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A renal mass

This patient presented with loin pain, a mass and haematuria.
1.  What does this specimen show?
2.  What other clinical features might he also have presented with?

This specimen is from a radical nephrectomy performed for a renal cell carcinoma. It shows a partially cystic lesion replacing much of the inferior pole of the kidney. Renal cell carcinomas are also known as hypernephromas (They were once believed to arise from the adrenal gland), clear cell carcinomas (because of their small nuclei and abundant clear cytoplasm) and Gravitz tumours.

The classic presentation of a renal cell carcinoma is with haematuria, loin pain and mass. This triad of symptoms occurs only in those who present late and today is seen in only 10% of patients. Renal cell carcinomas can present with 'clot' colic similar in nature to ureteric colic due to renal calculus. They are also able to produce quite marked systemic symptoms. They can present as a pyrexia of unknown origin or hypertension. They can present with polycythaemia due to the production of erythropoietin, or hypercalcaemia due to the ectopic production of PTH-like hormone.

Benign renal tumours are rare. All renal neoplasms should be regarded as potentially malignant. They can spread both directly into surround tissues and organs and can also spread via the renal vein and inferior vena cava. Caval spread is seen in about 10% of cases. Blood borne spread can result in 'cannon-ball' pulmonary metastases. The diagnosis can often be confirmed with an ultrasound scan. Abdominal CT scanning will allow identification of renal vein and caval spread. If caval spread occurs above the level of the diaphragm an echocardiogram should be obtained. Unless there is evidence of extensive metastatic disease treatment almost invariably requires a radical nephrectomy. the kidney is approached through either a loin or transabdominal approach. The renal vein is ligated early to reduce tumour spread. Resection should involve adjacent tissue and organs including the perinephric fat and adrenal. Radiotherapy and chemotherapy have little proven benefit in patients with renal cell carcinoma. Occasionally surgical resection of isolated solitary distant metastases (usually lung) offers the prospect of prolonged long-term survival.

Recent papers

Russco P.  Renal cell carcinoma:  presentation, staging and surgical treatment.  Semin Oncol 2000;  27:  106-176.

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