A 45 year old man presents with symptoms of urinary colic. In the history he has suffered from recurrent episodes of frank haematuria over the past week or so. On examination he has a left loin mass and a varicocele. The most likely diagnosis is:
Renal cortical adenoma
Squamous cell carcinoma of the renal pelvis
Renal adenocarcinoma are the most common renal malignancy and account for 75% cases.
Patients may develop frank haematuria and have episodes of clot colic.
A Grawitz tumour is an eponymous name for Renal Adenocarcinoma.
May metastasise to bone.
Renal cell carcinoma
Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to arise from the proximal convoluted tubule. They are usually solid lesions, up to 20% may be multifocal, 20% may be calcified and 20% may have either a cystic component or be wholly cystic. They are often circumscribed by a pseudocapsule of compressed normal renal tissue. Spread may occur either by direct extension into the adrenal gland, renal vein or surrounding fascia. More distant disease usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more commonly affected than females and sporadic tumours typically affect patients in their sixth decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less than 10% have the classic triad of haematuria, pain and mass.
Many cases will present as haematuria and be discovered during diagnostic work up. Benign renal tumours are rare, so renal masses should be investigated with multislice CT scanning. Some units will add and arterial and venous phase to the scan to demonstrate vascularity and evidence of caval ingrowth.
CT scanning of the chest and abdomen to detect distant disease should also be undertaken.
Routine bone scanning is not indicated in the absence of symptoms.
Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.
Assessment of the functioning of the contra lateral kidney.
T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological results to total radical nephrectomy. Partial nephrectomy may also be performed when there is inadequate reserve in the remaining kidney.
For T2 lesions and above a radical nephrectomy is standard practice and this may be performed via a laparoscopic or open approach. Preoperative embolisation is not indicated nor is resection of uninvolved adrenal glands. During surgery early venous control is mandatory to avoid shedding of tumour cells into the circulation.
Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or biological agents. These should not be administered outside the setting of clinical trials.
Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the bladder.