Chapter 090. Bladder and Renal Cell Carcinomas (Part 6)

Clinical PresentationThe presenting signs and symptoms include hematuria, abdominal pain, and a flank or abdominal mass. This classic triad occurs in 10–20% of patients. Other symptoms are fever, weight loss, anemia, and a varicocele (Table 90-4). The tumor can also be found incidentally on a radiograph. Widespread use of radiologic cross-sectional imaging procedures (CT, ultrasound, MRI) contributes to earlier detection, including incidental renal masses detected during evaluation for other medical conditions. The increasing number of incidentally discovered low-stage tumors has contributed to an improved 5-year survival for patients with renal cell carcinoma and increased use of nephron-sparing surgery (partial...
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Chapter 090. Bladder and Renal Cell Carcinomas (Part 6) Chapter 090. Bladder and Renal Cell Carcinomas (Part 6) Clinical Presentation The presenting signs and symptoms include hematuria, abdominal pain, anda flank or abdominal mass. This classic triad occurs in 10–20% of patients. Othersymptoms are fever, weight loss, anemia, and a varicocele (Table 90-4). Thetumor can also be found incidentally on a radiograph. Widespread use ofradiologic cross-sectional imaging procedures (CT, ultrasound, MRI) contributesto earlier detection, including incidental renal masses detected during evaluationfor other medical conditions. The increasing number of incidentally discoveredlow-stage tumors has contributed to an improved 5-year survival for patients withrenal cell carcinoma and increased use of nephron-sparing surgery (partialnephrectomy). A spectrum of paraneoplastic syndromes has been associated withthese malignancies, including erythrocytosis, hypercalcemia, nonmetastatichepatic dysfunction (Stauffer syndrome), and acquired dysfibrinogenemia.Erythrocytosis is noted at presentation in only about 3% of patients. Anemia, asign of advanced disease, is more common. Table 90-4 Signs and Symptoms in Patients with Renal Cell Cancer Presenting Sign or Symptom Incidence, % Classic triad: hematuria, flank pain, flank mass 10–20 Hematuria 40 Flank pain 40 Palpable mass 25 Weight loss 33 Anemia 33 Fever 20 Hypertension 20 Abnormal liver function 15 Hypercalcemia 5 Erythrocytosis 3 Neuromyopathy 3 Amyloidosis 2 Increased erythrocyte sedimentation rate 55 The standard evaluation of patients with suspected renal cell tumorsincludes a CT scan of the abdomen and pelvis, chest radiograph, urine analysis,and urine cytology. If metastatic disease is suspected from the chest radiograph, aCT of the chest is warranted. MRI is useful in evaluating the inferior vena cava incases of suspected tumor involvement or invasion by thrombus. In clinicalpractice, any solid renal masses should be considered malignant until provenotherwise; a definitive diagnosis is required. If no metastases are demonstrated,surgery is indicated, even if the renal vein is invaded. The differential diagnosis ofa renal mass includes cysts, benign neoplasms (adenoma, angiomyolipoma,oncocytoma), inflammatory lesions (pyelonephritis or abscesses), and otherprimary or metastatic cancers. Other malignancies that may involve the kidneyinclude transitional cell carcinoma of the renal pelvis, sarcoma, lymphoma, andWilms tumor. All of these are less common causes of renal masses than is renalcell cancer. Staging and Prognosis Two staging systems used are the Robson classification and the AmericanJoint Committee on Cancer (AJCC) staging system. According to the AJCCsystem, stage I tumors are