Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 6325 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

RENAL DATA FROM THE ASIA - AFRICA Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 1  |  Page : 120-126
Malignant Renal Tumors in Adults: A Ten-Year Review in a Nigerian Hospital


1 Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
2 Department of Medicine, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
3 Department of Anesthesia, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
4 Obafemi Awolowo University teaching Hospital Complex, Ile-Ife, Nigeria

Click here for correspondence address and email
 

   Abstract 

This study was undertaken to determine the age, sex, pattern of presentation, histopathology and outcome of management of adult patients with malignant renal tumors (MRT) in Nigeria. Using hospital records, a retrospective study was performed covering the period between January 1997 and December 2006. A total of 18 adult patients had been diagnosed to have MRT during this period. Information extracted and analyzed included the age of the patient, sex, presentation, investigations, type of histopathology, management and duration of follow-up. The mean age of the study patients was 47.5 years (range 16-80 yrs). The male: female ratio was 13 : 5 and the mean duration of symptoms was 43.6 weeks (range 2-104 wks). Sixteen patients (88.9%) presented in advanced stage. Symptoms included loin pain in 17 (94.4%), abdominal swelling in 15 (83.3%), weight-loss in 13 (72.2%) and hematuria in nine (50.0%). Ultrasound and intravenous urography assisted greatly in making the diagnosis. Thirteen patients (72.2%) underwent radical nephrectomy, tumors were not resectable in two (11.1%) and three others (16.7%) were deemed unfit to undergo surgery. The average tumor mass removed at surgery was 1.884 Kg (range 0.48-3.82 Kg). Renal cell carcinoma (RCC) accounted for 13 of the tumors (72.2%). Surgical complications include primary-hemorrhage, septicemia and tumor recurrence in one patient each (7.6%). Morbidity and mortality rates were 7.6% each. The average post-operative hospital stay and follow-up duration were 9.3 days and 37.5 months respectively. Our study suggests that RCC is the major MRT in our community. Most cases still present late with loin pain and swelling, weight loss and hematuria. This late presentation and sarcomatous type of tumor have negative influence on prognosis. Radical nephrectomy is beneficial in operable, locally advanced, non-metastatic MRT.

Keywords: Malignant renal tumors, Renal cell carcinoma, Loin pain, Loin swelling, Weight loss, Hematuria

How to cite this article:
Badmus T A, Salako A B, Arogundade F A, Sanusi A A, Adesunkanmi A, Oyebamiji E O, Bakare T, Oseni G O. Malignant Renal Tumors in Adults: A Ten-Year Review in a Nigerian Hospital. Saudi J Kidney Dis Transpl 2008;19:120-6

How to cite this URL:
Badmus T A, Salako A B, Arogundade F A, Sanusi A A, Adesunkanmi A, Oyebamiji E O, Bakare T, Oseni G O. Malignant Renal Tumors in Adults: A Ten-Year Review in a Nigerian Hospital. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Nov 19];19:120-6. Available from: http://www.sjkdt.org/text.asp?2008/19/1/120/37451

   Introduction Top


Malignant renal tumors (MRT) account for three percent of all malignant lesions seen in adult patients. MRT is common in the North Americans and the Scandinavians and less common in Africans and Asians, although recent findings indicate a 10-20% higher incidence in African Americans compare to their Caucasian counterparts. [1] In the United States, approximately 12,000 patients reportedly died of MRT in 1999 and approximately 30,000 new cases of renal cell carcinoma are diagnosed each year. [2] In Nigeria, earlier reports by Lawani et al in 1985 indicate that MRT accounted for 20.9% of all urogenital tumors, [3] whereas Klufio et al recently showed that MRT accounted for 10.4% of all urogenital tumors in Ghana. [4] In most developed countries, more than 50% of these tumors are incidentally detected during routine screening, at a time when the tumors were relatively small with bright hope for curative ablation. [5],[6] In contrast, earlier reports from Nigeria and other parts of Africa indicate that these tumors were often diagnosed in advanced stage because the patients present very late when they are moribund or unfit for surgical intervention [7],[8] with consequent poor prognosis after nephrectomy. [9]

The present study was carried out at the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, which provides specialized health care for the rural and semi­urban communities of Osun, Ondo, Ekiti, Kogi and partly Oyo, and Kwara states in south­western Nigeria. It was undertaken to deter­mine the current pattern of presentation, management and its outcome, of adult patients with malignant renal tumors in our commu­nity, and to compare our findings with other reports on this disease.


   Materials and Methods Top


The hospital records of 22 adult patients managed for MRT in our institution between January 1997 and December 2006 were reviewed; only 18 cases were confirmed with tissue diagnosis and were included in this study. Information extracted and analyzed included the age of the patient, sex, clinical features, investigations, histopathological diagnosis, outcome of management, and dura­tion of hospital stay and follow-up.


   Results Top


The mean age of the 18 adult patients with histopathological confirmation of MRT managed over the ten-year period was 47.5 years with a range of 16-80 years. The male: female ratio was 13:5 and the mean duration of symptoms was 43.6 weeks (range 2-104 weeks). The tumor was located on the left side in 10 patients (55.5%) and on the right in eight (44.4%). In two cases (11.1%), the tumor was in Robson stage 2, nine (50.0%) were in stage 3 and seven (38.9%) in stage 4. Symp­toms included loin pain in 17 (94.4%), abdo­minal mass in 15 (83.3%), weight loss in 13 (72.2%), hematuria in nine (50.0%), fever in two (11.1%), generalized body weakness in two (11.1%) and one patient (5.5%) each had mucous diarrhea and urinary frequency [Table - 1].

Three patients (16.7%) indulged in alcohol intake and cigarette smoking. There was hepatomegaly in five patients (27.8%), pallor in four (22.2%), hypertension in three (16.7%), jaundice and pleural effusion with respiratory distress, in two patients each (11.1%).

The histopathology results of tumor speci­mens obtained at surgery or autopsy, and the outcome of surgery are listed in [Table - 2],[Table - 3] respectively. Ultrasound and intravenous urography showed features of malignancy in all the patients.

Fifteen patients (83.3%) were operated upon; 13 (72.2%) underwent radical nephrec­tomy, while tumors were not resectable in two (11.1%). The remaining three patients (16.7%) were unfit for surgical intervention. The average tumour mass removed at surgery was 1.884 Kg (range 0.48-3.82 Kg). Six patients received post-operative radiotherapy. Amongst the 13 patients with radical nephrectomy, 11 (84.6%) had no surgical complications, one (7.7%) patient died of pulmonary embolism, and one other patient (7.7%) developed wound sepsis, septicemia, lobar pneumonia and hypertrophic scar. Other surgical complications included primary hemorrhage and tumor recurrence in one patient each (7.7%). The patients were followed-up with serial abdo­minal ultrasound and estimation of serum electrolytes, urea and creatinine. The average duration of hospital stay post-nephrectomy was 9.3 days (range 6-17 days). After an average follow-up of 54.1 months (range 9.6­83.9 months), seven patients (53.8%) are still alive and in stable condition. Two (15.4%) patients died five and 50 months post­nephrectomy, while three (23.1%) were lost to follow-up after an average period of 9.5 months (range 3-17 months). All the five patients (27.8%) in whom definitive surgery could not be performed died 2-3 months after presentation. All the patients were managed and followed-up jointly by the Urology and Nephrology departments.


   Discussion Top


Our study showed that MRT is commoner in males, aged 16-80 years, with peak incidence in the fifth and sixth decades of life (45-60 years). Aghaji et al also observed similar prevalent age-range in patients with renal cell carcinoma (RCC) in Eastern Nigeria. [8] Thus, the peak incidence of MRT in Nigeria occurs about a decade lower than the 50-70­years peak incidence reported in literature amongst the Caucasians. [1] The wide prevalent age-range observed in this series indicates that MRT can occur in any age. The male preponderance observed in this review is close to the 2:1 ratio reported in literature. [10]

The small number of patients managed over the ten-year period indicates that MRT is not very common in our immediate environ­ment. Like the earlier reports, [3],[8] this review also confirmed that RCC, which accounted for 13 (72.2%) of the tumors seen in this series, is the most common MRT [Table - 2].

In agreement with earlier reports, this review showed that loin pain (94.4%), abdominal swelling (83.3%), and hematuria (50.0%) are prominent symptoms of MRT (predominantly RCC in this review). [9],[10] This classic triad ("too late triad") denotes advanced disease. In developed countries, this triad is now rarely seen because, as earlier reite­rated, more than 50% of renal tumors are now incidentally discovered very early in these communities. [11],[12] This review also showed that weight loss observed in 72.2% of our patients is also an important symp­tom of MRT in our environment due to late presentation. In most African communities, late presentation has been observed as a major setback in the effective management of MRT. [7],[8],[9]

The average weight of the tumor mass removed at surgery in this series was 1.884 Kg (range 0.48-3.82 Kg, average 24 cm in the widest diameter). This is in contrast to the average pathologic renal tumor size reported in most developed societies, which ranges from 5-8 cm (average 5.4 cm) in the widest diameter and less than 0.5 kg in weight. [15]

This indicates that MRT in our community are relatively much bigger at presentation. This finding also closely reflects the late presentation in most of our patients in contrast to early detection in developed societies. [5],[6]

Although a moderate association between the incidence of RCC and the use of tobacco and exposure to cadmium has been established, [10],[13] this review showed that these factors are not important in the etio­pathogenesis in our community as only three (16.7%) of our patients indulged in cigarette smoking and none of them was an industrial worker.

Abdominal ultrasonography and intravenous urography were found very useful in esta­blishing the diagnosis in most of our patients. Computerized tomography scan also proved very valuable in two patients who could afford the cost. Apart from its non-invasiveness, it accurately depicted diagnostic features of RCC in these patients. Invasive procedures like renal arteriography may therefore, not be routinely required before radical nephrectomy. [14]

The value of surgery in the management of MRT lies on the fact that unlike other malignant tumors, RCC is relatively resistant to other systemic therapies like radiotherapy, chemotherapy or hormone therapy. [16],[17] In this series, radical nephrectomy, which has been recognized as the treatment of choice in localized RCC, [11],[18] was successfully carried out in 13 patients (72.2%) operated for locally advanced tumors with good results. The kidneys were removed outside the Gerota's fascia with ipsilateral adrenalectomy in all. Although recent reports indicate that adrenalectomy may not be routinely nece­ssary, [19] the huge tumor size and the upper pole location in most of the cases, and the need to ensure tumor-free margin, made attempts to salvage the ipsilateral adrenal gland difficult. Although the current trend is towards laparoscopic nephrectomy, [20],[21],[22] with the huge tumor sizes and extensive neo-vascularization observed in these tumors, it is doubtful whether most of our patients will be suitable for this procedure.

It is of note that despite the huge size of these tumors, only two (13.3%) of the 15 patients operated had metastasis in the liver. In these two patients, fixity of the tumors to the abdominal aorta, the inferior vena cava and the lumbar vertebrae rendered the tumors unresectable. Amongst the patients with radical nephrectomy, there was mortality in one patient who died of pulmonary embolism few hours after surgery and morbidity in one patient (7.7%) with sepsis. Two other patients had minor complications and the overall complication rate was 22.2%, which is marginally higher than the 20% reported in literature. [23]

Prognosis of RCC is influenced by involve-ment or otherwise of perinephric fat, regio-nal lymph nodes and/or renal vein/vena cava. [24] In this series, renal vein was involved in two patients (13.3%), which is slightly higher than the 4 - 10% reported in literature. [25] The perinephric fat was involved in 16 patients (88.9%). On the whole, the outcome of surgery in this review was good and the prognosis also was fairly good despite the advanced stage of the tumors. This result compares well with the findings of Mosharafa et al who observed similar outcome in advanced renal tumors. [26] Apart from the stage of the tumor, the histopathological type also influences prognosis. Malignant fibrous histiocytic sarcoma is known to have bad prognosis. [27],[28] The patient with this tumor died five months after exploration, while another patient with sarcomatoid RCC, which is also known to have bad prognosis, had local tumor recurrence eight months after surgery while awaiting radiotherapy.

Although no major problem has been reported in most patients following uninephrectomy, [29],[30] fifty percent reduction in renal mass may lead to glomerular hyper­filtration, progressive glomerulosclerosis and deterioration in the function of the remaining kidney, resulting in proteinuria and hypertension. [29],[31] Long-term management should therefore aim to preserve adequate renal function in the remaining kidney. [31] It has been suggested that glomerulopathy, can be prevented by reducing protein intake and treatment with a converting enzyme inhibitor. [32],[33] Moderate restriction of protein intake has been advised on all our patients and they are being followed up jointly with the nephrologists, with regular clinical evaluation, quarterly electrolytes, urea and creatinine measurement and abdominal ultrasonography for early detection of recurrence.

When last seen, seven (53.8%) of the patients with radical nephrectomy were still alive and in stable condition after an average duration of follow-up of 54.1 months (range 9.6-83.9 months), two (15.4%) died, one each at 5 and 50 months post­nephrectomy, while three (23.1%) were lost to follow-up after an average period of 9.5 months (range 3-17 months). All the five (27.8%) patients who could not have defi­nitive surgery had metastatic disease and they all died 2-5 months after presentation. It is known that metastatic RCC has poor prognosis with median survival of 6-12 months.[34],[35],[36]


   Conclusion Top


Renal cell carcinoma accounts for about 75% of all MRT in our community. It is commoner in males and most cases still present late with loin pain, loin swelling, weight loss and hematuria. Sarcomatous tissue type and late presentation have negative influence on prognosis. Radical nephrectomy is safe and beneficial in operable locally advanced non-metastatic MRT.

 
   References Top

1.Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr. Rising incidence of renal cell cancer in the United States. JAMA 1999;281(17): 1628-31.  Back to cited text no. 1    
2.Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics: 1999. CA Cancer J Clin 1999;49(1):8-31.  Back to cited text no. 2    
3.Lawani J, Nkposong EO, Aghaidiuno PU, Akute O. A twenty-year review of urologic tumours of the genito-urinary tract in Ibadan, Cancer in Nigeria, Ibadan Tropical Medicine Series; University of Ibadan Press: 1982:67-74.  Back to cited text no. 3    
4.Klufio GO. A review of genitourinary cancers at the Korle-Bu teaching hospital Accra, Ghana. West Afr J Med 2004;23 (2):131-4.  Back to cited text no. 4    
5.Thompson IM, Peek M. Improvement in survival of patients with renal cell carcinoma: The role of the serendipitously detected tumor. J Urol 1988;140(3):487-90.  Back to cited text no. 5    
6.Konnak JW, Grossman HB. Renal cell carcinoma as an incidental finding. J Urol 1985;134(6):1094-6.  Back to cited text no. 6    
7.Aina AO, da Rocha-Afodu. A review of renal tumours in Lagos. Niger Med J 1972;2(1):30-2.  Back to cited text no. 7    
8.Aghaji AE, Odoemene CA. Renal cell carcinoma in Enugu, Nigeria. West Afr J Med 2000;19(4):254-8.  Back to cited text no. 8    
9.Awori NW. Renal tumours in Kenya. Tropical Doctors 1975;5:170-2.  Back to cited text no. 9    
10.Kantor AF, Meigs JW, Heston JF, Flannery T. Epidemiology of renal cell carcinoma in Connecticut. J Natl Cancer Inst 1976;57 (3):495-500.  Back to cited text no. 10    
11.Skinner DG, Calvin RB, Vermillion CD, Pfister RC, Leadbetter WF. Diagnosis and management of renal cell carcinoma: A clinical and pathologic study of 309 cases. Cancer 1971;28(5):1165-77.  Back to cited text no. 11    
12.Gibbons RP, Monte JE, Correa RJ Jr, Mason JT. Manifestations of renal cell carcinoma. Urology 1976;8(3):201-6.  Back to cited text no. 12    
13.Kolonel LN. Association of cadmium with renal cancer. Cancer 1976;37(4):1782-7.  Back to cited text no. 13    
14.Roy C, Tuchmann C, Morel M, Saussine C, Jacqmin D, Tongio J. Is there still a place for angiography in the management of renal mass lesion. Eur Radiol 1999;9(2): 329-35.  Back to cited text no. 14    
15.Yaycioglu O, Rutman MP, Balasubramaniam M, Peters KM, Gonzalez JA. Clinical and pathologic tumor size in renal cell carcinoma; Difference, correlation and analysis of the influencing factors. Urology 2002;60(1):33-8.  Back to cited text no. 15    
16.Fugitt RB, Wu GS, Martinelli LC. An evaluation of postoperative radiotherapy in hypernephroma treatment - a clinical trial. Cancer 1973;32(6):1332-4.  Back to cited text no. 16    
17.Yagoda A, Petrylak D, Thompson S. Cytotoxic chemotherapy for advanced renal cell carcinoma. Urol Clin North Am 1993;20(2):303-21.  Back to cited text no. 17    
18.Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol 1969;101(3): 297-301.  Back to cited text no. 18    
19.Sagalowaky AI, Kadesky KT, Ewalt DM, Kennedy TJ. Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 1994;151(5):1181-4.  Back to cited text no. 19    
20.Hsu TH, Gil IS, Fazeli-Natin S, Soble JJ, Sung GT, Schweizer D, Novick AC. Radical nephrectomy and nephroureterectomy in the octogenarian: comparism of laparoscopic and open approaches. Urology 1999;53(6): 1121-5.  Back to cited text no. 20    
21.Matin SF, Gill IS, Worley S, Novick AC. Outcome of laparoscopic radical and open partial nephrectomy for the sporadic 4cm. or less renal tumor with a normal contra­lateral kidney. J Urol 2002;168(4 Pt 1):1 356-9; discussion 1359-60.  Back to cited text no. 21    
22.Meraney AM, Gill IS. Financial analysis of open versus laparoscopic radical nephrectomy and nephroureterectomy. J Urol 2002;167(4): 1757-62.  Back to cited text no. 22    
23.Swanson DA, Borges PM. Complications of trans-abdominal radical nephrectomy for renal cell carcinoma. J Urol 1983;129(4): 704-7.  Back to cited text no. 23    
24.Cherrie RJ, Goldman DG, Lindner A, deKernion JG. Prognostic implications of vena caval extension of renal cell carcinoma. J Urol 1982;128(5):910-2.  Back to cited text no. 24    
25.Schefft P, Novick AC, Straffon RA, Stewart BH. Surgery for renal cell carcinoma extending into the vena cava. J Urol 1978; 120(1):28-31.  Back to cited text no. 25    
26.Mosharafa A, Koch M, Shalhav A, et al. Nephrectomy for metastatic renal cell carcinoma: Indiana University experience. Urology 2003;62(4):636-40.  Back to cited text no. 26    
27.Ro JY, Ayala AG, Sella A, Samuels ML, Swanson DA. Sarcomatoid renal cell carcinoma: Clinicopathologic: A study of 42 cases. Cancer 1987;59(3):516-26.  Back to cited text no. 27    
28.Cangiano T, Liao J, Naitoh J, Dorey F, Figlin R, Belldegrun A. Sarcomatoid renal cell carcinoma: Biologic behavior, prognosis and response to combined surgical resection and immunotherapy. J Clin Oncol 1999; 17(2):523-8.  Back to cited text no. 28    
29.Foster MH, Sant GR, Donohoe JE, Harrington JT. Prolonged survival with a remnant kidney. Am J Kidney Dis 1991;17(3):261­-5.  Back to cited text no. 29    
30.Kamran T, Zaheer K, Hussain SW, Zahid KH, Akhtar MS. Are live kidney donors at risk? J Coll Physicians Surg Pak 2003;13 (3):153-6.  Back to cited text no. 30    
31.Solomon LR, Mallick NP, Lawler W. Progressive renal failure in a remnant kidney. Br Med J (Clin Res Ed) 1985;291 (6509):1610-1.  Back to cited text no. 31    
32.Novick AC, Schreiber MJ Jr. Effect of angiotensin-converting-enzyme inhibition on nephropathy in patients with a remnant kidney. Urology 1995;46(6):785-9  Back to cited text no. 32    
33.Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease: The role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med 1982;307(11):652-9.  Back to cited text no. 33    
34.Dekernion JB, Ramming KP, Smitt RB. The natural history of metastatic renal cell carcinoma: A computer analysis. J Urol 1978:120(2);148-52.  Back to cited text no. 34    
35.Ritchie AW, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983:10(4);390-400.  Back to cited text no. 35    
36.Katz SA, Davis JE. Renal adenocarcinoma: prognosis and treatment reflected by survival. Urology 1977;10(1);10-1.  Back to cited text no. 36    

Top
Correspondence Address:
T A Badmus
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State
Nigeria
Login to access the Email id


PMID: 18087141

Rights and Permissions



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]

This article has been cited by
1 Adult renal cancer in Senegal: Current epidemiological, clinical features, profilećs evolution over the two past decades [Le cancer du rein de lćadulte au SĂ©nĂ©gal: aspects Ă©pidĂ©miologiques et cliniques actuels et Ă©volution du profil sur les deux dernières dĂ©cennies]
Fall, B. and Diao, B. and Sow, Y. and Sarr, A. and Thiam, A. and Fall, P.A. and Ndoye, A.K. and Sylla, C. and Ba, M. and Mendes, V. and Diagne, B.A.
Progres en Urologie. 2011; 21(8): 521-526
[Pubmed]
2 Success of nephron-sparing surgery in the treatment of localized renal cell carcinoma
Oranusi, C.K. and Nwofor, A.M.E.
Nigerian Journal of Clinical Practice. 2011; 14(3): 380-382
[Pubmed]



 

Top
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    Conclusion
    References
    Article Tables
 

 Article Access Statistics
    Viewed3674    
    Printed81    
    Emailed0    
    PDF Downloaded477    
    Comments [Add]    
    Cited by others 2    

Recommend this journal