Renal Cell Carcinoma for NP

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Renal Cell Carcinoma for the Nurse Practitioner Licensing Exam

Renal cell carcinoma (RCC) is the most common type of kidney cancer, accounting for 85% of cases. It originates from the renal tubular epithelium and is classified into several subtypes, with clear cell RCC being the most common.

RCC typically affects individuals between 60-70 years of age and is more common in men. Risk factors include:
Smoking: Strongly associated with RCC.
Obesity: Particularly increases risk in women.
Hypertension: Both treated and untreated hypertension increase RCC risk.
Genetic Syndromes:
Von Hippel-Lindau (VHL) disease: A hereditary condition that predisposes patients to clear cell RCC.
Chronic Kidney Disease: Long-term dialysis and acquired renal cystic disease are associated with RCC.

RCC originates from the proximal renal tubular epithelium and includes several subtypes:
Clear Cell RCC: The most common subtype, accounting for 75-85% of cases. It is characterized by cells filled with lipid and glycogen.
Papillary RCC: The second most common type, associated with two subtypes (type 1 and type 2).
Chromophobe RCC: Rare, typically associated with a better prognosis compared to other subtypes.
RCC can invade local structures, including the renal vein, and metastasizes to distant organs such as the lungs, bones, liver, and brain.

RCC is often asymptomatic in its early stages and may be discovered incidentally on imaging. The classic triad of symptoms includes:
Hematuria: Most common presenting symptom, either gross or microscopic.
Flank Pain: Caused by tumor growth and stretching of the renal capsule.
Palpable Abdominal Mass: Typically seen in advanced disease.
Paraneoplastic Syndromes:
RCC can produce several paraneoplastic syndromes, including:
Hypercalcemia: Due to parathyroid hormone-related peptide (PTHrP) secretion.
Polycythemia: From erythropoietin production by the tumor.
Hypertension: Linked to increased renin secretion.

Imaging:
CT Scan: The gold standard for diagnosing RCC and determining the extent of the disease. It can assess tumor size, local invasion, and metastasis.
MRI: Used when there is concern for venous involvement (e.g., tumor thrombus in the inferior vena cava) or in patients where radiation exposure is contraindicated.
Urinalysis: Detects hematuria, though nonspecific.
Biopsy: Typically not required when imaging findings are classic for RCC but may be used for indeterminate cases or suspected metastasis.

Surgical Treatment:
Radical Nephrectomy: Removal of the kidney, adrenal gland, and surrounding fat. This is the mainstay treatment for localized RCC.
Partial Nephrectomy: Preferred for small tumors (<4 cm) or in patients with a solitary kidney to preserve renal function.
Systemic Therapy:
Targeted Therapy: Used for advanced or metastatic RCC, including tyrosine kinase inhibitors (e.g., sunitinib) and mTOR inhibitors (e.g., everolimus).
Immune Checkpoint Inhibitors: Agents like nivolumab are increasingly used for metastatic RCC, targeting immune pathways to inhibit tumor growth.
Ablative Therapies:
Radiofrequency Ablation (RFA) and cryoablation are options for patients who are poor surgical candidates, particularly for small tumors.

Key Points

RCC is the most common kidney cancer, with clear cell carcinoma being the predominant subtype.
Risk factors include smoking, obesity, hypertension, and genetic conditions such as Von Hippel-Lindau disease.
Symptoms include hematuria, flank pain, and paraneoplastic syndromes like hypercalcemia and polycythemia. Many cases are asymptomatic early on.
Imaging, particularly CT, is the gold standard for diagnosis, while biopsy is reserved for indeterminate cases.
Treatment involves surgical resection for localized disease, and systemic therapies like tyrosine kinase inhibitors or immune checkpoint inhibitors are used for advanced disease.
Prognosis is good for early-stage RCC but poor for metastatic disease.