presentation a 55 year old male presents to the clinic worried about the color of his urine. he...
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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
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