Symptoms of Renal Cell Carcinoma
Most renal cell carcinomas (>50%) are now detected incidentally on imaging and are asymptomatic, making the classical triad of flank pain, gross hematuria, and palpable abdominal mass uncommon (<10% of cases) and indicative of advanced disease with poor prognosis. 1
Incidental Detection vs. Symptomatic Presentation
The widespread use of abdominal imaging (ultrasonography, CT scans) has fundamentally changed how RCC presents in modern practice 1:
- Asymptomatic incidental findings account for more than 50% of current RCC diagnoses 1
- These incidentally detected tumors tend to be smaller and at earlier stages, contributing to improved survival outcomes 1
Classical Symptomatic Triad (Now Rare)
When the classical triad does occur, it signals advanced disease 2:
- Flank pain - indicates local tumor extension or invasion 1, 2
- Gross hematuria - the most common symptom when present, suggesting local tumor extension 1, 2
- Palpable abdominal or flank mass - indicates substantial tumor burden 1, 2
This triad occurs in fewer than 10% of patients and suggests advanced disease with poor prognosis 2, 3, 4.
Paraneoplastic Syndromes ("The Internist's Cancer")
RCC remains notable for paraneoplastic manifestations that may be the presenting feature 1:
- Hypercalcemia - from parathyroid hormone-related peptide secretion 1, 2
- Unexplained fever - without evidence of infection 1, 2
- Erythrocytosis - from erythropoietin production 1, 2
- Stauffer's syndrome - cholestatic liver dysfunction (elevated alkaline phosphatase, bilirubin) without hepatic metastases or intrinsic liver disease, which typically resolves after tumor resection 1, 2
Metastatic Symptoms
Patients may present with symptoms from distant metastases 1:
- Bone pain - from skeletal metastases 1
- Pulmonary symptoms - from lung parenchymal or mediastinal metastases 1
- Adenopathy - from lymph node involvement 1
- Neurological symptoms - from brain metastases 5
Constitutional Symptoms
Non-specific systemic symptoms include 1, 3:
Special Clinical Sign
New-onset varicocele in an older male should raise immediate suspicion for RCC, as it may indicate renal vein or inferior vena cava obstruction by tumor 2.
Risk Factor Context
Given the patient's smoking history, this is particularly relevant as cigarette smoking is an established risk factor for RCC 1, along with obesity and hypertension 1.
Clinical Pitfall
The shift toward incidental detection means clinicians must maintain vigilance when evaluating any renal mass on imaging, even in completely asymptomatic patients. The absence of the classical triad does not rule out RCC and should never delay appropriate diagnostic workup 1.