MSD Manual

Please confirm that you are a health care professional

Loading

Renal Cell Carcinoma

(Adenocarcinoma of the Kidneys)

By

J. Ryan Mark

, MD, Sidney Kimmel Cancer Center at Thomas Jefferson University

Last full review/revision Sep 2019| Content last modified Sep 2019
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Topic Resources

Renal cell carcinoma (RCC) is the most common renal cancer. Symptoms can include hematuria, flank pain, a palpable mass, and fever of unknown origin (FUO). However, symptoms are often absent, so the diagnosis is usually suspected based on incidental findings. Diagnosis is confirmed by CT or MRI and occasionally by biopsy. Treatment is with surgery for early disease and targeted therapy, an experimental protocol, or palliative therapy for advanced disease.

RCC, an adenocarcinoma, accounts for 90 to 95% of primary malignant renal tumors. Less common primary renal tumors include transitional cell carcinoma, Wilms tumor (most often in children), and sarcoma.

In the US, about 73,820 new cases of RCC and other kidney tumors and 14,770 deaths (2019 estimates) occur each year. RCC occurs slightly more often in men (male:female incidence is about 3:2). People affected are usually between 50 and 70 years old. Risk factors include the following:

  • Smoking, which doubles the risk (in 20 to 30% of patients)

  • Obesity

  • Excess use of phenacetin

  • Acquired cystic kidney disease in dialysis patients

  • Exposure to certain radiopaque contrast agents, asbestos, cadmium, and leather tanning and petroleum products

  • Some familial syndromes, particularly von Hippel–Lindau disease

RCC can trigger thrombus formation in the renal vein, which occasionally propagates into the vena cava. Tumor invasion of the vein wall is uncommon. RCC metastasizes most often to the lymph nodes, lungs, adrenal glands, liver, brain, and bone.

Symptoms and Signs

Symptoms usually do not appear until late, when the tumor may already be large and metastatic. Gross or microscopic hematuria is the most common manifestation, followed by flank pain, fever of unknown origin (FUO), and a palpable mass. Sometimes hypertension results from segmental ischemia or pedicle compression. Paraneoplastic syndromes occur in 20% of patients. Polycythemia can result from increased erythropoietin activity. However, anemia may also occur. Hypercalcemia is common and may require treatment. Thrombocytosis, cachexia, or secondary amyloidosis may develop.

Diagnosis

  • CT with contrast or MRI

Most often, a renal mass is detected incidentally during abdominal imaging (eg, CT, ultrasonography) done for other reasons. Otherwise, diagnosis is suggested by clinical findings and confirmed by abdominal CT before and after injection of a radiocontrast agent or by MRI. (See Genitourinary Imaging Tests.) A renal mass that is enhanced by radiocontrast strongly suggests renal cell carcinoma (RCC). CT and MRI also provide information about local extension and nodal and venous involvement. MRI provides further information about extension into the renal vein and vena cava and has replaced inferior vena cavography. Ultrasonography and intravenous urography may show a mass but provide less information about the characteristics of the mass and extent of disease than do CT or MRI.

Often, nonmalignant and malignant masses can be distinguished radiographically, but sometimes surgery is needed for confirmation. Needle biopsy does not have sufficient sensitivity when findings are equivocal; it is recommended only when there is an infiltrative pattern instead of a discrete mass, when the renal mass may be a metastasis from another known cancer, or sometimes to confirm a diagnosis before chemotherapy for metastases.

Three-dimensional CT, CT angiography, or magnetic resonance angiography is used before surgery, particularly before nephron-sparing surgery, to define the nature of RCC, to more accurately determine the number of renal arteries present, and to delineate the vascular pattern. (See Genitourinary Imaging Tests.) These imaging techniques have replaced aortography and selective renal artery angiography.

A chest x-ray and liver tests are essential. If chest x-ray is abnormal, chest CT is done. If alkaline phosphatase is elevated, bone scanning is needed. Serum electrolytes, blood urea nitrogen (BUN), creatinine, and calcium are measured. BUN and creatinine are unaffected unless both kidneys are diseased.

Staging

Information from the evaluation makes preliminary staging possible. The TNM (tumor, node, metastasis) system has been recently refined to be precise (see tables AJCC/TNM Staging of Renal Cell Carcinoma and TNM Definitions for Renal Cell Carcinoma). At diagnosis, RCC is localized in 45%, locally invasive in about 33%, and spread to distant organs in 25%.

Table
icon

AJCC/TNM* Staging of Renal Cell Carcinoma

Stage

Tumor

Regional Lymph Node Metastasis

Distant Metastasis

I

T1

N0

M0

II

T2

N0

M0

III

T1, T2

N1

M0

T3

N0, N1

M0

IV

T4

Any N

M0

Any T

Any N

M1

* For AJCC/TNM definitions, see Table: TNM Definitions for Renal Cell Carcinoma.

AJCC = American Joint Commission on Cancer; TNM = tumor, node, metastasis.

Adapted from Amin MB, Edge S, Greene F, Byrd DR, et al: AJCC Cancer Staging Manual, 8th edition. New York, Springer, 2018.

Table
icon

TNM Definitions for Renal Cell Carcinoma

Feature

Definition

Primary tumor

TX

No information to assess primary tumor

T0

No evidence of a primary tumor

T1

≤ 7 cm in greatest dimension

Limited to kidney

T1a

≤ 4 cm in greatest dimension

T1b

> 4 cm but ≤ 7 cm in greatest dimension

T2

≥ 7 cm in greatest dimension

Limited to kidney

T2a

> 7 cm but ≤ 10 cm in greatest dimension

T2b

> 10 cm in greatest dimension

T3

Extends into major veins or invades perinephric tissues but not beyond Gerota fascia or into the adrenal gland

T3a

Extends into renal veins or its segmental branches or invades perirenal and/or renal sinus fat, but not beyond Gerota fascia

T3b

The tumor is growing into the part of the large vein leading into the heart (vena cava) that is within the abdomen.

T3c

The tumor has grown into the part of the vena cava that is within the chest or it is growing into the wall of the vena cava

T4

The tumor has spread beyond Gerota’s fascia (the fibrous layer that surrounds the kidney and nearby fatty tissue). The tumor may have grown into the adrenal gland (on top of the kidney).

Regional lymph node metastasis

NX

Not assessable

N0

None

N1

Present

Distant metastasis

M0

None

M1

Distant metastasis, including spread to distant lymph nodes

TNM = tumor, node, metastasis.

Data from Amin MB, Edge S, Greene F, Byrd DR, et al: AJCC Cancer Staging Manual, 8th edition. New York, Springer, 2018.

Prognosis

Five-year survival rates range from about 81% for the American Joint Commission on Cancer (AJCC) stage grouping I (T1 N0 M0) to 8% for stage grouping IV (T4 or M1). Prognosis is poor for patients with metastatic or recurrent renal cell carcinoma (RCC) because treatments are usually ineffective for cure, although they may be useful for palliation.

Treatment

  • For early renal cell carcinoma (RCC), surgical treatment

  • For advanced RCC, palliative therapies or experimental protocols

Curative treatments

Radical nephrectomy (removal of kidney, adrenal gland, perirenal fat, and Gerota fascia) is standard treatment for localized RCC and provides a reasonable chance for cure. Results with open or laparoscopic procedures are comparable; recovery is easier with laparoscopic procedures. Nephron-sparing surgery (partial nephrectomy) is possible and appropriate for many patients, even in patients with a normal contralateral kidney if the tumor is < 4 to 7 cm. Partial nephrectomy is gaining popularity because it results in a lower incidence of chronic kidney disease than radical nephrectomy. Nonsurgical destruction of renal tumors via freezing (cryosurgery) or thermal energy (radiofrequency ablation), often percutaneously, are not currently recommended as primary treatment. They are being done in highly selected patients, but long-term data about efficacy and indications are not yet available.

For tumors involving the renal vein and vena cava, surgery may be curative if no nodal or distant metastases exist.

If both kidneys are affected, partial nephrectomy of one or both kidneys is preferable to bilateral radical nephrectomy if technically feasible.

Radiation therapy is no longer combined with nephrectomy; however, stereotactic body radiation therapy for small renal masses is being explored.

Adjuvant use of systemic therapy after surgery has failed to prolong survival in multiple clinical trials, yet improvements in disease-free survival seen in patients taking adjuvant sunitinib in S-TRAC led to its approved use following resection in high-risk patients (1).

Palliative treatments

Palliation can include nephrectomy, tumor embolization, and possibly external beam radiation therapy. Resection of metastases offers palliation and, if metastases are limited in number, prolongs life in some patients, particularly those with a long interval between initial treatment (nephrectomy) and development of metastases. Although metastatic RCC is traditionally characterized as radioresistant, radiation therapy can be palliative when RCC is metastatic in bone.

For some patients, drug therapy reduces tumor size and prolongs life. About 10 to 20% of patients respond to interferon alfa-2b or IL-2, although the response is long-lasting in < 5%. Many targeted therapies have shown efficacy for advanced tumors: sunitinib, sorafenib, bevacizumab, pazopanib, cabozantinib, axitinib, and lenvatinib (tyrosine kinase inhibitors) and temsirolimus and everolimus, which inhibit the mammalian target of rapamycin (mTOR).

The newest available systemic therapies for metastatic RCC that has progressed on targeted therapy are nivolumab and pembrolizumab. These monoclonal antibodies against PD-1 work by blocking the PD-1/PD-L1 interaction between tumor cells and infiltrating T-cells, thus blocking PD-1 pathway-mediated inhibition of the immune response, including the antitumor immune response. Nivolumab was shown to prolong overall survival by 5.4 months (25.0 vs 19.6 months; P < 0.002) when compared to everolimus in patients with advanced RCC who had been treated with one or more tyrosine kinase inhibitors (2). Combination nivolumab/ipilimumab has recently been shown to have a superior overall survival compared to sunitinib in patients with previously untreated intermediate and poor risk metastatic RCC (3). Likewise, combination pembrolizumab/axitinib outperformed sunitinib by improving overall survival, progression-free survival, and objective response rate across all risk groups (4). Both of these combinations are now used in the first line for patients with metastatic kidney cancer.

Other treatments are experimental. They include stem cell transplantation, other interleukins, anti-angiogenesis therapy (eg, thalidomide), and vaccine therapy. Traditional chemotherapeutic drugs, alone or combined, and progestins are ineffective.

Cytoreductive nephrectomy before systemic therapy is controversial now that CARMENA (Clinical Trial to Assess the Importance of Nephrectomy), a randomized phase III trial comparing cytoreductive nephrectomy followed by sunitinib and sunitinib alone showed survival was not worse when treating with sunitinib alone (5).

Increased knowledge of genetic subtypes of RCC is leading to evolving management recommendations that are more specific.

Treatment references

Key Points

  • RCC, an adenocarcinoma, accounts for 90 to 95% of primary malignant renal tumors.

  • Symptoms (most often gross or microscopic hematuria) usually do not develop until the tumor is large or metastatic, so incidental discovery is common.

  • Diagnose RCC by MRI or contrast-enhanced CT and do a chest x-ray and liver tests.

  • Treat most localized RCC by radical nephrectomy.

  • Treat advanced RCC with combination immunotherapy, targeted drug therapies, interferon alfa-2b or IL-2, palliative radiation, and/or surgery

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Also of Interest

Videos

View All
Overview of Intrarenal Acute Kidney Injury
Video
Overview of Intrarenal Acute Kidney Injury
3D Models
View All
Male Reproductive System
3D Model
Male Reproductive System

SOCIAL MEDIA

TOP