Editing Kidney Cancer: Diagnosis and Evaluation (section)

== History and Physical Exam ==

=== History ===
* '''<span style="color:#ff0000">Risk factors for RCC</span>''': smoking, hypertension, obesity, familial syndromes, CKD
*'''<span style="color:#ff0000">Family history</span>'''
*'''<span style="color:#ff0000">Symptoms</span>'''
**'''<span style="color:#ff0000">Most (>50%) of renal masses are diagnosed incidentally</span> during an evaluation for unrelated signs or symptoms.'''
*** '''Many remain asymptomatic and nonpalpable until they are locally advanced'''
**** Flank pain is usually due to hemorrhage and clot obstruction, but can also occur with locally advanced or invasive disease.
*** The “classic triad” of symptoms associated with a malignant renal mass was hematuria, flank pain and abdominal mass
****<5% of patients in contemporary series present with these symptoms
*** '''<span style="color:#ff0000">Symptoms of advanced disease:</span>''' 
****'''<span style="color:#ff0000">Flank pain</span>'''
*****Locally advanced RCC usually presents with pain, generally from invasion of the posterior abdominal wall, nerve roots, or paraspinous muscles.
****'''<span style="color:#ff0000">Gross hematuria</span>'''
****'''<span style="color:#ff0000">Constitutional symptoms such as weight loss, fever, and night sweats</span>'''
*** New onset coughing or other respiratory issues may suggest pulmonary metastases
*** New neurologic symptoms may suggest cerebral metastases
* '''Spontaneous perirenal hemorrhage is an uncommon presentation of RCC in which the underlying mass may be obscured. Repeat CT a few months later can provide a definitive diagnosis.'''

=== Physical Examination ===
* '''<span style="color:#ff0000">General'''
**'''<span style="color:#ff0000">Blood pressure'''
**'''<span style="color:#ff0000">Performance status'''
**'''<span style="color:#ff0000">Body habitus'''
**'''<span style="color:#ff0000">Dermatologic lesions</span>,''' which may suggest a familial RCC syndrome
*'''<span style="color:#ff0000">Lymphadenopathy'''
**'''<span style="color:#ff0000">Cervical/supraclavicular'''
**'''<span style="color:#ff0000">Axillary'''
**'''<span style="color:#ff0000">Groin'''
*'''<span style="color:#ff0000">Abdomen'''
**'''<span style="color:#ff0000">Prior abdominal scars'''
*'''<span style="color:#ff0000">Genitals'''
**'''<span style="color:#ff0000">Scrotum'''
***'''<span style="color:#ff0000">Varicocele'''
* '''<span style="color:#ff0000">Extremities'''
**<span style="color:#ff0000">'''Lower extremity edema'''
*'''<span style="color:#ff0000">Neurologic exam'''
**Should be performed if there is any suggestion of cerebral or spinal metastases
* Limited role in clinically localized disease 
*'''<span style="color:#ff0000">Physical exam findings suggestive of advanced disease (5):</span>'''
*# '''<span style="color:#ff0000">Palpable abdominal mass</span>'''
*# '''<span style="color:#ff0000">Nonreducing varicocele</span>'''
*# '''<span style="color:#ff0000">Right-sided varicocele</span>'''
*# '''<span style="color:#ff0000">Bilateral lower extremity edema resulting from venous involvement</span>'''
*# '''<span style="color:#ff0000">Palpable cervical lymphadenopathy</span>'''

=== Paraneoplastic syndromes in RCC ===
* '''Found in 10-20% of patients with metastatic RCC (<span style="color:#0000ff">NEW-HALF-CAP</span>):'''
*# '''<span style="color:#0000ff">N</span><span style="color:#ff0000">europathy</span>''' (3%)
*# '''<span style="color:#0000ff">E</span><span style="color:#ff0000">levated ESR </span>(56%, most common)'''
*# '''<span style="color:#0000ff">W</span><span style="color:#ff0000">eight loss</span>''' (34%)
*# '''<span style="color:#0000ff">H</span><span style="color:#ff0000">ypertension</span>''' (38%)
*#* Can be due to elevated renin production by tumour, compression of renal artery, or AV fistula in tumour
*# '''<span style="color:#0000ff">A</span><span style="color:#ff0000">nemia</span>''' (36%)
*# '''<span style="color:#ff0000">Elevated </span><span style="color:#0000ff">L</span><span style="color:#ff0000">FTs''' (14%)
*#* Due to nonmetastatic hepatic dysfunction, also known as Stauffer syndrome
*# '''<span style="color:#0000ff">F</span><span style="color:#ff0000">ever</span>''' (17%)
*# '''<span style="color:#ff0000">Hyper</span><span style="color:#0000ff">C<span style="color:#ff0000">alcemia</span>''' (5%)
*#* Can be due to (2):
*#*# Paraneoplastic phenomena (production of PTH-related protein)
*#*# Osteolytic metastatic involvement of the bone
*#* '''Signs and symptoms include nausea, anorexia, fatigue, and decreased deep tendon reflexes'''
*#* '''Management includes vigorous hydration followed by diuresis with furosemide and the selective use of bisphosphonates (if adequate renal function),''' corticosteroids or calcitonin
*# '''<span style="color:#0000ff">A</span><span style="color:#ff0000">myloidosis</span>''' (2%)
*# '''<span style="color:#0000ff">P</span><span style="color:#ff0000">olycythemia</span>''' (4%)
* '''Management'''
** '''Treatment of paraneoplastic syndromes has required surgical excision or systemic therapy''' and, except for hypercalcemia, medical therapies have not proved helpful.