The majority (at least 60 %) of RCCs are found incidentally on imaging.
The classic triad (“too late triad”) of flank pain, haematuria and a palpable mass is now rarely seen.
Symptoms from RCC may arise from:
- Local tumour growth
- Haematuria
- Flank pain
- Abdominal mass
- Lower limb oedema, from IVC obstruction
- Non reducing, or right sided varicocele
- Haemorrhage
- 50 % of spontaneous renal bleeds may be associated with a tumour (AML > RCC)
- Paraneoplastic syndromes
- Metastatic disease
- Weight loss
- Fever
- Night sweats
Paraneoplastic syndromes
Symptoms due to the systemic effects of a malignant tumour, but not due to metastatic disease or the tumour itself – usually due to substances secreted by the tumour.
10 – 20 % of patients with RCC have a paraneoplastic syndrome.
They are more common in metastatic disease and larger tumours.
They are a result of secretion of excess or pathologic secretion of either normal renal substances (1,25-dihydroxycholecalciferol), renin, EPO, prostaglandins), or other factors (PTH-like peptides, HCG, insulin etc).
| Elevated ESR | Most common |
| Hypercalcaemia | Up to 13 % – either paraneoplastic (PTH like peptides), or bone metastases
Needs medical management – hydration, Lasix, bisphosphanates |
| Hypertension | Renin production, encasement of renal arteries, AV fistula |
| Polycythaemia | Increased EPO production |
| Stauffer syndrome | 3 – 20 % – elevated ALP most common, as well as elevated bilirubin, transaminases, prothrombin time
No liver metastatic disease. |
| Weight loss, cachexia | |
| Anaemia | |
| Fever | Cytokines |
| Cushing syndrome | ACTH secretion |
| Hyperglycaemia | Insulin or glucagon secretion |
| Galactorrhoea | Prolactin secretion |
| Neuromyopathy | |
| Cerebellar ataxia |
Hypercalcaemia
Up to 13 % or more of RCC patients.
Paraneoplastic due to secretion of PTH like substances or can be due to effects of metastases on bone.
Symptoms and signs can be non-specific:
- Abdominal pains
- Nausea and vomiting
- Depressed tendon reflexes
- Anorexia
- Fatigue
- Confusion
- Constipation
- Renal stones
- Arrhythmia
- Myopathy
Treatment:
- Invite (renal) physician input
- IV hydration first line
- Followed by diuresis with frusemide
- Bisphosphonates next line standard of care
- Zoledronic acid seems to work very well in RCC related hypercalcaemia
- Other options include steroids or calcitonin
- Definitive treatment may require nephrectomy +/- metastasectomy
- Consider radiation if bone involvement is thought to be the cause