Renal Cell carcinoma (RCC) is the most common type of kidney malignancy in adults and has a low incidence rate in the general population. It is worth noting that, unlike other urological conditions, RCC patients can present with symptoms of bladder outlet obstruction in the tropics, where RCC has a low suspicion. The objective of this paper is to identify the classic triad of renal cell carcinoma, to promote the use of USS in the early detection of renal mass in low socio-economic areas where computed tomography (CT) scan and magnetic resonance imaging (MRI) may not be affordable by patients due to financial constraints and to identify the peculiarity of supra vesical bleed in renal malignancy. This manuscript highlights a case of RCC presenting to the surgery outpatient clinic (SOPC) with gross hematuria and a history of passage of clotted blood.

Renal cell carcinoma (RCC), Ultrasound scan (USS), Benign prostatic enlargement (BPE), Clot, Hematuria.

RCC is the most common type of kidney malignancy in adults and has a low incidence rate in the general population. It is worth noting that, unlike other urological conditions, RCC patients can present with symptoms of bladder outlet obstruction in the tropics, where RCC has a low suspicion. RCC is the most common type of kidney cancer in adults, and accounts for approximately 3% of adult tumors and 90-95% of neoplasms arising from the kidney. The global age-standardized incidence rate is 4/100,000 people.[1,2] Male to Female ratio is 2:1. In Africa, this incidence is low. And this is probably because of the low index of suspicion and underreporting of cases. RCC is associated with hematuria in 40% of cases, and there are also many disease conditions of the urinary tract, e.g, benign prostatic hyperplasia, Prostate Cancer, etc, that are associated with lower urinary tract symptoms (LUTS) and hematuria. This is a classic case of renal cell carcinoma, which was otherwise diagnosed incidentally, intraoperatively following an open prostatectomy for benign prostatic enlargement (BPE).[3]

Differential diagnostic methods are available for RCC. Generally, CT and MRI are used for diagnosis. Three-dimensional CT, CT angiography, or magnetic resonance angiography is used before surgery, mainly during nephron-sparing surgery, to outline the nature of RCC, to regulate the number of renal arteries present more precisely, and to define the vascular pattern. These tomography methods have replaced aortography and selective renal artery angiography.[4]

A chest x-ray and liver tests are necessary. If the chest x-ray is unusual, chest CT is done. If alkaline phosphatases are raised, bone scanning is required. Serum electrolytes, blood urea nitrogen (BUN), creatinine, and calcium are measured. BUN and creatinine are unchanged if both kidneys are diseased. Fluorodeoxyglucose (FDG) is not usually done in most primary RCCs, but it may be useful for preoperative staging in high-risk tumors and in response to systemic therapies in metastatic disease. A new positron emission tomography (PET) imaging agent, zirconium-89 (89Zr)-deferoxamine (DFO)-girentuximab, may recognize clear cell renal cell carcinoma. With extreme sensitivity and specificity.[5,6]

A 55-year-old male patient presented to the SOPC with a history of passage of bloody urine for 2 months. He gave a history of dysuria, urinary frequency, nocturia, and right-sided flank pain. He also gave a history of loss of appetite, weight loss, easy fatigability, dizziness, and headache. Since the onset of symptoms, he resolved to take self-medication for about a month, but symptoms worsened, as he noticed he was passing clotted blood in his urine. He subsequently was unable to void suddenly. He occasionally consumes alcohol and “Agbo” (locally made herbal concoction).

He visited a health facility, where he was investigated and was worked up for prostatectomy as confirmed by abdominopelvic and prostate USS. Before this moment, he was passed a Foley’s catheter to relieve the obstruction, which was actively draining bloody urine. He was discharged against medical advice (DAMA). He thereafter came to this facility.

On examination, he was moderately pale. No palpable abdominal mass. The liver and spleen were not palpable. There were no signs of peritonitis. His pulse rate is 96 beats/minute, blood pressure (BP):120/70 mmHg, temperature: 36.4 °C. He had a blood test which revealed the following: white blood cells (WBC):10,500/microliter, packed cell volume (PCV) 24%, platelets: adequate, serum electrolytes/urea/creatinine (E/U/Cr):1.1 mg/dL, chlorine (Cl): 90 mEq/L, bicarbonates (HCO3):26 mEq/L, urinalysis: bloody urine, fasting blood sugar (FBS):87 mg/dL, chest X-ray: unfolded aorta, ECG: sinus rhythm with possible left ventricular hypertrophy (LVH).

The patient had a repeat prostatic scan, which revealed an enlarged prostate. He subsequently was scheduled for an open prostatectomy for BPE. Pre-operative PCV-21%, which was managed accordingly with transfusion of blood and intravenous fluids.

Intra-operative findings are as follows:

1. An enlarged prostate that is not significant in causing an obstruction.
2. Worm-like clot arising from the right ureteric orifice, indicating a supravesical bleed.
3. Bloody urine is collected from the right ureteric orifice into the urinary bladder.

A prostatectomy could not be done in order not to worsen the intraoperative bleeding. A provisional diagnosis of RCC, to rule out papillary necrosis, was made. Intra-operatively patient was managed conservatively for blood loss. He was closed and scheduled for a repeat abdominopelvic ultrasound scan (USS). The USS report revealed a large, round soft tissue mass arising from the inferior pole of the kidney to rule out RCC.

Despite Conservative management with IV fluids and blood transfusion, Post-Operative PCV-16%.  He was scheduled for an emergency nephrectomy. Intraoperative findings were an enlarged, irregular lower pole of the right kidney. He subsequently had a radical right-sided nephrectomy and secondary closure of the urinary bladder. The surgery was well tolerated. Renal tissue was sent for histology, which was reported as RCC (adenocarcinoma). The patient thereafter commenced radiotherapy.

Renal cancer is the 14th most common cancer worldwide. Most malignant neoplasms of the kidney are a result of a primary or secondary tumor. Although metastatic lesions are more common than primary tumors. Secondary renal neoplasms are usually clinically insignificant and are principally discovered at postmortem examinations. RCC is the most common type of kidney cancer in adults and accounts for approximately 3% of adult tumors and 90-95% of neoplasms arising from the kidney. The global age-standardized incidence rate is 4/100,000 people. In Africa, it is low. Male to female ratio is 2:1.[1,5]

RCC may remain clinically occult during its course. Only about 10% of the patients with RCC will present with the classic triad of haematuria, flank pain, and flank mass, and it’s indicative of advanced disease. The frequency with which RCC clinically presents is shown in the table below.[6]

Table 1: Clinical presentation of RCC

The incidence has increased by more than 30% over the past two decades. It is generally accepted that the increased incidence rates reflect diagnosis at an earlier stage, largely due to more liberal use of radiological imaging techniques. However, advanced diseases have also been diagnosed more frequently, and mortality has increased as well. The rising incidence, however, has occurred in all clinical stages, but the greatest increase was observed in patients having localized tumors, which suggests stage migration because of early detection.[7]

Patients with RCC present with a range of symptoms, but many are asymptomatic until the disease is advanced. At presentation, approximately 30 % of individuals either have distant metastases or significant local-regional disease. Other patients, even some with only localized diseases, present with a wide array of symptoms and/or laboratory abnormalities. Because of this unusual characteristic, RCC was previously labelled the “internist’s tumor” because of the predominance of systemic rather than local manifestations. It was considered a “radiologist’s tumor”, given the frequency of incidental detection.[8]

Asymptomatic presentation may correlate with advanced disease. Indicators of symptomatic presentations include flank pain, flank mass, varicocele, constitutional symptoms, paraneoplastic syndromes, and bone pain related to metastatic disease. The presence of paraneoplastic manifestations (hypercalcemia, polycythemia, Cushing’s syndrome, persistent fever, Stauffer’s syndrome & pathological fractures) should raise clinical suspicion for the diagnosis. In addition, the examiner should look out for hypertension, supraclavicular adenopathy, and a flank or abdominal mass with bruit. However, gross hematuria with vermiform clots suggests upper urinary tract bleeding. USS was found to be a useful screening test, but contrast-enhanced CT scan is used to identify malignant features. MRI can be used in equivocal cases. Intravenous urogram (IVU) is the screening investigation of choice. The global mortality rate from kidney cancer was estimated to be 72,019 in 2008, with a global age-standardized mortality rate of 2.2 per 100,000 people per year.[1,6]

The history of passage of a vermiform clot in urine and massive hematuria should prompt the examiner to investigate a supra-vesical bleed and a renal malignancy. There should be a high index of suspicion for renal malignancy in a patient presenting with gross hematuria, flank pain, and a mass in the flank with or without paraneoplastic manifestations. With the poor prognosis following late detection and incidental diagnosis of RCC, USS will help in the early detection of renal mass.[4]

RCC presents with a variety of clinical features. It should be considered for patients presenting with LUTS, Hematuria, and a history of passage of vermiform clots in urine.

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Emele Cosmas U
Department of Surgery
State Specialist Hospital Asubiaro, Nigeria
Email: cosmase1@gmail.com

The author contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles and was involved in the writing – original draft preparation and writing – review & editing to refine the manuscript.

The informed consent was taken.

The author declares no conflict of interest.

None

https://doi.org/10.63096/medtigo30622469

Emele CU. Renal Cell Carcinoma: Incidental Diagnosis. medtigo J Med. 2024;2(4):e30622469. doi:10.63096/medtigo30622469 Crossref