HYPERTENSION:: A RARE PRESENTATION OF RENAL CELL CARCINOMA

Abstract

A 56-year-old man presented elsewhere with the chief complaints of headache and epistaxis 1 month in duration. Due to increased blood pressure of 215/120 and a diagnosis of essential hypertension, medical therapy with atenolol was started. After 2 months symptoms continued and the patient was referred to a cardiology clinic. Physical examination revealed a mass on the right side of the abdomen. Abdominal sonography demonstrated a right kidney mass. The patient was referred to us. He did not have a history of flank pain, discoloration of urine, dysuria, anorexia, weight loss, night sweating or cigarette smoking. There was no family history of diabetes mellitus or hypertension. Physical examination revealed high blood pressure (180/100) despite treatment with atenolol and captopril. The chest and heart were normal. During examination of the abdomen a 10 3 4 cm. firm, nontender mass was palpated in the right subcostal area, not far from the midline. Hemoglobin was 15 mg./dl. (normal 13 to 17), erythrocyte sedimentation rate 35 mm. per hour (normal less than 20), urinalysis normal, urine culture negative, blood urea nitrogen 30 mg./dl. (normal 20 to 50), creatinine 1 mg./dl. (normal 0.6 to 1.2) and alkaline phosphatase 450 units per dl. (normal 300 to 600). A 24-hour urinalysis indicated vanillylmandelic acid 3.5 mg. (normal 2 to 7). Peripheral plasma renin activity was 1 ng./ml. per hour (normal 0.2 to 2.3). Chest x-ray was normal. Excretory urography showed a mass in the right kidney with pressure effect on the right pelvicaliceal system. Computerized tomography of the abdomen confirmed a solid tumor with a hypodense area in the central portion, below the liver and right kidney, which was suggestive of renal cell carcinoma but an adrenal tumor could not be ruled out (fig. 1). The patient underwent right radical nephrectomy for right renal cell carcinoma. Convalescence was uneventful and antihypertensive drugs were discontinued. Blood pressure became stable at 140/95 on postoperative day 2, and the patient was discharged from the hospital after 5 days. Histological evaluation revealed granular type renal cell carcinoma with perinephric fat involvement but no involvement of the adrenal gland, lymph nodes or renal vein (fig. 2). Diagnosis was stage 2 renal cell carcinoma. DISCUSSION Renal cell carcinoma is a relatively prevalent cancer of the genitourinary system that can present with a wide variety of symptoms, some of which are related to the local effect of the tumor or due to secretion of hormone-like substances from tumor cells. Of these paraneoplastic symptoms hypertension, which has been reported in 14% to 35% of cases, is related to activation of the renin-angiotensin system.2 It is noteworthy that our patient presented with hypertension as a single symptom. To our knowledge this isolated occurrence is rare and a review of the literature revealed that nearly all of the patients who had hypertension due to renal cell carcinoma also had 1 or more other symptoms as well.3 Therefore, we believe that hypertension should be included in the differential diagnosis of renal cell carcinoma. With proper diagnosis and early surgical management dissemination of the tumor may be stopped and the survival of these patients improved.