What are the signs and symptoms of renal carcinoma, particularly in older adults with a history of smoking or underlying kidney disease?

Signs and Symptoms of Renal Cell Carcinoma

More than 50% of renal cell carcinomas are now detected incidentally on imaging before any symptoms develop, but when symptomatic, patients most commonly present with hematuria, flank pain, or a palpable abdominal mass—though the complete classical triad occurs in less than 10% of cases and indicates advanced disease with poor prognosis. 1, 2

Incidental Detection vs. Symptomatic Presentation

• Over half of all RCC cases are discovered incidentally during abdominal imaging (ultrasonography, CT, or MRI) performed for unrelated reasons 1
• This shift toward incidental detection has increased the proportion of small, early-stage tumors diagnosed 1
• However, symptomatic presentations still occur and warrant immediate evaluation 1, 2

Classical Triad (Advanced Disease Indicator)

The classical triad occurs in less than 10% of patients and strongly suggests locally advanced disease with poor prognosis 2:

• Flank pain - indicates local tumor extension or invasion 2
• Gross hematuria - the most common symptom when present, suggesting local tumor extension or invasion 2
• Palpable abdominal or flank mass - indicates substantial tumor burden 2

Critical pitfall: The presence of the complete triad is a late finding; do not wait for all three features before pursuing diagnostic workup 2, 3

Paraneoplastic Syndromes (20% Present as First Sign)

Paraneoplastic manifestations may be the initial presentation in approximately 20% of cases 4:

• Hypercalcemia - from parathyroid hormone-related peptide secretion, the most common paraneoplastic symptom 2
• Unexplained fever - without evidence of infection 2
• Erythrocytosis - from ectopic erythropoietin production 2
• Stauffer's syndrome - cholestatic liver dysfunction without hepatic metastases (rare) 2
• Persistent cough - as an unusual paraneoplastic presentation 5

Metastatic Symptoms (30% Metastatic at Presentation)

Approximately 20-30% of patients present with metastatic disease 4:

• Bone pain - bone is a common metastatic site 1, 6
• Pulmonary nodules or respiratory symptoms - lungs are the most frequent metastatic site 1, 6
• Neurological deficits - from brain or spinal metastases 6, 4
• Lower back pain with spinal cord compression - requiring emergency intervention 4

Special Presentation in Older Adults

• 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
• This is particularly important in patients with smoking history, as active and passive cigarette smoking is an established risk factor 1

Risk Factors Relevant to Presentation Context

In older adults with smoking history or underlying kidney disease, heightened suspicion is warranted because 1:

• Smoking is an established risk factor for RCC 1
• End-stage renal failure and acquired renal cystic disease increase RCC risk 1
• Hypertension is an established risk factor (though anti-hypertensive medications themselves are not) 1

Initial Diagnostic Approach When RCC is Suspected

When clinical signs suggest RCC, obtain 1, 2:

• Laboratory tests: serum creatinine, hemoglobin, leukocyte and platelet counts, lactate dehydrogenase (LDH), serum-corrected calcium, and C-reactive protein (CRP) 1, 2
• Imaging: Start with ultrasonography if varicocele or initial suspicion, followed by contrast-enhanced CT of chest, abdomen, and pelvis for definitive staging 2
• These laboratory values serve both diagnostic and prognostic purposes in risk stratification models 2

Key pitfall: Do not assume proteinuria is caused by RCC itself—it typically reflects underlying chronic kidney disease from shared risk factors and should be evaluated separately 7