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Renal and upper tract tumours

From Surgopaedia

Histopathology

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  • Benign
    • Adenoma
      • Cortical adenomas
      • Generally small
      • Asymptomatic
    • Angioma
      • May cause profuse haematuria, often in young adults
      • Needs angiogram to diagnose
    • Angiomyolipoma
      • Often associated with tuberous sclerosis
      • Typical appearance on CT
      • Can bleed into themselves
      • Malignant elements present in about 25%
  • Malignant
    • Renal cell carcinoma
      • Derives from renal tubular epithelial cells
      • Median age 64yo
      • Risk factors: genetics, obesity, male gender, hypertension, smoking, CKD, haemodialysis, kidney transplant, acquired cystic disease of the kidney
      • Subtypes:
        • Clear cell RCC
          • Most common - 83-88% of metastatic RCC
        • Papillary RCC
        • Chromophobe RCC
  • Grading:
    • Fuhrman grading system - 4 nuclear grades
    • Leibovich score following nephrectomy from 0 to 11


Presentation

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  • Classic triad of loin pain, loin mass and haematuria is present <10%
  • Mostly arise as incidental findings
  • Paraneoplastic syndromes can include hypercalcaemia, fever and erythrocytosis

Staging

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  • CT chest, abdo, pelvis
  • MRI can provide further information about invasion into nearby structures

Treatment

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  • Surgery
    • Indications: disease confined to kidney, also sometimes offered with cytoreductive intent to those with metastatic disease
    • Partial nephrectomy
      • Indicated with T1 tumour (equivalent oncological outcomes) and normal contralateral kidney; indicated in those with only one kidney; in those with bilateral RCC; in those with vHL
      • Complications:
        • Haematuria
        • Perirenal haematoma
        • Urinary fistula
        • AKI
        • Infection
    • Radical nephrectomy
      • Removal of kidney, perirenal fat, adrenal gland and regional lymph nodes
      • Mostly laparoscopic, especially stage I and II tumours
    • Active surveillance
      • Offered in conjunction with RFA ablation/cryotherapy to elderly patients or those that cannot have surgery
      • Intervention for growth to 3-4cm or by >0.5cm per year
  • Medical
    • Tyrosine kinase inhibitors can exploit the vascular nature of the lesion
    • Average duration of disease control is 8-9 months


Upper tract TCC

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  • Risk factors: same as bladder cancer
  • Often presents late with advanced disease
  • 40% will develop a bladder cancer at some point
  • Treatment
    • Nephroureterectomy, in the absence of metastatic disease

Nephroblastoma (Wilms' tumour)

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  • Histopathology
    • Elements from embryonic nephrogenic tissue
  • Usually discovered <5yo
  • Usually in one kidney
  • Haematuria - unfavourable symptoms suggesting extension into renal pelvis
  • Metastasis to lungs occurs early
  • Most unilateral tumours have neoadjuvant CTX followed by nephrectomy
  • 80% survive long term, but worse prognosis with mets
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