284 CHAPTER 6 Urological neoplasia

Renal cell carcinoma: presentation and investigations

More than 50% of RCCs are now detected incidentally on abdominal imaging carried out to investigate vague or unrelated symptoms. Thus, the stage at diagnosis of RCC is lower than it was because of widespread use of imaging modalities.

Presentation

Of the symptomatic RCCs diagnosed, 50% of patients present with hematuria, 40% with flank pain, 30% of patients notice a mass, and 25% have symptoms or signs of metastatic disease (night sweats, fever, fatigue, weight loss, hemoptysis).

Less than 10% patients exhibit the classic triad of hematuria, flank pain, and mass. Less common presenting features include acute varicocele due to obstruction of the testicular vein by tumor within the left renal vein (5%) and lower limb edema due to venous obstruction.

Paraneoplastic syndromes due to ectopic hormone secretion by the tumor occur in 10–40% of patients; these may be associated with any disease stage (Table 6.14).

Investigations

•Radiological evaluation of hematuria, flank pain, and renal masses is described on p. 5.

•Needle biopsy of renal masses is not recommended, since the result may be misleading and complications include hemorrhage and seeding of the biopsy tract.

•Urine cytology and culture should be normal.

•Full blood count may reveal polycythemia or anemia.

•Serum creatinine and electrolytes, calcium, and liver function tests are essential.

When RCC is diagnosed radiologically, staging chest CT and bone scan (if clinically indicated) will follow. Any suggestion of renal vein or IVC involvement on CT may be further investigated with MRI.

Angiography may be helpful in planning partial nephrectomy or surgery for horseshoe kidneys. Contralateral kidney function is assessed by uptake and excretion of CT contrast and the serum creatinine. If doubt persists, an isotope renogram is obtained.

286 CHAPTER 6 Urological neoplasia

Renal cell carcinoma: active surveillance

Surveillance of localized renal tumors is now performed more often in carefully selected patients. For incidental stage T1 renal masses, prolonged follow-up will be necessary, similar to that for low-risk prostate cancer. There are no currently established protocols.

Active surveillance is a reasonable option for patients with limited life expectancy or for those who are unfit for or do not desire intervention, especially those with T1a renal masses (<4 cm). These masses grow slowly growth and very infrequently progress to metastasis.1

The patient should be counseled about the small risk of cancer progression, possible loss of window of opportunity for nephron-sparing surgery, lack of curative salvage therapies if metastases develop, limitations of renal mass biopsy, and deficiencies of the current literature.

1 AUA Guideline for Management of the Clinical Stage 1 Renal Mass (2009). Available at: www. auanet.org/content/guidelines

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