Snapshot A 65-year-old man presents to his physician's office after noticing blood in his urine earlier this morning. This has never happened before and he denies any new medications or prior infection. He also reports to having flank pain for the past few weeks. Medical history is significant for hypertension. He has a 40 pack-year smoking history. On physical examination there is a firm, nontender, and homogeneous mass in the right flank. Computerized tomography (CT) scan of the abdomen is shown. Introduction Clinical definition renal malignancy originating from the proximal renal tubular epithelium Epidemiology Incidence represents 2-3% of all adult cancers accounts for ~85% of adult renal cancers clear cell carinoma is the most common type and other types include papillary carcinoma chromophobe carcinoma collecting duct carcinoma Demographics more common in men mean age is 60 years of age Risk factors tobacco smoking (most significant) obesity hypertension genetic factors acquired cystic renal disease ETIOLOGY Pathogenesis structural alterations in the short arm of chromosome 3 can result in sporadic or hereditary renal cell carcinoma in certain subtypes (e.g., clear cell) Associated conditions von Hippel-Lindau tuberous sclerosis paraneoplastic syndromes hereditary papillary renal carcinoma familial renal oncocytoma Presentation Symptoms hematuria occurs when the tumor invades the collecting system flank pain Physical exam palpable abdominal renal mass the mass is typically found to be firm nontender homogeneous scrotal varicoceles varicoceles do not empty with recumbancy involvement of the inferior vena cava can result in lower extremity edema ascites pulmonary emboli hepatic dysfunction Imaging CT scan indications an essential initial radiographic test for the evaluation of renal cell carcinoma for an accurate assessment of the extent of local and regional involvement patients must be evaluated for metastasis prior to surgery modality CT scan of the abdomen and pelvis before and after contrast administration findings enhancing lesion with contrast thickened irregular walls or septa Studies Histology indication to make a tissue diagnosis of renal cell carcinoma Differential Benign kidney tumors such as angiomyolipoma Urothelial carcinoma Lymphoma Treatment Medical systemic therapy indication used in patients with unresectable disease (e.g., metastasis and localy advanced) modality immunotherapy (e.g., interleukin-2) Surgical partial or radical nephrectomy indication considered definitive therapy in patients with localized renal cell carcinoma partial versus radical nephrectomy is dependent on a number of factors Complications Paraneoplastic syndromes resulting in hypercalcemia (secondary to parathyroid hormone-related peptide) hypertension (secondary to increased renin levels) erythrocytosis (secondary to increased erythropoeitin levels) Prognosis Poorer prognosis as the anatomic extent of the disease worsens tumor grade poor performance status paraneoplastic syndrome obesity