Sections

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.)

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

Differential Diagnoses

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Media Gallery

Gross image of a bivalved kidney showing renal cell carcinoma in the upper half. The periphery of the carcinoma is yellow (due to high lipid content) with a central gelatinous area of necrosis.
H and E, high power of a clear cell renal cell carcinoma. The tumor cells have abundant pale "clear" cytoplasm.
H and E, low power of a papillary renal cell carcinoma. There are "finger-like" projections of fibrovascular stroma lined by malignant tumor cells that lack the abundant clear cytoplasm seen in a clear cell carcinoma.
H and E, high power of a chromophobe RCC composed of cells with clear, reticular cytoplasm and some with eosinophilic cytoplasm. The cell borders are often more distinct in this carcinoma than others and the nuclei are often smaller and darker.
H and E, high power of a collecting duct carcinoma composed of tubules lined by malignant cells in a background stroma that is fibrotic.
Typical renal cell carcinoma. CT scan obtained before contrast enhancement has an attenuation measurement of 33.9 HU.

of 6

Author

Kush Sachdeva, MD Southern Oncology and Hematology Associates, Inspira Health Network

Disclosure: Nothing to disclose.

Coauthor(s)

Bagi RP Jana, MD, MBA, MHA, FACP Professor of Cancer Medicine, MD Anderson Cancer Center; Professor of Medicine, University of Texas Medical Branch at Galveston

Bagi RP Jana, MD, MBA, MHA, FACP is a member of the following medical societies: American Cancer Society, American Medical Association, American Society of Clinical Oncology, SWOG

Disclosure: Nothing to disclose.

Brendan Curti, MD Director, Genitourinary Oncology Research, Robert W Franz Cancer Research Center, Earle A Chiles Research Institute, Providence Cancer Center

Brendan Curti, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, Oregon Medical Association, Society for Immunotherapy of Cancer

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Prometheus Pharmaceuticals, BMS<br/>Received research grant from: Prometheus Pharmaceuticals, Viralytics, MedImmune, BMS, Galectin Therapeutics.

Chief Editor

E Jason Abel, MD Associate Professor of Urologic Oncology, Department of Urology, Associate Professor of Radiology (Affiliate Appointment), Department of Radiology, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

E Jason Abel, MD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, American Urological Association, Harris County Medical Society, Kidney Cancer Association, Society for Basic Urologic Research, Society of Urologic Oncology, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Wendy Hu, MD Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center

Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Mansoor Javeed, MD, FACP Clinical Assistant Professor of Medicine, University of California, Davis, School of Medicine; Consultant, Sierra Hematology-Oncology Medical Center

Mansoor Javeed, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Issam Makhoul, MD Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences

Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology

Disclosure: Nothing to disclose.

Michael Perry, MD, MS, MACP Nellie B Smith Chair of Oncology Emeritus, Director, Division of Hematology and Medical Oncology, Deputy Director, Ellis Fischel Cancer Center, University of Missouri-Columbia School of Medicine

Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Renal Cell Carcinoma Clinical Presentation

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