Presentation

A 55 year old male presents to the clinic worried about the color of his urine. He describes his urine as

becoming progressively more “reddish-brown” over the last few weeks. He does not exhibit pain or any

other concurrent symptoms.

History

Past Medical Hx: Hypertension, Hyperlipidemia, Atrial Fibrillation

Past Surgical Hx: Appendicitis as a child

Family Hx: Father died of heart disease, mother from “natural causes.” Both parents had a history of hypertension. Does not reports any history of malignancy.

Social Hx: Currently retired, previously worked in the steel mills. Lives at home with his wife and two dogs. Smoked 1.5 ppd for 25 years, although quit smoking about 5 years ago. Does not drink alcohol or use illicit drugs.

Medications: Lipitor, Hydrochlorothiazide, Metoprolol, Warfarin

Allergies: None

Physical Exam

Vitals:

T 37 ⁰C

BP 140/90

HR 90

RR 18

O2 100% on room air

General: Alert and oriented x 3, good concentration

Neuro: CN II-XII grossly intact, normal strength and sensation bilaterally, 2+ reflexes throughout

HEENT: PERRLA, EOMI, moist oral mucosa, no exudates

CV: RRR, no murmur, rubs, or gallops, nl s1 and s2

Resp: CTAB, no crackles or wheezes

Abd: Nontender, nondistended, normal bowel sounds. R sided flank mass.

Differential Diagnosis for Basic Hematuria Most common causes

UTI/STD

Nephrolithiasis

BPH

Less common causes

Trauma

Bladder Cancer

Renal Cell Carcinoma

Glomerulonephritis (IgA nephropathy most common)

Prostatitis

Polycystic Kidney Disease

Rare Causes

Sickle Cell Trait

Benign Familial Hematuria

Nephritic Syndrome

Paroxysmal Nocturnal Hemoglobinuria

AV Malformations

Athletic Nephritis

Alport Syndrome

Drugs

Sulfonamide

Quinine

Rifampin

Phenytoin

Laboratory Tests

BMP

Normal BUN/creatinine

CBC

Within normal limits

Urinalysis

Dipstick + for blood

>5 RBC’s per hpf

Otherwise negative

Urine Culture

Negative x48 hours

What is the next step?

Abdominal CT

Imaging

Biopsy

Renal cell carcinoma of the collecting duct type comprises <1% of all renal epithelial neoplasms and

presumably arises from or differentiates towards renal collecting ducts of Bellini.

Renal Cell Carcinoma

Renal cell carcinoma is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products.

RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases. It is also known to be the most lethal of all the genitourinary tumors.

Several subtypes of RCC exist; in this particular case, patient was found to have collecting duct tumor which manifests as gross hematuria rather than microscopic hematuria, which is more common in other subtypes.

Epidemiology

In the United States, there are approximately 65,000 new cases each year and about 13,500 deaths from RCC

RCC is approximately 50 percent more common in men compared with women

RCC occurs predominantly in the sixth to eighth decade of life with median age at diagnosis around 64 years of age

 Within the United States, Asian Americans or Pacific Islanders have the lowest incidence of renal cancers compared to American Indians/Alaska natives, Hispanic/Latinos, Whites, or African Americans

Epidemiology Continued

Risk factors include:

Smoking

HTN

Obesity

Alcohol

Diabetes

Polycystic Disease of the Kidney

Occupational exposure such as cadmium, asbestos, and petroleum byproducts

Analgesic abuse nephropathy

Genetic factors

Symptoms and Signs

Classic triad of RCC includes hematuria, flank pain, and a palpable abdominal renal mass, although occurs in only 9% of patients at most. When all three are present, usually indicative of locally advanced disease.

Most common symptoms include:

Hematuria

Observed only when tumor invades collecting duct system. Seen in roughly 40% of patients upon diagnosis.

Abdominal Mass

Associated with lower pole tumors, more commonly palpated in thin individual.

Scrotal Varicoceles

Majority left sided, seen in 11% of men with RCC. They typically fail to empty when patient is recumbent, as would be expected with primary idiopathic varicoceles.

Inferior Vena Cava Involvement

Lower extremity edema, ascites, hepatic dysfunction, and pulmonary emboli.

Variety of symptoms associated with disseminated disease, most common location of metastasis is lung, lymph nodes, bone, liver, and brain.

Symptoms and Signs Continued

Paraneoplastic symptoms due to ectopic production of various hormones (eg erythropoietin, PTHrP, gonadotropins, ACTH, renin, glucagon, insulin). Symptoms include:

Anemia

Hepatic Dysfunction

Fever

Hypercalcemia

Cachexia

Erythrocytosis

Amyloidosis

Thrombocytosis

Polymyalgia rheumatica

Treatment

Localized disease

 For patients with a resectable stage I, II, or III RCC, surgery is recommended as the primary treatment approach

Radical nephrectomy has been the most widely used approach and remains the preferred procedure when there is evidence of invasion

Partial nephrectomy (either open or laparoscopic) is an alternative for smaller tumors

Advanced Disease

Chemotherapy remains the primary treatment modality for advanced disease

Prognosis

Patients with stage I RCC have a five-year survival rate over 90 percent in most contemporary series

Patients with stage II disease have a reported five-year survival rates ranging from 75 to 95 percent

The reported five-year survival rate for patients with stage III RCC who undergo nephrectomy ranges from 59 to 70 percent

The median survival for patients with stage IV disease is 16 to 20 months in contemporary reports, and the five-year survival rate is less than 10 percent for patients with distant metastases