1. Some cases 55 yr male, presents with back pain. –Dipstick detects blood in urine –Pain localised to below right 12 th rib just medial to erector spinae muscle bulk. –Abdominal palpation shows large right kidney 82 year old male, admitted under CoE after a fall. Previously coping well. Tender right humerus and noted to have very baggy trousers. –Microscopic haematuria –Pathological fractures –Hypercalcaemic

2. Primary Renal Tumours Benign (But rare – malignant until proven otherwise!) Adenoma Angioma Angiomyolipoma Malignant Wilms’ - Children Renal cell carcinoma (75%)- Adults, adenocarcinoma TCC of pelvis and collecting system ( Balkan nephropathy – damp grain!) SCC of renal pelvis (stones, metastasis is early, rare, poor prognosis) This is small print! Paediatrics

3. Presentation of RCC Common Haematuria (frank / microscopic) +/- clot colic Loin pain Renal mass (all 3 ~ 15%, 1 ~ >95%) General debility –Malaise, reduced energy, weight loss –Pathological fractures Rare IDA / Polycythaemia (EPO) Hypertension (Renin) Hypercalcaemia (PTH) PUO ESR raised Metastases Nephrotic syndrome

4. More points + TCC RCC – uncommon below 50 years M:F = 2:1 FH – von Hippel Lindau (autosomal dominant, retina, CNS, phaechromocytoma, pancreas) Risk factors TCC of renal pelvis (similar to bladder) Multifocal (field change) Haematuria Clot colic Obstruction by clot at PUJ –Vague loin pain, loin mass –Hydronephrosis (unilateral)

5. Examination General: Weight loss, pale if clinically anaemic. May have oedema (IVC – abdomen, lower limbs), nodes Abdomen: Enlarged kidney, may be pushed down if upper pole lesion. Not tender or guarding. Varicoele (L>R) Bones: Swelling / Tenderness. Deposits – Very vascular, soft, compressible, pulsatile, bruit. Chest – Pleural effusion (spread thorough diaphragm, ipsilateral), signs of mass lesion (i.e. metastasis)

6. Enlarged kidney? Enlarged kidney 1.Reducible into loin (lies in paracolic gutter) 2.Usually unable to get above it on palpation 3.Moves with respiration 4.Resonant 5.Bimanually felt 6.Ballotable Differential Diagnosis Distended pelvicalyceal system Space occupying lesion –Cyst –Abscess –Tumour –Multiple: PKD Compensatory hypertrophy

7. Wilms’ tumour 18/12 baby boy brought to clinic by mum after noticing a ‘lump’ in abdomen whilst bathing Blood in nappy Mass in abdomen, very large occupying the upper area Pyrexial Unilateral / Bilateral renal mass Rapidly growing abdominal tumour (big tumour, small subject) Pyrexia (50%), related to tumour Haematuria Spreads quickly by blood – Lungs Bone, liver, brain rare Lymph spread – unusual DDX –Neuroblastoma (bony metastases) –Hepatoblastoma