A 55-year-old man comes to the office for a medical evaluation for life insurance. The patient feels well and has no chronic health issues. He takes no prescription medications but recently began taking over-the-counter supplements, which have improved his energy level. The patient has smoked a pack of cigarettes a day for 30 years but is trying to cut down. He drinks alcohol occasionally and does not use illicit drugs. Family history is notable for non-Hodgkin lymphoma in his brother. Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and oxygen saturation is 99% on ambient air. The patient's complexion is ruddy. There are no skin rashes or mucosal lesions. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender with no hepatosplenomegaly. Laboratory results are as follows:

In addition to recommendation for smoking cessation, which of the following is the best next step in management of this patient?

Question

A 55-year-old man comes to the office for a medical evaluation for life insurance.  The patient feels well and has no chronic health issues.  He takes no prescription medications but recently began taking over-the-counter supplements, which have improved his energy level.  The patient has smoked a pack of cigarettes a day for 30 years but is trying to cut down.  He drinks alcohol occasionally and does not use illicit drugs.  Family history is notable for non-Hodgkin lymphoma in his brother.  Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and oxygen saturation is 99% on ambient air.  The patient's complexion is ruddy.  There are no skin rashes or mucosal lesions.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  Laboratory results are as follows:
 
In addition to recommendation for smoking cessation, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with a 30-pack-year smoking history has erythrocytosis and hematuria, raising suspicion for renal cell carcinoma (RCC). RCC is a malignant tumor of the renal parenchyma or renal pelvis. Major risk factors include cigarette smoking, obesity, and hypertension. Patients classically develop the triad of flank pain, hematuria, and palpable abdominal mass; however, all 3 features are present in <9% of cases. Paraneoplastic syndromes such as constitutive erythropoietin production (erythrocytosis) are also quite common. renal parenchyma Patients with unexplained hematuria or other manifestations concerning for RCC require a CT scan of the abdomen to evaluate for a renal mass. (Choice A) Myeloproliferative disorders (eg, myelofibrosis) are diagnosed by bone marrow biopsy and can cause erythrocytosis. However, hematuria is not a typical feature of these disorders (unless patients have severe thrombocytopenia). This patient requires a CT scan of the abdomen to evaluate for RCC prior to any invasive procedure. (Choice C) Polycythemia vera is a chronic myeloproliferative neoplasm often associated with JAK2 mutations. Erythrocytosis is the defining feature; patients also often have aquagenic pruritus, hypertension, and arterial or venous thrombus. This patient with long-term cigarette use and hematuria is more likely to have erythrocytosis due to RCC. (Choice D) The diagnosis of RCC should not be delayed as patients may have progressive disease. (Choice E) Anabolic steroids can stimulate erythropoiesis and result in erythrocytosis. This patient with hematuria and chronic cigarette use is more likely to have RCC. Educational objective: Renal cell carcinoma is typically associated with smoking, obesity, and hypertension. Patients usually have hematuria, abdominal mass, and/or flank pain. Paraneoplastic syndromes (eg, erythropoietin secretion) are common. Diagnosis requires a CT scan of the abdomen.

A 55-Year-Old Man Comes to the Office for a Medical