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Case History

image A 65-year-old man is found to have microscopic haematuria during a routine follow-up examination for his hypertension. He has an extensive history of vascular disease and smokes 20 cigarettes a day. He is referred urgently to a urologist, and further investigations reveal a 3 cm malignant looking lesion in his right kidney. On review at the multidisciplinary team meeting, he is deemed not to be a suitable candidate for surgery in view of his comorbidities.

How should this patient be initially investigated by the urologist?

What is the differential diagnosis?

What local treatments are available for this patient?


How should this patient be initially investigated by the urologist?

image Patients with renal malignancies may be asymptomatic at presentation, developing symptoms once there is local extension (pain, macroscopic haematuria, varicocele) or metastatic disease, or with the development of paraneoplastic syndromes (anorexia, cachexia, erythrocytosis, thrombocytosis, hypercalcaemia and polymyalgia). The classic triad of flank pain, haematuria and a flank mass is only seen in about 10% of patients and suggests locally advanced disease.

Patients with microscopic haematuria need investigations that include assessment of the degree of anaemia, assessment of renal disease (e.g. glomerulonephritis, interstitial nephritis), urine cytological examination (which may demonstrate casts suggesting renal parenchymal disease or malignant cells shed into the urinary tract) and imaging (including a kidney-ureter-bladder [KUB] radiograph to look for calcification, e.g. calculi, calcified haematomas, calcified carcinomas).

Ultrasound is helpful in determining renal size and demonstrated the presence of renal masses. It is less sensitive than computed tomography (CT) in detecting small masses but is able to distinguish a simple cyst from a more complex one. CT urography (CTU) has largely replaced intravenous urethrography in the diagnostic pathway as it is more sensitive and provides other anatomical information. If a malignant lesion of the renal tract is seen, full staging is completed with a chest CT, which is more sensitive than a chest radiograph in detecting metastatic disease. A flexible cystoscopy is also needed to reveal any mucosal abnormality of the bladder, and it allows taking biopsy specimens for histopathological assessment. This can be done with minimal sedation, but if abnormal findings are present, examination under anaesthesia and further cystoscopy are warranted.

What is the differential diagnosis?

The differential diagnosis of a solid mass in the kidney includes malignant causes such as renal cell carcinomas (RCCs) (clear cell 75–85%, papillary 15%, chromophobe 5%, collecting duct 1%), transitional cell carcinomas or less commonly lymphomas and sarcomas. Secondary deposits (e.g. lung, ovary, breast and colon) can also occur. Benign causes include angiomyolipomas/hamartomas, oncocytomas and benign adenomas.

Of all small solid CT-enhancing renal masses 83–90% prove to be RCC on histopathological analysis,1,2 the remainder including renal adenomas and oncocytomas.


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