Renal Cell Carcinoma Clinical Presentation

Updated: Apr 03, 2017
  • Author: Kush Sachdeva, MD; Chief Editor: E Jason Abel, MD  more...
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Presentation

History

Renal cell carcinoma (RCC) may remain clinically occult for most of its course. The classic triad of flank pain, hematuria, and flank mass is uncommon (10%) and is indicative of advanced disease. Twenty-five to thirty percent of patients are asymptomatic, and their renal cell carcinomas are found on incidental radiologic study.

The frequency of the individual components of the classic triad is as follows:

  • Hematuria – 40%
  • Flank pain – 40%
  • A palpable mass in the flank or abdomen –25%

Other signs and symptoms include the following:

  • Weight loss (33%)
  • Fever (20%)
  • Hypertension (20%)
  • Hypercalcemia manifestations (5%)
  • Night sweats
  • Malaise
  • Varicocele (2% of males) - Usually left sided, due to obstruction of the testicular vein

Renal cell carcinoma is a unique and challenging tumor because of the frequent occurrence of paraneoplastic syndromes, including hypercalcemia, erythrocytosis, and nonmetastatic hepatic dysfunction (ie, Stauffer syndrome). Polyneuromyopathy, amyloidosis, anemia, fever, cachexia, weight loss, dermatomyositis, increased erythrocyte sedimentation rate (ESR), and hypertension are also associated with renal cell carcinoma.

Cytokine release by tumor (eg, interleukin (IL)-6, erythropoietin, nitric oxide) causes these paraneoplastic conditions. Resolution of symptoms or biochemical abnormalities may follow successful treatment of the primary tumor or metastatic foci. (Go to Paraneoplastic Syndromes for more information.)

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Physical Examination

Approximately 30% of patients with renal carcinoma (RCC) present with metastatic disease. The physical examination should include a thorough evaluation for metastatic disease, particularly in the following organs:

  • Lung (75%)
  • Soft tissues (36%)
  • Bone (20%)
  • Liver (18%)
  • Cutaneous sites (8%)
  • Central nervous system (8%)

The presence of a varicocele and findings of paraneoplastic syndromes should raise clinical suspicion for this diagnosis. In addition, look for hypertension, supraclavicular adenopathy, and a flank or abdominal mass with bruit. However, gross hematuria with vermiform clots suggests upper urinary tract bleeding.

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Staging

The following are briefly discussed in this section:

  • The Robson modification of the Flocks and Kadesky system
  • The tumor, nodes, and metastases (TNM) classification
  • The American Joint Committee on Cancer (AJCC) staging system

Robson staging system

The Robson modification of the Flocks and Kadesky system is uncomplicated and is commonly used in clinical practice. This system was designed to correlate stage at presentation with prognosis and is as follows:

  • Stage I – Tumor confined within capsule of kidney
  • Stage II – Tumor invading perinephric fat but still contained within the Gerota fascia
  • Stage III – Tumor invading the renal vein or inferior vena cava (A), regional lymph node involvement (B), or both (C)
  • Stage IV – Tumor invading adjacent viscera (excluding ipsilateral adrenal) or distant metastases

TNM classification

The TNM classification is endorsed by the AJCC. The major advantage of this system is that it clearly differentiates individuals with tumor thrombi from those with local nodal disease. In the Robson system, stage III disease includes both inferior vena caval involvement (stage IIIA) and local lymph node metastases (stage IIIB). Although patients with Robson stage IIIB renal carcinoma have greatly decreased survival rates, the prognosis for patients with stage Robson IIIA renal carcinoma is not markedly different from that for patients with Robson stage I or II renal carcinoma. The TNM classification system is delineated below.

Primary tumors (T) are defined as the following:

  • TX – Primary tumor cannot be assessed
  • T0 – No evidence of primary tumor
  • T1 – Tumor 7 cm or smaller in greatest dimension, limited to the kidney 
    • T1a - Tumor is 4 cm or smaller
    • T1b - Tumor is 4 - 7 cm in greatest dimension
  • T2 – Tumor larger than 7 cm in greatest dimension, limited to the kidney
    • T2a - Tumor is 7 - 10 cm in greatest dimension
    • T2b - Tumor is more than 10 cm in greatest dimension
  • T3 – Tumor extends into major veins or invades adrenal gland or perinephric tissues but not beyond the Gerota fascia
    • T3a – Tumor invades adrenal gland or perinephric tissues but not beyond the Gerota fascia
    • T3b – Tumor grossly extends into the renal vein(s) or vena cava below the diaphragm
    • T3c – Tumor grossly extends into the renal vein(s) or vena cava above the diaphragm
  • T4 – Tumor invading beyond the Gerota fascia

Regional lymph node (N) classification is not affected by laterality and is defined as follows:

  • NX – Regional lymph nodes cannot be assessed
  • N0 – No regional lymph node metastasis
  • N1 – Metastasis in regional lymph node(s)

Distant metastasis (M) is defined as the following:

  • M0 – No distant metastasis
  • M1 – Distant metastasis

AJCC staging system

The AJCC stages are as follows:

  • AJCC stage I – T1, N0, M0
  • AJCC stage II – T2, N0, M0
  • AJCC stage III – T1-2, N1, M0 or T3a-c, N0-1, M0
  • AJCC stage IV – T4; or any T, N2, M0; or any T, any N, M1

The division of patients with renal cell carcinoma into low-, intermediate-, and high-risk groups with or without metastases may be useful in choosing appropriate therapy for these individuals. [2, 18]

For more information, see Renal Cell Carcinoma Staging.

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