A 70 year old man presents with blood in his urine. He's noticed a few clots when he urinates and gets intermittent pain. His past medical history is significant for obesity, coronary artery disease, hypertension, COPD, and gout. He is on antihypertensives, aspirin, allopurinol, and a prn inhaler. His family history is notable for heart disease, obesity, and schizophrenia. He has a sixty pack year history of smoking and does occasional marijuana, but does not drink alcohol. He worked at a gas station for most of his life. Review of systems is positive for fever, night sweats, anorexia, weight loss, and fatigue.
On exam, he is an obese man and palpation of the abdomen is difficult, but you think you feel a firm, homogeneous, nontender abdominal mass. Testicular exam shows scrotal varices. You note mild lower extremity edema. Laboratory studies show hemoglobin of 9 g/dL, normocytic, normochromic, with low serum iron and transferrin but normal transferrin saturation. He also has an elevated serum alkaline phosphatase and hypercalcemia.
Challenge: What's the most likely diagnosis?
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Challenge: What's the most likely diagnosis?
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This is renal cell carcinoma. Risk factors include male gender, smoking, occupational exposure, obesity, acquired cystic disease of the kidney (associated with dialysis), analgesic abuse, nephropathy, and genetic predisposition; moderate alcohol may be protective. Patients can be asymptomatic or present in the fashion described. This patient also showed anemia of chronic disease. The presence of hepatic dysfunction without liver mets is Stauffer's syndrome. Hypercalcemia may occur in 15% patients with RCC.
Sources: UpToDate; nytimes.com.
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