Renal Cell Carcinoma

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.

T2

Greater than 7 cm but confined to kidney.

T3

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

T4

Invades beyond Gerota fascia, including contiguous adrenal invasion.

Most localised RCCs are asymptomatic.

Possible presentations include:

• Haematuria
• Flank pain
• Abdominal mass
• Anaemia
• Weight loss
• Fever
• Hypertension
• Hypercalcaemia

The classical triad of haematuria, flank pain and palpable mass usually indicates advanced disease.

Metastatic sites include:

• Lung
• Bone
• Nodes
• Liver
• Brain

RCC can extend through the renal vein into the inferior vena cava and occasionally the right atrium.

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