<Brief
History>
The 35 year-old man has been diagnosed as chronic
glomerulonephritis complicated with end stage renal disease
(ESRD) and has been on regular hemodialysis for six years. He
reported to have no history of hypertension, diabetes or viral
hepatitis in the past. His general condition was good and he
had a good hemodialysis quality with adequate control of Ca-P
product, serum albumin, KT/V. Besides, he had no need of
erythropoietin (EPO) injection, and his daily urine output was
less than 200 cc after starting hemodialysis.
Two months ago, he began to suffer from right flank
soreness, but he paid no attention to it. However, painless
gross hematuria developed two weeks prior to admission. There
were no other symptom such like fever, poor appetite, bowel
habit change or weight loss. Initially, he thought the
hematuria was due to infection and just took some antibiotics
by himself.
However, persistent painless hematuria
and gradually declined hemoglobin levels were noted. Renal
sonography was suggested by his attending physician, which
revealed a heterogenous renal mass (Figure
1.)
and another suspicious
mass (not shown). He was then admitted immediately to the
hospital for further evaluation and management.
<Laboratory and Image
Study>
1. CBC/DC & coagulation profiles:
Date |
WBC K/μL |
RBC M/μL |
Hgb g/dL |
Hct % |
MCV fL |
MCH pg |
MCHC g/dL |
Plt K/μL |
940511 |
10.3 |
3.55 |
9.6 |
29.2 |
82.3 |
27.0 |
32.9 |
489 |
940520 |
9.54 |
3.71 |
10.1 |
30.5 |
82.2 |
27.2 |
33.1 |
423 |
Date |
Blast |
Meta |
Band |
Seg |
Eos |
Baso |
Mono |
Lym |
940511 |
0 |
0 |
0 |
75.1 |
1.4 |
0.2 |
7.6 |
15.7 |
940520 |
0 |
0 |
0 |
60.0 |
2.9 |
0.6 |
6.4 |
30.1 | 2.
Biochemistry
Date |
BUN mg/dl |
Cre mg/dl |
Na mmol/l |
K mmol/l |
Cl mmol/l |
Ca mmol/l |
P mmol/l |
Mg mmol/l |
940511 |
65 |
6.43 |
135.1 |
4.54 |
99.0 |
2.02 |
4.86 |
0.89 |
940520 |
72 |
5.86 |
139.0 |
4.31 |
|
|
|
|
|
GOT U/l |
T/D-Bil mg/dl |
LDH U/l |
CRP mg/dl |
940511 |
20.0 |
0.25/ |
1437 |
10.42 |
940520 |
17.0 |
|
1097 |
5.54 | 3. Urine
analysis:
Date |
Appearance |
Sp. gr |
pH |
Protein mg/dL |
Glu g/dL |
Ketones |
O.B |
Urobil EU/dL |
Bil |
940511 |
R;T |
1.020 |
6.0 |
>300 |
- |
- |
4+ |
0.1 |
- |
940520 |
R,T |
1.026 |
6.0 |
>300 |
- |
- |
4+ |
0.1 |
- |
Date |
Nitrite |
WBC |
RBC /HPF |
WBC /HPF |
EpithCell / HPF |
Cast /LPF |
Crystal |
Bact |
940511 |
- |
30-35 |
numerous |
14 |
3-5 |
- |
- |
- |
940520 |
- |
- |
30-40 |
2-5 |
3-5 |
- |
- |
- |
<Course and
Treatment>
Abdominal CT scan with contrast medium
revealed two renal tumors which were highly suspected to be
renal cell carcinoma (RCC) (Figure
2A.) (Figure
2B.).
Series of cancer staging by CT scan showed
no definite renal vein or IVC thrombosis, and there was no
liver, lung metastasis. Besideds, there was no evidence of
bone metastasis on bone scan. The urologist performed a
cystoscopy which revealed no tumor mass in the urinary conduit
of right kidney. Laparoscopic nephrectomy was performed 3 days
after admission and the pathology revealed RCC, clear cell
type. The patient recovered well after operation with no more
symptoms of gross hematuria. However, EPO injection was
required to keep his hemoglobin/hematocrit within optimal
range.
<Analysis>
RCC accounts for approximately 3% of adult malignancies and
90-95% of neoplasms arising from the kidney. It is
characterized by a lack of early warning signs, diverse
clinical manifestations, resistance to radiation and
chemotherapy, and infrequent but reproducible responses to
immunotherapy agents such as interferon alpha and interleukin
(IL)-2. In the past these tumors were believed to derive from
the adrenal gland; therefore, the term hypernephroma often was
used. The tissue of origin for RCC is the proximal renal
tubular epithelium. The most common histological type of RCC
is clear cell. Renal cancer occurs in both a sporadic
(nonhereditary) and a hereditary form, and both forms are
associated with structural alterations of the short arm of
chromosome 3 (3p).
RCC is twice as common in men as in women. This condition
occurs most commonly in the fourth to sixth decades of life.
RCC may remain clinically occult for most of its course. The
classic triad of flank pain, hematuria, and flank mass is
uncommon (10%) and is indicative of advanced disease.
Twenty-five to thirty percent of patients are asymptomatic,
and their RCC are found on incidental radiologic study. The
most common presentations in order are hematuria (40%), flank
pain (40%), weight loss (33%), and palpable mass in the flank
or abdomen (25%). Approximately 30% of patients with RCC
present with metastatic disease. Organs involved include: lung
(75%), soft tissues (36%), bone (20%), liver (18%), cutaneous
sites (8%), and CNS (8%). The risk of RCC is increased with
the following: abuse of phenacetin-containing analgesics,
acquired cystic kidney disease associated with chronic renal
insufficiency, dialysis, tuberous sclerosis, renal
transplantation, VHL disease. In patients with ESRD who have
high hemoglobin level without the need of EPO injection, renal
malignancy, acute hepatitis, cystic kidey disease were often
mentioned.
Surgical resection remains the only known effective
treatment for localized renal cell carcinoma, and it also is
used for palliation in metastatic disease. More than 50% of
patients with renal cell carcinoma are cured in early stages,
but outcome for stage IV disease is poor. The probability of
cure is related directly to the stage or degree of tumor
dissemination, so the approach is curative for early stage
disease. Selected patients with metastatic disease respond to
immunotherapy, but many patients can be offered only
palliative therapy for advanced disease.
<Reference>
- Chemotherapy for renal cell
carcinoma. Semin Oncol 2000 Apr; 27(2): 177-86
-
Genetic and clinical aspects of
familial renal neoplasms. Semin Oncol 2000 Apr; 27(2):
138-49
-
Epidemiologic aspects of renal cell
cancer. Semin Oncol 2000 Apr; 27(2): 115-23
-
Renal-cell carcinoma. N Engl J Med
1996 Sep 19; 335(12): 865-75
-
Survival and prognostic
stratification of 670 patients with advanced renal cell
carcinoma. J Clin Oncol 1999 Aug; 17(8): 2530-40
-
Renal cell carcinoma: presentation,
staging, and surgical treatment. Semin Oncol 2000 Apr;
27(2): 160-76
-
Kidney cancer. Lancet 1998 Nov 21;
352(9141): 1691-6
-
EMedicine, Renal Cell Carcinoma.
January 20,
2005
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