Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 66-year-old man is evaluated for vague abdominal pain of several months’ duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications.

On physical examination, vital signs are normal. No lymphadenopathy is noted. Cardiopulmonary examination is normal. He has a slightly distended abdomen with vague left-sided upper abdominal fullness but without tenderness, rebound, or guarding. The rectal examination is normal, and the fecal occult blood test is guaiac-negative.

Laboratory studies indicate a hemoglobin level of 11.4 g/dL (114 g/L) and a mean corpuscular volume of 81 fL. Urinalysis reveals microscopic hematuria.

A CT scan of the abdomen demonstrates a 15-cm left upper kidney mass with 3-cm perirenal lymph node enlargement and multiple 1-cm pulmonary nodules on the lowest cuts of the chest portion of the scan. A thoracic CT confirms pulmonary nodules consistent with metastatic disease. A bone scan is negative.

Which of the following is the most appropriate initial management of this patient?

A: CT-guided lung biopsy
B: CT-guided kidney biopsy
C: Cytotoxic chemotherapy
D: Left nephrectomy

MKSAP Answer and Critique

The correct answer is D: Left nephrectomy.

The most appropriate management of this patient is left nephrectomy. This patient has advanced kidney disease as manifested by the classic triad of pain, a mass, and hematuria, and chest imaging is consistent with metastatic disease. Studies in patients presenting with advanced disease and treated with interferon alfa demonstrated that survival was improved by resection of the primary tumor. This is the only malignancy in which removing the primary tumor in the setting of metastatic disease can improve overall outcome rather than just reduce local symptoms. It is necessary to carefully select patients for nephrectomy; only those patients eligible for immunotherapy should be offered cancer resection.

CT-guided lung biopsy would be a reasonable method for documenting metastatic disease but only after the primary tumor has been resected.

A biopsy of the kidney mass is not recommended because biopsy results, positive or negative, would not change the need to perform a nephrectomy. In this patient with perirenal lymphadenopathy and pulmonary nodules suggestive of metastatic disease, a negative biopsy would be viewed as a false-negative result and would require follow-up surgical removal.

Systemic treatments, including vascular endothelial growth factor tyrosine kinase inhibitors such as sunitinib or sorafenib, may be helpful in patients with advanced-stage or metastatic renal cell cancer; however, cytotoxic chemotherapy has little effect in this setting.

Key Point

• Kidney cancer is the only malignancy in which removing the primary tumor in the setting of metastatic disease can improve overall outcome rather than just reduce local symptoms.

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