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Case history

image A 30-year-old woman was referred by her GP because of intermenstrual bleeding and was found to have an abnormal cervix at speculum examination. Biopsies confirmed squamous cell carcinoma of the uterine cervix. MRI staging demonstrated stage IIIB disease with left-sided hydroureter and hydronephrosis.

Concurrent chemoradiotherapy with weekly cisplatin was planned and, following completion of external beam radiotherapy, an intrauterine brachytherapy boost. After multidisciplinary team discussion, the patient was also referred to urology, prior to commencing treatment with curative intent, for consideration of ureteric stenting to preserve her renal function.

A short time after stent insertion she re-presented acutely and was found to have a deterioration in renal function (creatinine 800 μmol/l, urea 30 mmol/l). Urgent further imaging revealed an appropriately sited left ureteric JJ stent but new right hydronephrosis. Emergency percutaneous nephrostomy (PCN) was performed and a urinary catheter inserted in case of concomitant bladder outflow obstruction. Definitive chemoradiotherapy was planned to commence the following week.

What is the differential diagnosis of deranged renal function in a patient with pelvic malignancy?

How should deranged renal function be investigated?

What methods may be used to optimize renal function in a patient with an acute obstructive uropathy and what factors should be considered?

What is the relevance of this patient’s renal function to her ongoing cancer management?

What is the differential diagnosis of deranged renal function in a patient with pelvic malignancy?

An acute deterioration in renal function is common in patients with malignancy.1 The differential diagnosis is broad and consideration should be given to both the cancer and associated treatments in terms of aetiology. In a patient with a pelvic malignancy, an obstructive cause is high on the list of possibilities, but other factors such as treatment-related toxicities, neurological, medical or surgical causes should be considered.

Anatomical and obstructive causes

Malignant obstructive uropathy may be either intrinsic or extrinsic in nature. Any tumour intrinsic to the urinary tract can obstruct the urine flow from the renal pelvis downward. The commonest intrinsic cause in men is prostate cancer, causing either bladder outflow obstruction or ureteric obstruction. Urothelial cancers of the bladder and ureters may also cause intrinsic obstruction. Among women, the commonest cause of urinary tract obstruction is a gynaecological cancer, particularly cervical or ovarian. This is most often because of ureteric compression either due to the bulk of local disease or to pelvic/retroperitoneal lymphadenopathy. Generally, only bilateral obstruction causes deranged renal function and symptoms.

Treatment effects and toxicities

Any chemotherapeutic drug could have a detrimental effect on renal function, either through direct action (e.g. platinum compounds) or indirectly by causing dehydration through vomiting, diarrhoea or mucositis. A thorough history is helpful in determining a pre-renal drug cause. Immune checkpoint inhibitors targeting cytotoxic T lymphocyte-associated protein 4 (CTLA-4) or programmed cell death protein 1 (PD-1)/ programmed death-ligand 1 (PD-L1) are recognized ...

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