Updated: 9/9/2020

Renal Cell Carcinoma

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Snapshot
  • 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
  • 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
  • Prognosis 
    • poorer prognosis
      • as the anatomic extent of the disease worsens
      • tumor grade
      • poor performance status
      • paraneoplastic syndrome
      • obesity
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)
 

 

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Questions (1)

(M2.ON.15.39) A 53-year-old male presents to your office for abdominal discomfort. The patient states he first noticed pain on his right flank several months ago, and it has been gradually getting worse. For the past week, he has also noticed blood in his urine. Prior to this episode, he has been healthy and does not take any medications. The patient denies fever, chills, and dysuria. He has a 40 pack-year smoking history. Vital signs are T 37 C, HR 140/90 mmHg, HR 84/min, RR 14/min, O2 98%. Physical exam is unremarkable. CBC reveals a hemoglobin of 17 and hematocrit of 51%, and urinalysis is positive for red blood cells, negative for leukocytes. Which of the following is the most likely diagnosis? Tested Concept

QID: 103529
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Renal cell carcinoma

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Polycystic kidney disease

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Abdominal aortic aneurysm

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Pyelonephritis

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Renal oncocytoma

5%

(1/19)

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