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\title{Pattern and Presentation of Renal Cell Carcinoma Ingezira Hospital for Renal Diseases and Surgery}
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             \author[1]{Salih Yahia  Mohammed}

             \author[2]{Salih Yahia  Mohammed}

             \affil[1]{  Sudanese Medical Specialization Board}

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\date{\small \em Received: 8 April 2013 Accepted: 3 May 2013 Published: 15 May 2013}

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\begin{abstract}
        


Background: Renal cell carcinoma (RCC) is most commonprimary tumour of kidney in adult, responsible for (80-85%) of renal tumour (1) . Due to ultimately absence of studies in Sudan in assessing the pattern and presentation of RCC, we conducted this study in Gezira Hospital for renal diseases and Surgery, in period from January 2006-January 2012.Objective: To determine the clinical presentation, pathological pattern and stages of RCC in patients who treated in (GHRS).Results: A total of 60 patients were diagnosed to have RCC in duration of 5 years. The disease is more common in male, with peak incidence in the fifth and sixth decades. Incidentally diagnosed are 6 patients. Classical triad observed in 19patients .Mean duration of symptoms was 4 months. Some patients had metastasis in the lung, bones or liver when diagnosed. Most of the patients presented with loin mass, small number with cervical lymphadenopathy, lower limb edema or non reduciblevaricocele

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
enal cell carcinomas (RCCs) are the commonest primary renal tumour in adult responsible for 80 -85 \% of tumours, followed by transitional cell carcinoma (TCC). This tumour is relatively rare in paediatric where it replaced by Wilmstumour. \hyperref[b0]{(1)} Globally, the incidence of RCC varies widely from region to region with the highest rates observed in the Czech Republic and North America \hyperref[b0]{(1)} The incidence of RCC has been increased over last decades, and the size of mass decreased at diagnosis and so the stage, with proportional increases in 5years survival rate. This may be attributed to wide use of new imaging techniques and incidental diagnosis which approached more than (50\%) along with early surgical intervention.\par
There are number of environmental and clinical factors have been implicated in the aetiology of RCC. \hyperref[b1]{(2,}\hyperref[b2]{3)} These including hypertension, acquired cystic disease of the kidney (typically associated with dialysis), obesity, hepatitis C, smoking, occupational exposure to toxic compounds such as cadmium and asbestos, analgesic abuse nephropathy. Genetic abnormalities as Von Hippel-Lindaugene, which found in 50-60\% of cases, deletion of chromosome 3p and mutations in the p53 gene had been implicated. \hyperref[b1]{(2,}\hyperref[b3]{4,}\hyperref[b4]{5,}\hyperref[b5]{6,}\hyperref[b6]{7)} Previously, RCCs were classified by cell type and growth pattern \hyperref[b7]{(8)} This classification has recently changed to more accurately reflect the morphology, growth pattern, cell of origin, histochemical, and molecular basis of the different types of adenocarcinomas. \hyperref[b8]{(9,}\hyperref[b9]{10)} .Several distinct subtypes of RCC have been identified, including: Clear cell (75 to 85 \%), which typically have a deletion of chromosome 3p, arise from the proximal tubule. \hyperref[b10]{(11)} In addition to occurring in sporadic disease, clear cell carcinomas are specifically associated with von Hippel-Lindau disease. Papillary (chromophilic) (10 to 15\% ) are frequently multifocal and bilateral, and commonly present as small, early stage tumours, Chromophobe (5 to 10\%), Oncocytic (uncommon), Collecting duct (Bellini's duct) very rare, and less than 5 \% of RCCs are considered unclassified, these tumours had a worse prognosis compared with clear cell cancers \hyperref[b11]{(12,}\hyperref[b12]{13)} Symptoms associated with RCC can be due to local tumour growth, haemorrhage, paraneoplastic syndromes, or metastatic disease. \hyperref[b13]{(14)} With the more pervasive use of non-invasive imaging for the evaluation of nonspecific symptom, more than 50\% of RCCs are now detected incidentally. \hyperref[b14]{(15)}\hyperref[b15]{(16)} The classic trait of flank pain, heamaturia and abdominal mass presented in about 10 -15 \% of patient and indicate an advance disease (too late trait). Before the advent of ultrasonography and CT, most patients with RCC presented with one or more of these signs or symptoms, and many were incurable. Other indicators of advanced disease include constitutional symptoms, such as weight loss, fever, and night sweats, and physical Examination findings such as palpable cervical lymphadenopathy, non reducing varicocele, or bilateral lower extremity oedema due to venous involvement. A minority of patients present with symptoms directly rela-ted to metastatic disease. Paraneoplastic syndromes are found in 20\% of patients, like hyper-tension, nonmetastatic hepatic dysfunction, hyper-calcaemia, Cushing syndrome, polycythaemia, hypog-lycaemia, and other hormones related disorders. 
\section[{II.}]{II.} 
\section[{Patients and Methods}]{Patients and Methods}\par
This is a retrospective and prospective, descriptive, cross sectional and based study. was conducted in Gezira Hospital for Renal Diseases and Surgery in Wad Madani the second city in Sudan, which is a governmental class (A) hospital. It is tertiary hospital provide service to population of Gezira and neighbouring states. The hospital offers 24 hours emegency, laboratory, blood bank and pharmacy services. All patients with renal cell carcinoma diagnosed and managed in the hospital during the period from January. 2006-January 2012, and agreed to participate were enrolled in the study.\par
The sample size was 60 patients; data collected by detailed and structured questionnaire is to be filled directly by the patients. Most patients assessed by author. Data analyzed by computer using statistical package for social science (SPSS) software (v:17). 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
Data analysis of sixty patient was done, male were 36(60\%) and female were 24 (40\%), male to female ratio was 3:2,majority of patients were aged above 50year (81\%), and 61\% of them reside central area (Gezira and Khartoum states).\par
About 75 \% of patients have duration of more than one month when presented first time. Asymptomatic patient are few (6 patients) ( 10\%) , but more than half of patient have lion mass when presented first time 34 (57 \%),the classical triad of (Hematuria, lion pain loin mass )occurred in about 31.6 \% details shown in (table 1). More than half of the patients (57\%) their physical examination revealed palpable lion mass. Few patients had palpable cervical lymph node (6.7\%)non reducible varicocele (5\%) or lower limb oedema (3.3\%).\par
All patients had abdominal ultrasound as initial imaging of the mass followed by enhance CT scan; only four patients underwent MRI to assess the vascular system and bones. Chest X ray was the tool four lung and chest wall metastases, was done in all patients.\par
Two third of the patients 40(66.7\%) had clear cell type representing the most common type.\par
About 15 \% is papillary type, fewer are chromophope (10\%) and collecting duct (5\%), two cases were unclassified.\par
Early disease stages were constituted about 40\% (stage I ten and II fourteen), the rest 60\% were advanced stages (III twenty and IV sixteen). IV. 
\section[{Discussion}]{Discussion}\par
This study is prospective, descriptive, cross sectional and hospital based study. The data analysis was done, and due to lack of local studies in pattern and presentation of RCC in Sudan we had being obligated to compare the results with available regional and international studies. The analysis of patient's demographic feature showed that; the distribution between sexes is keeping with international one, 2:3 for female: male respectively. Some regional study in Nigeria showed female predominance with male to female ratio of 1:1.7. \hyperref[b16]{(17)} Most of the cases in this review were above age 50years, and the peak incidence between the fifth and sixth decades of life (46.7\%), which is one decade earlier than western world population where RCC is primary a disease of elderly with typical presentation in sixth and seventh decades. \hyperref[b14]{(15,}\hyperref[b15]{16)} The similar to our finding was reported in Nepal. \hyperref[b17]{(18)} Mean age at time of diagnosis was (58.3 years) which near to what was found in Nepal, which was (55year), and this was similar to the findings of choi et al and Pradhan et al.\par
In contrast mean age at Lagos and Obafemi hospitals was 41.8 years and 47.5 years respectively. The majority of RCC does not become symptomatic until advanced disease develops, due to the retroperitoneal location of the kidney. Local symptoms arise only after tumor achieved adequate size to displace or invade other organs \hyperref[b18]{(19)} .\par
In this study common presenting symptoms were hematuria (66.7\%) loin pain (48.3\%) and loin mass (57.3\%). Occurrence of the first two is more common in female and quite similar to the international one \hyperref[b18]{(19)} , but presence of loin mass is more in male and it is higher than international figures, this indicates that male patients do not seek medical advice until the mass dragged their attention. The rate of current symptoms is reversed when compared with Lagos study; hematuria (40.6\%), loin pain (86\%) and palpable loin mass (90.6\%). The classical triad appeared in one fourth of the patients 31.6 \%, it's higher than international reports 7-10\%, but similar to what reported in Nigeria (29-36\%).\par
In this review some patients presented with constitutional symptoms such as; pyrexia, weight loss and anaemia, their rates matching international. \hyperref[b14]{(15,}\hyperref[b16]{17,}\hyperref[b19]{20)} Constitutional symptoms have a great correlation with disease duration and stage. paraeneoplastic syndrome was observed in (33.3\%) , and this result is comparable with international studies (20-40\%). Distal metastases symptoms were found at time of diagnosis, surprisingly two third of them were male.\par
Concerning physical examination of the patients studied in this review more than half of them (57\%) presented with palpable loin mass, this is occur in one third of patients in western world \hyperref[b19]{(20)} ,this due to late presentation in our community . Other signs appeared Low frequency such as palpable cervical lymphadenopathy (6.7\%), limb oedema and varicocele; all are keeping with international and regional reports (15,17)   All patients in this study had abdominal ultrasound as initial imaging, which found to be very useful in diagnosing renal mass. CT scan done in all case also, it is the method of choice in staging of tumour and more sensitive than sonogarphy. It looks clear that when patient directed into right referral tract the diagnosis will be obvious. MRI as additional imaging to CT has been done in four cases, it more sensitive in assessing the vessels and bone lesions but had no other benefits over CT scan.\par
Regarding the histopathological patterns all these percentages are similar to the international ones.  {\ref (1018,}\hyperref[b18]{19)} but in Nigeria incidence of clear cell type was low as 33.3\% \hyperref[b19]{(20)} .The stage of disease in this study keeping with regional series where African people presented and diagnosed late, 60\% had locallyadvance or metastatic disease. \hyperref[b16]{(17,}\hyperref[b17]{18)} In contrast to international studies where the rule is early stages and increasing incidence of patients are incidentally diagnosed. \hyperref[b14]{( 15,}\hyperref[b15]{16,}\hyperref[b18]{19 )} V. 
\section[{Conclusion}]{Conclusion}\par
RCCoccurred one decade earlier than western population. Highest incidence in the fifth and sixth decades. Large number of patients presented with classical triad, most of them weremale. Incidentally diagnosed were fewer patients, two third of them were female. The commonest pathological type was clear cell.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_1}I}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.3951505016722408\textwidth}P{0.25301003344481604\textwidth}P{0.07675585284280936\textwidth}P{0.1250836120401338\textwidth}}
Clinical Presentation\tabcellsep \tabcellsep NO\tabcellsep \%\\
Durationweeks\tabcellsep \tabcellsep \tabcellsep 10\\
\tabcellsep Months Years\tabcellsep 45\tabcellsep 75\\
\tabcellsep \tabcellsep 9\tabcellsep 15\\
Presentation asymptomatic\tabcellsep \tabcellsep 6\tabcellsep 10\\
Haematuria\tabcellsep \tabcellsep 40\tabcellsep 66.6\\
\tabcellsep Loin pain\tabcellsep 39\tabcellsep 65\\
\tabcellsep Loin mass Classical triad\tabcellsep 34 9\tabcellsep 57 15\\
Conistutionalpyrexia\tabcellsep \tabcellsep 18\tabcellsep 30\\
\tabcellsep Weight loss\tabcellsep 27\tabcellsep 45\\
\tabcellsep Anaemia\tabcellsep 16\tabcellsep 26.7\\
ParaneoplasticAbnormalLFT\tabcellsep Hyper Calcaemia\tabcellsep 17 1\tabcellsep 28.3 1.6\\
Metastatic symptoms Lungs\tabcellsep \tabcellsep 3\tabcellsep 5\\
\tabcellsep Bones\tabcellsep 2\tabcellsep 3.3\\
\tabcellsep Liver\tabcellsep 4\tabcellsep 6.7\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.4904833836858006\textwidth}P{0.07190332326283988\textwidth}P{0.17975830815709967\textwidth}P{0.10785498489425982\textwidth}}
\tabcellsep Examination\tabcellsep No\tabcellsep \%\\
\multicolumn{2}{l}{Palpable lion mass}\tabcellsep \tabcellsep 7\\
\multicolumn{2}{l}{Palpable cervical lymph node}\tabcellsep \tabcellsep 6.7\\
\multicolumn{2}{l}{Bilateral Lower limb edema}\tabcellsep \tabcellsep 3.3\\
\multicolumn{2}{l}{Non reducible varicocele}\tabcellsep \tabcellsep 5\\
\tabcellsep \tabcellsep Table 3 : Histopathological Types\tabcellsep \\
\tabcellsep Type\tabcellsep NO\tabcellsep \%\\
Clear cell\tabcellsep \tabcellsep 40\tabcellsep 66.7\\
\multicolumn{2}{l}{Papillary ( chromophilic )}\tabcellsep 9\tabcellsep 15\\
\multicolumn{2}{l}{Chromophopes}\tabcellsep 6\tabcellsep 10\\
\multicolumn{2}{l}{Collecting duct}\tabcellsep 3\tabcellsep 5\\
\multicolumn{2}{l}{Unclassified}\tabcellsep 2\tabcellsep 3.3\\
\tabcellsep \tabcellsep Table 4 : Staging\tabcellsep \\
\tabcellsep Stage\tabcellsep NO\tabcellsep \%\\
Stage\tabcellsep i\tabcellsep 10\tabcellsep 16.7\\
Stage\tabcellsep ii\tabcellsep 14\tabcellsep 23.3\\
Stage\tabcellsep iii\tabcellsep 20\tabcellsep 33.3\\
Stage\tabcellsep iv\tabcellsep 16\tabcellsep 28.7\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
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\end{document}
