TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT

Renal cell carcinoma

Renal cell carcinomas are the most common renal tumours in adults. Average age at presentation is 55 years with a male : female ratio of 2 : 1. They arise from the proximal tubular epithelium and may be solitary, multiple and occasionally bilateral.

Clinical features

Haematuria, loin pain and a mass in the flank are the most common present-ing features. Other features include malaise, weight loss and fever. Left-sided scrotal varicoceles occur if the renal tumour obstructs the gonadal vein where it enters the renal vein. Twen1y-five per cent have metastases at presentation to bone, liver and the lung. Anaemia or polycythaemia and hypercalcaemia are other findings.

Investigations

■ Ultrasonography will distinguish a simple benign cyst from a more complex cyst or solid tumour.

■ CT scanning is more sensitive that ultrasound for detecting a renal mass and will show involvement of the renal vein or inferior vena cava. MRI is better than CT for tumour staging.

A presumptive diagnosis of renal carcinoma is made on imaging studies in patients with isolated solid renal masses and they will usually go straight to surgery (which provides tissue diagnosis and definitive treatment) without further investigation.

Management

Localized disease Radical nephrectomy is the preferred treatment. Partial nephrectomy is used if there is bilateral involvement or the contralateral kidney functions poorly. Ablative techniques (cryoablation or radiofrequency ablation) are used in patients with significant comorbid disease who would not tolerate surgery.

Metastatic or locally advanced disease Interleukin-2 and interferon produce a remission in 20% of cases. Targeted therapies which block the vascular endothelial growth factor (sunitinib, sorafenib, bevacizumab) or mTOR (temsirolimus) pathway are used in patients who cannot tolerate or do not respond to this treatment.

Prognosis

The 5-year survival rate is 60-70% with tumours confined to the renal parenchyma, but less than 5% in those with distant metastases.

Urothelial tumours

The calyces, renal pelvis, ureter, bladder and urethra are lined by transitional cell epithelium. Bladder tumours are the most common form of transitional cell malignancy. They occur most commonly after the age of 40 years and are four times more common in males. Predisposing factors for bladder cancer include:

■ Cigarette smoking

■ Exposure to industrial chemicals, e.g. p-naphthylamine, benzidine

■ Exposure to drugs, e.g. phenacetin, cyclophosphamide

■ Chronic inflammation, e.g. schistosomiasis.

Clinical features

Patients with bladder cancer usually present with painless haematuria (either visible or non-visible) or sometimes symptoms suggestive of a UTI (fre-quency, urgency, dysuria) in the absence of bacteriuria. Pain is usually due to locally advanced or metastatic disease but may sometimes occur from clot retention. Transitional cell cancers of the kidney and ureters present with haematuria and flank pain.

Investigations

Presentation is usually with haematuria and any patient over 40 years of age with haematuria should be assumed to have a urothelial tumour until proven otherwise (Fig. 9.3).

Management

Pelvic and ureteric tumours are treated with nephroureterectomy. Treatment of bladder tumours depends on the stage, but options include local diathermy or cystoscopic resection, bladder resection, radiotherapy, and local and sys-temic chemotherapy.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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