right upper arm and shoulder pain after lifting
a jug of orange juice. He does not have a significant past medical history and initially thought
that his pain was due to a work-related injury.
Upon initial evaluation in the emergency department he is found to have a fracture of his right
humerus. Given that the fracture appears to be
pathologic, further work-up is recommended.
•;What;are;common;clinical;presentations;of
RCC?
Most patients are asymptomatic until the
disease becomes advanced. The classic triad of
flank pain, hematuria, and palpable abdominal
mass is seen in approximately 10% of patients
with RCC, partly because of earlier detection of
renal masses by imaging performed for other
purposes. 10 Less frequently, patients present with
signs or symptoms of metastatic disease such
as bone pain or fracture (as seen in the case
patient), painful adenopathy, and pulmonary
symptoms related to mediastinal masses. Fever,
weight loss, anemia, and/or varicocele often
occur in young patients (≤ 46 years) and may
indicate the presence of a hereditary form of the
disease. Patients may present with paraneoplas-tic syndromes seen as abnormalities on routine
blood work. These can include polycythemia or
elevated liver function tests (LFTs) without the
presence of liver metastases (known as Stauffer
syndrome), which can be seen in localized renal
tumors. Nearly half (45%) of patients present
with localized disease, 25% present with locally
advanced disease, and 30% present with metastatic disease. 11 Bone is the second most common site of distant metastatic spread (following
lung) in patients with advanced RCC.
•;What;is;the;approach;to;initial;evaluation;for
a patient with suspected RCC?
Initial evaluation consists of a physical exam,
laboratory tests including complete blood count
(CBC) and comprehensive metabolic panel
(calcium, serum creatinine, LFTs, lactate dehydrogenase [LDH], and urinalysis), and imaging.
Imaging studies include computed tomography
(CT) scan with contrast of the abdomen and
pelvis or magnetic resonance imaging (MRI) of
the abdomen and chest imaging. A chest radiograph may be obtained, although a chest CT is
more sensitive for the presence of pulmonary
metastases. MRI can be used in patients with
renal dysfunction to evaluate the renal vein
and inferior vena cava (IVC) for thrombus or
to determine the presence of local invasion. 12
Although bone and brain are common sites
for metastases, routine imaging is not indicated
unless the patient is symptomatic. The value of
positron emission tomography in RCC remains
undetermined at this time.
Staging is done according to the American
Joint Committee on Cancer (AJCC) staging
classification for RCC; the Figure summarizes
the staging and 5-year survival data based on this
classification scheme. 4, 13
LIMITED-STAGE DISEASE
•;What;are;the;therapeutic;options;for;limited-
stage disease?
For patients with nondistant metastases, or
limited-stage disease, surgical intervention with
curative intent is considered. Convention suggests considering definitive surgery for patients
with stage I and II disease, select patients with
stage III disease with pathologically enlarged
retroperitoneal lymph nodes, patients with IVC
and/or cardiac atrium involvement of tumor
thrombus, and patients with direct extension of
the renal tumor into the ipsilateral adrenal gland
if there is no evidence of distant disease. While
there may be a role for aggressive surgical intervention in patients with distant metastatic disease,
this topic will not be covered in this review.
SURGICAL INTERVENTION
Once patients are determined to be ap-
propriate candidates for surgical removal of a