

Renal cell carcinoma (RCC) is accountable for 80-85 percent of all primary renal neoplasms. There may be multiple tumors in one kidney or there could be tumors in both kidneys. This type of renal cancer is seen most frequently. There are several histologic subtypes of RCC. Knowing the type of cell will decide the type of treatment. It is also helpful to determine if it is an inherited genetic syndrome.

The subtypes are [1] [9]:

  • Clear cell: The most common type of RCC (83%)
  • Papillary (11%)
  • Chromophobic (4%)
  • Collecting duct

Patient Information

Definition

Renal cell carcinoma (RCC) is the most common type of kidney cancer in adults accounting for 95% of renal tumors.

Cause

Cigarette smoking, obesity, occupational exposure to chemicals, chronic use of NSAIDS, and few genetic disorders are the most common causative factors.

Symptoms

Patients at risk should be precautious and report unusual symptoms such as blood in the urine, flank pain or a palpable mass in the abdomen or flank. 

Diagnosis

Diagnosis is generally by combination of physical examination, Laboratory tests and Imaging. Imaging forms an important part to know the spread, and to plan the treatment.

Treatment

Most of the early cases are cured. The treatment varies depending on the stage of the disease.

References

Article

  1. Cheville JC, Lohse CM, Zincke H, Weaver AL, Blute ML. Comparisons of outcomes and prognostic features among histologic subtypes of renal cell carcinoma.Am J Surg Pathol, 2003 May;27(5):612-24 
  2. Chow WH, Dong LM, Devesa SS. Epidemiology and risk factors for kidney cancer. Nat Rev Urol 2010; 7:245
  3. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin 2014; 64:9
  4. P. Lindblad. Department of Urology, Sundsvall Hospital, Sundsvall, Sweden. Scandinavian Journal of Surgery : SJS : Official Organ for the Finnish Surgical Society and the Scandinavian Surgical Society
  5. Schmidinger M, Vogl UM, Bojic M, Lamm W, Heinzl H, Haitel A, et al. Hypothyroidism in patients with renal cell carcinoma: blessing or curse?. Cancer. Feb 1 2011;117(3):534-44
  6. Renal Cell Carcinoma Author: Kush Sachdeva, MD; Chief Editor: Jules nlm.nih.gov/medlineplus/ency/article/000516.htm 
  7. Yi-Bin Chen, MD, Leukemia/Bone Marrow Transplant Program, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
  8. Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: The impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin 2011; 61:212.

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Last updated: 2019-07-11 21:12