Renal Cell Carcinoma

Table of Contents

Introduction

Generally asymptomatic until advanced
Classic Triad (9% of pts)
- Hematuria
- Flank Pain
- Abdominal Mass
Other Symptoms:
- Unexplained Weight Loss
- Abdominal Pain
Many paraneoplastic syndromes:
- Erythrocytosis
- AA amyloidosis
- PMR
- Hepatic Dysfunction

Abdo Ultrasound or CT
- Solid mass or complex cyst require further intervention
- Biopsy small lesions if possible.
- Large masses suspicious for cancer can be removed without biopsy. (still do CT to assess local/metastatic disease)

Large massess suspicious for malignancy on imaging --> remove without biopsy.
Non-metastatic:
- Radical or partial nephrectomy
- If not candidates for surgery:
  - Active Surveillance
  - Ablative Treatment (if small tumor)
Metastatic
- Poor outcomes.
- Often cytoreductive nephrectomy is done for metastatic disease (improves survival!!)
- For spinal compression: if single-level compression can refer to neurosurg followed by radiation (if multi-level, do radiation only) (RCT done showing benefit of neurosx+rads vs. rads alone)
  - Often needs to be embolized before any surgery (highly vascular, bleeds a lot)
NO ADJUVANT Therapy established (poor outcomes) (studies with targeted agents ongoing).
No cytotoxic therapy available.
Specific Therapies:
- Interleukin-2: can result in long-term remission in 10% (highly toxic and expensive)
- VEGF Inhibitors
  - Bevacizumab
  - Sunitinib (tyrosine kinase inh.)
  - Sorafenib
  - Pazopanib
  - Axitinib
- mTOR Inhibitors
  - Temsirolimus
  - Everolimus
VEGF inhibitors are often first-line, but poor evidence.
High Risk Features: LDH, performance status, lactate, calcium, anemia,