1. Renal cancer is the 7th most common cancer in the UK and is more lethal than prostate or bladder cancer, with over 40% of patients dying from the disease. 2. Risk factors include smoking, hypertension, obesity, acquired renal cysts/dialysis, and certain genetic syndromes. 3. Renal cell carcinoma is the most common type of kidney cancer, arising from the cortex. The clear cell type accounts for 75% of cases. 4. Imaging such as CT scans are important for staging and diagnosis. Incidental findings on scans have led to an increase in small renal masses being detected.

1. Renal Cancer
Dr.B.Balagobi
MBBS (Col)MD(Surgery) MRCS Ed FRCS Urology(Eng)
Consultant Urological Surgeon

2. Introduction
• 7th most common cancer in UK, 3% of all
cancers
• Rising due to increase in Imaging (incidentalomas)
– more SRM(Small renal mass)
• Deadly cancer
– Most lethal urological malignancy with >40% dying their
disease as opposed to ~20% with prostate/bladder
• More common in males (1.5x)

3. Risk factors
• Smoking
• HT
• Obesity
• Acquired Renal cysts/Dialysis
• Hereditary /Genetic
– Eg:Von Hippel-Lindau(VHL) syndrome
• young age,B/L RCC,multifocal RCC

4. Anatomy

6. Pathology
• Tumor arises from PCT cells(Cortex of the kidney)
• Macroscopic appearance
– Yellow in cross section
– Variegated appearance
• Haemorrhage,Necrosis
• Microscopy: clear cells-75%
– due to abundant glycogen in the cytoplasm)

7. Pathology:RCC
• Histological subtypes
– Clear cell (75%)
– Papillary Type I (5%)
– Papillary Type II (10 %)
– Chromophobe (5%)
– Collecting Duct Tumour
Clear cell Papillary Chromophobe

8. Pathology:Spread
• Local spread:
– Perinephric fat,Renal sinus
– Gerota’s fascia
– Grows into the renal vein,IVC,Even RA
– Obstruct the left testicular vein L/S varicocele
• Lymphatic
– Para aortic LN
• Blood
– Lungs, Brain, Bone, Liver

9. Tumour inside
Right atrium

12. TNM Staging

13. Contributors to Prognosis
• Pathologic stage(TNM)
• Histological subtype
– Clear cell>papillary>chromophobe
• Fuhrman Grade(1-4)
• Performance status of patient
• Tumour Necrosis

14. Pathology:Renal lesion
• Benign
– Cysts
• Bosniak cysts
• Congenital:PCKD
– Oncocytoma
– Angiomyolipoma(AML)
– Renal adenoma
• Malignant
– Primary
• Renal cell carcinoma(RCC)
• Renal pelvic tumour(TCC)
– Secondary

15. Clinical Features
• Over 50% detected incidentally with imaging for other reasons(US,CT)
• Classic triad (10%): indicates locally advanced disease
– Painless Haematuria (20%)
– Flank Pain (20%)
– Loin mass (10%)
• L/S Varicocele
• Metstatic symptoms:
– Bone pain, Adult onset headache/fit, Pleural effusion
• Paraneoplastic syndrome present in ~20%
– Hypercalcaemia(PTHrP)
– Hypertension(Renin)
– Polycythaemia(Erythropoitin)
– Staufer’s syndrome(Non metastatic liver dysfunction)
– PUO
– Anaemia,LOA,LOW

16. Investigations
• UFR
– microscopic haematuria
• Renal function(S.Cr),S.Ca,PT/INR,ALP(bone mets)
• Imaging
– USS/Abd
– Contrast CT/Abdomen,pelvis,chest
• Heterogenous and enhancing renal mass
– Bonescan,PET Scan(rarely)

17. CT

18. CT Scan:Bosniak Classification Renal Cysts
BOSNIAK DESCRIPTION % MALIGNANT
I Simple cyst 0%
II Thin septa/fine calcifications <5%
IIF >3cm/nodular ~5%
III Thick irreg wall/solid non-enhancing areas ~60%
IV Enhancing solid component ~100%

21. Bosnia

22. Renal cancer:Treatment
Depends on:
• Tumour factors
– TNM stage :Localized/Metastasis
– Tumour size
– Position of tumour
• Patient factors
– Performance status,Age
– Status of contralateral kidney
• Surgeon factors
– Availability of facility
– Surgeon experience

23. Management of Small Renal mass
• SRM = less than 4cm
– 20% benign
– Grows 3mm/yr,3% risk of mets
• Rx options
– Active surveillance Vs Watchful waiting
• Old age,cormorbidities
– Partial(Nephron sparin surgery=NSS)/Radical
Nephrectomy
– Ablation:Cryo therapy(cold)/Radio frequency
ablation(RFA)(Hot)

24. Cryo Vs RFA

25. Management of Renal cancer
• Larger tumours
– Partial nephrectomy(PN) if possible
• Absolute indications:
– Solitary functioning Kidney(SFK),B/L RCC,CKD
– Usually Radical Nephrectomy(RN)
• Surgery options
– Open surgery
– Laparoscopic Surgery
– Robotic surgery

27. Metastatic Renal cancer
• 1/3 of patients presents with mets.
• 1/3 of surgically treated patients develop mets.
• Rx Options
– Targeted Therapy
• Tyrosine kinase inhibitors-TKI(Sunitinib)
• Immunotherapy(checkpoint inhibitors Eg:Nivolumab)
– Cytoreductive Nephrectomy
– Embolization
• Primary tumour poor response to chemo or radio
therapy.