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Malignant renal masses

Introduction

Renal cell carcinoma (RCC) is the most common renal tumour. It accounts for approximately 3% of adult malignancies, 85% of renal malignancies and 2% of all cancer deaths. In 1999 in the UK, 3676 patients were diagnosed with RCC, with just over 2000 dying from the disease in the year 2000. In the USA, approximately 36 000 new cases occurred in 2005, with 12 500 deaths occurring in the same year. RCC is the most lethal of urological tumours, with approximately 40% of patients dying of the condition. Roughly 25% of patients present with locally invasive or metastatic disease. RCC is most commonly sporadic; however, distinct groups of patients have been identified that develop rarer hereditary forms.

History

RCC has a variety of synonyms. It has been termed hypernephroma, due to the fact it was incorrectly thought to arise from the adrenal gland. Its other names include Grawitz tumour after Paul Albert Grawitz, professor of pathology at Greifswald Germany, clear cell carcinoma and nephrocarcinoma.

In 1826 Konig first described the anatomy of kidney tumours. In 1861 Wolcott reported the first nephrectomy; interestingly, he presumed he was operating on a hepatoma. This was followed by the first 'planned' nephrectomy in 1869 by Simon. In 1903 the incorrect term hypernephroma was corrected by Albarran and Imbert, who recognized that these tumours originated from the kidney as opposed to the adrenal glands.

Epidemiology

Overall, RCC affects males twice as commonly as females. There are variations within the histological subtypes; for example, papillary RCC is five times more common in men. In general, RCC usually presents in the fourth to sixth decades of life.

Aetiological risk factors include:

  • Smoking.

  • Urban residents.

  • Low socioeconomic status.

  • Renal failure and long-term kidney dialysis.

  • Obesity.

  • Asbestos exposure.

  • Hypertension.

  • Anatomical: polycystic and horseshoe kidney.

  • Nutritional factors: vitamins A, C and E and fruit and vegetables are protective.

  • Genetic factors. Several inherited forms of kidney cancer exist: von Hippel-Lindau (VHL); inherited form of clear cell: hereditary papillary renal carcinoma; inherited form of type I papillary RCC: hereditary leiomyoma RCC; inherited form of type II papillary RCC: Birt-Hogg-Dube syndrome (BHD); risk of developing several different types of kidney cancer, including chromophobe RCC and oncocytoma.

Pathology

RCC is an adenocarcinoma of the renal cortex, probably arising from the proximal convoluted tubule. Macroscopically, RCCs are typically round and vary in size. They are generally comprised of areas of yellow or brown tumour interposed with areas of haemorrhage and necrosis. They are often surrounded by a pseudocapsule of compressed tissue. Up to 20% contain calcification, and are multifocal. Approximately 25% are cystic, with 2% of cases associated with synchronous or asynchronous bilateral tumours.

Histological classification

  • Conventional: comprise 80% of RCCs and arise ...

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