Medical aspects of renal carcinoma

A case report: A rare case of icteric variant of Stauffer's syndrome

INTRODUCTION

Stauffer's syndrome is a rare paraneoplastic non metastatic hepatic dysfunction related to renal cell carcinoma. It is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, a-2-globulin, y-glutamyl transferase, thrombocytosis, prolongation of prothrombin time and hepatosplenomegaly, in the absence of hepatic metastasis. A rare variant of it with cholestatic jaundice is described in four cases so far in literature.

CLINICAL PRESENTATION

We present a case of a patient presented with features of cholestatic jaundice who was found to have a left sided renal cell carcinoma in the work up.

DISCUSSION

This case illustrates the importance of considering paraneoplastic syndromes in mind when working up for patients presenting with hepatic dysfunctions without identifiable causes.

CONCLUSION

This may result in early identification and intervention which will result in better outcome and prolong survival rate.

Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist

Renal cell carcinoma (RCC) is estimated to account for 4.1% of all new cancer diagnoses and 2.4% of all cancer deaths in 2020 according to the National Cancer Institute SEER database. This will likely total 73,000 new cases and 15,000 deaths. RCC is one of the most lethal of the common cancers urologists will encounter with a 5-year relative survival of 75.2%. Renal cell carcinoma is one of a small subset of malignancies that are associated with tumor thrombus formation, which is tumor extension into a blood vessel. An estimated 4% to 10% of patients with RCC will have some degree of tumor thrombus extending into the renal vein or inferior vena cava at the time of diagnosis. Tumor thrombi change the staging of RCC and therefore are an important part of initial patient workup. It is known that such tumors are more aggressive with higher Fuhrman grades, N+ or M+ at time of surgery and have higher probability of recurrence with lower cancer-specific survival. Aggressive surgical intervention with radical nephrectomy and thrombectomy can be performed with survival benefits. Classifying the level of the tumor thrombus becomes vitally important in surgical planning as it will dictate the surgical approach. Level 0 thrombi may be amenable to simple renal vein ligation while level 4 can require thoracotomy and possible open-heart surgery with coordination of many surgical teams. Here we will review the anatomy associated with each level of tumor thrombus and attempt to construct an outline for surgical techniques that may be used. We aim to give a concise overview so that general urologists may use it to understand these potentially complicated cases.

Pulmonary manifestations of renal cell carcinoma

Renal cell carcinoma (RCC) accounts for majority of all primary renal neoplasms. Classic manifestations of RCC include the triad of flank pain, hematuria and a palpable renal mass. Patients with RCC can develop various extra renal manifestations including involvements of the lungs, inferior vena cava, liver and the bones. The pulmonary manifestations of renal cell carcinoma include metastatic disease including endobronchial, pleural, parenchymal or lymph node metastasis, pleural effusion or hemothorax. Pulmonary embolism and tumor embolism is another common manifestation of renal cell carcinoma. RCC is a highly vascular tumor and can cause pulmonary arterio-venous fistulas leading to high output failure. Rarely, RCC can also present with paraneoplastic presentations including cough or bilateral diaphragm paralysis. Drugs used to treat RCC have been associated with drug related pneumonitis and form an important differential diagnosis in patients with RCC on therapy presenting with shortness of breath. In this review we discuss the various pulmonary manifestations of RCC. A high index of suspicion with these presentations can lead to an early diagnosis and assist in instituting an appropriate intervention.

C-reactive protein is a strong predictor for anaemia in renal cell carcinoma: role of IL-6 in overall survival

OBJECTIVE

• To elucidate the association of progression of advanced renal cell carcinoma with anaemia and investigate factors influencing tumor-associated anaemia.

PATIENTS AND METHODS

• We analyzed different clinical variables to study associations with anaemia in 86 metastatic renal cell carcinoma patients. • 45 (52%) of patients had already developed anaemia prior to therapy.

RESULTS

• Anaemic patients had an increase in the serum markers C-reactive protein (CRP), IL-6 and erythropoietin (EPO). In addition we observed substantial correlation between IL-6 and CRP serum levels (R = 0.639, P < 0.0001). • Univariate logistic regression analysis revealed that patients with IL-6 >10 pg/mL had a considerable increase in risk for anaemia (odds ratio 3.86, P= 0.003). • In addition, patients with CRP >0.7 mg/dL had a very strong increase in risk for anaemia (OR = 14.08, P < 0.0001). • Stepwise multivariate logistic regression analysis confirmed CRP >0.7 mg/mL as the only independent predictor for anaemia. Cox-regression modeling selected serum IL-6 as the strongest independent prognostic indicator (hazard ratio 3.58, P < 0.0001).

CONCLUSION

• Anaemia depends on serum IL-6, which is a strong inductor of CRP and regulator of the iron-transport. Serum IL-6 may be considered as a target to treat cancer-related anaemia.

"Scrotal varicocele, exclude a renal tumour". Is this evidence based?

A scrotal varicocele is a common finding during both a scrotal clinical examination or during the course of a scrotal ultrasound examination and invariably found in the left hemiscrotum. Traditionally when a scrotal varicocele is found, the referring clinician requests a renal ultrasound examination or the sonographer extends the examination to include a renal examination; to exclude a retroperitoneal or renal tumour as the cause for the varicocele. The present article examines the relevance of performing the extended ultrasound examination by reviewing the pathophysiological pathways for the development of a varicocele in the presence of a renal or retroperitoneal tumour; the prevalance of co-existing renal or retroperitoneal tumours and a varicocele; and the male population in whom this extended examination may be necessary. The conclusion from available evidence suggests that a retroperitoneal tumour will manifest in other ways before the development of a varicocele, the young patient with a varicocele will almost never have a retroperitoneal tumour, and only when a varicocele develops in an older patient will an extended examination be relevant. Even then it will be a rare finding and there will be other clinical manifestations of the primary tumour.

Fulminant hepatic failure in nonmetastatic renal cell carcinoma

Paraneoplastic manifestations including reversible abnormal serum liver biochemistry are known to occur in at least one third of patients with renal cell carcinoma. This hepatic dysfunction has always been regarded as benign in nature and attributed to reactive nonspecific hepatitis. In contrast to this belief, we report here a more devastating course of an asymptomatic patient with nonmetastatic renal cell carcinoma which ranged from mere serum liver biochemistry derangement to a fatal end with fulminant hepatic failure within 10 days. To our knowledge, this is the first report of such a case.

Metastatic renal-cell carcinoma presenting as a cutaneous horn

Renal-cell carcinoma develops as an insidious neoplasm, frequently metastasizing to the skin. Cutaneous manifestations vary regarding morphology and sites of predilection. A patient was recently seen demonstrating a metastasis from a renal neoplasm. The lesion was unusual in that it grossly resembled a cutaneous horn. Dermatologists should continue to be alert to the possibility of renal tumor metastasis when evaluating cutaneous tumors.

Hormones in renal cancer

Plasma renin, erythropoietin and chorionic gonadotropin levels were evaluated in 57 patients with renal adenocarcinoma. Renin elevation, found in 37 per cent, was unrelated to blood pressure levels but was associated with high grade, high stage lesions of mixed histologic cell type and predicted a poor prognosis. Erythropoietin was raised in 63 per cent of patients and was more sensitive than renin in indicating the presence of renal adenocarcinoma. However, it was less specific and did not correlate directly with tumor grade, stage, histologic type, prognosis or hematocrit and hemoglobin levels. None of the patients had elevated chorionic gonadotropin levels. Therefore, we believe that renin and erythropoietin determinations may be of value as biochemical tumor markers in renal adenocarcinoma.

Manifestations of renal cell carcinoma

Patients with renal cell carcinoma often have no specific localizing symptoms or signs, and their presentation will often involve many organ systems. Since 40 per cent of these patients do not have genitourinary symptoms, care must be taken to avoid being misled by normal findings on urinalysis. More than 50 per cent of patients with renal cell carcinoma have vague symptoms suggesting a gastrointestinal origin; thus if primary gastrointestinal studies do not disclose a cause for these symptoms, excretory urography must be included as a screening procedure.

Erythrocytosis and renal cell carcinoma with pulmonary metastases: case report with 18-year followup and brief discussion of literature

A 42-year-old man was admitted to the Cancer Division of the American MedicalCenter in February, 1956. He had been treated for erythrocytosis beginning 6 months previously, with reduction of his hemoglobin to relatively normal values. On admission, a huge tumor of the left kidney was palable. Roentgenograms of the chest demonstrated small bilateral pulmonary metastases. A left nephrectomy was per formed, followed by wedge resection of a total of 16 metastatic nodules, 12 of which showed metasticrenal carcinoma. It is now 18 years since the last thoracotomy and the patient is well, leading a normal life, and free of any demonstrable malignant disease and any evidenceof erythrocytosis.

Hypercalcaemia associated with adenocarcinoma of kidney without demonstrable bone lesions

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