Renal Cell Carcinoma: Diagnosis and Management

 

Kidney cancer is one of the 10 most common cancers in the United States with 90% being attributed to renal cell carcinoma. Men, especially black men, are more likely to be affected than women. Renal masses, either cystic or solid, are best detected with contrast-enhanced, triple-phase computed tomography. Renal tumors are often detected incidentally during a computed tomography scan of the abdomen or chest that was ordered for unrelated symptoms. Hematuria serves as a warning sign that necessitates further evaluation and imaging leading to a diagnosis and treatment plan. Treatment options include active surveillance, ablation, nephron-sparing tumor excision, nephrectomy, and systemic treatment. Predictors of a poor prognosis include poor functional status and metastasis. In recent years new therapies have improved the prognosis for patients with metastatic disease. The family physician should be aware of risk factors (e.g., hypertension, tobacco use, exposure to trichloroethylene, familial syndromes) and lifestyle and dietary modifications that may reduce risk.

Kidney cancer is one of the 10 most common cancers in the United States.1 Renal cell carcinoma accounts for 90% of all kidney cancers.2 Death attributed to renal cell carcinoma accounted for 2% of all cancer deaths or approximately 14,000 persons in 2016.1,2 Men are diagnosed with renal cell carcinoma at almost twice the rate of women, and there is a greater prevalence in black men.3 Most cases are diagnosed between 60 and 70 years of age.1,2

Renal cell carcinoma is classified in three major histological subtypes: clear cell (75%), papillary (15% to 20%), and chromophobe (5%).4 Disease-specific survival is worst with clear cell renal cell carcinoma as it tends to be discovered at a more advanced stage.5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Patients 35 years or older who have asymptomatic microhematuria should have cystoscopy and imaging with multiphasic computed tomography urography performed.

C

17

Recommendation from consensus guideline based on observational studies

Refer for a urology consultation for gross hematuria without urinary tract infection, especially if the patient is older than 45 years.

C

25

Recommendation from consensus guideline based on observational studies

Refer for a urology consultation for any mass with Bosniak III or IV classification and for selected, low-risk patients with IIF classification, or any solid mass greater than 1 cm.

C

21

Recommendation from consensus guideline based on observational studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Patients 35 years or older who have asymptomatic microhematuria should have cystoscopy and imaging with multiphasic computed tomography urography performed.

C

17

Recommendation from consensus guideline based on observational studies

Refer for a urology consultation for gross hematuria without urinary tract infection, especially if the patient is older than 45 years.

C

25

Recommendation from consensus guideline based on observational studies

Refer for a urology consultation for any mass with Bosniak III or IV classification and for selected, low-risk patients with IIF classification, or any solid mass greater than 1 cm.

C

21

Recommendation from consensus guideline based on observational studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Risk Factors

Risk factors for renal cell carcinoma include hypertension, tobacco use, obesity, and acquired cystic kidney disease in the setting of end-stage renal disease.1,3,6 Occupational exposure to trichloroethylene can lead to the development of renal cell carcinoma and increased mortality from renal cell carcinoma.5,79 The International Agency for Research on Cancer labels trichloroethylene as carcinogenic to humans and specifically associates it with renal cancer.10 Occupational exposure to trichloroethylene is most commonly encountered by mechanics, dry cleaners, oil processors, polyvinyl chloride manufacturers, and low-nicotine tobacco producers.8

There are 10 familial syndromes that confer greater risk of developing renal cell c

The Authors

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RICHARD E. GRAY, DO, is medical director of the 374th Medical Group's Family Health Clinic, Yokota Air Base, Japan, and assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

GABRIEL T. HARRIS, MD, is director of Medical Student Clinical Education at University of Nebraska Medical Center/Offutt Air Force Base Family Medicine Residency, Offutt Air Force Base, Neb., and assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Author disclosure: No relevant financial affiliations.

Address correspondence to Richard E. Gray, DO, Family Medicine Residency Clinic, PSC 78 Box 1404, APO, AP 96326 (e-mail: richard.e.gray1.mil@mail.mil). Reprints are not available from the authors.

References

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8. Agency for Toxic Substances & Disease Registry. Toxicological profile for trichloroethylene. https://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=173&tid=30. Accessed August 10, 2017.

9. Chow WH, Dong LM, Devesa SS. Epidemiology and risk factors for kidney cancer. Nat Rev Urol. 2010;7(5):245–257.

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