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

Rare Causes
 UTI/STD
 Sickle Cell Trait
 Nephrolithiasis
 Benign Familial Hematuria
 BPH
 Nephritic Syndrome
Less common causes
 Trauma
 Bladder Cancer
 Renal Cell Carcinoma
 Glomerulonephritis (IgA
nephropathy most common)
 Paroxysmal Nocturnal
Hemoglobinuria
 AV Malformations
 Athletic Nephritis
 Alport Syndrome
 Drugs
 Prostatitis
 Sulfonamide
 Polycystic Kidney Disease
 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 fiveyear survival rate is less than 10 percent for patients
with distant metastases