Renal Cell Carcinoma

A 42-year-old woman came to the emergency department because of hematuria for 1 day, a low-grade fever, and weight loss over the past 2 months. She denied having any abdominal pain or urinary problems. Pallor was the only noteworthy physical finding. Laboratory test results disclosed the following values: hemoglobin, 7 g/dL; hematocrit, 26%; mean corpuscular volume, 86 µm3; blood urea nitrogen, 41 mg/dL; and creatinine, 1.7 mg/dL. Renal ultrasonography revealed a mass arising from the upper pole of the right kidney. Renal cell carcinoma was confirmed by biopsy.

Drs Navin Verma, Terence M. Brady, and Sonia Arunabh of Queens, NY, tell us that renal cell carcinoma has been called the “internist's tumor” because of the multiple presenting signs and symptoms. The diagnosis is often delayed until the disease is advanced because small, localized tumors rarely produce any symptoms.

Carcinoma of the renal parenchyma accounts for 2% to 3% of all cancers in adults and occurs more often in men than in women. The usual age at presentation is between 50 and 70 years. No specific cause has been identified. The “classic triad” of pain, hematuria, and a mass in the loin is seen in only 10% of patients. Fever, night sweats, and cachexia as well as paraneoplastic syndromes (such as hypercalcemia and erythrocytosis) also may be present.

Use ultrasonography in the initial investigation of a renal mass to confirm the tumor's origin and determine whether it is cystic or solid. CT scanning is indicated to assess the anatomy of a solid tumor and the extent of its spread and to evaluate the contralateral kidney. Intravenous urography is not particularly useful; angiography is warranted only when partial nephrectomy is considered or when tumor embolization may be needed for palliation in advanced renal cancers.

Renal cell carcinoma usually is treated by radical nephrectomy-which includes removal of the whole kidney, the surrounding fat, the adrenal gland, and Gerota's fascia. These cancers are resistant to chemotherapy and hormonal therapy; immunotherapy with interferon, interleukin-2, or lymphokine-activated killer cells has shown some success. Partial nephrectomy is done only to treat bilateral tumors or very localized unilateral tumors but has been associated with a local recurrence rate of approximately 10%.¹ This patient underwent a partial nephrectomy of the right kidney for resection of a localized unilateral tumor.

REFERENCE:1. Dawson C, Whitfield HN. ABC of Urology. London: BMJ Publishing Group; 1997.