Hypernephroma

Renal cell carcinoma (RCC) is the most common malignant neoplasm of the renal parenchyma accounting for 90% to 95% of cases (1). Adenocarcinoma is the preferred term as it reflects the tumour's origins.

Renal cell carcinoma is divided into different pathologic subtypes, of which the clear cell subtype represents about 75%

The cause of RCC is unknown. It mainly affects the elderly and exhibits a diverse range of presentations.

Most kidney cancer cases occur in the kidney, with much smaller proportions in the renal pelvis, ureter and urethra and paraurethral gland. In the UK, percentage distribution of cases diagnosed by anatomical site is as follows (2010-2012)

• kidney - 85.6%
• renal pelvis - 6.6%
• ureter - 5,7%
• urethra and paraurethral glands - 1.3%

The American Joint Committee on Cancer (AJCC) tumour node metastases (TNM) system is used to grade RCC into stages I to IV

• advanced RCC, in which the tumour is either locally advanced and/or has spread to regional lymph nodes, is generally defined as stage III
• metastatic RCC, in which the tumour has spread beyond the regional lymph nodes to other parts of the body, is generally defined as stage IV
• in 2006, of people presenting with RCC in England and Wales for whom staging information was available, an estimated 26% and 17% had stage III and stage IV disease, respectively
  • about half of those who have curative resection for earlier stages of the disease also go on to develop advanced and/or metastatic disease

Metastatic RCC is largely resistant to chemotherapy, radiotherapy and hormonal therapy.

The incidence represents about 2.2% of all invasive cancers and has a projected 2018 population age-standardised mortality rate of 1.8 per 100,000 (4,5).

Two-thirds of cases occur in men.

It is known that 30% of clear cell RCC will develop progressive disease after surgical treatment (6)

• these patients with high-risk ccRCC require adjuvant therapy after nephrectomy or resection of metastases

NICE kidney cancer guidance covers diagnosing and managing renal cell carcinoma in people aged 18 and over. The guideline emphasizes (7):

1. renal biopsy should be used more frequently
   • offer biopsy for suspected renal cell carcinoma (RCC), especially if lesion ≤4 cm and localised.
2. biopsy helps avoid unnecessary surgery
   • confirms diagnosis before nephrectomy → reduces removal of benign lesions.
3. suggests consideration of biopsy in additional scenarios
   • larger lesions if imaging suggests benign
   • before ablative (non-surgical) treatments
   • if patient requests it
4. imaging is central to diagnosis and staging
   • CT/MRI used to characterise renal masses and assess spread (standard pathway underpinning recommendations).
5. stratify management based on stage and tumour size
   • localised vs locally advanced vs metastatic disease determines treatment approach
6. nephron-sparing surgery preferred where possible
   • partial nephrectomy is favoured over radical when feasible (preserve renal function)
7. non-surgical options should be offered in selected patients
   • e.g. ablation or active surveillance for small tumours or high-risk surgical patients.
8. ensure MDT management
   • all patients should be discussed in a multidisciplinary team for treatment planning (standard NICE cancer care principle)
9. provide specialist support and personalised care plans
   • access to clinical nurse specialists
   • individualised treatment + follow-up plans
10. assessment for hereditary kidney cancer syndromes
    • e.g. Von Hippel–Lindau (VHL)
    • offer appropriate genetic evaluation and management

For comprehensive details then see the full NICE guideline.

Reference:

• (1) Chittoria B, Rini BI. Renal cell carcinoma. Cleveland clinic, Center for continuing education 2013
• (2) Cancer research UK 2015. Kidney cancer incidence statistics.
• (3) NICE (August 2009). Bevacizumab (first-line), sorafenib (first- and second-line), sunitinib (second-line) and temsirolimus (first-line) for the treatment of advanced and/or metastatic renal cell carcinoma
• (4)Howlader N et al. SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD. seer.cancer.gov/ csr/1975_2014/, based on November 2016 SEER data submission, posted to the SEER web site, April 2017.
• (5) Bray F et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians 2018;68(6):394-424. [PMID: 30207593]
• (6) Tsimafeyeu I, Basin MF, Bratslavsky G. Adjuvant therapy for renal cell carcinoma in 2023: hopes and disappointments. World J Urol. 2023 Jul;41(7):1855-1859. doi: 10.1007/s00345-023-04450-8
• (7) NICE (March 2026). Kidney cancer: diagnosis and management.