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Renal cell carcinoma

D Gillatt & A Okeke

A 69-year-old man with a history of hypertension and hemiparesis (from 2 CVAs) presented as an emergency case with haematuria. He had previously been diagnosed as having a non-functioning right kidney and a small lesion in the left kidney. His bleeding settled spontaneously and a repeat CT scan of his abdomen and pelvis showed an obstructed right kidney with 4% function.The lesion in his left kidney had increased in size considerably from approximately 1 cm to 3 cm diameter. He also had a severely unstable bladder.

A right radical nephrectomy was performed preceded by an ascending study and ureteroscopy. The ureteroscopy showed no obstructing lesion within the lower right ureter and the nephrectomy was performed through a 12th rib incision. There were some obvious small hilar lymph nodes that were sent separately to Histology.

Histology confirmed a moderately differentiated renal tumour which was invading into the capsule but not into the peri-nephric fat. The renal artery and vein were free from tumour and the sampled lymph nodes showed reactive changes only.

The patient made a steady post operative recovery but developed a chest infection that required antibiotics and vigorous physiotherapy.

Figures 1-3 show a follow-up CT scan and figures 4-5 a renal arteriogram 10 weeks later.


Fig.1	Fig.2	Fig.3

Fig.4

Fig.5

The bed of the previous right nephrectomy is filled with fluid and gas. The known tumour arises from the lower pole of the left kidney (Figs. 1-3). A dual arterial supply can be clearly seen on the arteriogram (Figs. 4-5). The smaller artery supplies the lower pole and takes a rather tortuous course before entering the renal hilum. Several small cysts are also evident in the left kidney but none of these have any detectable solid elements. There is also no evidence of para-aortic lymphadenopathy or other signs of spread.

The vascular anatomy is favourable for a lower pole partial nephrectomy. The patient may require perioperative renal assist and the renal unit have agreed to provide this if necessary. His 24 hour creatinine clearance is 48 mls per minute. The risk of possible total nephrectomy, rendering the patient anephric and therefore dialysis dependent, has also been discussed.

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