Renal Cell Carcinoma Clinical Presentation

Updated: Feb 19, 2021
  • 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%

Gross hematuria occurs less commonly than microscopic hematuria in renal cell carcinoma; when present, the appearance of blood throughout the stream suggests an origin in the upper urinary tract. Gross hematuria with vermiform clots also suggests upper urinary tract bleeding, with clot formation in the ureters.

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%)

Findings that should raise clinical suspicion for RCC include the following:

  • In male patients, the presence of a varicocele and findings of paraneoplastic syndromes
  • Hypertension, supraclavicular adenopathy, and a flank or abdominal mass with bruit
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