Renal Cell Carcinoma

Also known as: RCC

Renal cell carcinoma arises from renal tubular epithelium.

Major histological types include:

Clear cell RCC
Papillary RCC
Chromophobe RCC

Clear cell RCC is the commonest.

Many tumours are now discovered incidentally during abdominal imaging.

Important staging categories include:

T1a

Tumour 4 cm or smaller, confined to kidney.

T1b

Greater than 4 cm and up to 7 cm.

Greater than 7 cm but confined to kidney.

Extends into major veins or perinephric tissues but not beyond Gerota fascia.

Invades beyond Gerota fascia, including contiguous adrenal invasion.

Multiphasic contrast CT abdomen: standard renal mass characterisation and local staging.

MRI is useful for:

Venous tumour thrombus
Contrast contraindication
Complex cystic lesions

Stage the chest appropriately.

Biopsy is useful when histology will change management, particularly before:

Ablative therapy
Systemic therapy
Selected active surveillance

Routine biopsy before straightforward surgery for a clearly malignant renal mass is not mandatory.

T1 disease

Perform partial nephrectomy whenever technically feasible.

The goal is complete tumour excision while preserving functional renal parenchyma.

Partial nephrectomy is particularly important for:

Solitary kidney
Bilateral tumours
Chronic kidney disease
Hereditary RCC
Younger patients

Radical nephrectomy

Perform radical nephrectomy when:

Tumour is not safely amenable to partial nephrectomy
Large central tumour makes nephron sparing oncologically or technically inappropriate
Extensive local disease exists

Remove:

Kidney
Perirenal fat within Gerota fascia

The ipsilateral adrenal gland does not require routine removal without evidence of adrenal invasion.

Routine lymph node dissection is unnecessary in organ confined disease without suspicious nodes.

Small renal mass

For small T1a lesions, management can include:

Partial nephrectomy
Active surveillance in frail or elderly patients
Percutaneous thermal ablation in selected patients

Treatment should consider competing mortality risk and baseline renal function rather than operating on every small enhancing lesion.

Venous tumour thrombus

In a patient without prohibitive metastatic disease, radical nephrectomy with renal vein or IVC thrombectomy can provide curative treatment.

Preoperative imaging must define:

Cranial extent
IVC wall invasion
Hepatic vein relationship
Right atrial extension

High level thrombi require multidisciplinary vascular, hepatobiliary and sometimes cardiothoracic involvement.

Adjuvant pembrolizumab

Selected patients with high risk clear cell RCC after nephrectomy should be offered adjuvant pembrolizumab.

Eligible risk patterns include:

pT2 grade 4 or sarcomatoid
pT3
pT4
Node positive disease
Selected M1 patients rendered no evidence of disease after metastasectomy

Treatment begins after postoperative recovery, preferably within approximately 12 to 16 weeks.

A standard schedule can use:

Pembrolizumab 200 mg IV every 3 weeks

or approved equivalent dosing for approximately one year.

Metastatic RCC

Modern first line treatment usually uses immune checkpoint based combinations.

Examples include:

Nivolumab plus ipilimumab
Pembrolizumab plus axitinib
Nivolumab plus cabozantinib
Pembrolizumab plus lenvatinib

Choice depends on:

Histology
IMDC risk
Comorbidity
Disease tempo
Need for rapid tumour shrinkage

Cytoreductive nephrectomy is not automatically performed before systemic therapy in all metastatic patients.

It remains useful in selected patients with:

Good performance status
Limited metastatic burden
Resectable primary
Favourable response to initial systemic therapy
Symptomatic primary tumour requiring control

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Bladder Cancer

Most bladder cancers are urothelial carcinomas.

The critical treatment distinction is:

Non muscle invasive bladder cancer

Ta
T1
Carcinoma in situ, Tis

versus

Muscle invasive bladder cancer

T2 or greater

Ta is confined to urothelium.

T1 invades lamina propria.

T2 invades detrusor muscle.

Carcinoma in situ is a flat high grade intraepithelial malignancy.

Smoking is the dominant preventable risk factor.

Initial assessment includes:

Cystoscopy
Upper urinary tract imaging according to risk
Urine cytology for high grade disease

Cystoscopy cannot be replaced by urine cytology or a noninvasive urinary marker.

TURBT provides diagnosis, staging and initial treatment.

A high quality TURBT should:

Remove all visible tumour where safe
Include detrusor muscle in the specimen for most lesions
Submit tumour and deep components appropriately

Absence of detrusor muscle increases understaging risk.

Repeat TURBT within approximately 2 to 6 weeks when:

Initial resection is incomplete
T1 disease exists
Detrusor muscle is absent from a relevant initial specimen.

Low risk NMIBC

Complete TURBT.

Give a single immediate postoperative intravesical chemotherapy instillation when there is no:

Suspected perforation
Significant bleeding requiring continuous irrigation

An example is:

Mitomycin C 40 mg intravesically once

according to local preparation and dwell protocol.

Intermediate risk NMIBC

Options include:

Intravesical chemotherapy
One year BCG according to recurrence and progression risk

High risk NMIBC

Use full dose intravesical BCG with induction followed by maintenance.

A typical induction course is:

BCG intravesically once weekly for 6 weeks

followed by maintenance courses.

High risk treatment can continue for 1 to 3 years.

Immediate radical cystectomy should also be discussed in patients with features indicating major progression risk.

Very high risk or BCG unresponsive NMIBC

Radical cystectomy provides the most reliable oncological control.

Further BCG is inappropriate for true BCG unresponsive disease.

Bladder preserving systemic or intravesical approaches can be considered when cystectomy is declined or medically unsuitable. The 2026 landscape now includes additional immunotherapy combinations in selected high risk BCG naïve patients.

Muscle invasive bladder cancer

For resectable T2 to T4a disease, definitive treatment usually includes:

Perioperative systemic therapy
Radical cystectomy with pelvic lymph node dissection

Standard male cystectomy removes:

Bladder
Prostate
Seminal vesicles

with urinary diversion.

Current perioperative systemic treatment

For cisplatin eligible muscle invasive disease, a current standard option is:

Gemcitabine plus cisplatin with durvalumab perioperatively, followed by definitive cystectomy and postoperative durvalumab according to the established regimen. This treatment has demonstrated event free and overall survival benefit and is now incorporated into 2026 practice.

Patients who are ineligible for cisplatin can now be offered perioperative:

Enfortumab vedotin plus pembrolizumab

where available and appropriate.

Traditional neoadjuvant cisplatin combination chemotherapy remains appropriate when immunotherapy combinations are unavailable or unsuitable.

Do not substitute carboplatin for cisplatin as routine neoadjuvant curative therapy.

Bladder preserving trimodality therapy

Selected patients can undergo:

Maximal TURBT
Concurrent radiosensitising chemotherapy
Definitive radiotherapy

Best candidates generally have:

Solitary tumour
Good bladder function
Limited or no hydronephrosis
Ability to achieve substantial TURBT
No extensive CIS

Close lifelong cystoscopic surveillance is required.

Muscle invasive recurrence requires salvage cystectomy when feasible.

Renal Cell Carcinoma

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management