A 58-year-old Indian man presents with gross hematuria and right-sided flank pain for 3 weeks. On examination, he is afebrile with a palpable right upper quadrant mass. Contrast-enhanced CT abdomen shows a 6 cm heterogeneous mass in the right kidney with loss of fat planes but no invasion of adjacent organs. Chest X-ray and abdominal imaging show no distant metastases. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has a **locally advanced renal cell carcinoma (RCC)** with: - Large tumor (6 cm) with loss of fat planes (T3a-T4 stage) - No evidence of distant metastases (M0) - Good performance status - Resectable disease ## Management Strategy for Localized/Locally Advanced RCC **Key Point:** Radical nephrectomy remains the gold standard curative treatment for localized and locally advanced RCC (stages I–III without distant metastases) [cite:Robbins 10e Ch 20]. **High-Yield:** Surgical resection is the ONLY modality with curative intent in non-metastatic RCC. Systemic therapy (TKIs, immunotherapy) is reserved for metastatic disease or as adjuvant/neoadjuvant therapy in high-risk resectable cases. ## Why Radical Nephrectomy Is Correct | Feature | Implication | |---------|-------------| | Tumor size 6 cm | Exceeds threshold for nephron-sparing surgery (typically <4 cm) | | Loss of fat planes | Suggests T3–T4 disease; still resectable | | No metastases | M0 status; surgery offers cure | | Good PS | Fit for major surgery | **Clinical Pearl:** Radical nephrectomy includes en bloc resection of the kidney, adrenal gland, and regional lymph nodes (D2 lymphadenectomy). This is the standard of care for T3–T4, N0–N1, M0 disease. ## Why Other Options Are Incorrect 1. **Renal biopsy** — Not routinely needed when imaging is diagnostic (heterogeneous mass with loss of fat planes on contrast CT is pathognomonic for RCC). Biopsy risks tumor seeding and delays definitive treatment. 2. **Neoadjuvant TKI (sunitinib)** — Reserved for borderline-resectable or metastatic disease. This tumor is clearly resectable; upfront surgery is preferred. Neoadjuvant therapy may be considered in select high-risk cases but is not standard. 3. **Percutaneous ablation** — Appropriate only for small tumors (<4 cm, T1a) in patients unfit for surgery. This 6 cm tumor with loss of fat planes requires open radical nephrectomy for adequate margin and lymph node assessment.