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ukmla 2026

Renal Cell Carcinoma

The commonest primary renal malignancy (~90% of renal cancers), predominantly clear cell type, often presenting incidentally on imaging or with the classic triad of haematuria, loin pain, and palpable mass

Review date
reviewed 2026-04-05
Reading time
5 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Renal & Urologyless-commonchronic
On this page
Condition details
Renal & Urology
less-common
5 min read
reviewed 2026-04-05
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About This Page

This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

  • Commonest renal malignancy (~90%). Clear cell subtype most common (~70–80%). Risk factors: smoking, obesity, hypertension, VHL syndrome
  • Classic triad (haematuria + loin pain + palpable mass) present in only ~10% — most now detected incidentally on USS/CT
  • Paraneoplastic syndromes: polycythaemia (EPO), hypercalcaemia (PTHrP), Stauffer syndrome (hepatic dysfunction without metastases)
  • Staging: CT chest/abdomen/pelvis. Left-sided RCC may invade left renal vein → IVC → "tumour thrombus"
  • Treatment: radical or partial nephrectomy (curative). Metastatic: immunotherapy (nivolumab + ipilimumab) or TKIs (sunitinib, cabozantinib)

Overview

Renal cell carcinoma (RCC) is the commonest primary renal malignancy, arising from the renal tubular epithelium. The clear cell subtype accounts for ~70–80% and is associated with von Hippel-Lindau (VHL) gene mutations (both sporadic and hereditary). Other subtypes include papillary (type 1 and 2) and chromophobe. RCC is characterised by a propensity for vascular invasion (renal vein and IVC tumour thrombus), paraneoplastic syndromes (due to hormone production), and late metastasis (can metastasise many years after nephrectomy — "cannonball" lung metastases are classic).

Epidemiology

Approximately 13,000 new cases per year in the UK — the seventh most common cancer. Male:female ratio ~2:1. Peak incidence at age 60–70. Five-year survival is ~75% for localised disease but <15% for metastatic disease. Incidence is increasing, partly due to incidental detection on cross-sectional imaging performed for other reasons.

Clinical Features

Symptoms
Often asymptomatic — incidental finding on imaging (>50% now diagnosed this way)
Visible (macroscopic) haematuria
Loin/flank pain (dull, constant)
Palpable abdominal/flank mass
Constitutional symptoms: weight loss, fever, night sweats, fatigue
Left-sided varicocele that does not drain on lying flat (left renal vein invasion)
Symptoms of metastatic disease: bone pain, persistent cough (cannonball lung metastases)
Signs
Palpable flank mass (large tumour)
Hypertension (renin secretion)
Polycythaemia (EPO production — facial plethora)
Hypercalcaemia signs (confusion, constipation, polyuria — PTHrP secretion)
Left-sided varicocele that does not decompress when supine
Lower limb oedema (IVC obstruction from tumour thrombus)

Investigations

First-line
USS abdomenOften the initial investigation that identifies a renal mass incidentally. Can distinguish cystic from solid lesions
CT abdomen/pelvis (contrast-enhanced, 3-phase)Gold standard for characterisation and staging. Assesses local extent, renal vein/IVC invasion, lymph nodes, adrenal, liver
FBCPolycythaemia (EPO production) or anaemia (chronic disease). Also baseline for surgery
U&Es, calcium, LFTsHypercalcaemia? Stauffer syndrome (raised ALP, abnormal LFTs without liver metastases)? Renal function (assess before nephrectomy)
Second-line
CT chestStaging — exclude pulmonary metastases ("cannonball" metastases are classic for RCC)
MRI abdomenIf CT inconclusive or to assess IVC tumour thrombus extent
Specialist
Renal biopsyNot routinely required for typical solid enhancing renal mass (nephrectomy is diagnostic and therapeutic). Consider if diagnostic uncertainty or if non-surgical management planned
Bone scan/PET-CTIf bone metastases or systemic disease suspected

Management

NICE NG12 and EAU Renal Cancer Guidelines
1
Localised disease (curative)
  • Partial nephrectomy (nephron-sparing): preferred for T1 tumours (<7 cm), bilateral tumours, or solitary kidney
  • Radical nephrectomy: for larger tumours (T2+) or those not amenable to partial — includes Gerota fascia, perinephric fat, ± adrenal gland
  • Active surveillance: for small renal masses (<3 cm) in elderly/comorbid patients (growth rate typically slow)
  • Ablation (cryotherapy or radiofrequency): for small tumours in patients unfit for surgery
2
Metastatic disease
  • First-line: immunotherapy combination — nivolumab + ipilimumab (intermediate/poor risk) or pembrolizumab + axitinib (all risk groups)
  • TKIs (tyrosine kinase inhibitors): sunitinib, cabozantinib, pazopanib — for those unsuitable for immunotherapy
  • Cytoreductive nephrectomy: considered in select patients with metastatic disease (debulking before systemic therapy)
  • RCC is classically resistant to chemotherapy and radiotherapy (immune-mediated therapy is the paradigm shift)
3
Surveillance post-nephrectomy
  • CT chest/abdomen/pelvis at regular intervals (6-monthly then annually) — late recurrence possible
  • Monitor renal function in remaining kidney
  • Cardiovascular risk factor management (CKD progression risk)

Complications

  • Metastatic disease: Lung (most common — "cannonball" metastases), bone, liver, brain. Can metastasise late (>10 years after nephrectomy)
  • IVC tumour thrombus: Extension from renal vein → IVC. Can extend to right atrium. Requires specialised surgical technique
  • Paraneoplastic syndromes: Polycythaemia (EPO), hypercalcaemia (PTHrP), Stauffer syndrome (hepatic dysfunction), hypertension (renin)
  • CKD post-nephrectomy: Reduced nephron mass — monitor and manage cardiovascular risk
UKMLA Exam Tips
  • 1Classic triad (haematuria + loin pain + mass) present in only ~10% — most are incidental findings now
  • 2Left-sided varicocele that does NOT drain when lying flat → think left renal vein invasion by RCC
  • 3Cannonball lung metastases on CXR = think RCC (also thyroid, choriocarcinoma)
  • 4RCC is RESISTANT to conventional chemotherapy and radiotherapy — immunotherapy/TKIs are the standard
  • 5VHL syndrome (autosomal dominant): RCC + haemangioblastomas (CNS/retina) + phaeochromocytoma. Screen at-risk family members
  • 6Stauffer syndrome: raised ALP and hepatic dysfunction WITHOUT liver metastases — resolves after nephrectomy

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Verified Sources & References

EAU Renal Cancer Guidelines 2023
NICE NG12 — Suspected cancer
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