RENAL DATA FROM THE ASIA - AFRICA
Year : 2008 | Volume
: 19 | Issue : 1 | Page : 120--126
Malignant Renal Tumors in Adults: A Ten-Year Review in a Nigerian Hospital
TA Badmus1, AB Salako1, FA Arogundade2, AA Sanusi2, ARK Adesunkanmi1, EO Oyebamiji3, TIB Bakare4, GO Oseni4,
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
T A Badmus
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State
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.
|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;19:120-126
|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 Sep 21 ];19:120-126
Available from: http://www.sjkdt.org/text.asp?2008/19/1/120/37451
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.  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.  In Nigeria, earlier reports by Lawani et al in 1985 indicate that MRT accounted for 20.9% of all urogenital tumors,  whereas Klufio et al recently showed that MRT accounted for 10.4% of all urogenital tumors in Ghana.  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. , 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 , with consequent poor prognosis after nephrectomy. 
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
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.
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.
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.  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.  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. 
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, , 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). , 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. , 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. ,,
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. 
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. ,
Although a moderate association between the incidence of RCC and the use of tobacco and exposure to cadmium has been established, , 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. 
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. , In this series, radical nephrectomy, which has been recognized as the treatment of choice in localized RCC, , 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,  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, ,, 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. 
Prognosis of RCC is influenced by involve-ment or otherwise of perinephric fat, regio-nal lymph nodes and/or renal vein/vena cava.  In this series, renal vein was involved in two patients (13.3%), which is slightly higher than the 4 - 10% reported in literature.  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.  Apart from the stage of the tumor, the histopathological type also influences prognosis. Malignant fibrous histiocytic sarcoma is known to have bad prognosis. , 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, , 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. , Long-term management should therefore aim to preserve adequate renal function in the remaining kidney.  It has been suggested that glomerulopathy, can be prevented by reducing protein intake and treatment with a converting enzyme inhibitor. , 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.,,
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.
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