TUMOURS OF THE KIDNEY AND URINARY TRACT

TUMOURS OF THE KIDNEY AND URINARY TRACT

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RENAL ADENOCARCINOMA

This is by far the most common malignant tumour of the kidney in adults.
It is twice as common in males as in females.
The peak incidence is between 65 and 75 years of age and it is uncommon before 40.
The tumour arises from renal tubules.
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RENAL ADENOCARCINOMA

There is early spread of the tumour into the renal pelvis, causing haematuria, and along the renal vein, often extending into the inferior vena cava. Direct invasion of perinephric tissues is common. Lymphatic spread occurs to para-aortic nodes, while blood-borne metastases (which may be solitary) may develop almost anywhere in the body.
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Clinical features

About 60% of cases present with haematuria
40% with loin pain
Only 25% with a mass.
The triad of pain, haematuria and a mass is an important but late feature occurring in only 15% of cases.
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Clinical features
Systemic effects may be present, including fever, raised ESR, polycythaemia, disorders of coagulation, and abnormalities of plasma proteins and liver function tests.
Systemic effects may be due to tumour secretion of products such as renin, erythropoietin, parathyroid hormone-related peptide and gonadotrophins. The effects disappear when the tumour is removed but may reappear when metastases develop, and so can be used as markers of tumour activity.
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Investigations

The initial investigation is ultrasound, which allows differentiation between solid tumour and simple renal cysts.
Thereafter, a contrast-enhanced CT of the abdomen and chest should be performed for staging.
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Management and prognosis

Radical nephrectomy that includes the perirenal fascial envelope and ipsilateral para-aortic lymph nodes is performed whenever possible.
Renal adenocarcinoma is resistant to radiotherapy and chemotherapy but some benefit has been seen with immunotherapy using interferon and interleukin-2.
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Management and prognosis

Even when metastases are present, nephrectomy should always be considered; not only may systemic effects disappear, but there may even be regression of any metastases. Solitary metastases tend to remain single for long periods and excision is often worth while.
If the tumour is confined to the kidney, 5-year survival is 75%. This falls to only 5% when there are distant metastases.
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Tumours Of The Renal Pelvis , Ureter and Bladder

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The vast majority of these tumours arise from the urothelium or transitional cell lining.
Almost all tumours are transitional cell carcinomas.
Squamous carcinoma may occur in urothelium that has undergone metaplasia, usually following chronic inflammation or irritation due to a stone or schistosomiasis.
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Transitional cell is three times more common in men than women.

More than 80% of patients have haematuria, which is usually visible and painless.
It should be assumed that such bleeding is from a tumour until proved otherwise.
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A tumour at the lower end of a ureter or a bladder tumour involving the ureteric orifice may cause obstructive symptoms.
Examination is usually unhelpful. Rectal examination detects only very advanced tumours.
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Investigation

GUE
U/S
IVU, retrograde ureteropyelogram
CT abdomen, pelvis and chest
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Management
Small, large and even multiple superficial bladder tumours can be treated endoscopically by transurethral resection of the tumour(s) (TURT).
Intravesical chemotherapy (e.g. epirubicin, mitomycin C) is useful for treating multiple low-grade bladder tumours and for reducing their recurrence rate.
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Management

Regular 'check' cystoscopies are required and recurrences can usually be controlled by diathermy; only rarely will cystectomy be required for superficial disease.
Untreated patients with carcinoma in situ (Cis) have a high risk of progression to invasive cancer. The tumour responds well to intravesical bacille Calmette-Guérin (BCG) treatment but more aggressive treatment may be needed.
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Management

Transitional cell carcinoma of the renal pelvis and ureter is usually treated by nephroureterectomy and regular surveillance of the bladder, but if the tumour is solitary and low-grade it may be treated endoscopically; surveillance remains problematic.
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Prognosis

Depends on tumour stage and grade.
The 5-year survival rate varies from 50-60% in those with superficial tumours to 20-30% for those with deep muscle invasion.
Overall, about one-third of patients survive for 5 years.

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