Karan Wadhwa With the rise in use of cross‐sectional imaging, renal masses are increasingly being diagnosed and present a common referral to the urologist both acutely and on an outpatient basis. This chapter will present a brief overview of the diagnosis and provide guidance on the management of renal masses. Renal cancer makes up 2–3% of all cancer diagnoses with an increase in 2% over the past 20 years. 40% are diagnosed at a late stage, and renal cancer accounts for 3% of all cancer deaths, however kidney cancer survival overall has increased over the last 40 years. Men are more likely to be diagnosed than women (1.5 : 1), with a peak incidence between the ages of 60–70 and more likely in white races than Asians or black races. The main risk factors for developing renal cancer appear to be hypertension, smoking, and obesity. The genomic changes for the development of renal cancer start in childhood or adolescence and there is an increased risk with an affected first‐degree relative. Several genetic conditions also predispose to renal cancer such as Von‐Hippel Lindau disease, but only 8–10% of renal cancers are hereditary. The most common histological subtype of renal cancer is clear cell renal cell carcinoma (ccRCC), which also has the worst overall survival compared to papillary or chromophobe cancers. Papillary type renal cancer can be divided into type 1 and type 2 with distinct genetic features but overall with a higher survival rate than ccRCC. Lastly, chromophobe renal cancer has a myriad of genetic changes but has the best recurrence free and overall survival of the three main subtypes (see Table 20.1). Several other subtypes exist, but these make up only 10–15% of renal cancers and have variable clinical courses. Onset of renal cancer is usually insidious, and over half of renal cancers are diagnosed incidentally. The classic triad of loin pain, palpable flank mass, and visible haematuria is fortunately rare (6–8%) and usually indicates a poor prognosis. Up to one‐third of patients may suffer a paraneoplastic syndrome for example deranged LFTS (Stauffer’s syndrome). Breathlessness or cough may indicate lung metastases or pulmonary emboli and likewise back pain may indicate a metastatic process. Abdominal signs are usually absent, but one must be mindful to examine for chest/abdominal lymphadenopathy, a flank mass, or a varicocele (particularly right‐sided). Alongside clinical examination, urine should be dipped for haematuria, and baseline bloods including full blood count, urea, and electrolytes, liver function tests, bone profile, and lactate dehydrogenase should be measured in clinic. Aside from clinically diagnosed tumours, the patient usually comes to hospital with imaging such as an abdominal/renal ultrasound or CT scan. To accurately stage a patient with suspected renal cancer, a dedicated CT of chest, abdomen, and pelvis should be performed with contrast. The key features of a renal mass are size, location, enhancement (>20–30 Hounsfield units), invasion e.g. renal vein/IVC or adrenal, lymph node status, and metastases (lung/liver/bone). It is also important to consider the contralateral kidney in terms of presence, size, and shape. Table 20.1 Subtypes of renal cancer. Source: Adapted from EAU guidelines (Ljungberg et al. 2018).
20
Renal Cancer: Diagnosis and Management in the Outpatient Clinic
Incidence
Aetiology
Subtypes
Signs and Symptoms
Investigation
Related posts:
Role of Nurse Practitioners in Ambulatory Urogynaecological Care
The Management of Recurrent Urinary Tract Infections
Ambulatory Management of Renal Stone Disease
An Ambulatory Approach to Benign Prostatic Obstruction
Magnetic Resonance Imaging in Urology
Common Urethral and Vaginal Lesions in Ambulatory Urogynaecology
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
