62-year-old man with hematuria and a 7.8-cm renal mass
A 62-year-old man presents with 3 weeks of painless gross hematuria and new left flank discomfort. He has smoked 1 pack daily for 35 years. Blood pressure is 154/92 mm Hg, and examination shows a palpable left-sided abdominal fullness. Hemoglobin is 18.2 g/dL, creatinine is 1.1 mg/dL, and urinalysis shows numerous red blood cells without casts or infection. CT of the abdomen reveals a 7.8-cm enhancing mass arising from the upper pole of the left kidney with no renal vein invasion or distant metastases. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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B
Explanation
Clinical Pearl:
Localized renal cell carcinoma is treated primarily with surgery. Large enhancing renal masses suspicious for RCC usually do not require preoperative biopsy when imaging and clinical features already support definitive resection.
Explanation:
This patient has a large, enhancing renal mass with classic features of localized renal cell carcinoma, including painless hematuria and paraneoplastic erythrocytosis. For a surgically fit patient with a localized tumor of this size, radical nephrectomy is the standard management, especially when the mass is too large for nephron-sparing surgery to be preferred. Nivolumab plus ipilimumab is used for advanced or metastatic disease, not for a resectable kidney-confined tumor. Percutaneous biopsy can help when the diagnosis is uncertain or when nonsurgical management is planned, but it is not routinely required before nephrectomy for an obvious operable renal mass. Radiation therapy is not definitive first-line treatment for localized RCC because these tumors are managed primarily with surgery. Active surveillance is generally reserved for small renal masses or patients with major competing risks, not for a symptomatic 7.8-cm lesion.
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