A 57-year-old man comes to the physician for 2 episodes of blood in his urine. He also complains of fatigue and fever for the last 4 weeks. He has no other medical problems and takes no medications. The patient has a 50-pack-year smoking history but does not use alcohol or illicit drugs. His father died from a blood disorder, but the patient is unsure of the specific name. Vital signs are within normal limits. Examination shows a left-sided varicocele that fails to empty when the patient is recumbent. The remainder of the examination shows no abnormalities. Laboratory results are as follows:
Which of the following is the most appropriate diagnostic procedure?

Question

A 57-year-old man comes to the physician for 2 episodes of blood in his urine.  He also complains of fatigue and fever for the last 4 weeks.  He has no other medical problems and takes no medications.  The patient has a 50-pack-year smoking history but does not use alcohol or illicit drugs.  His father died from a blood disorder, but the patient is unsure of the specific name.  Vital signs are within normal limits.  Examination shows a left-sided varicocele that fails to empty when the patient is recumbent.  The remainder of the examination shows no abnormalities. Laboratory results are as follows:
 Which of the following is the most appropriate diagnostic procedure?

Quizplus · Accepted Answer

11ec25c8_d4f7_826a_bc81_73921cbf4ac5_MD0003_00 11ec25c8_d4f7_826b_bc81_19c55fb13d17_MD0003_00 This patient most likely has renal cell carcinoma (RCC). Most RCC patients are asymptomatic until the disease is advanced. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) is found in only 10% of patients; when present, it strongly suggests advanced/metastatic disease. Hematuria is seen in about 40% of patients and signifies tumor invasion of the collecting system. Scrotal varicoceles (most are left-sided) are observed in about 10% of patients. Varicoceles typically fail to empty when the patient is recumbent due to tumor obstruction of the gonadal vein where it enters the renal vein. Presence of this finding should always raise suspicion for mass obstruction to venous flow, as is seen in RCC. Twenty percent of patients may also have constitutional symptoms such as fever, night sweats, anorexia, weight loss, or easy fatigability. Ectopic production of erythropoietin by the tumor can produce polycythemia, although most advanced tumors are associated with anemia. CT scan of the abdomen is the most sensitive and specific test for diagnosing RCC and should be obtained when the index of suspicion is high. (Choice A) Chest x-ray is important to check for metastasis but will not indicate the diagnosis in this patient. (Choice C) The combination of fever, scrotal varicocele, and polycythemia would virtually exclude bladder cancer, although this patient is at risk due to his smoking history and presence of hematuria. Urine cytology is not helpful in diagnosing RCC. (Choices D & E) This patient's findings are unlikely to indicate testicular carcinoma; therefore, an ultrasound of the testicles or serum alpha-fetoprotein measurements would not be helpful. (Choice F) Erythrocytosis and thrombocytosis are seen as paraneoplastic manifestations of RCC. Bone marrow biopsy is not indicated at this time. Educational objective: Unilateral varicoceles that fail to empty when a patient is recumbent raise suspicion for an underlying mass pathology, such as renal cell carcinoma (RCC), that obstructs venous flow. CT scan of the abdomen is the most sensitive and specific test for diagnosing RCC. References: Paraneoplastic manifestations of renal cell carcinoma (http://www.ncbi.nlm.nih.gov/pubmed/8946620)

A 57-Year-Old Man Comes to the Physician for 2 Episodes