A 62-year-old woman comes to the office due to 6 weeks of malaise and intermittent fever. She has also had decreased appetite and unintentional weight loss but no bowel or bladder symptoms. The patient has a history of type 2 diabetes mellitus and hypertension, and 10 years ago she underwent total hysterectomy and bilateral salpingo-oophorectomy for early stage endometrial cancer. She has smoked a pack of cigarettes daily for 30 years and does not drink alcohol. She works as an accountant. Temperature is 37.9 C (100.2 F), blood pressure is 140/90 mm Hg, pulse is 90/min, and respirations are 16/min. On examination, she appears thin and pale. A hard mass is palpated over the right flank area. There is no abdominal tenderness, and bowel sounds are normal. The liver and spleen are not enlarged. No lymphadenopathy is present. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 62-year-old woman comes to the office due to 6 weeks of malaise and intermittent fever.  She has also had decreased appetite and unintentional weight loss but no bowel or bladder symptoms.  The patient has a history of type 2 diabetes mellitus and hypertension, and 10 years ago she underwent total hysterectomy and bilateral salpingo-oophorectomy for early stage endometrial cancer.  She has smoked a pack of cigarettes daily for 30 years and does not drink alcohol.  She works as an accountant.  Temperature is 37.9 C (100.2 F), blood pressure is 140/90 mm Hg, pulse is 90/min, and respirations are 16/min.  On examination, she appears thin and pale.  A hard mass is palpated over the right flank area.  There is no abdominal tenderness, and bowel sounds are normal.  The liver and spleen are not enlarged.  No lymphadenopathy is present.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d95c_14a7_bc81_1b8497fe86c5_MD0003_00 This patient's unintentional weight loss, smoking history, and hard flank mass raise strong suspicion for renal cell carcinoma (RCC), a primary malignant neoplasm of the kidney. Most cases arise in patients age >50; risk is greatest in former or current smokers and those with obesity, hypertension, and/or occupational exposure to toxic compounds (eg, asbestos). Although RCC is classically associated with the triad of flank pain, hematuria, and a palpable abdominal mass, <10% of patients have all 3 of these symptoms. RCC is sometimes discovered incidentally on abdominal imaging, but patients often have ≥1 the following: Unintentional weight loss An abdominal or flank mass that is firm, nontender, and moves with respiration Hematuria (when the tumor invades the renal collecting system), which may lead to iron deficiency anemia Intermittent fever Paraneoplastic syndromes (eg, ectopic erythropoietin production, hypercalcemia) Patients with suspected RCC usually require abdominal CT with and without contrast for further evaluation followed by staging imaging (eg, CT chest). Nephrectomy or partial nephrectomy provides a tissue diagnosis. (Choices A and B) Although acute diverticulitis is common in older adults, it usually causes significant lower abdominal pain and (sometimes) a tender abdominal mass and leukocytosis. Acute appendicitis typically arises in younger (not older) adults and usually causes right lower quadrant abdominal pain, anorexia, vomiting, and leukocytosis. This patient with 6 weeks of symptoms, no abdominal pain, and no leukocytosis is unlikely to have acute diverticulitis or appendicitis. (Choice C) Hydronephrosis primarily occurs in the setting of urinary tract obstruction and is generally asymptomatic unless the obstruction is acute (eg, renal stone). It is not typically associated with a flank mass, and weight loss and systemic symptoms would be unusual. (Choice D) Non-Hodgkin lymphoma often causes B symptoms (eg, intermittent fever, night sweats, weight loss), but it usually (>70%) also causes painless peripheral lymphadenopathy and can cause hepatosplenomegaly. Furthermore, it rarely arises in the kidney. (Choice E) Polycystic kidney disease (PKD) is an autosomal dominant disorder that typically causes bilateral cystic renal enlargement and progressive renal failure. Although flank pain and hematuria are common complications of PKD, this patient's unintentional weight loss; unilateral, hard flank mass; and smoking history make RCC far more likely. In addition, a patient age >60 with PKD would likely have a more significant creatinine elevation. Educational objective: Renal cell carcinoma is common in older patients who smoke. It often presents with weight loss, hematuria, firm/nontender flank mass, and/or intermittent fever.

A 62-Year-Old Woman Comes to the Office Due to 6