A 58-year-old man from Delhi presents with a 3-month history of flank pain, haematuria, and constitutional symptoms (weight loss 4 kg, low-grade fever). On examination, he is pale and has a palpable left flank mass. Contrast-enhanced CT abdomen shows a 6 cm heterogeneous mass in the left kidney with fat stranding and no distant metastases. Chest X-ray and brain MRI are normal. Baseline renal function is normal (creatinine 0.9 mg/dL). What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has a **localized renal cell carcinoma (RCC)** with no evidence of metastatic disease. The imaging findings (6 cm mass, fat stranding) and clinical presentation are classic for RCC. The absence of distant metastases and normal renal function make him a candidate for curative surgical resection. ## Management Algorithm for Localized RCC ```mermaid flowchart TD A[Suspected RCC on imaging]:::outcome --> B{Metastatic disease?}:::decision B -->|Yes| C[Metastatic RCC]:::outcome C --> D[Systemic therapy ± cytoreduction]:::action B -->|No| E[Localized RCC]:::outcome E --> F{Renal function adequate?}:::decision F -->|Yes| G[Radical nephrectomy]:::action F -->|No| H[Nephron-sparing surgery or ablation]:::action G --> I[Adjuvant therapy if high-risk features]:::action H --> I ``` ## Why Radical Nephrectomy is Correct **Key Point:** For localized RCC (Stage I–III, no metastases), **radical nephrectomy with regional lymph node dissection** is the gold standard curative treatment. **High-Yield:** - Radical nephrectomy removes the kidney, perirenal fat, Gerota's fascia, and ipsilateral adrenal gland (if involved). - Regional lymph node dissection improves staging accuracy and may confer survival benefit in node-positive disease. - This patient has no contraindications: normal contralateral kidney function, no distant metastases, and fit for surgery. **Clinical Pearl:** The presence of constitutional symptoms (fever, weight loss) and haematuria does not change the management of localized disease — these are paraneoplastic manifestations and will resolve post-nephrectomy if disease is completely resected. ## Adjuvant Considerations | Feature | Implication | |---------|-------------| | 6 cm mass | T2 (intermediate risk) | | No necrosis/sarcomatoid noted | Standard risk | | No nodal involvement (on imaging) | N0 | | No metastases | M0 | | **Stage:** II–III | Candidate for adjuvant therapy if high-risk features confirmed on pathology | **Tip:** Post-operative pathology may reveal high-risk features (Fuhrman grade 3–4, sarcomatoid, necrosis) → adjuvant sunitinib or pazopanib is then considered. But surgery is the immediate next step. [cite:Robbins 10e Ch 20]