eMedicine Specialties > Oncology > Carcinomas of the Genitourinary Tract

Renal Cell Carcinoma

Author: Kush Sachdeva, MD, Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner
Coauthor(s): Issam Makhoul, MD, Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences; Mansoor Javeed, MD, FACP, Clinical Assistant Professor of Medicine, University of California Davis; Consultant, Sierra Hematology-Oncology Medical Center; Brendan Curti, MD, Director, Genitourinary Oncology Research, Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute, Providence Portland Medical Center
Contributor Information and Disclosures

Updated: Jun 25, 2009

Introduction

Background

Renal cell carcinoma accounts for approximately 3% of adult malignancies and 90-95% of neoplasms arising from the kidney. It is characterized by a lack of early warning signs, diverse clinical manifestations, resistance to radiation and chemotherapy, and infrequent but reproducible responses to immunotherapy agents such as interferon alpha and interleukin (IL)-2. New agents, such as sorafenib and sunitinib, having anti-angiogenic effects through targeting multiple receptor kinases, have activity in patients failing immunotherapy. In the past, these tumors were believed to derive from the adrenal gland; therefore, the term hypernephroma was used often.

Pathophysiology

The tissue of origin for renal cell carcinoma is the proximal renal tubular epithelium. Renal cancer occurs in both a sporadic (nonhereditary) and a hereditary form, and both forms are associated with structural alterations of the short arm of chromosome 3 (3p). Genetic studies of the families at high risk for developing renal cancer led to the cloning of genes whose alteration results in tumor formation. These genes are either tumor suppressors (VHL, TSC) or oncogenes (MET).

At least 4 hereditary syndromes associated with renal cell carcinoma are recognized: (1) von Hippel-Lindau (VHL) syndrome, (2) hereditary papillary renal carcinoma (HPRC), (3) familial renal oncocytoma (FRO) associated with Birt-Hogg-Dube syndrome (BHDS), and (4) hereditary renal carcinoma (HRC).

von Hippel-Lindau disease is transmitted in an autosomal dominant familial multiple-cancer syndrome, which confers predisposition to a variety of neoplasms, including the following:

  • Renal cell carcinoma with clear cell histologic features
  • Pheochromocytoma
  • Pancreatic cysts and islet cell tumors
  • Retinal angiomas
  • Central nervous system hemangioblastomas
  • Endolymphatic sac tumors
  • Epididymal cystadenomas

Renal cell carcinoma develops in nearly 40% of patients with von Hippel-Lindau disease and is a major cause of death among these patients. Deletions of 3p occur commonly in renal cell carcinoma associated with VHL disease. The VHL gene is mutated in a high percentage of tumors and cell lines from patients with sporadic (nonhereditary) clear cell renal carcinoma. Several kindreds with familial clear cell carcinoma have a constitutional balanced translocation between 3p and either chromosome 6 or chromosome 8. Mutations of the VHL gene result in the accumulation of hypoxia inducible factors (HIFs) that stimulate angiogenesis through vascular endothelial growth factor and its receptor (VEGF and VEGFR, respectively). VEGF and VEGFR are important new therapeutic targets.

Hereditary papillary renal carcinoma is an inherited disorder with an autosomal dominant inheritance pattern; affected individuals develop bilateral, multifocal papillary renal carcinoma. Germline mutations in the tyrosine kinase domain of the MET gene have been identified.

Individuals affected with familial renal oncocytoma can develop bilateral, multifocal oncocytoma or oncocytic neoplasms in the kidney. Birt-Hogg-Dube syndrome is a hereditary cutaneous syndrome. Patients with Birt-Hogg-Dube syndrome have a dominantly inherited predisposition to develop benign tumors of the hair follicle (ie, fibrofolliculomas), predominantly on the face, neck, and upper trunk, and are at risk of developing renal tumors, colonic polyps or tumors, and pulmonary cysts.

Frequency

United States

The age-adjusted incidence of renal cell carcinoma has been rising by 3% per year. According to the American Cancer Society, in 2007 there will be 51,590 cases (31,990 in males and 19,600 in females) of malignant tumors of the kidney diagnosed in the United States with 12,890 deaths (8,080 in males and 4,810 in females); renal cell cancer accounted for 80% of this incidence and mortality.1 The greatest increase in incidence currently is observed in African Americans.

International

Number of deaths worldwide from kidney cancer exceeded 100,000 in 2001.

Mortality/Morbidity

Renal cell carcinoma is the eighth or ninth leading cause of cancer death in the United States. The 5-year survival rates initially reported by Robson in 1969 were 66% for stage I renal carcinoma, 64% for stage II, 42% for stage III, and only 11% for stage IV.2 Except for stage I, these survival statistics have remained essentially unchanged for several decades.

Race

Renal cell carcinoma is more common in people of Northern European ancestry (Scandinavians) and North Americans than in those of Asian or African descent. In the United States, its incidence has been equivalent among whites and African Americans, but incidence among African Americans is increasing rapidly.

Sex

Renal cell carcinoma has a male-to-female preponderance of 1.6:1.

Age

This condition occurs most commonly in the fourth to sixth decades of life, but the disease has been reported in younger people who belong to family clusters.

Clinical

History

Renal cell carcinoma may remain clinically occult for most of its course. The classic triad of flank pain, hematuria, and flank mass is uncommon (10%) and is indicative of advanced disease. Twenty-five to thirty percent of patients are asymptomatic, and their renal cell carcinomas are found on incidental radiologic study.

  • Most common presentations
    • Hematuria (40%)
    • Flank pain (40%)
    • Palpable mass in the flank or abdomen (25%)
  • Other signs and symptoms
    • Weight loss (33%)
    • Fever (20%)
    • Hypertension (20%)
    • Hypercalcemia (5%)
    • Night sweats
    • Malaise
    • Varicocele, usually left sided, due to obstruction of the testicular vein (2% of males)
  • Renal cell carcinoma is a unique and challenging tumor because of the frequent occurrence of paraneoplastic syndromes, including hypercalcemia, erythrocytosis, and nonmetastatic hepatic dysfunction (ie, Stauffer syndrome). Polyneuromyopathy, amyloidosis, anemia, fever, cachexia, weight loss, dermatomyositis, increased erythrocyte sedimentation rate, and hypertension also are associated with renal cell carcinoma. (For more information, see Paraneoplastic Syndromes.)
    • Cytokine release by tumor (eg, IL-6, erythropoietin, nitric oxide) causes these paraneoplastic conditions.
    • Resolution of symptoms or biochemical abnormalities may follow successful treatment of the primary tumor or metastatic foci.

Physical

  • Gross hematuria with vermiform clots suggests upper urinary tract bleeding.
  • Look for hypertension, supraclavicular adenopathy, and flank or abdominal mass with bruit.
  • Approximately 30% of patients with renal carcinoma present with metastatic disease. Physical examination should include thorough evaluation for metastatic disease. Organs involved include:
    • Lung (75%)
    • Soft tissues (36%)
    • Bone (20%)
    • Liver (18%)
    • Cutaneous sites (8%)
    • Central nervous system (8%)
  • Varicocele and findings of paraneoplastic syndromes raise clinical suspicion for this diagnosis.

Causes

A number of  environmental and genetic factors have been studied as possible causes for renal cell carcinoma.
  • Cigarette smoking doubles the risk of renal cell carcinoma and contributes to as many as one third of all cases. The risk appears to increase with the amount of cigarette smoking in a dose-dependent fashion.
  • Obesity is another risk factor, particularly in women; increasing body weight has a linear relationship with increasing risk.
  • Hypertension may be associated with an increased incidence of renal cell carcinoma.
  • Phenacetin-containing analgesia taken in large amounts may be associated with increased incidence of renal cell carcinoma.
  • There is an increased incidence of acquired cystic disease of the kidney in patients undergoing long-term renal dialysis; this predisposes to renal cell cancer.
  • Tuberous sclerosis
  • Renal transplantation: Acquired renal cystic disease of the native kidney also predisposes to renal cell cancer in renal transplant recipients.
  • VHL disease: This inherited disease is associated with renal cell carcinoma.

More on Renal Cell Carcinoma

Overview: Renal Cell Carcinoma
Differential Diagnoses & Workup: Renal Cell Carcinoma
Treatment & Medication: Renal Cell Carcinoma
Follow-up: Renal Cell Carcinoma
References
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Further Reading

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Keywords

renal cell adenocarcinoma, hypernephroma, hypernephroid tumor, Grawitz tumor, von Hippel-Lindau syndrome, VHL syndrome, VHL disease, hereditary papillary renal carcinoma, HPRC, familial renal oncocytoma, FRO, Birt-Hogg-Dube syndrome, BHDS, hereditary renal carcinoma, HRC, Stauffer syndrome, renal cancer, pheochromocytoma, pancreatic cysts, epididymal cystadenomas, endolymphatic sac tumors, central nervous system hemangioblastomas, retinal angiomas, islet cell tumors, fibrofolliculomas, colonic polyps, colonic tumors, pulmonary cysts, paraneoplastic syndromes, hypercalcemia, nonmetastatic hepatic dysfunction, polyneuromyopathy, amyloidosis, anemia, dermatomyositis, hypertension, varicocele, cigarette smoking, obesity, unopposed estrogen therapy, asbestos exposure, cystic kidney disease, renal dialysis, tuberous sclerosis, renal cell carcinoma

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Contributor Information and Disclosures

Author

Kush Sachdeva, MD, Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner
Disclosure: Nothing to disclose.

Coauthor(s)

Issam Makhoul, MD, Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences
Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology
Disclosure: Nothing to disclose.

Mansoor Javeed, MD, FACP, Clinical Assistant Professor of Medicine, University of California Davis; Consultant, Sierra Hematology-Oncology Medical Center
Mansoor Javeed, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Brendan Curti, MD, Director, Genitourinary Oncology Research, Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute, Providence Portland Medical Center
Brendan Curti, MD is a member of the following medical societies: American College of Physicians, Oregon Medical Association, and Society for Biological Therapy
Disclosure: Nothing to disclose.

Medical Editor

Michael Perry, MD, MS, MACP, Nellie B Smith Chair of Oncology Emeritus, Professor, Department of Internal Medicine, Division of Hematology and Oncology, University of Missouri/Ellis Fischel Cancer Center
Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association
Disclosure: Bionumerik Consulting fee Consulting; Proactya Consulting fee Consulting; GSK Consulting fee Consulting; NovoNordisk Consulting fee Consulting; Amgen Honoraria Speaking and teaching; GSK Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Wendy Hu, MD, Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center
Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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