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Source: Walko CM, La-Beck NM, Walsh MD. Renal Cell Carcinoma. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=8011227. Accessed August 6, 2012.

  • Malignant tumor of kidney

  • Genetic factors contribute to 15% of cases of renal cell carcinoma (RCC); remaining 85% believed to be sporadic.

  • Clear cell RCC
    • Predominant subtype responsible for most cases.
    • Affects proximal tubule.
    • Likely to metastasize.
    • Results from inactivation of von Hippel-Lindau (VHL) tumor suppressor gene on chromosome 3p25.
      • Leads to increased production of growth factors, including:
        • Vascular endothelial growth factor (VEGF)
        • Transforming growth factor (TGF)
        • Platelet-derived growth factor (PDGF), as well as others responsible for angiogenesis and cell growth
  • Papillary RCC types 1 and 2
    • Occur in proximal tubule.
    • Account for 5–10% of RCC cases.
    • More favorable prognosis than clear cell.
      • Prognosis with type 1 better than type 2.
    • Associated with multiple genetic abnormalities.
  • Chromophore and oncocytoma subtypes
    • Occur in intercalated cells of collecting system.
    • Account for 5–10% of RCC cases
    • Associated with wide variety of chromosomal abnormalities.
    • Oncocytomas relatively benign and rarely metastasize.

  • Fifth most common cancer in men; sixth most common in women.

  • Most cases diagnosed incidentally following computed tomography (CT) scans done for unrelated reasons.

Signs and Symptoms

  • Classic triad symptoms, seen in <10% of patients:
    • Flank pain
    • Hematuria
    • Palpable abdominal mass
  • Other presenting symptoms are:
    • Fatigue
    • Weight loss
    • Anemia
    • Hypertension
    • Fever
    • Lower extremity edema
  • Metastatic disease symptoms:
    • Bone pain
    • Adenopathy
    • Pulmonary

Means of Confirmation and Diagnosis

  • Results from biopsy

Laboratory Tests

  • Complete blood count (CBC)
  • Metabolic panel
  • Lactate dehydrogenase
  • Coagulation profile
  • Urinalysis

Imaging

  • CT: contrast and noncontrast of chest, abdomen, and pelvis or
  • MRI of chest, abdomen, and pelvis

Diagnostic Procedures

  • Biopsy of surgical specimen

Staging

  • Tumor staging utilizes TNM system.
  • Factors associated with prognosis include:
    • Positive surgical margins
    • Metastatic spread
    • Presence of sarcomatoid architecture
    • Tumor subtype, grade, and stage
      • Tumor stage most powerful prognostic indicator.
  • Memorial Sloan-Kettering Cancer Center (MSKCC) Prognostic Factors Model was developed for patients with metastatic disease.
    • Low risk: No poor prognostic risk factors present.
    • Intermediate risk: One or two factors
    • High risk: ≥3 factors (Table 1)
  • These criteria used by clinicians to determine optimal therapy.

Table 1. MSKCC Poor Prognostic Factors

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