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Renal Cell Carcinoma

Renal Cell Carcinoma is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Renal cell carcinoma (RCC) arises from the parenchyma of the kidney (as opposed to urothelial cancer, which arises from the renal pelvis/calyces). According to SEER, there is estimated to be 63,990 new cases (including renal pelvis) in 2017, making up 3.8% of all cancers diagnosed. It is the eighth most common cancer diagnosed in the United States.
  • Characterized by obscure and varied presentations, including paraneoplastic syndromes, vascular findings, and uncommon metastatic sites
  • Metastatic disease landing sites commonly include bones, lung, and regional lymph nodes.
  • Early, aggressive surgical management provides the best opportunity for cure.
  • System(s) affected: renal/urologic

Epidemiology

Incidence
  • Predominant age: patients in 5th to 7th decades; median age at diagnosis is 64 years.
  • Male to female 2:1
  • Age-adjusted incidence is increasing 3% per year, likely due in part to increased detection as an incidental finding on imaging studies.
  • >60% are detected as an incidental finding.
  • The incidence of RCC is rising, whereas the death rate from RCC has concurrently decreased (SEER).
  • The rate of metastatic disease increases with the size of the renal mass.
    • 1.1% (1 to 2 cm), 3.3% (2 to 3 cm), 6% (3 to 4 cm)

Etiology and Pathophysiology

  • Most common site of metastatic disease is lung.
  • Pathogenesis: loss of von Hippel-Lindau (VHL) gene resulting in decreased degradation of hypoxia-inducible factor (HIF) which in turn leads to increased expression of angiogenic growth factors (vascular endothelial growth factor [VEGF] and platelet-derived growth factor [PDGF])
  • Five distinct subtypes
    • Clear cell: 70–80%; proximal tubule, solitary
    • Papillary renal cell (previously termed chromophilic): 10–15%; proximal tubule; tumors tend to be bilateral and multifocal; type 1 and more aggressive type 2 variant
    • Chromophobe: 3–5%; intercalated cells; tend to have a less aggressive course
    • Medullary: <1%; typically affects younger patients; most are at an advanced stage with metastases at time of diagnosis; occurs almost exclusively in patients with sickle cell trait
    • Collecting duct: <1%, aggressive disease with high mortality

Genetics
  • 2–3% of cases are familial, with several autosomal dominant syndromes described.
  • Oncogenes localized to the short arm of chromosome 3 may have etiologic implications. Chromosome 3p12-p26 is specific for clear cell RCC.
  • Multiple hereditary types of RCC have been established, although VHL remains the most common, predisposing the clear cell RCC and vascular lesions.
  • Hereditary papillary RCC is an autosomal dominant form of disease associated with multifocal papillary renal tumors and a 5:1 male predominance; no extrarenal manifestations
  • Other familial RCC include Birt-Hogg-Dubé (BHD) syndrome, hereditary leiomyomatosis and RCC (HLRCC), tuberous sclerosis.

Risk Factors

  • Prior diagnosis of RCC—risk increases to 2–4% for a metachronous RCC in absence of familial disease.
  • Smoking, active and passive
  • Obesity
  • Hypertension (Antihypertensive medications are not independently associated with RCC.)
  • End-stage renal failure: Patients on hemodialysis have an increased risk of RCC.
  • Acquired renal cystic disease
  • Tuberous sclerosis
  • Family history of RCC
  • Heavy-meat and high-fat dairy products
  • Lower socioeconomic status
  • Heavy metal exposure (cadmium, lead)
  • Environmental toxin exposure (asbestos, petroleum by-products, chlorinated solvents)
  • Complex renal cyst
    • Bosniak classification
    • I: simple cyst
    • II: low risk of future malignant transformation
    • IIF: small risk of malignant transformation with follow-up warranted
    • III and IV: 50–100% risk of malignancy

General Prevention

  • Smoking may contribute to 1/3 of all cases.
  • Diet heavy in fruit and vegetables may be protective.

Commonly Associated Conditions

  • VHL disease: 30–45% of these patients develop clear cell tumors.
  • Tuberous sclerosis: associated primarily with angiomyolipoma and clear cell tumors
  • HLRCC: cutaneous and uterine leiomyomas; more aggressive type II papillary RCC. 15–30% develops RCC.
  • BHD: associated with oncocytomas and chromophobe RCC, benign cutaneous lesions, lung cysts, and associated risk of pneumothorax
  • Sickle cell trait: With few exceptions, renal medullary tumor is seen in young African American males with sickle cell trait.
  • Adult polycystic kidney disease
  • Renal cystic disease from chronic renal failure

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Citation

Stephens, Mark B., et al., editors. "Renal Cell Carcinoma." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116908/all/Renal_Cell_Carcinoma.
Renal Cell Carcinoma. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116908/all/Renal_Cell_Carcinoma. Accessed March 19, 2019.
Renal Cell Carcinoma. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116908/all/Renal_Cell_Carcinoma
Renal Cell Carcinoma [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116908/all/Renal_Cell_Carcinoma.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Renal Cell Carcinoma ID - 116908 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116908/all/Renal_Cell_Carcinoma PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -