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The Anatomy of a Question
The Anatomy of an Explanation
Renal cell carcinoma is the most common type of primary kidney neoplasm. It is most often diagnosed incidentally after a kidney mass is identified on imaging performed for other reasons. However, in other cases, patients present with symptoms and signs related to the tumor
Many symptomatic patients have advanced locoregional disease or distant metastasis. The most common symptoms and signs of localized disease include flank pain, a palpable kidney mass, hematuria, and weight loss. The classic triad includes flank pain, palpable abdominal mass, and hematuria, but all three components are rarely present. Hematuria typically occurs from local invasion of the collecting system. Abdominal or flank masses are more commonly palpable in lower pole tumors and in thin patients. Scrotal varicoceles occur in a minority of cases. Inferior vena cava involvement also occurs in a minority of cases and may present with lower extremity edema, ascites, or pulmonary embolism.
The most common sites of metastasis are the lymph nodes, liver, lungs, and brain. Paraneoplastic syndromes may be present at the time of presentation or may occur during the disease course.
Patients with renal cell carcinoma are often anemic with iron studies in the pattern of anemia of chronic disease. Other paraneoplastic manifestations include hepatic dysfunction in the absence of metastasis, fever, hypercalcemia, and erythrocytosis.
Patients who present with symptoms of renal cell carcinoma require abdominal imaging. CT of the abdomen is the recommended initial radiologic study. The diagnosis is confirmed by tissue diagnosis via biopsy, which is most often achieved through partial or total nephrectomy of tumors suspicious for renal cell carcinoma.
The treatment of resectable renal cell carcinoma is surgical removal. Radical nephrectomy is the most common approach.