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The Anatomy of a Question


A 70-year-old man has a solid kidney mass identified on abdominal imaging performed for unrelated reasons. The radiologic features of the mass are concerning for malignancy. Which of the following is the classic triad for the most likely diagnosis?

Answer choice options
  • A. Abdominal mass, ascites, and weight loss
  • B. Abdominal mass, flank pain, and hematuria
  • C. Flank pain, hematuria, and weight loss
  • D. Flank pain, left-sided varicocele, and weight loss

The incorrect options (distractors) are not totally wrong. These options can be diagramed as follows:

Most Correct
Least Correct
  • B.
    Abdominal mass, flank pain, and hematuria These three findings make up the classic triad for renal cell carcinoma.
  • D.
    Flank pain, left-sided varicocele, and weight loss Weight loss and varicocele are not part of the triad, but scrotal varicoceles are present in up to 10% of individuals
  • C.
    Flank pain, hematuria, and weight loss Weight loss is not part of the triad but may be a presenting symptom.
  • A.
    Abdominal mass, ascites, and weight loss Ascites and weight loss are not part of the triad.

The combination of amazing teaching images and clearly written explanations gave me so much confidence for my shelf exam. In the end, I scored top 3 in my class!

-Diane Harrington

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.


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