Int J Biol Med Res.

2011; 2(4): 1178 – 1180

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Volume 2, Issue 4, Oct 2011

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Case Report
Renal cell carcinoma: unmasking the masquerade
AO Adekoya a *, BJ Adekoya a, OO Desalu b, A Aderibigbe b
a*
Lagos State University Teaching Hospital,Lagos, Nigeria
b
University of Ilorin Teaching Hospital, Ilorin, Nigeria *

ARTICLE INFO ABSTRACT

Keywords: Renal Cell Carcinoma is not uncommon among patient in the developing world. However cases
Carcinoma
Cell might be missed if there is no high index of suspicion
Mask
Renal
c Copyright 2010 BioMedSciDirect Publications IJBMR -ISSN: 0976:6685. All rights reserved.

1.Case Presentation

Mrs. B.H. a 75yr old retired School teacher, presented with a The following were investigation results:
month history of right loin pain that was localized, worse at night Serum electrolyte and urea and creatinine (E & U + Cr)
and with no identifiable specific aggravating or relieving factors.
Na, K. U Cr Urate Ca PO4
The loin pain was accompanied with a fever that was high grade
and intermittent. She had no dysuria, urethral discharge, 09/08/ 140 4.1 9.8 146 0.49 2.40 1.1
mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L
frequency, nocturia or hematuria. She however had a cough that
was productive of whitish sputum. There was no history of FBC PCV WBC N L ESR.
associated chest pain, difficulty in breathing or significant weight 31/07/17% 11.3 x106/L 85% 14% 43mm/h
loss She was the mother of a permanent secretary and she Urinalysis Bld Prot leucocyte Others SG
enjoyed full complement of social support. 28/07/+ -ve -ve NAD 1.025
On examination she was febrile and was dehydrated. The Pulse 01/08/Trace -ve -ve NAD 1.025
was 100bpm. The BP was. 90/60mmHg and she had first and
second heart sounds only. Respiratory rate was 22 cycle per Urine MCS
WBC - 3-4/HPF. Mixed growth
minute with coarse bibasal crepitations. She had a mass palpable
in the right lumbar region. This was hard, rough and tender and it Abdominal Ultrasound showed
was dull to percussion. One could get above and below it. It was not 26/07/ -Rt kidney - 13cm lobulated margins and loss of corticomedullay
differentiation. Has accentuated renal parenchymal echos
attached to the overlying skin. The left kidney was not palpable.
Lt kidney and other organs were normal
She also had Right renal angle tenderness. Enlarged right kidney 12.8 x 7.0cm

She was managed as a case of right pyelonephritis possibly

c o m p l i c a t i n g r i g h t r e n a l t u m o u r.
She improved significantly on intravenous ciprofloxacin 200mg 12
hourly and tab tramadol 50mg 12 hourly. She was discharged after
8 days of hospital admission. The abd USS was repeated . The
conclusion then was right renal neoplasm.Despite the initial
* Corresponding Author : AO Adekoya
improvement,a reassessment 2 weeks later showed a worsening
Lagos State University Teaching Hospital,
Lagos, Nigeria of right loin pain and restlessness. She had evening low grade
E.mail: debobola02@yahoo.com pyrex ia . Pa in wa s desc rib ed a s b it in g in n a t u re.
c
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 Adekoya et.al / Int J Biol Med Res. 2011; 2(4): 1178 – 1180
1179

Urinalysis: Bld (+) Prot (+) The risk factors for renal cell carcinoma include smoking,
Urea was 13.7mmol/L, Cr =159µmol/L,. obesity and hypertension [5]. None of these was found in this
She had no frank hematuria. patient. There is also a male predominance with ratio off 1.6:1.0.
Physical examination then was significant for mild pitting pedal Renal cell carcinoma also has a genetic basis. However, there
edema. Pulse 108bpm BP 110/68mmHg. She was tachypnoeic was no history of similar illness in this patient's family. There has
with bibasal coarse crepitation. been a significant revolution in the understanding of the genetic
There was right renal angle tenderness. A mass was palpable in basis of this condition. The most consistent cytogenetic finding in
the right loin. sporadic renal cell tumours is the deletion of the short arm of
Repeat Investigations showed. chromosome 3. This observation provides evidence for the
presence of tumour suppressor genes which have been mapped in
Electrolyte,Urea and Creatinine: the 3p21-P26 and 3P13-P24 regions and whose loss promotes the
Na, K. U Cr
initiation of tumour growth [6].
08/09/ 134mmol/l 3.6mmol/L 12.5mmol/L 100mol/L RCC is not a single entity, but rather comprises the class of
tumors of renal epithelia origin resulting from distinct genetic
Urinalysis SG Bld Prot Others
abnormalties with unique morphological features. There are
09/09/ 1.015 -ve -ve NAD several different types of cancers, each caused by a different gene
Urine MCS WBC:0-1/HPF yeast cell(++) and affecting a different molecular pathway, and each with
Mixed growth. potentially different clinical course that responds differently to
Abd USSRight kidney was 13.2cm in bipolar length with distorted therapy [7,8].
parenchyma echoes. It was multinodular with loss of corticomedulary
differentiation in keeping with renal cell cancinoma. Other organs were The classical presentation of renal cell carcinoma includes the
essentially normal
triad of flank pain, hematuria and a palpable abdominal mass. Few
FBC PCV WBC N L ESR
patients present in this manner. Many textbooks and publication
24/08/ 19% 6.5 80% 20% 75mm/h -- refer to renal adenocarcinoma as the internist tumour [9] or the
ABDOMINAL COMPUTED TOMOGRAPHY SCAN: 'great imitator in medicine'[10].Our patient had presented with
Right renal neoplasm involving the IVC, with metastases to lungs . features suggestive of pyelonephritis, although, she was also found
Further history showed no family history of renal tumor or to have a flank mass at presentation. The case report by Eke et al
malignancy . She has also remained normotensive since period of mentioned above better described the 'imitator' nature of RCC.
presentation. She is being managed conservatively as a case of
advanced right renal cell carcinoma She is on tab tramadol 50mg 12 Roughly half the cases are now detected because a renal mass is
hourly as needed. She is alive and presently being co-managed with incidentally identified on radiographic examination.
the Urologists, on follow up.
Gross or microscopic hematuria is an important clinical clue to
the diagnosis of renal cell carcinoma. It was therefore not
2.Discussion surprising that our patient had microscopic hematuria. The
hematuria of renal tumours is characteristically gross, total and
Renal Cell Carcinoma is the 7th leading malignant condition intermittent in nature, although some instances of
among men and the 12th among women in the United States microhematuria have also been observed. The hematuria could
where it accounts for 2.6 percent of all cancers [1]. There is also be so gross as to produce worm-like clots, corresponding to
paucity of information on the incidence of this condition in casts of the ureter
Nigeria. Aghaji et al reported 74 cases of RCC over a ten year period
in Enugu [2].A case report from Port-Harcourt by Eke et al This patient presented with loin pain. This is however not a
presented a case of RCC masquerading as scalp swelling [3]. In the constant feature of RCC. The frequency of loin pain have been
United States, 36,160 new cases of renal cancer were predicted to reported to range between 20 and m 45 percent. It is an inconstant
occur in 2005. many of which were being discovered earlier feature that results from the progressive distension of the fibrous
because of widespread availability of radiographic testing . renal capsule by the growing tumour. It could also result from
Nevertheless, 12,660 death were predicted to occur from the traction of the adjacent structures. The passage of clot in gross
disease in 2005 [1]. hematuria may also produce pain that simulates the pain of acute
ureteric obstruction. However, loin pain resulting from renal cell
Renal cell carcinoma arises from the renal epithelium and
carcinoma follows the presentation of hematuria while the pain of
accounts for about 85% of renal cancers.
acute ureteric obstruction preceeds the hematuria [11].
Incidence rate are closely related to ageing, as with other
Palpable mass is mostly found in advanced disease condition.
malignancies such as cancers of the prostate and colon. De Reijke
The frequency of its occurrence is put between 6 and 50 percent.
et al in a data taken from standardized cancer rates per 100,000
Our patient presented with palpable right renal mass. Manuel
population showed a steady increase in frequency with each
reported that 1 in every 4 cases had clinically detectable mass
passing decade after the age of 30years with a minimum incidence
[11].
before that age. The percentage distribution by age group shows a
peak incidence in the seventh decade [4] .This is in accordance She also had evidence of distant metastasis which was
with the age of our patient. She presented at the age of seventy- confirmed with CT Scan .This patient also had symptoms and signs
five.(although, this was already in the early eight decade) referable to the detected site of metastasis. She had productive
 Adekoya et.al / Int J Biol Med Res. 2011; 2(4): 1178 – 1180
1180

cough. This is unusual. Mostly, features of affectation of metastatic [9] Pantuck AJ, Zeng G, Belldegolun AS, Figlin RA Pathology, Prognosis and
site may not be present even when those sites are detected on targeted therapy for renal cell carcinoma: Exploiting the hypoxia induced
pathway. Clin Cancer Res, 2003;9:4641-4652.
radiologic investigation [11] .Renal Cell Carcinoma is well known
[10] Pavlovich CP. Schmidt LS. Searching for the hereditary cause of renal cell
for its propensity to metastasize by way of both venous and
carcinoma. 2004; 4:381-393.
lymphatic routes. Ritchie and Dekernion found that 23%s of
[11] Manuel UA Renal Cell Cancer and other tumours. Oxf. Text. Med Oxford
patients with RCC present initially with metastatic disease and Univ. Press. 1997;18:1.
25% develop metastasis disease within 5 years of nephrectomy [12] Ritchie AWS, Dekernion JB: The natural history and clinical features of renal
[12]. It should be emphasized that multidetector computed carcinoma. Semin Nephrol. 1987;7:131-139.
tomography (MDCT) represents a fast, relatively inexpensive, and [13] Ranka SP, Drazen Perkov, Ranko 5, Bozilar O and Kristina P. Venous Spread
reliable diagnostic method for evaluating the venous spread of of renal cell Carcinomas: MDCT. Abdominal Imagiang. 2006;10:261.
RCC as well as the level of its upper extent [13]. Our patient also [14] Montie JE, Steward BH, Straffon RA, Banowsky LH Hewitt CB, Montague
presented with a high ESR (although, her PCV was 17%). This is OK. Immunotherapy of disseminated renal cell carcinoma with transfer
factor. Journal of Urology.. 1977;117:272-275.
similar to the presentation of the series reported from Enugu. It is
however surprising that weight loss was not a chief complain in
this patient. This may be attributed to her strong social support.
The choice of treatment is a matter of clinical experience. This
also depend on the convictions that the treatment might modify
the course of the disease or produce a remission of distant
metastasis, although this has only been reported in less than 1
percent of patients [14. Our patient is presently receiving
symptomatic treatment. She receives tab tramadol 50mg 12
hourly as needed and she is being co-managed with the urologist.

6.References

[1] Jemal A. Murray T, Ward E et al. Cancer statistics, cancer J Clin. 2005;; 55:1-
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[2] Aghaji AE, Odoemene CA. Renal cell carcinoma in Enugu, Nigeria. West Afr J
Med. 2000;19(4): 254-258
[3] Eke N, Eghwrudjakpor P, Echem RC. Renal carcinoma presenting as scalp
swelling. Niger J Med. 2003;12(3) : 154-156
[4] Kiely JM. Hypernephroma. The internist's tumor Medical Clinic of North
America . 1966; 50: 1067-84.s
[5] Ewert EE. Conception RL, Pires EM. Hyperrnephroma: The great imitator.
Medical clinics of North America. 1963;47:431-436.
[6] Reijke TM, Schlantmann TJ, Dabhoiwala NE. Adenocarcinoma of the kidney
in childhood. Urologia Internationalis. 1987;42: 220-223.
[7] Chow WH, Gridley G, Fraumeni JF Fr, Jerrvholm B, Obesity, Hypertension
and the risk of kidney cancer in men. N Engl J Med. 2000; 343: 1305-1311.
[8] Kohno T, Sekine T, Tobisu K, Oshimura M, Yokota J. chromosome 3p deletion
in a renal cell carcinoma cell line established from a patient with Von
Hippel Lindau disease. Japanese Journal of Clinical Oncology. 1993; c Copyright 2010 BioMedSciDirect Publications IJBMR -ISSN: 0976:6685.
23:226-231. All rights reserved.