Renal Tumours Flashcards
What are the benign renal tumours?
Angiomyolipoma
Oncocytoma
What are malignancies associated with the kidney?
RCC
TCC
Lymphoma and other mets
What is the pathological appearance of oncocytoma?
It is a spherical, capsulated, brown/tan coloured mass which has a star-shaped or spoke wheel patterned central scar.
Aggregates of Eosinophils
Mitosis is Rare
Mitochondria packed (similar to Chromophobe RCC)
What are symptoms of oncocytoma?
Loin Pain
Haematuria
Often an Incidental Finding
What are investigations for oncocytoma
Radiologically, these are very difficult to differentiate from Chromophobe RCC.
Classic Sign is the Spoke Wheel Central Scar in a mass.
Follow radiology with biopsy to confirm Oncocytoma with certainty.
What is treatment for oncocytoma?
Same treatment as Chromophobe RCC
Partial Nephrectomy for Small Masses Radical Nephrectomy for Large Masses
What is the major risk factor for angiomyolipoma?
Tubular Sclerosis
What is the pathology for angiomyolipoma?
Blood vessels (angio), immature smooth muscle (myo) and fat (lipoma) are seen, hence the name.
What are symptoms of angiomyolipoma?
Loin Pain
Mass
Haematuria
Wunderlich’s Syndrome i.e. A Massive Retroperitoneal Bleed with Sudden Pain
What are investigations for angiomyolipoma?
USS CT (Surrounding black shadowing represents fat)
What is the treatment for angiomyolipoma?
If 1-3cm, observe once diagnosed and discharge men.
If 1-3cm, pre-menopausal women should be monitored as they exert hormonal influence with oestrogens
4cm is the Cut-Off i.e. Elective Embolization OR Partial/Radical Nephrectomy otherwise risk of spontaneous bleeding increases markedly Emergency Embolization to stop bleeding OR Nephrectomy if the tumour is Large
What is RCC?
Adenocarcinoma of the renal cortex and is often noted to arise from the Proximal Convoluted Tubule origin
What are risk factors of RCC?
Renal failure and dialysis Smoking Obesity Hypertension Asbestos Cadmium Phenacetin VHL Syndrome (50% of patients develop RCC) Sickle Cell Disease Male
What is the pathology of RCC?
Tan coloured, lobulated, solid mass.
10-25% contains cysts and generally, it is predominantly cystic
What are the types of RCC?
Clear Cell Papillary Chromophobe Collecting Duct Medullary
What are symptoms of RCC?
Loin pain
Haematuria
Mass
All 3 of the above i.e. Israel Triad which is a less common presentation
Pyrexia of unknown origin
Variocoele, often on the left side, as the left testicular vein drains directly into the renal vein on the left hand side
Paraneoplastic Syndrome e.g. ACTH, Insulin, Renin, EPO etc.
Stauffer’s Syndrome i.e. Abnormal Liver Function NOT due to Metastases along with Fever and Anorexia
How is RCC staged?
T1; up to 7cm
T2 >7cm; confined to kidney
T3; invasion beyond kidney into renal vein, perinephric fat, renal sinus and IVC which is more common in right side due to anatomy
T4; beyond gerotas fascia into surrounding structure
What are investigations for RCC?
USS
CT Chest, Abdomen and Pelvis for staging
FBC; RFTs and LFTs
What is the treatment for RCC <3cm?
Surveillance in elderly unfit patients
Ablation techniques in fit, elderly and selected young patients
Partial nephrectomy for fit young patients
What is the treatment of RCC >3cm?
Partial nephrectomy (for patients with long life expectancy) via the robotic technique but there is risk of haematuria and bleeding afterwards. Radical nephrectomy
What is the gold standard treatment for extremely large RCC?
Laparoscopic radical nephrectomy
What does RCC follow-up consist of?
FBC; in particular LFTs as deranged LFTs can indicate Liver Metastases
Imaging i.e. CT or USS + CXR, depending on how bad the cancer was (minimise radiation in younger population so mix and match)
Duration 5-10 years
What are the types of Testicular Cancer (TC)?
Seminomatous, common in men aged 35-45 years (Sergeant’s Disease)
Non-Seminomatous, common in men aged <35 (Troop’s Disease)
Based on involvement of seminal vesicles
What are risk factors of TC?
Being White
Previous TC which causes increased risk in contralateral testicle
HIV
Family history of TC
Cryptorchidism (failure of testicle descending) is found in 5-10% of TC Patients Orchidopexy done before 13 years causes a 2 fold risk while orchidopexy done after 13 years causes a 5 fold risk - essentially it should be done as soon as Cryptorchordism is detected
What is the presentation of TC?
Scrotal lump i.e. A hard, non-tender, irregular, intratesticular mass
Discolouration of affected teste
Asymmetry of testes
Delayed presentation occasionally seen
Acute pain due to bleeding in 5% of presentations
Weight loss, neck lumps, chest symptoms or bone pain suggest widespread disease
What is involved in examination for TC?
Examine normal side first Assess for epididymis involvement Examine spermatic cord and scrotal skin Look for abdominal mass as this is an indication of advanced disease Secondary Hydrocoele
What are investigations for TC?
USS and once confirmed, CT Chest and Abdomen for staging
Tumour Markers should be raised: Alpha Foeto Protein (AFP), B-HCG, LDH
FBC, in particular LFTs and RFTs
What is management of TC?
Gold Standard is Radical Inguinal Orchidectomy
Re-check Tumour Markers 1 Week post-surgery and if they remain elevated, do a CT scan to check for metastases
Further follow up by Oncology with Chemotherapy as an adjuvant (even in non-metastatic disease) as it has been shown to improve outcome significantly
What if a mass if found on examination of TC elsewhere?
Urgent CT scan to confirm metastases, followed by oncology chemotherapy referral
List common penile cancers
SSC, often on Glans which invades into the tissue
Kaposi’s Carcinoma, which is linked to HIV
BCC
Malignant Melanoma
Sarcomas
What are symptoms of penile cancer?
Hard, painless groin mass/lump
Urinary Retention
Inguinal Lymphadenopathy
What are investigations for penile cancer?
MRI to assess tumour depth
CT Abdomen, Pelvis and Chest
What is treatment for penile cancer?
For Preputial Lesions, circumcision
For Superficial Glans Lesions, resurfacing
For Deep Glans Lesions, glansectomy
For Advanced Disease, total penile amputation with formation of perineal urethrostomy
For Inguinal Lymphadenopathy, lymphadectomy but note that there is a high risk even if not involved
An African man is most likely to get testicular cancer?
No.
African, Asian and South American men are more likely to have penile cancer while white men are more likely to get testicular cancer.
What are the types of non-seminomatous TC?
Yolk Sac Choriocarcinoma Embryonal Trophoblast Teratoma (most common)
Which non-seminomatous TC produces Alpha Foeto Protein?
Yolk Sac
Which non-seminomatous TC makes men pregnancy test positive?
Trophoblast, through B-HCG secretion
What do Seminomatous TC produce?
LDH
What do non-seminomatous TC produce?
Alpha Foeto Protein
B-HCG
What is Hydrocoele?
The accumulation of fluid around the testes, between the two layers of the tunica vaginalis and therefore, the fluid is walled off by a mesothelial lining
What is Spermatocoele?
A cyst that develops within the vas of epididymis due to an unknown cause and is usually, ASYMPTOMATIC.
How do spermatocoele patients present?
Sensation of fullness
Lump, often present after self examination
Feelings of heaviness down there
What is Variocoele?
Distension of the venous plexus that drains the testis.
How does Variocoele present?
It is usually asymptomatic but patients describe their balls having an inside feeling of a ‘bag of worms’ and often, may present after having felt a lump.
What is the epithelium of the foreskin?
Squamous, hence why it is susceptible to SSC
What is penile papilloma associated with?
HPV
What are the types of Penile Intraepithelial Neoplasia?
Differentiated (i.e. NOT related to HPV)
Dedifferentiated (i.e. Related to HPV) otherwise known as Non-Differentiated
