6. Renal neoplasms and disorders of the adrenal gland; Benign prostatic hyperplasia Flashcards
Renal cell carcinoma (RCC)
Most common malignant tumor of the kidney. It is an adenocarcinoma arising from
tubular epithelium. It has a tendency to grow into the renal vein and IVC.
Renal cell carcinoma risk factors
• Smoking • Obesity • Asbestos • Phenacetin (analgesic) • Von Hippel Lindau syndrome (autosomal dominant inactivated VHL tumor suppressor gene on chromosome 3)
Renal cell carcinoma symptoms
• Hematuria • Palpable abdominal mass • Flank pain • Paraneoplastic symptoms: - HTN, - weight loss, - anemia, - polycythemia
Robson staging for Renal cell carcinoma
- Stage 1: Tumor within renal capsule (80% 5 year survival)
- Stage 2: Outside capsule, within Gerota’s fascia surrounding the perinephric fat (60%)
- Stage 3: Involvement of regional lymph nodes, renal vein, or IVC (20%)
- Stage 4: Adjacent organs or distant metastasis (10%)
Diagnosing RCC
Start with an US that can show a cyst with an intracystic element or calcified wall.
Follow up with contrast enhanced CT.
The mass will enhance with the contrast and renal vein involvement can be shown.
CT scan of the chest can demonstrate potential metastasis. Bones are major site, also abdom inal or thoracic.
RCC treatment
RCC does NOT respond to chemotherapy or radiation.
Partial nephrectomy if the tumor is <4cm and isolated to within the renal fascia.
For all others, radical nephrectomy, including perinephric fat, lymph nodes, and adrenal glands.
Renal artery embolization can be done as palliative care.
VHL patients should probably have both kidneys removed and kidney transplant.
Immunotherapy with anti-VEGF agents, as well as IL-2 or INF-alpha treatment are palliative for metastatic disease. .
List the renal neoplasms
Renal cell carcinoma
Angiomyolipoma
Oncocytoma
Wilms tumor
Transitional cell carcinoma of the pelvis/ureter.
Angiomyolipoma
A hamartoma: Benign overgrowth of well-differentiated cells, often with one element predominating.
Frequently bilateral.
Often associated with Tuberous sclerosis (AD syndrome with mental retardation and epilepsy).
Can cause gross hematuria and internal hemorrhage. If it is larger than >4cm it should be removed due to risk of bleeding.
Oncocytoma
1/3 of cases occur together with RCC. Arise from collecting ducts. Cannot be distinguished radiographically from RCC. Should be removed.
Epithelial cells from the collecting ducts characterized by an excessive number of mitochondria, resulting in an abundant acidophilic, granular cytoplasm
Wilms tumor
Most common urinary tract malignancy in childhood. Median age is 3 years old.
20% familial, 5% are bilateral.
Arise from abnormal proliferation of remnants of immature kidney (metanephric blastema).
Presents as a palpable abdominal mass.
Prognosis is 55-95%, depending on stage and histological subtypes.
Treatment: Radical nephrectomy with or without chemotherapy (actinomycin, vincristine or doxorubicin)
Transitional cell carcinoma (TCC) of the renal pelvis and ureter
Arise from transitional cells of renal pelvis. Presents as painless gross hematuria.
Urine cytology will show malignant cells.
Diagnosis is made with IV urography and CT scan.
Treatment: Nephro-ureterectomy with chemotherapy.
NB: Reoccurrence in the bladder in 50% of cases and contralateral kidney in 2%.
List the disorders of the adrenal glands (8)
Cushing´s syndrome - any cortisol hypersecretion or administration
Cushing’s Disease - Pituitary ACTH adenoma
Conn’s syndrome - Hyperaldosteronism
Adrenal cysts
Adrenal carcinoma
Pheochromocytoma
Ganglioneuroma
Neuroblastoma
Benign prostatic hyperplasia
Most common urological disease
Causes bladder outlet obstruction and increasingly difficult urination.
Mainly hyperplasia in the transitional zone
What causes obstruction in BPH
• Mechanical obstruction: The direct effect of the enlargement of the gland.
• Dynamic obstruction: Smooth muscle fibers within the prostate are richly innervated by adrenergic fibers of the sympathetic nervous system.
Giving alpha1-blockers (tamsulosin or doxazosin) are used to decrease sympathetic stimuli and relax the smooth muscles.
• Detrusor response: As the outlet resistance increase, the bladder responds by
increasing its force of contraction, to try to maintain flow.
This will eventually cause detrusor muscle hypertrophy and hyperplasia, and collagen deposition
–> severe bladder decompensation and dilation –>
ureterovesicle obstruction –> hydronephrosis –> renal insufficiency.
Symptoms of BPH
• Obstructive symptoms: Decreased urinary flow Staccato flow Difficult to start Residual volume in bladder Feeling of incomplete evacuation
• Irritative symptoms: Nocturia Pollacisuria (increased frequency) Urgency Alguria (painful urination)
