Renal & Urology

Renal Cancer

Renal cancer is usually renal cell carcinoma arising in the renal parenchyma; it is often found incidentally, while visible haematuria, venous invasion or paraneoplastic features should trigger urgent staging and uro-oncology assessment.

In a nutshell

Renal cancer is usually renal cell carcinoma and is often found incidentally. Visible haematuria in adults aged 45 or over needs suspected-cancer referral when unexplained or persistent after UTI treatment. Stage with multiphasic CT/MRI and chest/pelvis imaging, use biopsy when it can change management, and choose localised treatment by lesion size, operability and renal preservation.

Classic presentation

An older adult has an incidentally detected enhancing renal mass; alternatively, visible haematuria with a new renal mass or unexplained hypercalcaemia prompts urgent staging and uro-oncology MDT review.

Key points

Most adult kidney cancers are renal cell carcinomas; renal-pelvis tumours are upper-tract urothelial cancers and follow a different pathway.
The classic triad of haematuria, loin pain and a flank mass is late and uncommon; many lesions are incidental.
Current NICE NG256 recommends multiphasic contrast CT or contrast MRI, chest and pelvic staging, and biopsy for suitable lesions 4 cm or smaller when the result can inform management.
Offer surgery for suitable localised solid masses or Bosniak 4 cysts 2 cm or larger; partial nephrectomy is preferred when renal preservation and complete excision are both feasible.
For selected small lesions, active surveillance, thermal ablation and SABR are alternatives when surgery is unsuitable or declined; biopsy is required before ablation or SABR.
Advanced RCC treatment is risk- and appraisal-specific; use the current NICE systemic anticancer-therapy pathway rather than memorising one fixed drug sequence.
After treatment, risk-based imaging and renal-function follow-up are part of the treatment pathway.

First-line investigation

Multiphasic contrast-enhanced CT of the abdomen, or contrast MRI when CT is unsuitable, followed by chest and pelvic staging if RCC is suspected.

Management

Recognise the cancer pathway

Refer unexplained or post-UTI persistent visible haematuria in adults aged 45 or over on a suspected cancer pathway, and discuss a suspicious renal mass in the uro-oncology MDT.^2,1

Characterise, stage and biopsy appropriately

Use multiphasic contrast CT or contrast MRI, complete chest and pelvic staging, and offer or consider biopsy when the result could change management; do not biopsy a surgically managed lesion with venous extension merely to satisfy a routine rule.^3,4

Balance cancer control and renal preservation

For suitable localised lesions 2 cm or larger, offer surgery after MDT discussion and choose partial versus total nephrectomy using lesion anatomy, comorbidity and the importance of preserving renal function.⁵

Use active surveillance, ablation or SABR selectively

For smaller or inoperable lesions, follow the NICE size-based options; active surveillance is a secondary-care pathway, and thermal ablation or SABR requires prior biopsy confirmation of malignancy.^5,3

Treat advanced disease and protect remaining kidney function

Use the current NICE advanced-RCC systemic pathway and risk assessment, then provide risk-based CT/MRI follow-up, eGFR monitoring and ACR assessment when eGFR is below 60 ml/min/1.73 m².^6,5,4

Exam traps

The haematuria–loin pain–mass triad is late and uncommon; an incidental mass is a typical presentation.
Renal-pelvis urothelial carcinoma is not the same disease as renal parenchymal RCC.
Biopsy is no longer simply 'not routine': offer it for a suitable lesion 4 cm or smaller when it can inform management, but do not biopsy when it cannot change treatment.
Do not call every small mass an automatic nephrectomy: current NICE guidance includes active surveillance, thermal ablation and SABR in selected patients.
Partial nephrectomy is not chosen by size alone; complete tumour excision, lesion complexity, comorbidity and renal preservation all matter.
A new left varicocoele is a clue to renal-vein or retroperitoneal obstruction, but it is not diagnostic of RCC.
Do not prescribe a memorised immunotherapy/tyrosine-kinase sequence for advanced RCC without checking the current NICE appraisal, risk group and NHS protocol.

Illustrations

Cystic renal cell carcinoma on contrast CTAxial and coronal contrast-enhanced CT views showing a large predominantly cystic renal cell carcinoma arising from and distorting the right kidney.Hellerhoff, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.