From the Guidelines
The next step for a 65-year-old male with a 4.4 cm mass on the left renal hilum concerning for renal cell carcinoma is referral to a urologist for further evaluation and management. The urologist will likely order additional imaging studies such as a contrast-enhanced CT scan of the chest, abdomen, and pelvis if not already done, to better characterize the mass and assess for metastatic disease 1. Laboratory tests including complete blood count, comprehensive metabolic panel, and urinalysis should be completed.
Key Considerations
- The urologist will determine whether the patient is a candidate for surgical intervention, which is the standard of care for localized renal cell carcinoma 1.
- For a tumor of this size, a partial nephrectomy (nephron-sparing surgery) or radical nephrectomy may be considered depending on the tumor's exact location and the patient's overall health status.
- Prompt referral is important as renal cell carcinoma can be aggressive, and early intervention improves outcomes.
- The 4.4 cm size places this tumor at likely stage T1b, which has generally favorable outcomes with appropriate treatment 1.
Prognosis and Treatment
- The primary predictors of a tumor’s biology and prognosis include pathological stage, histology, and grade 1.
- Patient, tumor and treatment related factors must be carefully considered and communicated using a shared decision-making process consistent with the patient’s inherent preferences and tolerance of uncertainty 1.
Recommendations
- Referral to a urologist for further evaluation and management is the next step.
- Additional imaging studies and laboratory tests should be completed to better characterize the mass and assess for metastatic disease.
- Surgical intervention, such as partial nephrectomy or radical nephrectomy, may be considered depending on the tumor's exact location and the patient's overall health status.
From the Research
Next Steps for a 65-Year-Old Male Patient with a 4.4 cm Mass on Left Renal Hilum
- The patient has been diagnosed with a mass concerning for renal cell carcinoma, and the next step would be to conduct further imaging tests to confirm the diagnosis and determine the stage of the cancer 2, 3.
- Computed Tomography (CT) is the first-choice imaging method for renal cell carcinoma, providing detailed information about the tumor size, vascularity, and metastatic spread 4, 5.
- Magnetic Resonance Imaging (MRI) can be used as an alternative or in addition to CT, especially for patients who require further imaging or have allergies, pregnancy, or surveillance concerns 2, 3.
- The imaging characteristics of renal cell carcinoma can vary depending on the subtype, and CT and MRI can help identify and subtype the tumor 4, 6.
- A combination of different imaging techniques, such as CT or MRI and contrast-enhanced ultrasound, may be useful for specific questions or to increase diagnostic accuracy 5.
Imaging Options
- CT scan: provides detailed information about the tumor size, vascularity, and metastatic spread 4, 5.
- MRI: allows better characterization of renal cell carcinoma subtypes with its soft-tissue resolution and contrast agent usage advantage 4.
- Ultrasound: can be used as a complementary imaging modality, especially for patients who require further imaging or have allergies, pregnancy, or surveillance concerns 2, 5.
Diagnostic Performance
- CT scan: median sensitivity and specificity of 88% and 75%, respectively 5.
- MRI: median sensitivity and specificity of 87.5% and 89%, respectively 5.
- Ultrasound: diagnostic performance varies greatly depending on the technique, with contrast-enhanced ultrasound having a median diagnostic sensitivity of 93% 5.